Category: Book Reviews

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.


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.

Book Reviews

Elizabeth Barnes, The Minority Body, Oxford University Press, 2016

Professor Elizabeth Barnes has produced a tightly and carefully reasoned philosophical examination of the significance of disability. It provides a clear defense of certain core principles of the disability rights movement in contrast to the many professional philosophers (those which I will term ‘mainstream bioethicists’) who consider that movement to be ill-conceived. An example of this tradition can be seen in the volume From Choice to Chance: Genetics and Justice, coauthored by four of the most prominent bioethicists of the turn of the century (Buchanan, Brock, Daniels, & Wikler 2000). (For discussion see Amundson & Tresky 2007, 2008.) I confess to the prejudice implied by my label of ‘mainstream bioethicists’ as those beset by the prejudice of ableism. The late Adrienne Asch considered herself a mainstream bioethicist even though her progressive views of disability were rare among her colleagues.

Disability rights is a serious civil rights movement, equal in significance to gay rights, feminism, resistance against discrimination on the basis of ‘race,’ and a number of other such movements. Just as earlier generations of philosophers assumed the legitimacy of the social prejudices of their own times, mainstream bioethicists have assumed the correctness of prevailing assumptions about disability. In this tradition, disabilities are conceptualized as inimical to well-being, they essentially involve suffering, and any civic ameliorations of the problems of disability are seen to result only in slight improvements to the essentially low quality of a disabled life. Barnes argues the contrary. Disabilities should be conceived as mere differences, not bad differences. Her neutral model of disability comports with a great deal of testimony from disabled people themselves. But such testimony is vulnerable to principled dismissals from their philosophical critics (few of them disabled). Barnes proceeds to argue against those dismissals, concluding that they are cases of testimonial injustice. I will sketch aspects of these two conclusions: first her neutral model of disability, and second her defense of the contrary testimony of disabled individuals against dismissal.

The Value-Neutral Model. Barnes acknowledges that individual cases of disability often co-occur with lowered well-being. However she argues that it is a mistake to conclude that disability is itself the cause of lowered well-being. Arguments in favor of the conceptual linkage between disability and lowered life quality are common in the literature. For example: Disability is abnormal function, normal life opportunities require normal function, sub-normal life opportunities therefore imply reduced well-being, which proves that disability implies reduced well-being. (This argument is reconstructed from Buchanan et al. 2000.) How does Barnes refute this inference? She begins by distinguishing between local ‘bads’ and global ‘bads.’ Global bads are things that are bad for you on the whole, largely without respect to your situation. Local bads are bad for you only with respect to certain contexts or situations. This is nearly all she needs to reveal the value-neutrality of disability. Using a list of individual cases of ‘goods’ and ‘bads’ she shows (a) that many things that are highly valued by individuals also have serious ‘bads’ associated with them and (b) that many people who have significant disabilities also find important ‘goods’ associated with their disabling conditions. To weaken our assumptions of the bad-making properties of disabilities, Barnes cites some important examples of conditions that have recently been socially reclassified from ‘assumed to be bad-making’ to ‘assumed to be neutral.’ One of these is gayness. She reports gayness to be a neutral trait, even though it can surely be associated with very low well-being when it occurs in a social context that is heavily prejudiced against gayness. Our own society has only recently come to hold that gayness is a neutral trait. Not long ago, and certainly within my lifetime, gayness was classified as a psychiatric illness by medical authorities and deemed (by typical Americans) to cause very low well-being. We must notice that majority agreement with Barnes’s assessment that gayness is a neutral trait is not necessary for the strength of her argument. Even if her view about gayness (which I share) is not shared with the general public, it is surely shared among the majority of liberal, college educated Americans. (The recent election has shaken my confidence in guessing the opinions of my fellow countrypersons.) The important point is not that academics are correct in our views, but that we have changed our views with respect to gayness in recent decades. Barnes offers a corresponding argument with respect to biological sex, and claims that being a man is neutral with respect to well-being. This view was rejected not only by Aristotle, but by many others (predominantly men, the sex that dominates the historical record) well into the 20th century. (I was shaken by Barnes’s hypothetical discussion of how the lives of men might be assumed to be much lower in quality than those of women [131]. I would have been more comfortable if she had stuck with social prejudices that matched my own.) Even if we liberals relinquish our claim to objective correctness, Barnes’s point stands. Earlier assumptions about how traits influence well-being have changed. The assumption about disability might change also. We must not assume the contrary, especially if evidence is against it.

Taking Their Word for It. What is the evidence that disability is neutral with respect to well-being? Some of it comes from questionnaires which clearly indicate that the average self-assessed well-being of disabled individuals is only slightly lower than that of non-disabled individuals. Published autobiographical reports often reflect similar valuation. One of Barnes’s many examples from this literature is Dostoevsky, who we learn had a serious form of epilepsy that strongly affected him throughout his adult life. Nevertheless, Dostoevsky valued his epilepsy highly because the special experiences that accompanied seizures, stating that “all you healthy people don’t even suspect what happiness is” (quoted in Barnes 2016, 109).

Nevertheless, mainstream bioethicists continue to believe that disabled people have a much lower level of well-being than nondisabled people. They do not change their opinions in the face of this apparent counterevidence. Instead they come up with reasons to dismiss the counterevidence. This is my second topic: Barnes’s discussion of the grounds on which mainstream bioethicists dismiss the disability-positive testimony of disabled people.

Disabled testimony is dismissed by likening it to cases like Stockholm Syndrome (in which hostages come to sympathize with their captors) or abused spouses who refuse to testify against their abusive partners out of a belief (that we presume to be irrational) that they are better off with the abuser than without him or her. The philosophical details of this problem are too complex to even summarize here, but Barnes does a fine job of explaining why dismissing the testimony of disabled people about their own well-being does not count as a liberation of victims from their delusions, as it would be for Stockholm Syndrome hostages or agreeable abused spouses. Instead it is an illegitimate dismissal of legitimate testimony. Barnes labels these dismissals as ‘testimonial injustice’ following philosopher Miranda Fricker (Fricker 2007). Disability studies authors (including your modest commentator) have rejected this kind of dismissal with similar purposes as Barnes. Unlike most other disability studies writers, Barnes has a close and detailed understanding of the theoretical background that underlies the dismissal. Her detailed discussion is welcome.

Overview. Barnes’s careful and concentrated philosophical discussions may not be attractive to some disability studies authors, who favor a more socially oriented approach to the problems of disability. She does little to position her writings in the context of other disability studies authors, except those that give autobiographical reports on their own well-being. A clearer acknowledgement of those relationships would have been useful. The book’s close philosophical focus will endear it neither to all disability rights advocates (it will seem curiously bloodless to some) nor, at first glance, to all philosophers (whose prejudices are being challenged). She reports that her entire book is aimed at providing a justification for the “disability pride” movement. I do not share that particular goal. It seems to me that the disability rights movement requires ‘pride’ only as a rhetorical flourish, as other ethnic movements have used it. But the arguments are especially valuable within the philosophical community. The neutral model of disability and other products of Barnes’s analysis are independently important. I was once told that one of my naïve efforts at explaining disability rights to philosophers was the first such published account (Amundson 1992). Since then the growth of interest in disability among philosophers has been impressive, though not overwhelming. It is time that close analytic attention was given to these problems, and Barnes’s book is a promising contribution.

Ron Amundson
University of Hawaii at Hilo
Hilo, HI, USA


Amundson, R. 1992. “Disability, handicap, and the environment.” Journal of Social Philosophy 23: 105-118.

Amundson, R., & Tresky, S. 2007. “On a bioethical challenge to disability rights.” Journal of Medicine and Philosophy 32: 541-561.

Amundson, R., & Tresky, S. 2008. “Bioethics and disability rights: conflicting values and perspectives.” Journal of Bioethical Inquiry 5: 111-123.

Buchanan, A. E., Brock, D. W., Daniels, N., & Wikler, D., eds. 2000. From chance to choice: genetics and justice. Cambridge: Cambridge University Press.

Fricker, M. Epistemic Injustice: power and the ethics of knowing. Oxford: Oxford University Press.

Book Reviews

David Shoemaker, Responsibility from the Margins, Oxford University Press, 2015

David Shoemaker’s highly innovative and intricately argued new book draws on much of his previous work together with substantial original material to form a detailed and cohesive treatment of responsibility. The book is engaging, crisp, and admirably clear. It is marvelously ambitious in its strategy and framework, engagement with multiple literatures, and decidedly novel approach to Strawsonian theory. Moral philosophers, psychologists, clinicians and practitioners, and anyone who has ever wondered about “marginal agents” – people with dementia, autism, (manic-)depression, OCD, and psychopaths – will find much to entice them in this thorough and accessible treatise.

Shoemaker’s starting point – the phenomenon he aims to explain – is the observation that many of us feel a certain ambivalence toward marginal agents of the sort mentioned above. When we interact with or read case studies of marginal agents, we feel a “profound unease,” which Shoemaker diagnoses as caused by the fact that “these agents seem worthy of some responsibility responses but not others, which suggests that they are responsible in some ways but not in others” (3). This is the foundational premise of the entire book. For Shoemaker, responsibility responses include but are not at all limited to the standard praise, blame, and resentment; admiration and contempt, approval and disapproval, pride and shame, anger and regret are all brought in under this unusually wide conception of responsibility responses (a point I’ll return to in my final remarks). The idea is that psychopaths may deserve contempt but not anger, patients with dementia may deserve admiration but not resentment, and so on and so forth.

Starting from responsibility responses puts Shoemaker squarely in the Strawsonian camp of moral responsibility theorists. Put in the simplest of nutshells, P.F. Strawson’s revolutionizing argument for sidestepping the free will problem in “Freedom and Resentment” was that we should stop thinking of responsibility responses as only justified by certain metaphysical facts, i.e., by the fact that we are agents with free will, and instead think of our responsibility responses as justified by their role in (unavoidably necessary but also intrinsically valuable) social practices of caring about and responding to others’ manifestations of goodwill or ill will toward us (Strawson 1962). In Part I, Shoemaker introduces three main modifications[1] to Strawson’s view. The first is that Shoemaker draws a tripartite distinction amongst the “attitudes and intentions towards us” or the “quality of others’ wills towards us” that Strawson takes to be the object of reactive attitudes (Strawson 1962 48, 56); he distinguishes between the quality of others’ character, the quality of others’ judgment, and the quality of others’ regard for us. The second is an account of responsibility responses in terms of “sentiments” (along the lines of metaethical and aesthetic sentimentalism), where sentiments are dispositions to feel a special type of emotions that are culturally universal and recalcitrant to judgment.[2] The third, following closely from the second, is slipped into an unobtrusive argument that if the appropriateness of our responsibility responses are not justified by metaphysical facts then “it must be a matter merely of how the responses somehow fit with their objects” (19). In other words, Shoemaker understands the justification of responsibility responses in terms of fittingness. Responsibility responses are justified when they are fitting to their objects, just as emotional and aesthetic responses are appropriate when they are fitting to their objects.[3]

Shoemaker thus identifies three paradigmatic pairs of sentiments (and other related emotions) that correspond to the three different objects of our responsibility responses: agential disdain and admiration (along with contempt, abhorrence, awe, veneration, etc.) are the fitting positive and negative responses to good and bad character; agential regret and pride (etc.) are the fitting responses to good and bad judgment; and agential anger and gratitude (etc.) to good and bad regard. These correspond to what Shoemaker calls responsibility as attributability (directed at character), answerability (directed at judgment), and accountability (directed at regard). Part I of the book is devoted to laying out this theory and defending the distinctiveness of each of the three types of responsibility.

In Part II, Shoemaker shows how this tripartite account accommodates our ambivalent responses to marginal agents; in each case, he argues that the condition in question disrupts some of the capacities or psychic elements required for one form of responsibility, but leaves intact others required for other forms of responsibility. People with depression have mitigated attributability for their actions, because the depression has interfered with the cares and commitments that constitute a person’s character (or “deep self”), but they may still be capable of responding to reasons and experiencing empathy in the ways required for answerability and attributability. Psychopaths lack the capacities for experiencing empathy (or have severely mitigated capacities to do so) required to sustain properly moral regard for others, so they are exempt from accountability, but they still have the capacities for character and judgment[4] that are required for attributability and answerability. And people with mild intellectual disabilities are exempt from (or have mitigated) answerability, because they lack the cognitive and adaptive capacities – reasoning, planning, learning – that are required for properly reasons-responsive evaluative judgment; but they may still have cares and commitments that constitute their distinctive selves and they may still be capable of empathy, especially for those with whom they have close relationships, in such a way as to preserve their attributability and accountability. Shoemaker provides similar accounts for people with mania, scrupulosity,[5] high-functioning autism, dementia, and poor formative circumstances (i.e., morally deprived childhoods), demonstrating impressive mastery of the empirical literature around each of these marginal cases. The book really shines when Shoemaker draws on the resources of his tripartite theory to make illuminating proposals for further empirical and clinical investigation. He writes: “[O]nce we move beyond the deeply entrenched all-or-nothing model of responsibility, the tripartite theory opens us up to a new, nuanced set of tools for both those who treat and those who suffer from (at least some of) these disorders” (145). In short, a more fine-grained moral theory can help us better conceptualize complex psychological phenomena, while in the other direction, diving into real-life details prompts the development of more sophisticated moral theory.

In the remainder of this review, however, I will raise three worries for the project: one regarding the general strategy, and two regarding Shoemaker’s sentimentalist take on Strawsonian theory. My first worry is that, insofar as Shoemaker claims that the puzzle to be solved is the fact of our ambivalent responses to marginal agents, it is not clear that the tripartite theory is really necessary. Shoemaker says very little to characterize the phenomenon or what he actually means by “ambivalent” responses, other than that the “unease of ambivalence” is not the unease of uncertainty, before diagnosing it in (the already quite theory-laden) terms of feeling that agents merit some responsibility responses rather than others (3). There might be alternative ways of explaining this ambivalence, however. It might not be genuine ambivalence, for instance, if our responsibility responses are simply keyed to certain facets of the cases which feel warranted or not depending on whether those facets are made salient at a given moment or not. In other words, like optical illusions that flip from duck to rabbit, young girl to old woman, depending on which cues we focus on – but where the picture is either of a duck or a rabbit, and not a part-duck/part-rabbit – perhaps, too, a marginal agent could be responsible when her case is viewed under a certain light, and not responsible under a different light, but it not be the case that under a single description[6] some responsibility responses are appropriate while others are not.

Or, to take another visual metaphor inspired by Shoemaker’s own discussion of “local blindnesses” whereby an agent may be responsive to reasons only in some domains but not others (82), perhaps we could think of our ambivalent responses as picking up on domain-specific gaps in more unified responsibility-conferring capacities that are overall intact. For example, on accounts that would deny Shoemaker’s attributability-answerability distinction,[7] it might be that a marginal agent is a responsible agent overall for her actions and attitudes in virtue of how it is possible for them to flow from her evaluative judgment, but that she lacks responsibility for specific actions and attitudes flowing from certain judgment “blindnesses,” or domains over which her capacity for judgment is blocked or lacking. Thus a person with depression might still count as a responsible agent in virtue of the fact that her evaluative judgment is intact overall, as evidenced by the fact that she manages to sustain quite a few minimally requisite actions, e.g., feeding herself, keeping her job; but there are large and important swaths of a full human life, e.g., her relationships, her activities, in which the operation of her evaluative judgment is too distorted for her to be responsible for them. This last observation might be related to the fact that Shoemaker claims to be giving an account of responsible agency, rather than responsibility for particular actions, which suggests, finally, that some of our ambivalence toward marginal agents might also be handled by distinguishing between how we feel toward them as agents versus how we feel toward them as agents in light of specific instances of behavior.

I suspect, however, that the puzzle of ambivalent responsibility responses might be (at least somewhat) less central to the motivations behind the tripartite theory than suggested, and we could simply think of marginal agents as exemplary case studies for illustrating its power. This brings me to my second set of worries, however, which is that the trifold sentimentalist strategy and framework – marvelously conceived though it is – may not be enough to sway those who prefer unified accounts of responsibility that can still save the phenomena. The costs of relatively minor or esoteric counterexamples may not outweigh the benefits of simplicity. Out-of-character actions and whims,[8] for instance, which Shoemaker takes to be instances of answerability without attributability (59, 83), seem to me still attributable to agents as manifestations of some kind of character trait, even if not the obvious ones: a wandering mind, an active curiosity, sublimated anxieties and desires, a love of spontaneity, and so on. (This move would be akin to one Shoemaker makes in his own analysis of scrupulosity, according to which such agents’ general “moral orientation” and perfectionist stance renders many of their thoughts and attitudes still properly attributable to them.) Or they may manifest pro tanto evaluative judgments rather than all-things-considered evaluative judgments[9] about the worth of some action.

I also found myself worried at times about proposals that, while innovative, struck me as potentially ad hoc or insufficiently grounded in deeper justification. If debates about the deep self have centered around Platonic versus Humean accounts, for instance, is it a satisfying resolution to simply combine them into an ecumenical position, without further diagnosis, explanation, or motivation? If the dominant philosophical and psychological view is that anger fundamentally involves revenge, is it enough to point to the existence of some cases in which people feel frustrated if they cannot communicate to the objects of their anger that “This is for what you did to me!” (105)? (For surely we can imagine agents whose anger leads them to want simply to annihilate and destroy the objects of their anger, or whose anger is satisfied when revenge can be carried out anonymously such that their objects “never even knew what hit them”.) Is it fair game to simply declare that we have “empathic control” when identifying with others’ perspectives leads us to certain kinds of emotional or reasons-responsiveness, such that these are “up to us” in the way that things over which we have voluntary control or rational control are up to us? (For the latter have been understood as “up to us” because they derive from our wills or our evaluative judgment, which have been argued to be constitutive of moral agency; but such an argument has yet to be made for empathic capacities.)

Finally, there were some moves that seemed to betray some artificiality in the tripartite taxonomy of sentiments. In the case of admiration (one of the emotional syndrome pair for attributability), for instance, Shoemaker restricts the sentiment to agential admiration, setting aside cases in which we admire non-agents, e.g., the Grand Canyon; but when it comes to finding the emotional syndrome pair for answerability, Shoemaker simply sets aside disappointment on the grounds that it is not restricted to agents. This leads him to adopt a first-personal emotional syndrome pair for answerability (pride-regret) that does not match the third-personal pairs for attributability and accountability. And although Shoemaker acknowledges that we may sometimes feel regret even when we absolutely do not manifest any flaw in evaluative judgment, he dismisses these as non-paradigmatic cases of regret which do not count as genuine responsibility responses. Of course, any theory – especially new and ambitious ones – will contain anomalies. But since Shoemaker’s job is to convince us that there really are three fundamental pairs of sentimentalist responsibility responses and since his work is otherwise so thoroughly grounded in empirical evidence, I am hopeful for more reason to think that the tripartite theory has successfully latched onto natural kinds in our actual practice rather than being a theoretical framework imposed from the armchair.

This brings me to my final worry, about the sentimentalist fittingness approach to justifying responsibility responses. In developing his tripartite theory, Shoemaker has broadened his responsibility responses beyond the responses of resentment and indignation on which other theorists have focused.[10] To be sure, Strawson himself does identify a wide range of reactive attitudes, including “gratitude, resentment, forgiveness, love, and hurt feelings” (49). But this is in the first stage of Strawson’s argument, in which he is pointing out the existence of reactive attitudes in general; the second stage of his argument is to explore whether an understanding of specific reactive attitudes can “bring us, if possible, nearer to a position of compromise in a more usual area of debate” (56), where the usual debate, of course, centers around “desert, responsibility, guilt, condemnation, and justice” and the problem of free will (64). Moreover Strawson is clear that he is interested primarily in moral responsibility,[11] that is, in the “concept of moral responsibility and of the practices of moral condemnation and punishment” (62). It is no accident that desert, condemnation, justice, and above all free will – precisely those concepts that Shoemaker sets aside in his last chapter – are concepts that intimately involve concerns about fairness. Thus when Shoemaker declares that appeals to unfairness constitute “the wrong kind of reason,” since they are orthogonal to questions of whether some responsibility response is fitting to its target in the way that aesthetic responses are (201), this seems to me a significant deviation from the Strawsonian project. Even if it is (quasi-aesthetically) fitting to feel contempt toward a vicious agent, concerns about determinism and free will – Strawson’s target – arise only when we worry about whether it is morally appropriate for us to feel that way toward an agent who did not have, e.g., the (fair) opportunity to avoid becoming vicious. Similarly, when Shoemaker disavows the centrality and relevance of harsh treatment to responsibility, this seems to depart altogether from the Strawsonian starting point that begins with our practices of moral condemnation and punishment.

Shoemaker, of course, is aware of this difficulty, stating: “I want to insist on the crucial distinction (a distinction I believe has long been overlooked) between the fittingness of various sentimental responsibility responses and the appropriateness of harsh treatment of offenders” (223). I cannot help but suspect, however, that this final, insisted-upon distinction suggests that the fundamental distinction might hold between just two faces or concepts of responsibility, as defended (in different ways) by theorists such as Gary Watson (2004), Tim Scanlon (1998), Iris Marion Young (2011), and myself. If I am right about this, then Shoemaker will have offered us an exceptionally elegant and richly-detailed Strawson-inspired theory of the first (aretaic or attributability) concept of responsibility, while more or less setting aside the second (substantive or accountability) concept of responsibility with which Strawsonians typically concern themselves. But none of this detracts from the huge contribution that Shoemaker has achieved in this book with his exciting and fruitful new framework for thinking about responsibility.

Robin Zheng
Yale-NUS College


Scanlon, Thomas. 1998. What e owe to each other. Cambridge: Belknap Press of Harvard University Press.

Smith, Angela M. 2012. “Attributability, Answerability, and Accountability: In Defense of a Unified Account.” Ethics 122.3: 575-89.

Strawson, P.F. 1962. “Freedom and Resentment.” Perspectives on moral responsibility. Eds. Fischer, John Martin and Mark Ravizza. Ithaca, NY: Cornell University Press, 1993. 45-66.

Wallace, R. Jay. 1994. Responsibility and the moral sentiments. Cambridge: Harvard University Press.

Watson, Gary. 2004. Agency and answerability: selected essays. Oxford: New York: Clarendon; Oxford University Press.

Young, Iris Marion. 2011. Responsibility for Justice. New York: Oxford University Press.

Zheng, Robin. 2016. “Attributability, Accountability, and Implicit Bias.” Implicit Bias and Philosophy, Volume 2: Moral Responsibility, Structural Injustice, and Ethics Eds. Saul, Jennifer and Michael Brownstein. New York: Oxford University Press, 62-89.


[1] Or, depending on how invested one is in Strawsonian exegesis (the temptation of which I try, but perhaps not hard enough, to resist as far as possible in this review), three main interpretive extensions.

[2] The latter simply refers to the tendency of some emotions to remain even when certain beliefs that constitutively define that emotion are given up, e.g., continuing to fear a spider even after one has acquired reason to give up the belief that it is dangerous.

[3] This sort of fittingness view has been defended with regard to blame in particular; see, e.g., Arpaly (2002) and Hieronymi (2004).

[4] This is true, at least, for nonmoral judgments. But they may lack the capacity for moral judgments that require having moral regard for others, and hence lack answerability in these domains.

[5] A form of OCD involving obsessive thoughts about morality, e.g., that one has committed a moral wrong merely by imagining a certain event.

[6] Whether there is an objectively best way of describing the case might depend on deeper commitments about the nature of responsibility, e.g., whether responsibility is primarily a metaphysical or practical matter.

[7] The difference for Shoemaker consists primarily in the fact that answerability is limited to evaluative judgment, while attributability ranges more widely across commitments and cares that are distinct from or not grounded in specific judgments.

[8] This addresses the second of Shoemaker’s three arguments for the distinction between attributability and answerability. In response to the third counterexample of an agent who holds two conflicting attitudes that are singly unobjectionable but irrational when combined, a unified account theorist might endorse Smith’s (2012) reply and argue that what deserves criticism is not the irrationality of this configuration, but the irrationality of failing to take steps to alter the configuration once the conflict has become so salient. For most of us likely harbor at least some irrational configurations of conflicting attitudes (like contradictory beliefs) which are not worth the time or effort to resolve.

[9] A unified account theorist might use this to argue against Shoemaker’s first argument: cares and commitments might be grounded in pro tanto rather than all-things-considered judgments.

[10] See, most notably, Wallace’s (1994) arguments for narrowing the class of reactive attitudes to those which hold someone to an expectation, e.g., resentment, indignation, and guilt (25-33).

[11] More fully, Strawson writes: “The concepts we are concerned with are those of responsibility and guilt, qualified as ‘moral’, on the one hand— together with that of membership of a moral community; of demand, indignation, disapprobation and condemnation, qualified as ‘moral’, on the other hand—together with that of punishment” (62).


Book Reviews

Jennifer Greenwood, Becoming Human: The Ontogenesis, Metaphysics, and Expression of Human Emotionality, MIT Press, 2015

Becoming Human by Jennifer Greenwood is one of the most thought-provoking books on emotion and its expression I have read. At its core, it attempts to provide an account of the development of full human emotionality and in so doing argues the emotions are “transcranial.” Emotions are radically realized outside our nervous systems and beyond our skin. As children, we are functionally integrated affectively with our mothers; so much so that in a sense our emotions are not ours alone. Regardless of whether one agrees with her radical claims, it is a must-read for those interested in emotion and expression. In order appreciate the significance of this book, let me sketch its contents and raise a few criticisms.

Many, but certainly not all, psychologists and philosophers assume that there are basic emotions (BEs) and higher-cognitive emotions (HCEs). The former include fear, anger, disgust, happiness, surprise, and sadness; and the later include guilt, shame, and pride amongst others. BEs are thought of as natural kinds involving facial expression, homologous traits shared with non-human primates, specific brain structures, and stereotyped behaviors. HCEs differ in that they often do not have unique physiological profiles, facial expressions, dedicated brain regions, and culturally vary quite a bit. Greenwood argues that there are affective precursors that develop into BEs and HCEs. However, the distinction between BEs and HCEs lulls us into naïve views about nature and nurture, biology and culture. We have not taken their development from childhood as seriously as we should. Both develop through time.

Greenwood has us consider human infants. They are completely dependent on their caregiver who is usually their mother. They can cry and exhibit motor unrest to convey how things are going for them. Their emotional precursors are ostensive and expressive. They are ostensive insofar as they direct the attention of the mother to sources of displeasure and they are expressive insofar as they signal that displeasure. They are referentially opaque but through time become less so. Thus, these emotional precursors are natural signs which occur when proprioceptive and interoceptive thresholds have been crossed and help is needed. Crying and motor unrest are assistance-soliciting devices. Mothers are equipped with “intuitive parenting” skills by which they can identify what things are helpful and harmful to their child. They instinctually respond to the child’s stress and try to remove the sources of it. This also involves mimicry in speech and mirrored facial expressions of their child. These are assistance-producing devices. Through repeated interactions of these assistance-soliciting and assistance-providing devices, the child’s emotionality advances through functional integration with the mother. Not only do these interactions provide feelings of pleasure but also new neural machinery develops as the result of these dynamic interactions. There are complex causal interactions between child and mother, which scaffold the child’s emotions and their expression. It is also through the same mechanisms that language appears as well. “Motherese” helps the child to understand the boundaries between clauses and how to command, request, declare, and to question. Thus, our first conversations are with our mothers. Greenwood offers an explanation of how infants begin with affect expressions and species-typical behaviors to express themselves, move to communicating with gestures and inflected vocalization, and finally develop language. And, referential clarity increases with the development of the emotions and language. The child’s species-typical behavior patterns coupled with the mother’s intuitive parenting skills provides the necessary and sufficient conditions for generating a semantic lexicon. These natural and conventional signs have their declarative and imperative content secured by a kind of teleosemantics inspired by the work of Ruth Millikan.

These are bold hypotheses that Greenwood has offered. She additionally argues that the hypothesis above gives strong support to Transcranialism, or the Extended Mind hypothesis, about the emotions. It says that mental states and processes extend outside the nervous system. Intracranialists deny this claiming that the scaffolding provided by the world outside the body is simply that of “support”. That is, they claim Transcranialists conflate causation and constitution. Greenwood utilizes the work of Robert A. Wilson (2004) on the metaphysics of realization to challenge this. Roughly, a property R realizes G if it is plays the G-role or has the G-function. Philosophers of mind have typically assumed that the physical properties sufficient for mental roles or functions were exhausted by the intrinsic physical properties of individuals. However, this is exactly the assumption that Wilson and Greenwood challenge. According to Wilson, there are core and non-core realizers. Core realizers are those parts of a system which play a “crucial role” in producing or sustaining a property of interest. Non-core realizers are necessary but are not crucial for the producing or sustaining the property of interest. For example, a core realizer for fear is the amygdala whereas the thalamus is a non-core realizer. Transcranialism about emotions claims that the realization of emotions is radically wide; a total realization of an emotion can have core and non-core realizers located outside the individual experiencing the emotion.

As we have seen, Greenwood claims emotions are essentially ostensive-expressive devices that evolved by natural selection for interpersonal tasks and only later for intrapersonal ones. She also argues that Wilson’s model of radically wide realization provides the metaphysical machinery for defending transcranialism about human emotions. Going beyond earlier externalisms, she contents the internal and external resources are deeply functionally integrated and play complimentary roles in our emotions. The mind extends our emotions into the world, and the world extends into our emotions. It is “synchronous modulation” of the child and mother during the development of emotions and language which widely realizes those emotions.

Greenwood’s claims and arguments are extremely bold. Let me conclude by raising some points of criticism. Greenwood has effectively argued that human infant’s emotions develop through a dynamic coupling with their mothers. They are functionally integrated. I find the evidence she presents fairly convincing. If child and mother are functionally integrated with respect to the child’s emotions, then they are widely realized. If they are widely realized, then those emotions are transcranial. Therefore, those emotions are transcranial. First, like Victor of Aveyron, some feral children develop without the benefit of a mother or even a direct caregiver. They are raised by wolves as it were. Though they may be developmentally challenged in various ways, one might argue that they experience a full range of human emotions. This suggests that the dynamic coupling with a caregiver, and specifically a mother, is not necessary for the development of human emotions. Without good empirical evidence, I am suspicious of this claim. Anecdotal reports of feral children strike me as inconclusive at best. Second, let’s suppose that this dynamic coupling is required. Still, one might object even accepting that it is through this functional integration the emotions are widely realized, we needn’t accept that they are transcranial. Striking a match causes a fire at the end of the stick but only so if there is oxygen present. We treat the striking as the cause and the oxygen as a background condition. Thus, even if we grant that a core realizer of a child’s fear is the amygdala and non-core realizer are the mother’s assistance-producing devices, it seems that we can still appeal to the cause/background condition distinction. Through this, we can resist the more radical transcranialist’s claims. Of course, much more work is needed to make good on this claim. For example, the cause/background condition claim must be more than pragmatic. However, if we can, then I think we can argue that functional integration is causal and not constitutive. Third, let’s suppose that Greenwood has made her case that the emotion experienced by human children are transcranial. She grants human emotions move from interpersonal functions to intrapersonal ones. I doubt that emotions are generally interpersonal or intrapersonal en masse. Still, it is open whether at least some human emotions after childhood are exaptations to new intrapersonal challenges. If this is correct, then even if human emotions during childhood evolved to be transcranial they become intracranial later in life. The emotions of adults are screened-off from those of human children in a way that doesn’t threaten the project of psychologists and philosophers I mentioned at the beginning.

Regardless of my worries, Greenwood’s is an impressive book from which I learned quite a bit. I strongly encourage those interested in emotions and expression to read it. Your mother would have wanted you to.

Jay Odenbaugh
Associate Professor
Department of Philosophy
Lewis & Clark College
Portland, OR, USA


Wilson, Robert A. 2004. Boundaries of the Mind: The Individual in the Fragile Sciences Cognition. Cambridge University Press.


Book Reviews

Eula Biss, On Immunity: An Inoculation, Greywolf Press, 2014

In On Immunity: An Inoculation, essayist and author Eula Biss has given academics and clinicians interested in the public’s skepticism of vaccines, and of science skepticism more generally, a fresh look at what drives these phenomena. Despite public health’s continued success in maintaining high rates of coverage for vaccines across the United States, recent measles, mumps, and rubella outbreaks in the U.S. (and globally for that matter) have harmed lives and indicate cracks in the vaccine uptake façade. From a public health perspective, it’s all hands on deck to make sure vaccine coverage stays high. Biss’s outsiders’ view of these issues offers bioethicists, public health practitioners, and physicians much to consider as we address ongoing challenges to vaccination.

Do not read On Immunity expecting a scholarly analysis of the state of vaccine refusal and resistance. The book is instead part self-reflection (how Biss samples but rejects anti-vaccine sentiments), part observation (the ways vaccines both capture and reflect popular understanding and anxiety about the body, about germs, and about medicine more generally) and part research (into the history of anti-vaccine thought as well as its contemporary impact).

Throughout the book, Biss’s physician father acts as sort of a scientific straight man, laying out both the joys and challenges of medical and scientific practice. In one of these moments, Biss recalls how her father taught her about blood types, and about how both he and she were universal donors. With type O negative blood, Biss would come to understand her universal donor status “more as an ethic than as a medical concept” (18). This belief in a communitarian ethic runs throughout the book. “If we imagine the action of a vaccine not just in terms of how it affects a single body,” Biss writes, “but also in terms of how it affects the collective body of a community, it is fair to think of vaccination as a kind of banking of immunity.” “Contributions to this bank are donations to those who cannot or will not be protected by their own immunity,” she concludes (19).

For those of us who spend time considering vaccine policy, these are obvious points, as are the conclusions to be drawn from them. But what Biss offers its academic readers is a less jargon-filled and stilted way to talk about the importance and fear of vaccines, and thus provides some insight into what we might do to shore up vaccine coverage. One suggestion Biss has is to abandon the term “herd immunity.” In her analysis, it is a negative metaphor, one that “suggests we are cattle, waiting, perhaps, to be sent to slaughter.” “And it invites,” she continues, “an association with the term herd mentality, a stampede towards stupidity.” In its place, Biss suggests the concept of “shared immunity,” rooting the metaphor instead on natural examples like the cooperation of honeybees and collective problem solving. If the herd assumes we are foolish, the notion of shared immunity roots the nature of vaccine coverage in cooperation (21).

Some have read On Immunity as a weak embrace of anti-vaccinationism, if only to have the reader take a taste of it, understand its essence, and be “inoculated” against its impact (Oppenheimer 2014). But I read this book differently. In fact, this is less a vaccine-world Rashamon, and more of an opportunity for scholars and policymakers to view the challenges and mindset of anti-vaccine thought, through the eyes of a sympathetic yet disapproving observer.

Biss’s chapter on how popular misunderstandings of toxicity have seeped into anti-vaccine thought, for example, is especially relevant as policy makers and ethicists consider how to respond to the threats to herd or shared immunity. Fears of toxicity, which she acknowledges is a loosely defined idea in the public’s mind, can at once refer to the ingredients in vaccines, the accumulation of vaccines in the body, or environmental exposures more generally. Biss argues that such references to toxicity by both anti-vaccine boosters and the Gwyneth Paltrow-set “strikes me as an old anxiety with a new name” (75). While she acknowledges the impact and dangers of environmental pollutants, Biss believes that what the pre-germ theory idea of filth once represented “with its moralist air, the evils of the flesh,” today is now expressed in terms of toxicity. “The word toxic,” she writes, is a catch all term that “now condemns the evils of our industrialized world.” Theories of filth and toxicity “allow their subscribers to maintain a sense of control of their own health by pursuing personal purity” (75). This gets played out in a variety of ways, including our search for the “natural,” as well as in vaccine resistance.

An academic reader of the book may also consider Biss’s failure to correct the misinformation that the anti-vaccine community thrives on as a shortcoming, or even fatal flaw of the book (142). I do not share this concern. This book is not meant for the vaccine doubters or resistors who tout their wares on the internet and at alternative medicine conferences. It is instead meant for us: the ethicists, clinicians, and policy makers who are struggling with the challenges we face in an increasingly vaccine resistant or hesitant public. It may well be that the response to anti-vaccinationism is a question of policy and public health ethics: how much should we limit people’s civil liberties to protect the public health. But when I hear studies and pundits suggest that anti-vaccine skeptics are immovable and that we must institute our most draconian policies to preserve our collective health, I find myself the skeptic and worry that we as a field have given up too easily. At the very least, On Immunity offers a retort to this line of thinking, providing vaccine ethicists and policy makers with both rhetorical and practical ways (see above examples about a communitarian ethic, herd immunity, and toxicity) to view and push back against the anti-vaccine movement.

There is one line in the book that continues to resonate with me. Biss writes that “the belief that public health measures are not intended for people like us is widely held by many people like me” (24). While her thinking here is not surprising, it is perhaps the most fundamental challenge to the current anti-vaccine trend. And it is thinking like this that has given largely white, highly educated, and middle and upper middle class families the rationale to resist or refuse vaccination. It is a position of privilege that threatens the public health, a sense of privilege that is not simply the fault of the non-medical public. It is rooted in class and racial tensions that Biss highlights. In a visit to her son’s pediatrician, Biss questions the necessity of the hepatitis B vaccine. Her doctor tells her that it is a vaccine for the inner city, “designed to protect babies of drug addicts and prostitutes.” “In retrospect,” she recalls, “I am ashamed of how little of his racial code I registered.” “Relieved to be told that this vaccine was not for people like me,” she concludes, “I failed to consider what exactly that meant” (24).

But that failure is not hers alone. It is our failure—in ethics, in public health, and in medicine. If people continue to assume, as Biss puts it, that public health “is for people with less—less education, less health habits, less access to quality health care, less time and money” (24), then we will continue to struggle with this novel strain of anti-vaccinationism and be threatened by public health challenges that lie ahead.

Michael Yudell
Dornsife School of Public Health
Drexel University
Philadelphia, PA, USA


Oppenheimer, Mark. 2014. “This Book Empathizes with Anti-Vaxxers, Who Don’t Deserve Empathy.” The New Republic. September 29. Full article »

Book Reviews

Alice Crary, Inside Ethics: On the Demands of Moral Thought, Harvard University Press, 2016

In this original and insightful new work, Alice Crary proposes that we see human beings and animals as creatures that are “inside ethics,” which is to say that they possess “characteristics that are simultaneously empirically discoverable and morally loaded” (4). This view rejects what Crary sees as the dominant paradigm in moral philosophy, wherein empirical observations about human beings and animals are viewed as morally neutral and shorn of any evaluative characteristics. Her view has implications for a range of topics in moral philosophy and bioethics, including debates about disability, moral status, moral individualism, animal ethics, and animal mindedness. Here, I’ll focus primarily on summarizing chapters 1-3—which contain what Crary refers to as the work’s central argument—before turning to a few thoughts and criticisms of that argument.

Chapter 1 lays out the broad paradigm in moral philosophy that Crary opposes—that of seeing human beings and animals as “outside ethics,” or devoid of empirically discoverable and objective moral characteristics. She traces the tendency to see human beings and animals as outside ethics to what she describes as a “hard metaphysic,” where objective moral values are not viewed as part of the fabric of the world, but things that we impose on a world that is itself morally neutral (14). Chapter 2 is devoted to arguing for the work’s central claim: that human beings and animals have empirically discoverable and objective moral characteristics.

In making this argument, Crary begins by establishing what moral characteristics are and discussing how we ascribe them to humans and animals. Moral characteristics are ethically inflected psychological categories—such as, for example, jealousy, guilt, fear, or happiness. Importantly, these categories “resist any meaningful reduction or translation to physical terms” (37). This is because, in applying these psychological categories to humans and animals, we necessarily invoke certain ethically loaded conceptions of what makes a good human or animal life that are not themselves reducible to physical terms (80). When, for example, researchers set out to study jealousy in dogs, “their efforts depend for their success” on an “understanding of canine life and of the place of jealousy within it” (79). Psychological characteristics are, in this sense, “only at home in human and animal lives in which some things matter in that they are, say, to-be-feared, to-be-sought, to-be-eaten, to-be-protected, or to-be-befriended” (88). In other words, we bring ethically loaded concepts of what makes a good human or animal life to bear on our understanding of the psychological characteristics of humans and animals.

But there is still the further claim that such moral characteristics are objective and empirically discoverable; in other words, that one can apply these characteristics in a genuinely descriptive manner. It might be the case, for example, that in attributing the concept of jealousy to dogs, we make a mistake—perhaps even a mistake that stems from a problematic tendency toward anthropomorphism on our part. If this thought is right, then our claims about dogs being jealous or afraid would not be truth-tracking or objective; they would be merely subjective expressions of our own emotions, preferences, or biases.

Crary resists this possibility by proposing that we reconceptualize our understanding of objectivity. She thinks that her opponents—in denying that moral characteristics are objective—rely on what she calls a narrow conception of objectivity. The narrow conception of objectivity takes the world to be “available to thought” in a manner that is “unmediated” by concepts (55). Further, proponents of the narrow conception think that this kind of connection with the world provides a firm foundation for empirical knowledge. Proponents of the narrow conception would deny that moral characteristics are objective because objectivity, for them, involves accessing the world in a manner unmediated by normatively- or morally-inflected concepts. To argue against the narrow conception of objectivity, Crary marshals arguments made by Wittgenstein, McDowell, and others, who resist the idea that there exists a non-conceptual “given” that can provide this kind of foundation for empirical knowledge (47-55). These arguments lead Crary to suggest a “wider” alternative to the narrow conception. Proponents of this wider conception of objectivity deny the existence of a non-conceptual “given” that can provide a foundation for empirical knowledge and affirm the conceptualist view that deploying normatively loaded concepts is necessary for acquiring empirical knowledge. If this wider conception of objectivity is right, then Crary has opened up a space in which we can start to see the ascription of moral characteristics to humans and animals as objective and truth-tracking—in other words, we can start to see humans and animals as “inside ethics.”

But in relying on a conceptualist view to defend the wide conception of objectivity in chapter 2, Crary recognizes a threat to her argument that non-human animals are “inside ethics” in virtue of their psychological qualities. This threat comes from the fact that conceptualist doctrines like the one that Crary defends in chapter 2 are often taken to imply that non-human animals “lack any but the most primitive qualities of mind” (93). In order to avoid this, and thereby show that our attribution of morally inflected psychological qualities to animals is not misguided, she urges us to recognize a continuum of concept-use that runs from being governed by immediate, biological drives, to primitive concept-use, to full rationality. She thinks that, just like we consider young children to be primitive concept-users, we should think about many non-human animals—she focuses primarily on dogs—in this way (113-18). So we should read certain dog behavior, for example, as trustworthy as opposed to “merely predictable” (120). Showing how conceptualism needn’t result in skepticism about animal minds allows Crary to claim that non-human animals have empirically observable, objective moral characteristics, so that when we label a dog’s trustworthy behavior as such, we are not engaging in mere misguided anthropomorphism.

The latter chapters of the book draw out what Crary sees as the moral upshot of understanding humans and animals as “inside ethics”: the recognition of moral characteristics in humans and animals calls for certain forms of moral response, like attention and concern (88). Furthermore, given that our empirical knowledge of humans and animals’ psychological qualities must draw on ideas about what matters morally in their lives, she argues in chapter 4 that this means that all human beings and animals are of moral concern, qua their status as human beings or animals (121). Chapter 7 applies her view to two issues in applied ethics: eating animals and experimenting on them. Here, she focuses on two nonfictional works: Jonathan Safran Foer’s Eating Animals and the documentary Project Nim (255). She argues that both works urge us to see animals as “inside ethics,” insofar as they portray various animals as “living lives of significance” that deserve certain sorts of moral attention, like sympathy or respect (265).

Throughout the work, Crary claims that her argument shows that all humans and all animals are inside ethics (121). However, I wonder whether—by Crary’s own lights—she is in fact able to retain this claim (121). Given her commitments, it seems to me that the scope of creatures who are inside ethics must be either narrower or broader than this: either it is the case that not all animals are inside ethics, or it is the case that all animals as well as all plants are inside ethics.

Let’s start with why the scope may have to be narrower. Consider Crary’s  response to McDowell’s arguments about animal mindedness. McDowell draws a distinction between world and environment (1994, 105-07): humans occupy a normatively structured world, while non-rational animals merely occupy environments that are structured by mere biological imperatives. For McDowell, this means that all animals are not minded in the relevant sense and are controlled by mere biological drives. Crary’s denies this universal claim by showing how some animals are not best characterized as mere automata, following only biological drives (107).

However, in this discussion, Crary exclusively focuses on the ways in which domesticated animals, like dogs, are inside ethics (113-18). We can see how it makes sense to speak of dogs “who are integrated into household routines” as trustworthy as opposed to merely predictable, for example, because they are trained to abide by social norms in various ways (120). Trained dogs would be capable of having some degree of the “free, distanced orientation” from immediate biological impulses that McDowell attributes exclusively to rational human beings (1994, 117). But what of non-domesticated animals, wild animals, or animals that otherwise take no part in the human social world? By arguing that dogs are at least proto-concept-users, Crary may have successfully blocked the implication that all animals are mere automata; however, that does not entail the further claim that all animals, including non-domesticated ones, truly possess the kinds of psychological qualities Crary is interested in. Given this, I think Crary needs to give an argument for why non-domesticated animals possess such qualities. If such an argument is not forthcoming, then it seems like all Crary has shown is that domesticated animals are properly described as “inside ethics.”

There are (at least) two ways of avoiding this problem. One would be to argue that there is more than one route to being a concept-user. Perhaps, for example, domesticated dogs and wild bottlenose dolphins are both concept-users, but in different ways. This seems to me the most promising route out of this problem, but Crary does not develop this line of thought in Inside Ethics.

A second route is to drop the commitment that moral thought in her sense is truth-tracking or objective. Perhaps we ascribe concepts like fear or shame to non-domesticated animals anthropomorphically. Maybe there is even a case to be made that we should anthropomorphize non-domesticated animals this way, insofar as it increases sympathy for them or amplifies concern for their welfare. In other words, perhaps there are independent reasons we should think about creatures as being “inside ethics,” even if that sort of thinking is not objective or truth-tracking.

However, if Crary drops this commitment to objectivity, she runs into other problems. Namely, it then becomes unclear why we shouldn’t consider a much wider class of creatures to be “inside ethics.” Why not, for example, see individual plants as things about which we can have morally loaded empirical knowledge? After all, in order to understand features of any given plant—why its leaves droop at night, or why its stems turn certain colors when lacking nutrients—we must draw upon ideas about what makes life good for plants of that kind. Goethe, for example, takes up this attitude toward plants in his work The Metamorphosis of Plants:

The nub of tranquil life, kept safe and dry,
Swells upward, trusting to the gentle dew,
Soaring apace from out the enfolding night.
Artless the shape that first bursts into light—
The plant-child, like unto the human kind—
Sends forth its rising shoot that gathers limb
To limb, itself repeating, recreating… (2009, 2-3)

Here Goethe clearly anthropomorphizes plants, attributing to them certain kinds of psychological properties that they do not, in fact, have. But there is no question that this poem attempts to achieve a certain kind of sympathetic understanding of the goods of plant life, and what it might mean for that life to go well. Does this mean, then, that we must extend moral concern to individual plants, as Crary suggests we should to humans and animals? This would make the scope of beings that are inside ethics much broader than Crary claims. This implication would also be unwelcome: if beings that are “inside ethics” call for “certain forms of moral attention and concern” (88), and if plants, too, are inside ethics, then it seems we must devote moral attention and concern to individual plants. This requirement could make moral thought far too demanding.

Crary needs the objectivity component of the project in order to block this move. With this in place, she could argue that our interpretation of a plant as possessing psychological properties— “trusting to the gentle dew,” for example—is mere poetic anthropomorphism, because we know that plants do not possess concepts, and are thus not minded in the relevant sense. But this move risks coming at the cost of Crary’s commitment to the idea that all animals—not simply domesticated ones—are “inside ethics,” since the apparent moral features of non-domesticated animals may also be appropriately characterized as mere poetic anthropomorphism. What is in fact included inside ethics may therefore be either broader or narrower than Crary claims.

That said, this work has much to offer, and is a breath of fresh air in many respects. Crary is right that the argument of her second chapter fleshes out and defends previously undefended aspects of Philippa Foot’s project in Natural Goodness (2001). Inside Ethics can also be read as a way of elaborating upon and defending Cora Diamond’s brief, suggestive, and intriguing remarks in her famous essay “Eating Meat and Eating People,” wherein Diamond urges us to think of non-human animals as creatures deserving of pity (1978). Crary’s work also poses a distinctive and welcome challenge to the dominant trend in moral philosophy of seeing living beings as “outside ethics,” and calls for those who subscribe to that outlook to defend it. Though not without its flaws, Inside Ethics ultimately offers a fresh way of thinking about moral philosophy that is stimulating, ambitious, and original.

Hailey Huget
Georgetown University
Washington, DC, USA


Diamond, Cora. 1978. “Eating Meat and Eating People.” Philosophy 53 (206): 465-479.

Foot, Philippa. 2001. Natural Goodness. Oxford: Oxford University Press.

Goethe, Johann Wolfgang von. 2009. The Metamorphosis of Plants. Cambridge: MIT Press.

McDowell, John. 1994. Mind and World. Cambridge: Harvard University Press.

Book Reviews

Maggie Nelson, The Argonauts, Graywolf Press, 2015

Writing this review on a plane headed to a conference on queering sexuality, with newly shorn pink hair, I note to myself that I’m hitting a lot of stereotypes. I’m a philosopher, a professor of women studies, a feminist researcher, a parent who identifies as bisexual, and it’s with all these hats on that I’m reading and reviewing Maggie Nelson’s book The Argonauts.

I’m starting this way because it seems odd to review The Argonauts without any personal detail, though the inclusion of personal information isn’t something I get to do much as an academic philosopher. But The Argonauts is such a personal and philosophical book that it calls for that kind of response from those who read it. I won’t tell you my love stories or tales of my relationship with my pregnant body but I sort of want to. Maybe later I’ll write about that. The Argonauts is a one-person call for combining theory and memoir, and Maggie Nelson does it so very beautifully. I found myself marking passages, messaging friends with quotations from the book, and most of all, reading chunks aloud to people.

If you’d described this book to me I would have sworn I’d hate it. I love literature and I love philosophy but I love them separately. Together seems pretentious, I would have said. Yet, The Argonauts is anything but. It’s a philosophical memoir with lots of ideas but zero footnotes. Instead the names of authors discussed are mentioned in the margins. Readers are left to do their own work though frankly for most of the readers, I suspect they’ll be familiar. Which names? Wittgenstein, and Judith Butler, and Sarah Ahmed. Also, Jacques Lacan, Eileen Myles, and Lucille Clifton. I did wonder how accessible The Argonauts would be for readers outside academia. But maybe that’s not the point. Maybe we are the intended audience, those of us who lead these lives, read these books, and create families in an intentional way.

Backing up a bit, The Argonauts is the story of the author, Maggie Nelson, and her love, Harry. It’s the story of two people falling in love and making a family. The Argonauts begins with a declaration of love and progresses through love, marriage, and parenthood in the usual order of things. But other than the order there is nothing usual about this book. This is a queer love story, about queer families, and queer parenthood. The declaration of love happens right at the start. We’re thrown right in to the lives of a couple, newly in love. Nelson writes:

During our first forays out as a couple, I blushed a lot, felt dizzy with my luck, unable to contain the nearly exploding fact that I’ve so obviously gotten everything I’d ever wanted, everything there was to get. Handsome, brilliant, quick witted, articulate, forceful, you. We spent hours and hours on the red couch, giggling. The happiness police are going to come and arrest us if we go on this way. Arrest us for our luck. (16)

The book’s title comes from Roland Barthes who describes the subject who utters “I love you” as being “like the Argonaut renewing his ship during his voyage without changing its name.” The phrase “I love you” must be renewed by each use. We meet our heroine, as she falls in love, after a period of singlehood and new sobriety, with Harry. Maggie and Harry are moving in together and making plans and deeply in love, but the author still isn’t sure what pronoun to use for her love. Luckily she likes saying “Harry” a lot.

The Argonauts is a love story but more than that it’s a story of queer family making. It’s also a story of physical transformations. During the course of the book both Maggie and Harry’s bodies change. Maggie gets pregnant using IVF and Harry has top surgery and starts taking testosterone. You might be tempted to think of this as Maggie becoming more “feminine” while Harry becomes less but that’s not the way it felt for Nelson. She talks about dinner out at a restaurant where she was recognized as pregnant and Harry passed as a guy and the waiter talked excitedly about his family to them. That’s the outside but Maggie writes, “On the inside, we were two human animals undergoing transformations beside each other, bearing each other loose witness. In other words, we were aging” (83). The writing about motherhood is the most beautiful and unsentimental I’ve read. I also loved the passages on combining parenting small children with an academic career and writing. There are words of wisdom here too about step parenting. I loved the musing about queerness and radical politics and about the meaning of “queer.” The book also engages with the meaning of gender. Of course.

Nelson writes, “A friend says he thinks of gender as a color. Gender does share with color certain ontological indeterminacy: it isn’t quite right to say that an object is a color, nor that the object has a color. Context also changes it: all cats are gray, etc. Nor is color voluntary, precisely. But none of these formulations means that the object in question is colorless” (15).

I confess that I have been carrying this book around and shoving it into friends’ hands saying, you have to read this. Even friends who don’t normally read books are being subject to my evangelism about this one. But it’s not perfect, of course, it’s not.

There are some details missing from the narrative and I wanted to know more. The baby nearly dies of a horrible illness but very little is said. I take it that’s because there’s nothing philosophically interesting about the near death of an infant. Or it’s just too awful to talk about. It’s a terrifying near tragedy. It’s not that ideas rather than narrative drive the book. Rather the bits of the narrative plot that get more attention are those with philosophical significance. What about the scary stalker? How did top surgery work out for Harry? Again I want to know how it all turns out. Also, not all the themes in the story are connected to the narrative. Sex work for example. Religion, death, and dogs make appearances too. You need to be patient with messy when you’re reading this book. Bodies are messy, love is messy, gender is messy, and so too are families and sex.

For a book about love and babies and family, there’s less sex than you might expect, though it starts well: “…the words I love you come tumbling out of my mouth in an incantation the first time you fuck me in the ass, my face smashed against the cement floor of your dank and charming bachelor pad. You had Molloy by your bedside and a pile of cocks in a shadowy unused shower stall. Does it get any better? What’s your pleasure? you asked, then stuck around for an answer” (1). The author writes of a weekend away with Harry. “Just don’t kill me, I said as you took off your leather belt, smiling” (6). Why the move away from that topic and instead childbirth and breastfeeding? Oh, right. Nevermind. There’s a great line about sex in the time of small children and big careers. We’re told, “We have a right to our kink and our fatigue both.” (110) Yes, yes you do.

I’m thinking of designing a graduate course around this book where we read it and selections from the authors mentioned along the way. Certainly, even if I’m not that ambitious, I’ll include it on the reading list for my course on alternative family values. That’s an exciting thought on a hot summer day. And you? You should read this book.

Samantha Brennan
Department of Women’s Studies and Feminist Research
Rotman Institute of Philosophy
Western University
London, ON, Canada

Book Reviews

Mark A. Largent, Vaccine: The Debate in Modern America, Johns Hopkins University Press, 2012; Mark Navin, Values and Vaccine Refusal: Hard Questions in Ethics, Epistemology, and Health Care, Routledge, 2016

Over the last twenty years or so, vaccines have developed as one of the standard examples of major public scientific controversies, alongside climate change and genetically modified foods. This public contention has attracted scholarly attention, and the current review examines two recent attempts at such scholarly intervention. While both books have their limitations, I recommend both to anyone interested in a sophisticated introduction to the vaccine controversy. Specifically, the first substantive chapter of each book would be an excellent set of readings for one-session discussion of the controversy in a bioethics class or science communication workshop.

Mark Largent’s Vaccine: The Debate in Modern America was published in 2012 by Johns Hopkins University Press (Largent 2012). Largent is a historian of science at Michigan State University, and most of the book takes the form of historical narratives of some key figures or moments in the development of the vaccine controversy. Mark Navin is a political philosopher at Oakland University in Auburn, Michigan, and so his Values and Vaccine Refusal—published in 2016 by Routledge—focuses on a more abstract analysis of arguments (Navin 2016). Both books are broadly accessible. While Largent’s book was published a few years ago, the two books work well together; thus the current, joint review.

Before getting into the details, let me introduce some terminology and provide a brief overview of the state of the vaccine controversy and vaccine compliance. Following Navin, vaccine denial is a denial of mainstream medical beliefs about the safety and efficacy of vaccines, while vaccine refusal is the behavior of refusing routine childhood vaccinations. That is, roughly, denial is a matter of belief while refusal is a matter of behavior. Public health officials often focus on vaccine compliance, which is simply the logical negation of refusal, viz., accepting all routine childhood vaccinations; or on vaccine coverage, which is the percentage of a population (often children in kindergarten) who have received recommended vaccinations. Largent focuses on vaccine hesitancy, which refers primarily to (subjective) doubt about vaccine safety and efficacy, and so secondarily the prudence of vaccine compliance or refusal. The difference between vaccine denial and hesitancy is the difference between confident rejection and uncertainty. Vaccine hesitant or denialist parents will often have more or less specific and well-articulated vaccine concerns. These concerns can be narrowly understood as reasons to doubt the safety or efficacy of vaccines, or they can be understood more broadly as reasons to doubt the all-things-considered prudence of vaccine compliance. The possibility that vaccines can cause autism is a widespread vaccine concern, despite being thoroughly rejected by the mainstream medical community.

Popular media coverage of the controversy often gives an oversimplified impression of a rapid, widespread drop in vaccine coverage. Nationally, coverage rates for four major, longstanding immunizations (MMR, DTP/DTaP, polio, and HepB) have remained steady since 2000, at around 90% or more of preschool children (Centers for Disease Control and Prevention 2015). Coverage is lower for immunizations that have been added to the recommendation list more recently, such as rotavirus and HepA, but even here the national trends are towards increased coverage over time. By contrast, there is more variance at the state and county level (Ernst and Jacobs 2012), including some state-level increases in personal or philosophical exemption rates since the 1990s (Omer et al. 2012; Richards et al. 2013). Some epidemiological research has shown that vaccine refusal tends to occur in geographical clusters (Lieu et al. 2015), such as Ashland, Oregon, and parts of the Bay Area in California. Such vaccine refusal clusters have been associated with preventable disease outbreaks, such as an outbreak of measles in San Diego in 2008 (Sugerman et al. 2010); although other outbreaks, such as outbreaks of pertussis, appear to be due to “waning immunity” rather than vaccine refusal patterns (Phadke et al. 2016).

Compared to vaccine compliant parents, vaccine hesitant parents tend to be better educated, have higher socio-economic status, and be more knowledgeable about vaccines (Navin 2016, 10). These patterns conflict with popular representations of vaccine hesitant or denialist parents as ignorant or “antiscience” (for example, Novak 2016), though not with representations of them as privileged (for example, Powell 2015). Vaccine risk perceptions are not (or not strongly) correlated with political party identification or similar measures (Blank and Shaw 2015; Kahan 2015), meaning that vaccine hesitancy is not an example of “liberal antiscience” in the way that climate skepticism is associated with political conservatism. Indeed, the social psychologist and science communication researcher Dan Kahan has argued that this comparison is dangerous; in the terminology I’m using here, linking vaccine hesitancy to partisan political identities might drive vaccine hesitant parents into entrenched denial, and thus exacerbate the controversy (Kahan 2013).

I proceed as follows. The next two sections provide critical overviews of Largent’s and Navin’s books, respectively. I conclude with an overall, pragmatic assessment of the two books.


Largent’s overall thesis is stated succinctly in the first sentence of the second paragraph: “The modern American debate over vaccines and autism is a proxy debate” (1; unheaded citations in this section are to Largent 2012). That is, while some parents have genuine concerns about the possibility that vaccines can cause autism, they also have broader concerns about—among other things—condescending medical authorities, corporate power, and their individual responsibilities to protect and care for their children. These broader issues cannot be settled by evidence that vaccines are safe and effective. Consequently, Largent suggests, the controversy cannot be settled by educating “ignorant,” “hysterical” parents; and some policy proposals, such as strengthening laws in order to compel vaccine compliance, might make things worse.

Chapter 1 introduces an extremely insightful distinction between two conceptions of risk. Public health officials work with what we might call a statistical conception of risk, which is characteristic of epidemiology, decision theory, and related disciplines. Risk is the (quantitative) probability of a (quantifiable) hazard, such as the chance of contracting measles or suffering a serious side effect from a vaccine. Society is a (possibly structured) mass of individuals; when applied to this mass, risk probabilities can be expressed as frequencies, expected total numbers of individuals who will suffer the hazard. Insofar as probabilities are implicitly understood as bets, mass society functions as the casino, with each individual who is vaccinated (or not) a single roll of the dice; the “rational” policy is generally assumed to be the one that produces the “optimal” “long-run” ratio of wins to losses.

Largent points out that this is not how parents conceptualize risk: “While health officials work with a sample size of thousands or even millions, parents consider risks one child at a time. . . . ‘What if your child is that one in a million?'” (20-1). We might say that parents have an individual conception of risk. For a parent, the probability that their child will suffer a side effect from a vaccine cannot be conceived as a bet or gamble: if this roll of the dice is lost, the parents cannot adjust their strategy and try again on the next roll. This is because, simply, for a parent their child is not an indistinguishable, interchangeable molecule in the social mass. (Paul Thompson has made a related distinction throughout his career; see Thompson 2012).

Since Largent doesn’t tease out the epistemological implications of these two conceptions of risk, permit me a paragraph to do so here. A statistical conception of risk does not necessarily need to understand why or how, say, a vaccine causes a certain side effect. So long as public health officials can reliably predict the number of children in society as a whole who will suffer side effects or contract measles, they can determine “optimal,” and therefore “rational,” vaccine policies. By contrast, for an individual conception of risk, the details of the causal connections between the vaccine and side effect are crucial, because vaccine hesitant parents urgently need to know whether the vaccine will cause the side effect in this particular child. Consequently, because of their different conceptions of risk, vaccine hesitant parents and public health officials have different epistemological goals—reliable population-level predictions vs. individual-level causal understanding. These different epistemological goals lead to different research priorities, in line with an observation by philosopher Maya Goldenberg: “While some [groups of vaccine hesitant parents] accept that a serious adverse event after vaccination is extremely rare, they think that research into the factors precipitating those rare events must be a priority. . . . This is not anti-science; it is a demand for participation in setting the research agenda” (Goldenberg 2016, 568). Further, evidence that is adequate for public health officials—such as findings from strictly correlational epidemiological studies with high statistical power—can be deeply inadequate for vaccine hesitant parents—insofar as such studies provide no causal understanding. Because public health officials and parents have different conceptions of risk, they have different epistemological goals; and so they may disagree about what research methods are needed to produce evidence that vaccines are safe and effective (compare Hicks 2015).

Largent’s next chapter examines the ways in which vaccine concerns moved from fringe religious, “alternative medicine,” or “anti-government conspiracy theor[y]” communities to the American mainstream. Largent begins with a review of early twentieth century vaccine concerns and vaccine denialist communities, focusing on the development of chiropractic as one of the major forms of alternative medicine (39-51). Largent argues that many contemporary vaccine concerns and views first emerged among chiropractors, but also that trust-building and engagement has been effective “in swaying chiropractors over to supporting, or at least not overtly undermining, vaccines” (50). Largent next argues that, over the last two decades of the twentieth century, fringe views moved into the mainstream due to high-profile controversies about connections between, first, HIV/AIDS and polio vaccines (51-61), and second, Gulf War syndrome and anthrax vaccines (61-7). As he puts it, “The public and professional debates . . . imported some of the alternative medical community’s concerns about the unintended consequences of vaccines into mainstream discussion” (61).

Chapter 3 begins Largent’s extensive discussion of the specific autism-vaccination controversy. Here Largent examines “two distinct notions about autism” (72). On the one hand is the mainstream medical conception, which recommends behavioral and pharmaceutical treatments to manage the symptoms of autism, asserts that the “autism epidemic” is an artifact of more adequate diagnostic standards, and is confident that there is no link between vaccines and autism. On the other hand is an approach associated with alternative medicine that sees autism as preventable and perhaps even reversible, especially through dietary interventions and avoiding hypothesized triggers such as vaccines (72-3). Much of the chapter focuses on thimerosal, a mercury-based preservative. Historically, thimerosal was widely used; since 1999, in response to public concern, it has gradually been taken out of most vaccine formulations, but is still used in annual flu vaccines.

Chapter 4 examines the case of Andrew Wakefield, the British medical researcher who is (in)famous for his highly controversial 1998 paper arguing for a causal connection between autism and the MMR vaccine. The first quarter of the chapter provides context, namely, Wakefield’s work in the 1990s on connections between viral infections and inflammatory bowel diseases. Largent notes two features of Wakefield’s rhetoric during this time period: he “all[ied] himself and his work closely with his patients” (100, 112) and argued for the publication of controversial work (linking Crohn’s disease to the MMR vaccine, for example) on the grounds that “if his group’s research was not publicized and it was later learned that [their findings were true] . . . the public’s faith in vaccines would be irrevocably damaged” (104). The first feature helps explain why vaccine hesitant parents might trust Wakefield more than more “distant” or “impersonal” public health officials: he shares parents’ individual, rather than statistical, conception of risk. The second feature challenges simple interpretations of Wakefield as “antivaccine” or “antiscience.” Taking Largent’s gloss (and the supporting quotations from Wakefield) at face value, Wakefield appears as an advocate for more and better scientific research on vaccine safety, not an irrational opponent of vaccines as such. At the same time, Wakefield’s critics argue that his findings are easily misinterpreted by the general public, sparking excessive fear and prompting parents to “shun immunization” (quoted on 111).

Most of the rest of chapter 4 examines the fallout from the 1998 MMR-autism paper. As criticisms mounted and reasonable debate became invective, Wakefield became entrenched, alienating his collaborators. From the perspective of the medical establishment, the conclusive refutations of a MRR-autism link were three large epidemiological studies (one of these included all children born in Denmark from 1991 to 1998) (121-2). In 2004, in light of the countervailing evidence and the effects of the 1998 paper on vaccination rates, ten of the thirteen authors—not including Wakefield—voluntarily retracted the paper (131-2). Around the same time, a journalist raised allegations that Wakefield had committed serious research misconduct, including conflicts of interest, manipulating data, and deceiving the ethics committee; the Lancet rejected several of these allegations, but did find that Wakefield failed to disclose conflicts of interest (129-30). Ultimately, in May 2010, Wakefield’s registration to practice medicine in the UK was removed.

Chapter 5 focuses on high-profile participants in the public vaccine controversy, especially Jenny McCarthy (138-48), and to a lesser extent Paul Offit (148-9) and Amanda Peet (149-52). Largent argues that McCarthy should be understood as a representative of vaccine hesitant parents, that is, as a consequence rather than a cause of vaccine hesitancy; as he puts it, McCarthy “has not started a campaign; rather, she has stepped into a void to give voice to millions of Americans who have a tremendous anxiety over the modern vaccine schedule and have found little or no support from science or medicine” (147). McCarthy was raised in a middle-class Catholic family in Chicago (139), and as an advocate she emphasizes parental agency (142, 147) and rejects mainstream medicine’s “fatalistic attitude towards autism” (144). These aspects of her persona make it easy for parents concerned about vaccines or autism to identify with her.

In the final substantive chapter, Largent offers an overview of the concerns and structural factors that, on his view, drive parents’ concerns and otherwise contribute of the vaccine controversy. Briefly, these are

  1. significant increases in the number and pace of vaccines recommended for young children;
  2. vaccines, such as varicella (chickenpox), that trouble a distinction between therapeutic and enhancement medical technologies;
  3. the lack of a clear and realistic goal for vaccine policy;
  4. gender divisions between public health officials (often men) and vaccine-hesitant parents (often women), mothers and fathers, and parents (often mothers) and children at risk for autism (boys more often than girls);
  5. concerns about the postmarketing surveillance system for vaccines, including the possibility that adverse events are underreported and that “long-term side effects are easily overlooked” (166);
  6. the “all-or-nothing approach to vaccination,” which provides no room for parents who might prefer to delay some vaccinations or spread out bundled shots (such as the MMR triple-shot);
  7. the fact that “the duty of policing vaccine compliances [is placed] on daycare and school administrators and staff” and the use of the law to compel vaccine compliance (170); and
  8. insurance structures that create strong incentives for pediatricians to bundle vaccinations and “spend as little time as possible discussing . . . vaccines with parents” (170).

Largent also makes occasional comments relevant to what Foucauldians call “biopolitics”—that is, the use of “health” as a rationalization for governing individual behavior (see, for example, 158)—and concerns about “inappropriate corporate influence” on vaccine development, testing, and policy (171).

From a perspective informed by the methods of sociology and anthropology, Largent’s claims about the eight concerns or contributing factors often seem weakly supported. That is, Largent might be correct that, say, increases in the number and pace of vaccines are a major concern for vaccine hesitant parents; and he does provide at least some evidence to support these claims, e.g., demonstrators chanting “Too many, too soon.” But this evidence is often quite limited. By my lights, survey or interview data from vaccine hesitant parents would make this final chapter more compelling. On the other hand, treated as hypotheses, Largent’s claims are at least plausible. They suggest important policy alternatives to removing exemptions or imposing legal penalties on vaccine-hesitant parents.


Navin’s book neatly divides into two halves. The first, comprising chapters 1-3, deals with what we might broadly call epistemological issues. Here Navin draws heavily on conceptual tools from social epistemology, feminist epistemology, and cognitive and social psychology. The second half, comprising chapters 4-6, examines political issues surrounding mandatory vaccination, working within the public reason tradition of liberal political philosophy.

Navin’s arguments in the first three chapters challenge or significantly complicate three widespread explanations of the controversy, namely, that vaccine denialist parents are ignorant, irrational, or emotional. Such narratives are all instances of what science communication and STS [science and technology studies] scholars call the “deficit model” of public scientific controversies (Wynne 1991; Gross 1994; Durant 1999). These scholars have argued that the deficit model rationalizes the use of coercion or technocratic intervention rather than democratic deliberation, leads to the neglect of non-credentialed expertise, and stigmatizes critical publics. As an example of the last point, Navin notes that vaccine denial is sometimes described as “hysteria,” thereby activating sexist stereotypes (21; all unheaded citations in this section are to Navin 2016). For these reasons, it’s highly plausible that the deficit model can lead to polarization, which can make a controversy even worse.

Chapter 1 examines the epistemology of vaccine denial, drawing heavily on José Medina’s work in virtue epistemology, Miranda Fricker’s concept of testimonial injustice, and feminist epistemologists including Sandra Harding and Lorraine Code. Navin argues that, in response to “physicians’ historical and ongoing abuse of their epistemic power,” vaccine denialists have formed “democratic communities of ‘parent-researchers’ that reject the authoritarianism of traditional medical practice” (22). Navin characterizes a number of criticisms of mainstream medicine, including historical and ongoing paternalism, the influence of commercial interests, and the failure to respect the testimony and concerns of vaccine hesitant mothers (24-31). These concerns seem to justify parents’ distrust of mainstream medicine, and Navin goes on to praise vaccine denialist communities for their “democratic norms for allocating epistemic authority” and fostering “collaborative relationships between pediatricians and parents” (34ff).

However, Navin also argues that vaccine denialist communities suffer from some serious epistemic vices, especially their disregard for “differences in expertise and competence” (41). He goes on to offer (by my count) four arguments that parents should defer to physicians’ expertise about both “the likely outcomes of various options” and “value judgments about which medical interventions would be best for children” (39). Three of these arguments appeal to the epistemic reliability of either credentialed medical experts or “meta-experts,” that is, experts on who has expertise. I worry that these arguments will strike vaccine denialist parents as question-begging: by their lights, it’s at least not obvious that these experts really are epistemically reliable. A fourth argument is more interesting, I think. Navin points out that the “The reason to make space for mothers’ concerns, questions, and experiences” is to produce a “creative tension with the views of experts” (40), that is, to subject the assumptions and methods of mainstream medicine to critical scrutiny that is informed by parents’ experience and interests (elsewhere in this chapter, Navin cites Longino 2002). However, since vaccine denialist communities do not engage with mainstream medical experts, this creative tension is never realized.

At the end of the chapter, Navin offers at least three pieces of advice to the mainstream medical community: to develop “more democratic practices for allocating epistemic authority among parents and pediatricians” (45), to address gender inequalities that lead to condescension towards concerned mothers, and to build bridges to the vaccine denialist communities (46). This chapter offers valuable insight and advice for mainstream public health officials and science communicators who need to understand the vaccine denialist perspective.

In chapter 2, Navin applies the bias and heuristics literature in psychology to vaccine hesitancy, denial, and acceptance. This branch of cognitive psychology aims to understand actual human reasoning in terms of “heuristics,” “quick and dirty” inference patterns that are simple and fast but can be contextually unreliable (Kahneman, Tversky, and Slovic 1982). Here Navin examines how these inference patterns could help explain some vaccine hesitancy. For example, vaccine hesitant parents might recall dramatic online videos about vaccine side effects much more easily than dry statistics about measles epidemics, and infer that the side effects pose a much greater risk than measles; this would be an instance of the availability heuristic or bias (63).

Many analysts and commentators on the vaccine controversy have proposed that vaccine denial can be explained by such cognitive heuristics (see, for example, Goldman 2010; Lombrozo 2015). Navin’s discussion is more sophisticated than these others in three respects. First, Navin repeatedly notes that his analysis is speculative. He cites empirical support when it is available, but does not overstate the strength of this evidence. He is explicitly developing hypotheses, not claiming to have conclusively explained vaccine hesitancy. Second, Navin explicitly rejects the further claim that vaccine hesitancy is irrational merely because it is (assuming that it is) explained by heuristics and biases (57). This is because, third, Navin repeatedly points out that vaccine acceptance can also be explained by heuristics and biases. As he puts it, “The same forms of automatic reasoning that lead some parents to reject vaccines lead other parents to embrace them. Also, pediatricians are not immune to the influence of common cognitive shortcuts” (57). That is, almost no one forms their beliefs through a systematic review of primary research and a careful calculation of costs and benefits. Instead we rely on the messy combination of half-remembered testimony, dramatic narratives, and epistemic trust. Thus, condemning vaccine hesitant or denialist parents as irrational would also imply that vaccine compliant parents and clinicians are irrational.

Chapter 3 draws on cognitive psychology research on disgust, purity, and other strong emotional reactions. Navin suggests that “some parents seem inclined to refuse vaccines because they are especially committed to a cluster of ideals, including ‘purity’, ‘cleanliness’, ‘sanctity’, and ‘the natural'” (97). The ambiguity here is intentional: part of Navin’s point is that different people might understand these ideals in different ways, such as a religious obligation vs. a concern with chemical “toxins.” Most of the chapter is devoted to laying out different varieties of this “ethics of purity.” Like chapter 2, Navin’s argument is explicitly speculative: he is showing how a commitment to one or another version of the ethics of purity could lead to vaccine refusal, not making a confident claim that many vaccine refusers do indeed have such values. At the end of the chapter, Navin includes two sections, respectively discussing the implications of his analysis for public health officials (120-2; primarily that education about safety and effectiveness may not be an effective response to vaccine refusal and that framings that effectively address one variety of the ethics of purity may be counterproductive for other varieties) and briefly presenting three theoretical critiques of the ethics of purity (122-4; namely, that it fails a public reason test for public political discourse, that some purity ideals are unrealizable, and that some purity ideals cause harm).

The second half of Navin’s book, chapters 4-6, takes up a series of political philosophy issues relating to mandatory vaccination. Chapter 4 argues for a moral duty to vaccinate. Navin first notes that “Utilitarianism is the dominant . . . moral backbone of much public policy, including public health policy” (138). Obviously utilitarianism provides a powerful case for vaccination; just as obviously, most parents are not utilitarians about their children’s health, in ways that parallel Largent’s discussion of the two conceptions of risk. Setting aside utilitarianism, Navin goes on to offer two broadly deontological arguments for a duty to vaccinate. First, he argues that herd immunity is a valuable public good (141-2), and that we have duty to make a fair contribution to established schemes for maintaining valuable public goods (142ff). Second, we have a duty to “show special concern for people who are at heightened risk of harm” (149); in the context of vaccines, these include both people who cannot be safely vaccinated (including young children and sufferers of certain autoimmune disorders) (149-50), as well as people who are especially vulnerable to the economic harms of epidemics (150-2). For example, many working class single parents may not be able to afford to take time off work to care for sick children or stay home during a quarantine. While these arguments are common in public discourse about vaccines, as far as I know Navin is the first person to develop sophisticated versions that frame them in terms of major ethical theories.

Chapter 5 justifies coercive or mandatory vaccination laws on the grounds of “protecting children’s fundamental interests,” preventing harm, and “ensur[ing] the fair distribution of . . . costs” for the public good of herd immunity (164). This last argument builds on the public goods analysis of herd immunity developed in chapter 4 (178-83). This chapter also includes important discussions of informed consent (166-8), paternalism (168-73), and the use of coercion (181-84). While Navin’s analysis in this chapter is forceful, he also introduces several qualifications: “less coercive (and, indeed, non-coercive) measures are preferable when they are effective” (166, 181, 186); the use of coercion is generally less justified for vaccines against less harmful or non-communicable diseases (173, 175-6) and when herd immunity is sufficiently robust that vaccine refusal is unlikely to increase anyone else’s risk (184); and that the political decision to use coercion depends on “pragmatic considerations,” such as whether “using less coercion would prevent forms of political and social backlash that would weaken herd immunity even more” (186).

Finally, in chapter 6, Navin argues for three claims regarding exemptions to mandatory vaccination laws. First, arguments from principles of liberal justice and protection for conscientious objectors do not provide compelling arguments in favor of exemption (199-204), although pragmatic considerations—such as the possibility of backlash or polarization—can provide compelling arguments in some cases (204-5). Second, for conceptual and epistemological reasons, the state is not in a good position to distinguish “religious” and “philosophical” exemptions (205-11). And third, burdensome exemption policies—such as requiring parents to attend a vaccine education session in order to receive an exemption—can strike a reasonable pragmatic compromise (211-3). Even if such policies do not actually change anyone’s mind—recall that vaccine denialist parents tend to be better-informed about vaccines than vaccine compliant parents—the burden may prevent some vaccine hesitant parents from rejecting mandatory vaccines, without the kind of heavy-handed coercion that could trigger polarization and backlash. In January 2016, Navin and Largent co-authored an opinion piece in the Detroit Free Press that argued in favor of this kind of burdensome exemption policy (Largent and Navin 2016).

While Navin’s analysis in these chapters is rich and nuanced, I have two deep concerns. First, throughout these chapters—as in chapter 1—Navin relies heavily on the assumption that mainstream medical officials are epistemically reliable experts, and thus that their claims about vaccine safety and effectiveness should be accepted. Of course, vaccine denialists reject this assumption. In response, Navin assumes that the epistemic vices identified in chapter 1 can be idealized away, and that once this is done, “many vaccine denialist mothers would agree that coercive vaccination laws are justified” (165). Yet a vaccine denialist parent might question Navin’s grounds for thinking that we can idealize vaccine denialism away like this. But then the controversy erupts again, at the meta level: what beliefs, epistemic practices, or values can and can’t be legitimately idealized away for the purpose of formulating generally acceptable vaccine policies? More generally, this hypothetical approach to political philosophy has been the target of serious criticisms by deliberative democrats (Young 2000; Richardson 2002; Gutmann and Thompson 2004).

My second concern is with Navin’s focus on mandatory vaccination policies itself. As indicated above, Navin’s discussion of this topic is nuanced, and he ultimately argues for the use of non-coercive measures, such as education sessions. But these subtleties are often mentioned only briefly, and therefore can be easily overlooked. Specifically, I worry that many readers might conclude that completely eliminating non-medical vaccine exemptions would be justified, use simplified versions of Navin’s arguments to push for such policy changes, and that these changes would cause a polarizing backlash. While this is clearly not Navin’s intention, it seems to me like a foreseeable consequence of the way he has framed the book: “exemptions aren’t justified, but can be part of a good pragmatic compromise” can easily be read as “exemptions aren’t justified.”


Both Largent’s and Navin’s books are attempts to intervene in the vaccine controversy. A successful intervention, I assume, has at least three constitutive goals: to facilitate understanding and rectify misconceptions across the two sides of the controversy, to diagnose underlying problems that contribute to it, and to suggest previously unrecognized paths forward. Thus, beyond their scholarly merits, both books can be judged in terms of these three pragmatic goals.

Both books offer extremely valuable insights, especially into the epistemology of vaccine denial. As I sketched above, Largent’s distinction between the two conceptions of risk and Navin’s discussion of vaccine denialist communities point to much deeper issues, and I do not think we can expect to make progress in the controversy without coming to terms with their implications.

Next, both books identify several of underlying problems that contribute to the vaccine controversy. Both identify mainstream medicine’s habits of paternalism, arrogance, and dismissal of parents’ concerns—exacerbated by gender dynamics—as major contributing factors; Navin also points to the socio-epistemic isolation of vaccine denialist communities. While these diagnoses are speculative, they still provide a touchstone for generating new policy approaches to the controversy.

What about paths forward? Given their analyses, what should parents, or pediatricians, or science communicators, or public health officials do? Both authors occasionally offer a few pieces of advice, such as Navin’s defense of burdensome exemption policies. However, neither offers anything like a chapter of concrete proposals. This might be because so many of their diagnostic claims are hypotheses, with limited empirical support; but it seems to me that they could still be used to suggest some potential policies. Indeed, taking an adaptive management approach, the best way to gather evidence that could support Navin’s and Largent’s diagnoses might be to use them to design policy interventions (Norton 2005).

All together, while Largent’s and Navin’s books may be weak on constructive suggestions, they make important contributions to understanding the vaccine controversy. They are especially worthwhile for anyone interested in developing a sophisticated and informed perspective on vaccine hesitant and denialist parents. I highly recommend both books.

Daniel J. Hicks
Science and Technology Policy Fellow
American Association for the Advancement of Science
Washington, DC, USA


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Book Reviews

Glenn Cohen, Patients with Passports: Medical Tourism, Law, and Ethics, Oxford University Press, 2014

Glenn Cohen’s Patients with Passports: Medical Tourism, Law, and Ethics offers a thorough examination of the growing practice of medical tourism, the legal regulations governing it, and the many ethical issues it raises for policy-makers, health care providers, and prospective medical tourists. Demonstrating mastery of the relevant literatures in the social sciences, law, ethics, and political philosophy, Cohen provides a comprehensive overview of the current practice of medical tourism, and offers well-argued, sensible policy advice to guide its reform. Cohen’s book is a significant achievement of interdisciplinary scholarship and is essential reading for scholars and policy-makers.

Medical tourists, Cohen claims, are people who travel to a foreign country for the primary purpose of getting health care. While the popular image of medical tourism in the U.S. context involves patients from high-income countries such as the U.S. traveling to low-income countries such as Mexico, India, or Thailand to access less costly health care or services that are illegal in their home country, Cohen notes that a good deal of medical tourism does not fit this image. Medical tourism also occurs between high-income countries—e.g., Canadian patients seeking care in the U.S.; between low- and middle-income countries—e.g., Cuba is a major destination for patients from many Caribbean and Central American countries; and from low-and middle-income to high-income countries as wealthy patients in the former seek what they presume to be better care in the latter. Although Cohen’s book touches on the legal and ethical issues raised by all of these different flows of medical tourists, the focus of his analysis largely concerns high-income patients—i.e., patients from high-income countries or high-income patients from low- and middle-income countries—seeking care in low-income countries.

Cohen’s book is divided into two parts: (1) medical tourism for services that are legal in the patient’s home country—e.g., hip replacements or cosmetic surgeries; and (2) medical tourism for services that are illegal in the patient’s home country—e.g., transplant tourism and tourism for assisted suicide. I discuss each part in turn before offering some critical remarks.

Regarding medical tourism for services legal in the patient’s home country, Cohen first focuses on medical tourists paying out-of-pocket for health care. These patients may be uninsured or underinsured and so see medical tourism as an affordable way to get care. Cohen explains first that these patients face a lack of information regarding the quality of care that many foreign hospitals and clinics offer—e.g., information regarding clinical outcomes and the risk of disease transmission—which makes informed decision-making difficult. Cohen also explores the question of the regulations home countries and international bodies should put in place to address this lack of information. Is it sufficient to require hospitals and clinics to disclose materially relevant information to prospective patients, for example, by making third-party accreditation conditional on such disclosure? Or, should home governments take steps to restrict patient choice, for example, by making patients who seek medical care from certain foreign providers ineligible for government provided health care such as Medicare or Medicaid? Cohen, quite sensibly, opts for a middle position, one that does not involve restricting patients’ choices but also goes beyond simply mandating the disclosure of information. Cohen suggests that regulators implement a “channeling regime,” a set of regulations that nudge or incentivize patients to make good choices. For example, regulators could create a list of “approved” and “unapproved” providers and services.

Medical tourists paying out of pocket also face the problem of legal liability. Focusing on U.S. medical tourists, Cohen explains that they face a substantial reduction in the likelihood and amount of financial recovery for medical malpractice compared to U.S. patients who do not travel abroad. Here too Cohen recommends that U.S. regulators introduce a channeling regime rather than simply providing patients with information regarding medical malpractice law in destination countries or restricting patient choice. Such a regime could involve incentivizing foreign facilities to make themselves subject to litigation under U.S. law. Cohen also examines the liabilities that home country physicians may face with respect to patients who become medical tourists. He argues that while such physicians likely face a low risk of being held liable for advising patients on medical tourism options, they could be sued and held liable for the malpractice of a foreign physician if they decide to offer follow-up care. Cohen offers a number of regulatory suggestions to ensure that the risk of such liability does not incentivize home-country physicians to deny medical tourists follow-up care.

Cohen turns next to medical tourists who pay for services through private or public insurance programs. Focusing first on U.S. medical tourists with private insurance, Cohen notes that many private insurers in the U.S. are currently experimenting with medical tourism pilot projects. These programs aim to cut costs by offering patients incentives to receive nonemergency care in places such as India, Thailand, or Costa Rica. Cohen offers a comprehensive discussion of the legal and ethical implications of these programs, as well as other possible insurance plans that would not merely incentivize medical tourism, but mandate it as a condition of coverage. Here too, Cohen supports the use of a channeling regime to address the problems of quality and liability that arise in this context, for example, restricting—by quality considerations—the foreign facilities to which insurance companies may direct patients, specifying the types of care insurance companies must provide domestically, and prohibiting insurance companies from using foreign providers that do not agree to be subject to U.S. medical malpractice law. With respect to questions of plan type—i.e., whether private insurers should be permitted to offer plans that incentivize or even mandate medical tourism—Cohen opts for an approach that not only permits libertarian paternalist interventions but also modest restrictions on consumer choice. Because consumers exhibit significant bounded rationality problems even with respect to domestic private health insurance choices, Cohen suggests that governments implement robust regulations governing plans that penalize consumers for accessing domestic care, and even limit the size of positive incentives insurance companies may offer to consumers to receive care abroad.

Cohen also discusses the legal and ethical questions surrounding medical tourism with public insurance. He focuses here on the European Union (EU), where people regularly receive health care services in a different Member State, and where EU institutions have struggled to specify the rules governing reimbursement for cross-border care. Though too complicated to summarize here, Cohen’s discussion of the relevant case law and a recent comprehensive EU Directive is clear and thorough. On the whole, Cohen finds many aspects of the emerging EU regulation to be promising, and to offer models for regulatory issues other jurisdictions may face, including the U.S. should Medicare or Medicaid ever incorporate incentives for medical tourism.

Cohen concludes his discussion of medical tourism for legal services with an empirical and ethical examination of the effects of such tourism on low- and middle-income destination countries. As Cohen notes, many scholars have criticized medical tourism on the grounds that it creates an inequitable two-tier health care system in the destination country that is harmful to these countries’ low-income residents. While medical tourists from high-income countries may have access to excellent, specialized care in high quality institutions in low-income destination countries, the poor and marginalized residents of these countries often lack access to basic health care services.

Cohen first explores whether medical tourism does in fact negatively affect residents’ access to health care in destination countries. Cohen identifies six “vectors” by which medical tourism may have such negative effects, including the internal brain drain of destination country health care professionals to the medical tourist patient population; the inelasticity of the supply of health care professionals and facilities in the destination country; and the unlikelihood of profits from the medical tourism industry “trickling down” to low-income residents. Cohen admits that there is not enough data to determine conclusively whether medical tourism is net harmful to low-income residents in any particular destination country. But, he concludes that there is sufficient evidence to show that this concern regarding net harm is a plausible one.

On the assumption that such net harm does occur, Cohen explores second whether high-income home countries or international bodies have any duty of global justice to do anything about it. Cohen considers this question from the perspective of three families of views on global justice: cosmopolitanism, statism, and “intermediate” theories that fall between these two alternatives. Cohen does not find an overlapping consensus amongst these theories regarding the question of home country obligations, but he does identify two “central tendencies” amongst these theories. The first is that the case for home country intervention in medical tourism is stronger with respect to private-insurer prompted medical tourism since prevention of such tourism is unlikely to expose home country citizens to deficits in health care access. The second is that the case for home country intervention is stronger with respect to government-prompted medical tourism since here the home country is causally responsible for the harms to low-income residents of destination countries. As an example of such an intervention, Cohen suggests that home countries could restrict medical tourism to facilities and countries that have adopted policies to prevent the imposition of harms on low-income residents.

Cohen also considers the obligations of destination countries and medical tourists from high-income countries. As Cohen notes, determining the obligations of destination countries is simpler—compared to home countries—since it is widely acknowledged that governments have a duty to protect and promote their citizens’ health. But, he acknowledges that these countries’ policy options may be limited due to constraints of the global economic system and rules of international trade. Still Cohen recommends a number of regulatory interventions destination countries could implement to prevent medical tourism from limiting citizens’ access to health care, including taxes on medical tourism providers and regulation of the amount of time health care professionals can devote to providing services for medical tourists. Relying on the work of Jeremy Snyder et al. (2013), Cohen formulates a decision-making procedure medical tourists can use to ensure that their medical tourism is ethical.

The second part of Cohen’s book concerns medical tourism for services that are illegal in the patient’s home country. Cohen starts by examining the law and ethics surrounding what is arguably the most controversial example of this form of medical tourism, transplant tourism, or tourism involving the purchase of an organ (usually a kidney). As well as providing a comprehensive overview of the existing data regarding sellers, buyers, and brokers, Cohen explores the multitude of bioethical questions this form of tourism raises, working through existing literatures concerning the ethics of organ sales in general, as well as transplant tourism in particular. Cohen rejects common corruption, crowding out, coercion, and exploitation arguments in support of prohibiting transplant tourism. Instead, relying on existing data which shows that the majority of kidney sellers regret their decision, Cohen argues that the real moral problem with transplant tourism resides with the informational deficits and bounded rationality exhibited by sellers. While these problems could be addressed by a well-regulated international market in organs, Cohen is not confident that such a market is feasible. He therefore concludes that a prohibition on transplant tourism is morally permissible as a form of justified paternalism, and is likely the best feasible policy option. Successful enforcement of such a prohibition, Cohen argues, requires a multimodal approach, involving better enforcement of destination country prohibitions, professional self-policing, and the introduction of various home-country regulations to deter transplant tourism and increase the supply of donated organs.

Cohen turns next to the law and ethics of medical tourism for assisted suicide and abortion. Both are examples of what Cohen calls “circumvention tourism” since the aim of the patients in question is to access services legal in the destination country but illegal in the home country. Cohen explores the legal question regarding whether—under international law—home countries may prosecute their citizens for seeking or assisting assisted suicide or abortion abroad, finding that they may; and also explores the ethical question of whether they should do so. In tackling this issue, Cohen sidesteps the question of what domestic legislation regarding assisted suicide and abortion should be, proceeding instead on the assumption that whatever domestic legislation is in place is normatively well-grounded. The question Cohen addresses is thus whether home countries should prosecute citizens who access or assist abortions or assisted suicides abroad, on the assumption that domestic prohibitions of these services are just. On the basis of lengthy and sophisticated argumentation, Cohen claims that they should, though he admits the argument for doing so in the case of assisted suicide is weaker than in the case of abortion.

Cohen also examines the law and ethics of fertility tourism. A number of countries legally prohibit certain forms of reproductive technologies and surrogacy contracts and so their citizens often travel to countries where such contracts are legal, including low-income countries like India and high-income countries like the U.S. After providing an overview of the empirical evidence regarding this type of tourism, Cohen first addresses the question of whether home countries should criminalize fertility tourism that circumvents home country prohibitions, including prohibitions regarding egg and sperm sales, commercial surrogacy, sex selection, and anonymous sperm donation. Proceeding on the assumption that home country legislation is ethically sound, Cohen argues that whether extraterritorial criminalization is justified or not depends on the home country’s justification for the domestic prohibition. If the justification is to prevent harm to the resultant child—a justification often appealed to in order to support prohibitions on anonymous sperm donation and the use of reproductive technologies by single individuals or LGBT couples—then home countries should criminalize circumvention fertility tourism. Home countries have no reason to discriminate in this context between harm done domestically and harm done abroad. If the justification for domestic criminalization references concerns regarding corruption and commodification—a common justification for prohibitions on commercial surrogacy—Cohen suggests that home countries also have reason to criminalize circumvention tourism, though the reason is much stronger, Cohen claims, when the prohibited practice is intrinsically corrupting rather than simply likely to have corrupting effects. If the justification for home country prohibitions is exploitation—a common justification for prohibiting commercial surrogacy—then, Cohen suggests, there may be no justification for criminalizing circumvention tourism. Where a surrogacy contract is located, Cohen argues, greatly influences whether it is exploitative or not. Focusing on surrogacy contracts in India, Cohen notes that such contracts are often a very good deal for low-income Indian women, given their other options, and so it is arguable that surrogacy contracts between such women and fertility tourists are not exploitative.

Finally, Cohen addresses the question of whether home countries should grant citizenship or at least residency to children born abroad through circumvention fertility tourism. In cases where both home and destination countries permit the reproductive practice in question, or where the grounds for home country prohibitions do not justify extraterritorial criminalization, Cohen suggests that countries should work to facilitate immigration of the resultant child to the home country. In cases of circumvention tourism where extraterritorial criminalization is justified, Cohen argues that it is permissible under certain circumstances for home countries to not extend citizenship or residency to children resulting from circumvention fertility tourism, and that the appropriate policy for home countries is one that weighs the deterrent and retributive value of not granting such status, against the possible harms to the resulting child—e.g., of not being raised by his or her intended parents or of being stateless.

In his final chapter, Cohen explores the law and ethics of medical tourism for experimental therapies unavailable in the patient’s home country, focusing on tourism for stem cell therapies. Cohen first offers a comprehensive overview of the existing literature regarding the practice of stem cell tourism, finding little regulatory oversight of clinics offering unproven therapies to patients. He then addresses two ethical and regulatory questions that the practice of stem cell tourism raises. First, how might the current “wild west” of stem cell tourism be regulated to foster innovation while protecting patients? Second, what are the duties of states and physicians in cases where parents take their children abroad to receive stem cell therapies?

With respect to the first question, Cohen suggests that there is a legitimate role for stem cell therapy innovation outside of the rather restrictive regulatory regimes of many countries. He therefore argues in favor of a channeling approach to regulation, one that directs patients to legitimate clinics and promising therapies. More specifically, Cohen suggests that a review system proposed by the International Society for Stem Cell Research be implemented by a national, supranational, or international body as a way of accrediting clinics and the particular stem cell therapies they offer. With respect to the second question, Cohen argues that states have an obligation to protect children from stem cell tourism unless there is scientific evidence to suggest that the risks to the child are minor and/or outweighed by the legitimate promise of clinical benefit. Cohen argues further that physicians have a duty to report parents to child protective services in cases where this condition is not satisfied (though he of course recommends that physicians first attempt to dissuade parents from seeking such stem cell therapies for their children).

Patients with Passports is an ambitious book and, for the most part, Cohen successfully realizes his aim of providing a comprehensive treatment of the legal and ethical issues raised by medical tourism. My only criticism is that Cohen’s ethical analysis is at times uneven, with some policies receiving greater argumentative support than others. For example, Cohen’s policy proposals on transplant tourism and circumvention tourism for assisted death, abortion, and reproductive services are rigorously defended. By contrast, I found Cohen’s treatment of the effects of medical tourism for legal services on low-income residents of low- and middle-income countries to be largely unsatisfying. As I note above, to determine whether high-income home countries have duties of justice to address the potentially negative effects of their citizens’ medical tourism, Cohen explores prominent theories of global justice and investigates their implications for medical tourism. Cohen finds no overlapping consensus amongst these theories regarding this issue, but claims that they nonetheless share two central tendencies—that states and international organizations have the strongest duties to intervene in insurer-prompted and government-prompted medical tourism. It wasn’t entirely clear to me why Cohen thinks the various theories of global justice under discussion—particularly cosmopolitan and statist theories—share these tendencies, and Cohen says very little to justify this claim. As a result, Cohen’s conclusions regarding the duties of high-income home countries regarding legal medical tourism lack sufficient support. Cohen admits that his policy prescriptions with respect to this issue are tentative and that his aim is limited to mapping the terrain of global justice theories and commenting on their application to medical tourism. But it strikes me that Cohen could have arrived at less tentative, better-supported conclusions had he adopted a less theoretical, bottom-up approach to this question, that is, an approach that considers the feasible policy options on the table and adjudicates amongst them on the basis of widely-held principles of political morality.

I also found Cohen’s conclusions regarding the duties of states and physicians regarding pediatric stem cell tourism to be in need of further argumentation. Cohen adopts strong positions on these questions, but, in my view, does not sufficiently support them. Recall that Cohen claims that states have an obligation to protect children from stem cell tourism unless there is scientific evidence to suggest that the risks to the child are minor and/or outweighed by the legitimate promise of clinical benefit, and that physicians have a duty to report parents to child protective services in cases where this condition is not satisfied. Cohen notes that a possible implication of his view is that states should intervene—and physicians should report – in most cases of pediatric stem cell tourism. Cohen recognizes that other scholars have taken a slightly weaker position on the question of physician obligations in particular, granting physicians more discretion with respect to cases where the risks are unknown or uncertain—the most common case of pediatric stem cell tourism. But, Cohen says very little to explain why his stronger view is the correct one. I don’t think Cohen’s position is necessarily wrong, but a physician’s decision to report parents to child protective agencies is weighty and consequential. In my view, Cohen needs to say much more to establish that his view on this question is the appropriate one to guide practice.

In closing, I would emphasize that these criticisms of Cohen’s book are quite minor, amounting only to requests for further defense of prima facie sensible policy prescriptions. Patient with Passports is an excellent and impressive book, and I expect it to make a significant and lasting contribution to discussions regarding the legal and ethical issues raised by medical tourism.

Douglas MacKay, PhD
Assistant Professor, Duncan and Rebecca MacRae Fellow, Department of Public Policy
Core Faculty Member, Center for Bioethics
University of North Carolina at Chapel Hill
Chapel Hill, NC, USA


Snyder, Jeremy, Valorie Crooks, Rory Johnston, and Paul Kingsbury. 2013. “Beyond Sun, Sand, and Stiches: Assigning Responsibility for the Harms of Medical Tourism.” Bioethics 27 (5): 233-242.

Book Reviews

Firmin DeBrabander, Do Guns Make Us Free?: Democracy and the Armed Society, Yale University Press, 2015

Many critics of American gun culture and policy argue that the public health benefits of stricter regulations compensate for the associated loss of freedom: a bit less freedom is an acceptable cost for the expected gains in public safety. By contrast, gun advocates sometimes claim that freedom to own guns underlies all other important freedoms and therefore deserves priority over considerations of public health. In this volume, philosopher Firmin DeBrabander takes a distinct critical approach, denying any significant loss of freedom associated with gun control. Widespread gun ownership in the context of lax regulation makes Americans—and anyone else similarly situated—less free.

In developing his case for this thesis, DeBrabander argues more specifically that strong gun rights and widespread gun ownership (1) do not liberate us from fear, (2) don’t protect us from tyranny, (3) serve as a diversion for those in power, and (4) constitute a threat to free speech and assembly. The book offers a political and cultural analysis of the gun rights movement in the United States. Although the author’s tone is highly critical of the status quo, he mentions in the Preface that he does not oppose gun ownership with wise regulations (xv). The book supports gun control rather than a ban on private gun ownership.

Chapter 1, “The Culture of Fear,” provides a helpful overview of American gun culture, featuring lax regulation along with high rates of gun ownership and gun violence. DeBrabander notes that gun violence is disproportionately experienced by urban African Americans and that the strongest support for gun rights comes from suburban and rural whites, who are least in need of armed self-defense. The discussion illuminates the gun lobby’s strategy of dichotomizing law-abiding citizens and those intent on doing them harm, identifying “bad guys” and the mentally ill—rather than easy access to firearms—as the chief cause of gun tragedies. The emphasis on dangerous people, according to the author, has been part of a general strategy of cultivating fear in prospective gun owners, and may help to explain why Americans tend to believe that violent crime has increased in recent decades when in fact it has declined.

Chapter 2, “Guns, Government, and Autonomy,” addresses gun ownership in relation to law, political philosophy, and freedom. Like many scholars who favor stronger gun regulations, DeBrabander is critical of the U.S. Supreme Court’s landmark 2008 case, District of Columbia v. Heller, in which the court asserted that the Second Amendment grounds a right to individual gun ownership. He also criticizes the NRA’s slippery slope reasoning—that new gun regulations will unacceptably increase the risk of sliding to gun bans and confiscation—while deftly demonstrating that John Locke’s political philosophy does not support the gun lobby’s agenda. Locke and his intellectual brethren opposed the vigilantism that is encouraged by the NRA and Stand Your Ground laws, whose bias in favor of shooters and against victims DeBrabander does a great job of exposing. Don’t citizens need to be armed to protect themselves against tyranny? No, the author argues. Not only would arms prove useless against the power of the U.S. military; brandishing arms against government personnel who harbor unjust intentions would probably increase one’s chances of getting killed.

Chapter 3, “The Face of Oppression,” argues that the gun rights movement, contrary to its public image of hostility towards government, actually consolidates government power. In an interesting discussion of Machiavelli’s notoriously underhanded advice to political rulers, DeBrabander argues that congressional leaders’ hostility toward even the most sensible gun regulations cannot be explained by lobbying power alone. Rather, part of the explanation must be in terms of a shrewd political calculation: that one can keep the masses relatively happy with guns and the accompanying illusion of freedom. By contrast, if a government shows that it does not trust citizens to own and handle guns, it unflatteringly lumps ordinary individuals with felons and the mentally ill. The present strategy works all the more if government officials and politicians portray the government itself as untrustworthy and incompetent, as Republican leaders have been wont to do. In this way, many Americans come to believe that voting is useless, since the system is rigged, whereas gun ownership makes an individual more powerful, respected, and free.

Chapter 4, “Guns and the Threat to Democracy,” continues the author’s challenge to the idea that guns protect our rights and democratic values. Whereas the emphasis in chapters 2 and 3 was on the relationships between individuals and their government, the emphasis in chapter 4 is on individuals in relation to each other. NRA official Wayne LaPierre claims that gun rights are foundational to the exercise of other rights such as freedom of speech and free assembly. Criminologist John Lott contends that “shall issue” (nondiscretionary concealed carry) laws, by exploiting the deterrent effects of guns, offer the most cost-effective way to reduce crime (Lott 2010, 164-166). In response, DeBrabander argues that such deterrence is highly unlikely in the most crime-ridden urban neighborhoods and that society needs to focus on the real drivers of crime such as poverty, lack of opportunity, and drug addiction. He also presents an excellent, well-documented critique of Lott’s scholarship without bogging the reader down with arcane methodological points and statistics. Rebutting the claim that guns are women’s great equalizers against domestic batterers, he points out that battered women are more likely to get shot in domestic disputes if there are guns in the house. In response to the NRA’s appeals to a dangerous world in which guns afford necessary personal protection, he makes the good point that the NRA has—through its effective lobbying—helped to create this dangerous world. The true motive of the campus carry movement, he suggests, is to help make guns more familiar and acceptable to the mainstream middle class. As for the growing trend of people arriving at protests (e.g., against the Affordable Care Act) heavily armed, he notes that the visible presence of arms intimidates opposing voices. Rather than guaranteeing or protecting the right to free speech, guns in public inhibit speech and reasoned, open discussion. What protects free speech and other rights is not a heavily armed citizenry, DeBrabander argues, but respect for the rule of law. Such respect allows police and courts to perform their functions and obviates the vigilantism encouraged by the guns right movement.

Continuing with several of these themes, chapter 5, “Power and Democracy,” makes the case that gun rights arguments lead to the threat of armed rebellion against government, contrary to the American ideal of orderly transfers of power. While the gun rights movement encourages fear of Obama and his allies, who are said to be advancing a socialist agenda, it simultaneously encourages the proliferation of guns in public, thereby threatening the rule of law and a peaceful society. The more the gun lobby has its way, the more we move away from civil society and towards a Hobbesian state of nature. DeBrabander does an excellent job, again without overloading the reader with technicalities and jargon, exposing some of the most dubious features of current American gun policies—for example, that the ATF cannot share gun trace data with local law enforcement, crippling efforts to identify and investigate corrupt gun dealers and traffickers. Near the end of the book, he offers this comment:

In Jefferson’s view, our republic requires official, sanctioned methods for radical change. The violence of revolution is destructive of, not conducive to, freedom. The gun rights movement fails to grasp this—or chooses to ignore it. Much like the nonviolent movements led by King and others, Jefferson aims to enable radical change within the rule of law. Once rule of law is undermined, so are all possibilities for political freedom. (233)

Do Guns Make Us Free? combines excellent scholarship with accessibility. I am persuaded by its case that private gun ownership tends to make us less free. (Disclosure: I am an applied ethics scholar who has written in favor of substantial gun control.) Although I am not always persuaded by the cultural and political analysis—for example, I suspect that lobbying alone can account for Congress’s pitiful inaction with regard to gun safety (see above)—the analysis is deep, perceptive, and powerful. The author’s engagement with such political philosophers as Locke, Machiavelli, de Tocqueville, Rousseau, and Jefferson is highly illuminating and frequently succeeds in undermining gun advocates’ efforts to ground their ideas in those of great thinkers. One of the book’s most impressive achievements is all too scarce in books authored by philosophy professors: being engaging while presenting a great deal of salient factual information.

This reviewer would be remiss if he did not register a few points of disagreement or complaint. First, an explicit analysis of the concept of freedom would have been welcome. The author does pretty well relying on the reader’s likely intuitions about what is compatible with freedom and what is not. But it is possible that what he includes under the penumbra of freedom—including freedom from fear—exceeds some gun advocates’ more libertarian understanding of liberty as the absence of external constraints. Second, the chapters contain several (of what struck me as) digressions, discussions that distractingly remove the reader from the main thread of argument. (See, for example, Chapter 1’s discussion of drones and perceptions of war and Chapter 3’s discussion of Obama’s claimed right to assassinate U.S. citizens without due process.) Third and finally, the author commits a stylistic faux pas that I urge my philosophy students to avoid at all costs: stating that some author asserts such-and-such without indicating one’s own attitude toward the assertion. Too many paragraphs begin with the likes of “In his book Living with Guns, Craig Whitney argues that…” (59), or “Greewald says of the surveillance state…” (138). The problem with such attributions without critical appraisal is that they either (1) reflect a book report mode, describing literature rather than doing independent analysis, or (2) commit the fallacy of appeal to authority, as if the mere fact that so-and-so asserted such-and-such provided reason to believe such-and-such. Fortunately, the book as a whole leaves no doubt as to DeBrabander’s views about guns’ threat to freedom and the basis for his views.

David DeGrazia
George Washington University
Washington, DC, USA


Lott, John. 2010. More Guns, Less Crime, 3rd edition. Chicago: University of Chicago Press.