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Call for papers – Time Sensitive!

Call for Papers – Time Sensitive!

The Kennedy Institute of Ethics Journal announces a special emergency, open-access issue on Ethics, Pandemics, and COVID-19

Papers from 3,000-12,000 words on ethical issues raised by the COVID-19 pandemic are invited. Papers on resource allocation; duties towards the vulnerable; rights to privacy and mobility; pandemics and xenophobia; the ethical and existential significance of social distancing; and any other ethical issues (in a broad sense of ethics) raised by the pandemic are welcome. In keeping with the mission of the journal, we wish to publish papers that are practically relevant and engaged as well as conceptually rigorous. We are aiming for an extremely fast turn around. Submissions will be reviewed in-house at Georgetown University for speed, and they will receive at least one anonymous review, so this will count as an anonymous peer reviewed article for curriculum vitae purposes.


We are aiming for online publication by midsummer, to come out in print as our September issue. Please direct any questions to Editor-in-Chief Quill Kukla at rkukla@gmail.com, or Acting Editor Travis Rieder at trieder@jhu.edu. Papers may be submitted through our usual submission portal at https://kiej.scholasticahq.com/. Deadline for submissions is May 15, 2020.

Book Reviews

Jenny Reardon, The Postgenomic Condition: Ethics, Justice, and Knowledge After the Genome, University of Chicago Press, 2017.

In The Postgenomic Condition, Jenny Roberts asks whether massive investments in genome sequencing have yielded meaningful knowledge. Her book presses important questions about what has really been gained from high through-put sequencing of strings of A, C, G, and T, and who has benefited from the genome project and its aftermath. More fundamentally, her target is liberalism in science and in bioethics; the volume is less about genomics than it is more generally about the business of contemporary science. Roberts asks telling questions, tells illuminating stories, and raises trenchant criticisms.  Nonetheless, she comes perilously close to over-simplified attacks on technology, capitalism, and contemporary forms of science.

Roberts narrates significant events in genome sequencing to reveal failures in liberal democratic approaches to six core areas of concern: information, inclusion, the people, persons, property, privacy, and the public. Roberts structures each of the narratives to end with questions about whether the enterprise has been worthwhile.  The questions are both a strength and a weakness of the volume; not always well-formed, they are often left frustratingly unanswered.

 The “information of life” tells the story of the race to sequence the genome between public sector groups led by Francis Collins and corporate sponsors led by Craig Venter.  According to Roberts, the race was overtaken by the technological power needed for efficient sequencing.  Humans at the laboratory bench were replaced by sequencing machines and thus “many on the ground feared that genomics ushered in a technocratic and capitalist mode of producing information, one in which computer-run machines designed to increase speed and efficiency replaced humans who sought knowledge and justice.” In exchange for efficiency, Roberts opines, we got the industrialization of biology and instead of the free flow of information we got “the life of information.” (44) This dehumanization of science, Roberts contends, left “one central question…How can we know and act ethically in a world where life becomes information, information becomes capital, and capital is equated with freedom?” (27)

“Inclusion” narrates controversies over early efforts to ascertain whether there are significant genomic variations among population subgroups.  Projects seeking to obtain genome information from isolated indigenous populations and then from racial and ethnic minorities in the United States were fraught with charges of exploitation and racism.  Despite the rejection of biological bases for race, concerns remained over failures to include minorities in medical research. Amidst apologies for the Tuskegee syphilis study, the National Human Genome Research Institute (NHGRI) funded a major research project at Tuskegee on the genetics of heart disease.  Although designed to address a major health problem of the area, the project soon failed in recruiting subjects.  Concerns were the history of suspicion from the syphilis study, along with the charge that such an expensive genetics study would not address the health needs of an area of the country lacking effective access to even minimal emergency care.  According to Roberts, technology was the other culprit: Tuskegee simply did not have the sequencing power needed for high powered genomic research. 

Further issues attended efforts to increase diversity in genomic understanding internationally. In her case study of the international haplotype map (HapMap) assembly of genomes from different communities across the globe, Roberts describes difficult problems of community engagement and consent. To avoid any suggestion of discrimination, the HapMap sought to sample large, genetically variable populations.  HapMap sponsors also sought to discuss issues and concerns with community members.  At the point of constituting community, however, they foundered; the “people” of Japan, for example, were simply the Japanese population and there was no easy way to determine whether a small number of samples obtained from population members were in any way representative of genomes in Japan.  Nor was there a political theory adequate to address questions such as who should be included in the HapMap, other than existing global political delineations themselves.

Some particular political delineations, however—Iceland, Estonia, and Scotland in particular—had taken up their own genome initiatives. These efforts proved paradoxical, on Roberts’ account. Iceland’s outright commercialization of the data of its residents through deCODE generated intense controversy over the assumption that genetic data should be treated as a natural resource.  Roberts ends her description of Iceland’s deCODE with the observation that it “foreshadowed the crisis of value that would soon come to characterize the postgenomic condition” and with unanswered questions: “What kind of thing was the human genome, and who had the right to know and control it? A nation? A corporation? All humans” (99).  Roberts then recounts how Iceland’s example of commercialization was not followed by Scotland.  Generation Scotland (GS) attempted to assemble Scottish DNA for medically relevant research. While presented as a resource for Scotland, to be used by researchers in Scotland, GS found itself without sufficient local technological resources to perform the needed sequencing.  But by the time GS recognized this problem, the infrastructure they had built to seek feedback from participants about use of their samples had been disbanded.  Efforts to re-consent participants to the newer plans to send samples outside of Scotland foundered.  The resulting reduction in available samples, compounded by the economic crisis in 2008, left GS with an apparently useless resource and, according to Roberts, these nagging questions: “in these postgenomic times, is there any ‘thing’ at all? If not, and we are unable to gather around a thing of clear value, should scientists and society proceed?” (118)

Roberts’ treatment of direct to consumer (DTC) genomics further illustrates the strengths and weaknesses of her book. Her case example is 23andMe, selected for its success and for its announced commitment to making individual genetic information available to the wider public.  According to Roberts’ overall plan for the volume, the liberal value put to the test by this case example is property. Yet issues about data as property largely fade into the background of a wider critique of whether 23andMe creates knowledge. Roberts situates this debate in the context of the politics of knowledge more generally: “the debates over personal genomics make visible a broader contemporary struggle over how to constitute knowledge and justice in the midst of challenges to the credibility of dominant institutions, and investments in informatics as the new infrastructure for collective living and understanding.” (121-122)

As Roberts tells the story, the original vision behind 23andMe was research, specifically the assembly of sufficiently large data sets of genotype and phenotype information to understand the significance of genetic variants for Parkinson’s disease. Acquiring genetic material from saliva samples was the easy step; far more difficult was the enterprise of assembling sufficient phenotypical data to illuminate the significance of genetic variants. Roberts details how 23andMe created an engaging social media experience to encourage people to submit ongoing phenotypic information. On Roberts’ view, 23andMe portrayed itself as revolutionizing genetics by linking it to individual identity and freedom. However, it was in fact encouraging consumers to become patients-in-waiting as they “par[took] in biocapitalism” and paid to “play with [their] genome on the 23andMe website (128). Indeed, 23andMe belied its supposed democratization with its initially high price tag and appeals to computer-savvy “digerati.” When it was pushed out to wider populations, it attracted claims that the information it provided consumers was meaningless or potentially harmful; both the Food and Drug Administration and California regulators objected to any suggestion that the company was engaged in medical testing.  These objections were bolstered by the observation that companies curated DTC information differently.  Conflicts also emerged between supposedly more impartial academic science and corporate science. Roberts ends this discussion once again with a question, this time from life scientists: would the “science for the people” envisioned by 23andMe and the DTC movement enact the displacement of science “and the takeover by machines and their multinational corporations?” (143)

Roberts concludes her stories with case studies of privacy and justice.  On privacy, she questions whether terms and conditions of receiving medical care should include sharing data for research.  From her personal experience as a patient expected to share data at UCSF, Roberts segues to the Personal Genome Project (PGP), an effort based at Harvard to allow anyone interested to have their genome sequenced at a low cost and shared openly. The corporate benefit of the PGP was available DNA to develop faster and cheaper sequencing capabilities for do-it-yourself personal biology. The benefit to researchers was breaking what they saw as the bureaucratic over-regulation of medical research. The claim to openness was upfront acknowledgement that privacy in medical research cannot be guaranteed; even deidentified data bears significant potential for re-identification with a sufficiently rich data set. To be sure that participants were willing, PGP deliberately did not engage in recruitment; the result is a database that is almost exclusively white.

On justice, Roberts locates genetics at the epicenter of contemporary structural injustice.  She contrasts the vast wealth of the UCSF Mission Bay campus and nearby commercial facilities such as the sequencing giant Illumina with the deep poverty of Hunter’s Point only a few blocks further south. Her concerns about justice reach far beyond whether minorities are benefiting from genetic medicine to whether it is justifiable to allocate massive investments to “big science” when clinics that provide basic preventive care to the poor lack funds.  While Roberts is surely right to question the structural injustice furthered by investment decisions, targeting the genome project and the research infrastructure associated with it may be unfair; at most, investment in genome science is part of a larger picture of contemporary maldistribution. Relatedly, Roberts sees supposed efforts to democratize genomics by bringing in communities as ultimately undemocratic failures confront the full meaning of what is “in-formation” rather than informative.  Roberts further questions the introduction of information technology into medical records, arguing that although some information of value may emerge, the benefits overall are less clear. Cooperation and transparency about medical information, she contends, has become the province of Salesforce and other data analytics firms rather than serving the individuals who have become subsumed and forgotten in biocapitalism. Instead, Roberts cites a suggestion from an African American group discussion of The Immortal Life of Henrietta Lacks: we might tag everyone’s biospecimens in a way that could enable them to log on and see how these specimens have been used (192).

So how should we move forward in the postgenomic world? Roberts has three central ideas. First, we must recognize that information is a source of power and turn this power back into the hands of people, not through more efficient consent forms but through the creation of conditions that give people effective control over the use of their bodily tissues (182). Here, we must recognize how money flows around information, not just with its use but in its production, curation, and storage. Roberts urges transparency about the environmental impact of data processing.  We should make difficult decisions to move away from boutique “tailored” medicine (183) to investments that include us all.  Roberts’ second idea is that to do this, we must invest, she says, in “institutions that support the arts of collective judgment.” (184). In so doing, we must reimagine what is possible and think about creating meaning beyond a biotechnical idea of health.  We must, she says, “re-member” life. Third, we must bring justice in as a gathering concern, reconsidering its relegation to last place in the Belmont Report and liberal approaches to research ethics. Roberts concludes that, as publics, we must question the meaning of science and technology, link policy discussions to policy change, and keep at the forefront the relationship between innovation in science and technology and inequality.

Roberts admits that her view is highly programmatic and will need to be instituted differently in different contexts.  As a non-ideal theorist, I fully agree.  Yet she ends the volume with a mixed message about contemporary science.  On one side is the need to reassert human control over technology.  On the other side is pessimism about our ability to gain knowledge to further such reassertion. Here, Roberts asks “Under these conditions, how can anybody know what the public interest is and if it is being represented when one shares their data and DNA?” (201)

This final question struck me as primarily an expression of despair rather than an attempt to grapple with the substantive issues that it raises.  Careful thinking about public interests in health information, including but not limited to genomic information, is sorely needed.  In this regard, it is important to counter misunderstandings that foster genetic exceptionalism.  Other health information, for example about infectious or environmental exposures, has implications beyond the individual to whom it immediately pertains. Neither protestation about technological imperatives nor insistence on individual ownership of health information is particularly useful in the effort to developed principled accounts of permissible (and even potentially obligatory) uses of health information. Instead, we need to consider injustices in current forms of collection and use of health information—including, as Roberts appropriately asks—whether to prioritize genomic information over information about social determinants of health, or how to integrate these and other forms of health information.  We also need to consider how to move forward towards greater forms of inclusion in the pursuit of health justice that respect all concerned. As one example, we must consider when it is unjust to make use of data from or about individuals (and, importantly with big data, these are not the same) if these uses fail to benefit or even harm the individuals concerned.  As another, we need far more work on the obligations of data users to data sources and sharers, even in circumstances in which efforts to gain useful knowledge flounder.

Much remains to be asked and learned about the genome project.  Roberts’ book is in some respects an illuminating start but it leaves largely unaddressed the critical questions about justice that she asks.

Leslie Francis

University of Utah

Salt Lake City, Utah

Editor's Pick

Editor’s Pick, September 2019: David M. Peña-Guzmán and Joel Michael Reynolds

The Editor’s Pick for our September 2019 Issue is David M. Peña-Guzmán and Joel Michael Reynolds’s paper, “The Harm of Ableism: Medical Error and Epistemic Justice.”

One of our guest editors for this special issue, Sandra L. Borden writes, “The authors argue for a specific kind of knowledge-based medical error originating in ableism. They characterize ableism as an epistemic schema that contributes to insidious schematic error. The issue is not only what providers know, but how they know within the dominant epistemology of medicine.”

This paper advances a clear, powerful argument about an urgent issue, and we are pleased to highlight it and offer the opportunity to download it at this link.

Editor's Pick

Editor’s Pick, June 2019: Jonathan Kaplan

The Editor’s Pick for our June 2019 issue is Jonathan Kaplan’s paper, “Self-Care as Self-Blame Redux: Stress as Personal and Political.” Kaplan’s article opens up an entirely new and clearly important topic for bioethicists: the concept and role of ‘self-care.’ It takes up popular imperatives to take care of oneself as care suggestions and considers them through a bioethical lens. Kaplan’s essay can be read as a strikingly original contribution to the exciting and growing new literature critiquing ‘healthism,’ placing self-care in the bioethical terrain.

Download a copy of Kaplan’s paper here.

Book Reviews

Rik Peels and Martijn Blaauw, The Epistemic Dimensions of Ignorance, Cambridge University Press, 2017.

The Epistemic Dimensions of Ignorance is a provocatively framed collection of essays dealing with a variety of epistemic issues related to the concept of ignorance. The first three essays in the volume have to do with the nature of ignorance itself. Le Morvan and Peels’ contribution provides an overview of some relevant literature, and distinguishes between two views on the nature of ignorance, which they call the Standard View and the New View. In both cases, ignorance is conceived of as a lack or absence of something; what distinguishes the two views is the issue of what is lacking. On the Standard View, the ignorant agent lacks knowledge, whereas on the New View, they lack true belief. Nottelmann and Brogaard, in their respective essays, consider different ways in which we might classify ignorance. Nottelmann outlines three dimensions along which we might classify a type of ignorance: first, the kind of thing about which the epistemic subject is ignorant, such as a fact, the existence of an entity, or the answer to a question; second, the degree of ignorance the subject displays, for instance, in practical ignorance; and last, the order of ignorance, since it is possible to be meta-ignorant – a point that is made by Medina, both in his contribution to this collection and in his earlier (2012) book on the subject. Brogaard’s essay can be seen as further clarifying the first of these dimensions, arguing on the basis of linguistic analysis that there are three types of ignorance: ignorance of facts, subject matter, and how to perform a particular activity. This linguistic analysis, however, has implications for the kind of thing that ignorance is, since it ultimately speaks against the Standard View in arguing for a difference between ignorance and a lack of knowledge.

The next several essays in the volume connect ignorance to other epistemic concepts. Olsson and Proietti consider treatments of ignorance and doubt in several possible worlds frameworks, ultimately concluding that ignorance and doubt are not simply negations of knowledge and belief, respectively. Blome-Tillmann, taking the Standard View as background, extends contextualism about knowledge to contextualism about ignorance. This allows him to provide an interesting contextualist response to standard skeptical arguments, say about the existence of the external world. Brown’s essay discusses two versions of an objection to anti-intellectualism which argues that it leaves us more ignorant than we would ordinarily take ourselves to be. On the anti-intellectualist view, a difference in stakes between hearer and speaker can undermine knowledge transmission through testimony; Brown argues that, even though there can be some conflicts, our frequent reliance on testimony and memory as sources of knowledge should not lead us to reject anti-intellectualism. Another interesting essay by Pritchard considers cases in which being ignorant has epistemic value. For instance, being ignorant of a misleading defeater might help us gain further true beliefs.

The editorial framing, however, of the last three essays is curious:

We have included these essays, even though they are not confined to the epistemic dimensions of ignorance. This is because religious epistemology is typically part of epistemology, the epistemology of race has interesting things to say on collective ignorance in its relation to individual ignorance, and group belief and group knowledge have recently become big issues in epistemology (9).

What this seems to mean is that these final three essays, as with much of the epistemology of ignorance literature they draw on (at the very least, the Fricker and Medina draw on that literature), incorporate the social and political dimensions of ignorance. That is, they discuss ignorance as it occurs in our non-ideal world, and as it is produced in agents who are all socially situated in some way. But the acknowledgement of such traditions and bodies of work in epistemology is in tension with the initial, and indeed motivating, claims of the book. The first sentence of the book’s back blurb is, “Ignorance is a neglected issue in philosophy.” In light of the Fricker and Medina essays, this seems obviously false, given the rich contributions by philosophers of race and gender to the development of epistemologies of ignorance. In their introduction to the volume, the editors make a more precise claim—though still one that bears further consideration—that epistemologists have hardly paid attention to ignorance, as they acknowledge that areas of philosophy other than epistemology have dealt with the issue of ignorance. The one exception they note within epistemology is in the area of radical skepticism (1). Given, however, that Linda Martín Alcoff’s contribution to the collection Race and Epistemologies of Ignorance (2007) provides a typology of existing arguments in the epistemology of ignorance, the claim, even, that it has been neglected in epistemology is puzzling.

Before drawing out the issues with the framing of this volume, I should note that none of this should be taken as a criticism of its individual essays, as contributions to epistemology, and to the epistemology of ignorance in particular. I think that there might have been some cases in which greater (or some) consideration of the more explicitly social literature might have been beneficial, however, and we might see this as a missed opportunity. For instance, the several essays discussing classifications of ignorance tend to consider it primarily as an absence or lack of something, where the nature of the thing lacking is up for disagreement. But those writing on ignorance in the philosophy of race tradition often write about it as something produced or cultivated. It might have been helpful to see how this would play a role in the taxonomies of ignorance discussed in some of the earlier essays in the volume. Similarly, the work on epistemic value might also have considered ways in which being racially ignorant could potentially have epistemic as well as social benefits, for instance, by allowing agents to take advantage of knowledge-granting opportunities that they might cede if they were more socially responsible.

To return to the initial editorial claim, though, that epistemology has generally ignored the phenomenon of ignorance, note that it could be interpreted in several different ways. It could mean that the well-developed literature in epistemologies of ignorance that draws from the philosophy of race has generally been ignored by a lot of mainstream epistemologists. This seems true (and to the detriment of much of mainstream epistemology), but, given that most of the essays in the book do not engage with this literature either, it is not clear that this is what the editors meant. Moreover, there seems to be some general inattentiveness to the potential social impact of this work. The front cover art, entitled “Spring’s Landfall” features a pink-clad young woman, blindfolded, attempting, it seems, to row a flower-filled boat with two sticks through a field. Ignorance, illustrated, is feminine, hapless, and blinded.

Instead, there seem to be two other ways in which this claim could be interpreted. One is that “epistemologists” refers to epistemologists whose work does not consider the social situatedness of agents. So this would exclude those who work on epistemology in a way that is fundamentally attentive to factors such as gender, race, or disability. Second, there is the possibility that the editors themselves are ignorant of the fact that the literature on epistemology and ignorance is substantial, despite its lack of inclusion in many anthologies and collections. Both of these interpretations are disappointing, but provide interesting case studies for applications of epistemologies of ignorance. So I will use the tools from the Fricker and Medina essays in the volume to analyze this.

In the first case, in which epistemology is construed in such a way that it excludes many philosophers who would self-describe as epistemologists, we might wonder whether there is a kind of hermeneutical marginalization. As Fricker’s essay describes such a situation, we might think that “some social groups have less than a fair crack at contributing to the shared pool of concepts and interpretive tropes that we use to make generally shareable sense of our social experiences” (163).

It might be difficult to make the case that groups of philosophers working on ignorance from particular non-mainstream perspectives are sufficiently cohesive to count as social groups. But we might also note that a lot of work done in anti-oppressive philosophy generally is done by people who experience at least some form of oppression, whether it be in terms of gender identity, race, or disability. But if such work is not counted as epistemology proper, then we have a situation in which, say, feminist epistemology does not have a fair crack at contributing to the shared pool of epistemic concepts that we use to engage in dialogue about the nature of knowledge.

This seems to be detrimental to members of social groups whose lived experience is better captured by the tools of feminist epistemologies, and those other excluded epistemologies of ignorance. It can also serve to signal to those interested in doing that kind of work that such pursuits are less inherently philosophical, or perhaps that considering epistemic practices that are more familiar to them is a question of ethics rather than epistemology. But it also seems epistemically detrimental to the philosophical community as a whole, since the hermeneutical resources for talking about epistemology generally are unequally distributed among its members.

The second situation, in which working epistemologists can be unaware of the extent of the literature on epistemologies of ignorance, might also be a case study, perhaps as a case of meta-ignorance. But we might also worry about the extent to which such meta-ignorance might be structurally reinforced. Meta-ignorance is extremely similar to the higher-order ignorance that Nottelmann considers (54-5), but as Medina describes it, is often associated with privilege and a lack of epistemic friction. Not only is it ignorance at the object level, but it is also ignorance of one’s own epistemic limitations (183). Moreoever, meta-ignorance is not always culpable. It might be culpable if it is also active ignorance, meaning ignorance that resists correction. This might be a matter of individual epistemic vice or bad faith, but can also be structurally produced, as Charles Mills notes in writing about white ignorance. As such, it might be worth considering what structural factors might contribute to the marginalization of particular bodies of philosophical literature.

In general, this book collects together some well-formulated and clear essays on the various epistemic topics related to ignorance. Its principal problem is not the quality of its contributions, but its motivating conceit. It purports to fill a gap in the epistemic literature, though it is not clear that the identified gap exists. Also, claiming that there is such a gap can contribute to the marginalization of philosophical work written by philosophers from underrepresented groups. But at the very least, the claim that there is such a gap allows for an interesting application of the conceptual tools of the epistemic literature that the editorial framing largely neglects.

Audrey Yap

University of Victoria

Victoria, B.C.

References

Fricker, Miranda. 2007. Epistemic Injustice. New York, NY: Oxford University Press.

Medina, José. 2012. The Epistemology of Resistance. New York, NY: Oxford University Press.

Sullivan, Shannon, and Nancy Tuana (Eds.) 2007. Race and Epistemologies of Ignorance. Albany, NY: SUNY Press.

Book Reviews

Sean Valles, Philosophy of Population Health: Philosophy for a New Public Health Era, Routledge, 2018

Sean Valles’ Philosophy of Population Health marks an important contribution to the analysis of philosophical issues relevant to a broad range of issues at the interface of population and public health. The book exemplifies the constructive contributions scholars from philosophy of science and ethics can make to advance our understanding core issues in this area, historically dominated by concern for medicine and the delivery of health care to individuals. Professor Valles’ contribution joins the work of Alex Broadbent and the philosophy of epidemiology, and the work of Angus Dawson and Marcel Verweij and Ruth Faden and Madison Powers and others in public health ethics.

The stated purpose of the book is to advance a population health framework and spark a dialogue between philosophy and population health. The book succeeds in achieving both aims. In the introduction, Professor Valles notes that unlike in previous philosophical work where “we typically find a combination of individually avoidable errors dubious shortcuts and ill designed methods. All the while philosophers of science and medicine still tend to have an abiding respect and appreciation for the science/medicine, critiquing in the hopes of making things better. When scrutinizing the philosophical underpinnings of a new interdisciplinary program such as in my previous work on evolutionary medicine and personalized genomic medicine I’ve come to expect extensive, if not fatal, problems. Imagine my surprise at encountering population health science and finding nothing really fundamentally broken. What I found instead was a field that has many debates and unsettled theoretical and practical questions that remain to be sorted out.” (3) This optimistic perspective pervades the book which is quite useful in sorting out some of the philosophical issues at the interface of the philosophy of medicine, philosophy of science and ethics relevant population health.

The book is well organized and laid out. The introductory chapter provides a blueprint of a philosophy of and for population health. A brief overview commences with a broad definition of public health and population health and explains how the aims and methods of these are distinct from clinical medicine and healthcare. The core philosophical issues and arguments to be addressed in each chapter are outlined, as are the methodological and normative commitments of the author.

The book is divided into three parts: Part 1: What should health mean in population health science; Part 2: What causes and effects matter most in population health; Part 3: How can population health science better promote equity health equity. Each section contains chapters which systematically address key concepts and engage deeply with the current literature. The chapters explore key epistemological, ethical and metaphysical issues related to the concept of health, a social concept of health, health as a life course trajectory and how accounts of causation expand the boundaries of population health and how causation can be understood in population health. Part 3 brings things together through the lens of ethics and evidence. Each of the chapters ends with a case study that illustrates the issues that are raised in the chapter. The case studies are exceptionally well chosen as they are drawn from contemporary events and touch on Indigenous health, environmental issues, communicable disease and migrant health.

What is most notable about this book is the way that the author skillfully and with great nuance explicates and distils the arguments of the many debates about population health and the determinants of health. He successfully and clearly lays out some of the key boundary issues concerning the scope and range of population health, summarizes and brings coherence to the many debates concerning the nature of causation, and sympathetically navigates the sometimes bitter arguments between public health and health care. The discussion of health equity is noteworthy in bringing clarity to the discussions of how equity is defined in health and its relationship to theories of justice.

Professor Valles is committed to an expansive concept of health and argues for the irreducible role that social forces play in the creation of health. He also argues for a life course trajectory concept of health. He is unabashedly supportive of pluralism in our metaphysical, empirical, ethical and methodological engagement with population health. Professor Valles provides an update and spirited defense of the 1946 World Health Organization definition of health, which has come under significant criticism in recent years. His reconstructed argument yields a new definition of health as a life course trajectory of complete well-being in a social context.

This concluding chapter argues for the overarching need for a spirit of humility and collaboration. As Valles notes, power relationships take on a special importance for population health science. He argues further that humility is key to population health sciences success: “Humility is needed in three areas: an overarching epistemic humility recognizing that no single person or perspective can have a full understanding of population health; intersectoral humility recognizing that no sector of society (government, health care etc) is elevated above the others; and a disciplinary humility recognizing that no contributing discipline in interdisciplinary population health science is elevated above the others.” (181)

Professor Valles has skillfully drawn together and woven into a coherent framework a diverse set of literature dating back to the 19th century and the origins of social medicine. He does justice to the literature and acknowledges the importance of integrating elements of modern preventive medicine with a sustained explication of the work of Geoffrey Rose. He also highlights the significance of modern frameworks such as the WHO Social Determinants of Health Commission.

I believe that some readers, no doubt wed to a particular theory, may take issue with arguments raised in the discussion of causation. Professor Valles contrasts his approach with that of Alex Broadbent’s as set out in his book Philosophy of Epidemiology. Professor Valles endorses the notion of fundamental cause theory as a particularly promising contribution to population health science. His endorsement of this theory should stimulate significant debate. Similarly, I think there may be scholars committed to a particular theory of justice and of particular interpretations of health equity that may resist the pluralism that he endorses.

I highly recommend this book to scholars, public health and health care practitioners, policy makers and the general reader interested in population health. The book is an excellent complimentary source to Population Health Science by Keyes and Galea, for those interested in a more technical approach to population health. Few books I know of so skillfully and effortlessly employ concepts form the philosophy of science, philosophy of medicine, and ethics. I hope this book finds its way into undergraduate and graduate courses in schools of public health, faculties of medicine, and into graduate courses in philosophy of science and philosophy of medicine. I hope that this book stimulates the creation of new courses in philosophy of population and public health. Many curricula at schools of public health leave little room for engagement with the wide range of diverse philosophical views relevant to their field. I believe that this book would help provide a sound foundation for early 21st century graduate students struggling with the deeper concepts raised by the practice of public health and population health.

Ross Upshur

Dalla Lana School of Public Health

Bridgepoint Collaboratory for Research and Innovation

Lunenfeld Tanenbaum Research Institute, Sinai Health Systems

University of Toronto

Toronto, Canada

Editor's Pick, Uncategorized

Editor’s Pick, December 2018: Alison Reiheld

Our Editor’s Pick for our December 2018 issue is Alison Reiheld’s paper, “Rightly or for Ill: The Ethics of Individual Memory.” This paper takes up a rich issue that has yet to receive significant philosophical attention: the ethics of memory. The paper asks questions such as: when are we morally blameworthy or praiseworthy for remembering, forgetting, or encoding a memory in a specific way, and what are the ethical principles that should govern our practices of remembering and forgetting? By understanding remembering and forgetting as constructive activities involving agency and choices, Reiheld examines and answers these questions with admirable philosophical clarity.

Download a copy of Reiheld’s paper here.

Book Reviews

Carl Cranor, Tragic Failures: How and Why We are Harmed by Toxic Chemicals, Oxford University Press, 2017

Long before there were any professional philosophers who identified as doing socially engaged or socially relevant philosophy of science, Carl Cranor was demonstrating exactly how philosophical reflections on science can and should inform law and policy. Cranor is a philosopher who also is a professor of law. He is thus in a unique position to explain how failures in legal protection are tied in part to ignorance about the nature of scientific inquiry. His Regulating Toxic Substances (Cranor 1993), Toxic Torts: Science, Law, and the Possibility of Justice, (Cranor 2006, Cranor 2016), and Legally Poisoned: How the Law Puts Us at Risk of Toxicants (Cranor 2011) explain and describe how the law in many cases has failed to protect our health. He traces these failures to unrealistic standards of evidence, particularly for demonstrating links between toxic substances and human health. Tragic Failures: How and Why We are Harmed by Toxic Chemicals, gives a clear overview of the entire body of current regulatory law and policy as concerns environmental toxins. It is written with great transparency, for a wide audience. It is not just an elegant summary of the state of the law and environmental policy; it is an exceptionally humane call for better thinking about the nature of science, and a passionate call for justice with respect to environmental risks to our health.

The book opens with the story of a cancer cluster among workers and locals near a DuPont plant in Parkersberg, West Virginia. Cranor weaves vivid case studies such as this into a larger argument that all of us have been subject to higher levels of exposure than we would in a different legal context. In particular, Cranor attributes these levels of exposure to the U.S.’s postmarket laws for industrial chemicals, which were modeled in part on nuisance laws. While such laws might be appropriate for visible substances, like burning rivers or smoggy air, such laws were not appropriate for the large majority of potential toxicants, many of which are invisible, diffuse and not immediate in their effects. Postmarket laws put such substances into the environment with no legally required toxicity testing. This places the burden of proof of harm on federal agencies, or (in the case of toxic torts) those who claim to have been harmed. Testing is voluntary, and according to the 1976 Toxic Substances Control Act (Toxic Substances Control Act 15 U.S.C. ch. 53 (1976)), as many as 62,000 chemicals manufactured or imported into the U.S., already in use were “grandfathered” in as “safe.” Manufacturers are not required to routinely test chemicals to demonstrate safety before putting them into the environment, though they may voluntarily do so. As much as 22,000 additional chemicals have been added to the pool to which we are all exposed, including fire retardants, byproducts of rocket fuel, and a variety of potential endocrine disruptors. As a result, according to Cranor as many as 84,000 untested substances have entered the market since the 1970s, or were grandfathered in, only a small percentage of which have been subsequently tested for toxicity, and a yet smaller percentage have been removed from the market. Because such testing is voluntary, and the costs (both immediate, and potential) to industry of voluntary premarket testing are high, postmarket laws create and invite willful ignorance of potential harms. The first half of the book documents some of these harms, and explains how and why certain populations have been particularly vulnerable: namely, children. It is, quite frankly, a devastating read, but essential for anyone concerned with how U.S. law protects us from harm (or, has failed to do so).

The second half of the book engages with toxic torts. Given the failures of protection from regulatory law, tort law (in principle) gives those harmed means of receiving compensation, and (ideally) serves to incentivize safe workplaces and safe disposal of potential toxins. Unfortunately, the decision in Daubert v Merrell Dow Chemical has not only failed to protect citizens from harm, but also positively fostered ignorance and injustice, according to Cranor (Daubert v. Merrell Dow Pharmaceuticals, Inc. 509 U.S. 579 (1993). The Daubert decision (or, perhaps better: interpretations of this decision) led to a shift in admissibility of expert testimony. Prima facie, the view defended by Judge Blackmun, that expert opinion must have “a reliable scientific foundation and be relevant to the task at hand,” seems plausible. However, Blackmun’s gloss on having a scientific foundation opened the door to questioning of expert testimony. Moreover, subsequent decisions were taken to establish precedent by defendants for the requirement that epidemiological studies be present, or must show a specific risk increase. But of course, evidence other than epidemiological studies can be quite compelling, and setting particular increase in risk as the standard necessary for proof is at best arbitrary. In other words, Daubert shifted matters of assessment of quality of testimony to the judge presiding over a case. But, many judges have no training in relevant science. Without knowing how weight of evidence is assessed given a body of epidemiological and toxicological studies, various judges appealed to arbitrarily high standards for the kind of research of relevance to assessment of toxicity. This in turn led to failure after failure at redress for plaintiffs. Given the great expense of toxic torts, and the high chance of failure on the part of plaintiffs, Cranor argues that this effectively shrunk the deterrence effects of toxic torts cases, leading all of us to be more vulnerable to harm from industry, which of course was no longer motivated to be particularly cautious about workplace exposure or externalities.

The final chapters explain and describe how weight of evidence is assessed in service of scientifically warranted judgments of toxicity, and discusses how the relatively recent Lautenberg Act attempts to reform and address some of the failures of Toxic Substances Control Act. One particular chapter, “How Demands for Ideal Science Undermine the Public’s Health,” should, in my view, be required reading for all federal court judges. Cranor reviews why a scientific ideal (represented by Furst) has mistakenly guided judges’ views about what is required to establish toxicity. The details matter, but his point can be put relatively straightforwardly: sufficient evidence for belief, in terms of ideal scientific “proof” of causation, is a different matter from sufficient evidence for protecting the public from harm. There is a difference, in other words, between evidence we require for belief in the ideal case in science, and what evidence we ought to require to act in the context of regulatory policy and toxics law.

What may Cranor have done better? The book is written for a broad audience, and based on Oxford lectures, so he had limited space, but it may have been useful – at least for philosophically inclined readers – to delve deeper into the principles underlying some of his arguments. For instance, in some of his discussion of law and policy, he makes reference to Rawls’s principles of justice; not all readers may have been moved by this appeal, and so cashing out how and why one might arrive at the same general conclusions from different starting points might have an interesting and worthwhile project. Another concern is to do with the matter of distinguishing warrant for belief and warrant for action. Perhaps making more explicit when there can be good grounds for appeal to values in setting standards of evidence for legal action might have been useful. While philosophers of science are (by now) mostly convinced that values of some sort or other play some role in setting standards of evidence, a careful explanation of why such a view can be maintained consistently without denying objectivity, by Cranor’s lights, might have been valuable. In particular, how and why should we make the role of values in setting standards for policy relevant science transparent? What counts as adequate transparency? Others (Mayo, Steel, Douglas, and Cranor himself) have spoken to this question of precaution and values in science, but it may have been useful to have a general overview of this matter in the context of discussion of Furst’s standards, for example, toward the end of the book. One can imagine some philosophically naïve readers pushing back against Cranor’s claim that ideal evidence for scientific “proof” is simply not appropriate in contexts of the law and toxic torts: Why not, they may ask? Isn’t that exactly why we appeal to science in the first place, to settle matters of fact, before we turn to matters of value? Speaking to this all too common view of the nature of objectivity and “proof” in science may have been helpful.

That said, the book is an engaging and provocative discussion of the history of regulatory and tort law, covering the history leading up to the Clean Air Act, the Clean Water Act, the Toxic Substances Control Act, and the precedents in toxic torts, including but not limited to the Daubert v. Merrill Dow Chemical. In addition, it brings readers up to date with the current law, providing a nuanced explanation of the science of environmental toxins, and its import for law and policy. I would not hesitate to assign this book in any course in philosophy of public health, bioethics, environmental ethics, law or policy. Philosophers of science, law and environmental policy especially can gain from this book, not only in teaching, but also in informing their own thinking. It not only reviews the history of environmental regulation, but brings those who brings readers familiar with toxics law up to date: explaining how and why the Lautenberg Act (which was passed just as the author was completing the book) attempts to improve upon the 1976 TSCA, or Toxic Substances Control Act, and how it may have done far better. I sincerely hope more philosophers of science seek to follow Cranor’s example of socially engaged philosophy of science, in service of better law, and better health.

Anya Plutynski

Washington University in St. Louis

St. Louis, MO



References

Toxic Substances Control Act 15 U.S.C. ch. 53 (1976)

Daubert v. Merrell Dow Pharmaceuticals, Inc. 509 U.S. 579 (1993)

Cranor, C. (1997). Regulating toxic substances: A philosophy of science and the law. Oxford: Oxford University Press.
———. (2006a). Towards a non- consequentialist approach to acceptable risks. In Tim Lewens (Ed.), Risk: Philosophical Perspectives (36– 53). London: Routledge.
———. (2006b). Toxic torts: Science, law, and the possibility of justice. Cambridge: Cambridge University Press.

———. (2011). Legally poisoned: How the law puts us at risk from toxicants. Cambridge, MA: Harvard University Press.

Book Reviews

Cathy Gere, Pain, Pleasure, and the Greater Good: from the Panopticon to the Skinner box and beyond, University of Chicago Press, 2017

The opening pages to Pain, Pleasure, and the Greater Good read almost like an historical mystery or an ethical “whodunit,” (hint: it was the Utilitarians), capturing the reader’s attention immediately. It is certainly pleasing to encounter a work on utilitarianism that is not another dry philosophical text. Yet, ultimately, do the author’s philosophical points get lost in the rhetorical intricacies? I will return to this question at the end of the review.
In the introduction, Cathy Gere sets out her intellectual territory by discussing the notorious Tuskegee medical study, which, alongside the medical war crimes of the Third Reich, is usually seen as starting the discussion on the ethics of medical research. Insightfully, Gere points out that at stake was not a battle between good and evil, but a “conflict between two different conceptions of the good” (4). One, the greatest good for the greatest number – medical utilitarianism – and the other, informed consent. The rest of the book traces the history – and triumphs – of medical utilitarianism.

We are perhaps so used to multiple informed consent forms in our own personal medical encounters that we forget how recently these forms became an established part of medical procedures and research practices in Anglo-European medicine. Gere’s analysis serves as a useful reminder that it was only in the 1970s that the philosophical foundations for medical ethics were fully established. These are understood to be autonomy (we have the right to decide what happens to us), beneficence (essentially the costs versus benefits of research), and justice. This third pillar of justice was to ensure that research subjects were not solely drawn from vulnerable populations, and Gere points out that justice has since become assimilated into informed consent policies and procedures. Thus, autonomy is morally primary in research ethics, but beneficence – essentially (medical) utilitarianism – is a close second.
Gere recognizes that utilitarian reasoning will always ground medical research, but she argues that we must understand why “informed consent arose as a necessary corrective” (12). The right to informed consent she aims to prove in this work “is a principle explicitly formulated to trump utility considerations” (225). Gere then supplies throughout the book convincing evidence of a long history of problematic theories and troubling scientific experiments that were supposedly justified by considerations of utility. One particularly gruesome example from the late 1800s is the case of Mary Rafferty, who presented at a hospital with an ulcer so deep that part of her cerebral cortex was exposed. American physician Roberts Bartholow decided to probe her brain with a needle to see her responses, an experiment intended to gain scientific knowledge but not to treat Rafferty herself. Unsurprisingly, Rafferty was caused pain and suffering. After four days of experiments, she fell into a coma and subsequently died.

Medical utilitarianism, argues Gere, is not a moral procedural overlay on top of apparently value-neutral medical research. Rather, it is a fundamental worldview of the medical subject itself, the human animal, a subject driven by pain and pleasure, reward and punishment. And it is the history of this animal – through Gere’s account of utilitarian theory(ies) – that drives this book. This history begins in Chapter Two, which is primarily a discussion of Bentham’s utilitarianism. Gere offers a charmingly written overview of Bentham’s life and philosophy. But it is unclear – at least to this reader – the purpose of this overview. There are more insightful accounts of both the man and his theories elsewhere. But Gere’s philosophical biographies multiply, leaving the reader struggling to find the argumentative core of this central chapter for the book. We are offered biographies of Hobbes, and Locke, with a brief excursion into the lives and thought of Hutcheson, Hume, Smith, Beccaria, Hartley, and Priestly, all in only 20 pages. We then circle back to Jeremy Bentham, only to be informed of such minutiae as the street where he was born and the marital happiness of his parents.

Chapter Four examines the contributions of the next generation of British utilitarians, such as John Stuart Mill and the utilitarian psychology of Alexander Bain. In many ways, the discussion of Bain is more significant than that of Mill, as the former is often neglected in histories of philosophy and science. Bain provided a material foundation for human psychology. As Gere notes, his theory was not especially original, but it was historically important because it was grounded on the primal experiences of pleasure and pain. Chapter Five traces the history of utilitarian psychology in America, and we learn of some horrific human experiments that were performed under the guise of the search for scientific knowledge. These experiments were driven by the relief of pain or the production of pleasure; for example, Robert Heath “cured” one young man’s homosexuality by associating heterosexual sex with the pleasurable stimulation produced by electrodes implanted in his brain.

In the final chapter, we are in the closing decades of the twentieth century. This final chapter may be the most fascinating and informative of the book, because, among its elements, Gere explains how the “sovereign individual of reformist medical ethics” has mutated “from informed citizen to empowered consumer” (204). The advent of AIDS meant that thousands of people were desperate for treatment to save their lives, and they were not prepared to wait for drugs to go through lengthy FDA approved trials. AIDS activists argued that they had the right to choose for themselves to participate in experimental drug trials. Thus, the autonomous individual was now making a utilitarian argument: arguing for pain avoidance for the benefit of the many with AIDS.

Gere’s work is potentially important, adding to critiques of medical utilitarianism. However, it repeats what is essentially the Kantian-utilitarianism dichotomy without allowing for alternative perspectives or questioning the legitimacy of the dichotomy itself. Gere’s work is historiography and not intended to be a meta-ethical discussion, so perhaps this last comment is unfair. However, even taken as history of philosophy, the work is at times shaky. While the first references to the author’s own philosophical history may serve to humanize the work and draw in the reader, this particular reader grew weary of the many references to such things as reading philosophy in Christ Church Meadows in Oxford (23). Such autobiographical references seem to serve little intellectual purpose, and they sometimes strike false notes.

This latter comment may seem like a petty point, but it seems to be part of a bigger problem with this work. Unnecessary repetitions between chapters eventually make the work seem casually written, and the chapters themselves did not connect and build well one onto the other. Often there is jarring modern slang: Bentham “burned” through his formal education (86); Henry Beecher “nailed it” (47). Overall, the impression is that one is reading a series of lectures for students by the “cool” professor. We get vignettes of famous philosophers and amusing descriptions of their foibles or absent-minded antics; for example, Thomas Hobbes is anachronistically described as having “a little soul patch beneath his lower lip” (70); and Adam Smith’s The Theory of Moral Sentiments can “profitably be read as an Enlightenment version of How to Win Friends and Influence People” (83).

Writing intertwined history and philosophy is difficult. When Gere’s work is seamless, it sparkles. But too often the different elements are not interwoven carefully and the reader is left wondering what purpose the information and arguments serve. A firm copy editor should have taken this text in hand. Ultimately, I am disappointed. I wanted to like the work very much.

Catherine Villanueva Gardner

University of Massachusetts

Dartmouth

Book Reviews

Katie Watson, Scarlet A: The Ethics, Law, and Politics of Ordinary Abortion, Oxford University Press, 2018

“This book isn’t a blueprint for a new conversation. It’s an explanation of why we need one, and an invitation to participate in moving that forward,” (12) says Katie Watson in the introduction to her book Scarlet A: The Ethics, Law and Politics of Ordinary Abortion. She does herself a disservice with this; in many respects her text provides us with just that – a model for what a more productive discussion of how society responds to and organizes around the issue of unwanted pregnancy might look like; a question that has remained contentious across the centuries and for which we may never have an ‘answer’. It is precisely because perceptions of abortion are so hard to prise apart from our attitudes towards women, sex, social roles and the meaning of motherhood, that we may never find permanent peace – more a truce that each generation must work out for itself anew. And Watson’s book could well be a handbook this generation needs in its arsenal as it seeks a settlement for the 21st century.

Watson, a professor of bioethics and medical humanities, wrote this book while experiencing pregnancy herself and the text reflects, as she says, the journey she has been on as a lawyer, a woman and now a mother. I work as the director of communications for a British charity providing abortion care and advocacy and for my part read this book in the Autumn of 2018; I reflected upon her thoughts as we campaigned to fully decriminalize abortion in the UK – including in Northern Ireland, where there has been no access to lawful abortion. While the book is written in reference to the febrile conversation in the US, there is much that is relevant from a European perspective – and much we can learn from successes and challenges on either side of the Atlantic.

Scarlett A is a reference to the sentence given to the character Hester Prynne in the novel The Scarlet Letter; when pregnancy reveals she has committed the sin of adultery she is to forever wear a scarlet A as a symbol of shame. Watson contends abortion stigma today brands the women who need this care and the professionals who provide it with an invisible scarlet A that most women, and indeed many care providers, will never reveal. It is this stigma which prevents women from speaking about ordinary abortion, the theme which shares the title of this book. Watson identifies ordinary abortion as the key component missing from the conversation, a conversation which is dominated by heart-wrenching tales of extraordinary abortion including rape, fatal fetal anomaly, and pregnant 12 year olds. One in five US (and UK) pregnancies end in abortion and most are for the ‘ordinary’ reason of not wanting to be a mother, or expand one’s family, at that time – and it is real stories of ordinary abortion which pepper Chapters 1 and 2, interwoven with analysis of the competing abortion narratives – “abortion is always a difficult decision” (50) (the stories illustrate it isn’t); “abortion is a women’s issue” (60) (yet this neglects the fact that many abortions are the result of a decision taken within a relationship); abortion is about sex and promiscuity (yet abortion is also a family issue, and the majority of women who have abortions are already mothers). Why don’t we hear more stories of abortion as a straightforward decision, as a couples’ issue, as a family issue, Watson asks. Ordinary abortion is a large part of abortion experience and a small part of abortion narratives.

Chapter 3 explores the language we use to speak about abortion and which in turn shapes our debate, using the case of a 17 year old girl in a small Utah town who paid a local boy to assault her so that she would miscarry her 7 month pregnancy in legal proceedings that sought to establish that that pair had undertaken the attempted murder of a ‘human being’. Against this backdrop Watson looks at the vocabulary employed by all stakeholders in the abortion discussion – life/potential life, unborn child/pregnancy, late-term/midtrimester (to describe a second trimester abortion) – “none of our words… say whether abortion is ethical or should be legal. But every one of them seems to be the first step towards different conclusions, so of course, they’re contested. These linguistic gymnastics are part of why it makes it so hard to even start a conversation about abortion” (85). It is also one reason why Ann Furedi , author of the Moral Case for Abortion which Watson’s book references, believes those who are pro-choice should not skirt around words (she herself uses the word killing in relation to abortion). “I don’t think it helps to obfuscate or be mealy-mouthed. That creates the impression that you want to draw a veil over what happens. You have to be prepared to be quite blunt.”(Meredith, 2016) In the Utah case, a distressingly vulnerable teenager – extremely poor ( she lived in a house without running water), facing abandonment by a boyfriend who was a convicted criminal if she did not end the pregnancy – became the impetus for her state legislature to pass a bill defining self induced abortion as murder after prosecutors found they could not convict her under existing legislation. Watson describes her as being a minor in need whose needs were ignored by her community until she tried to harm her fetus, and “Then her fetus got the attention she did not.”(90) The case thus provides the perfect segway in to the sentiments of Chapter 4 of the respective positioning of woman and fetus – “We can see a woman, or we can see her embryo or fetus, but we can’t see both simultaneously” (100).

In her subsequent critiques of the approaches to abortion ethics, which Watson broadly distinguishes between autonomy approaches that focus on women and biological ones, which focus on embryos or fetuses; and the public health ones which skirt around both – that women will suffer greater harm if abortion is inaccessible – she provides an excellent account of the various underpinnings used to argue whether abortion is permissible – and if so – in Chapter 5, then when. And she also reaches into whether it is acceptable to ask why, and to question whether the phrase “don’t judge me” (173) – is really apt. “Pro-choice doesn’t mean you can’t have opinions about other people’s choices, or that you can’t think a woman is wrong about moral status. To be ‘pro-choice’ is to recognize that your neighbor is a moral thinker too. In a pluralistic society, she’s allowed to disagree with your assessment, and you must have reciprocal respect for each other’s conclusion”(172). She argues the need to understand that when you disagree with someone’s reasons for abortion, that what is really happening is you are disagreeing on the moral status of embryos or fetuses; “moving from judgment of reasons to disagreement on moral status can help us productively discuss our true conflict”, Watson argues. And it is with the same clarion call for honesty in Chapter 6 that she navigates the clinic TRAP laws – or ‘Trojan Horse’ abortion regulations aiming to create obstacles to access under the false guise of patient safety as well as regulations mandating waiting periods, dressed up to look like a minor imposition, a sensible precaution to ensure a woman is certain of her choice, but with the effect of infantilizing women, besmirching doctors, and in areas where clinics are few are far between, creating significant delays to care or make associated costs prohibitive. This climate of what Watson calls “structural stigma” (184) in which doctors can also be forced to read from a script regardless of the needs of the individual patient before them, in which abortion is treated differently from all other forms of healthcare, are far more damaging than clinic blockades by protesters. And in a heartbreaking but perfectly pitched epilogue, Watson recounts her own abortion following a diagnosis of a fetal anomaly; the conversation with the hospital where she was receiving her prenatal care where an abortion cost $20,000 rather than the $700 at Planned Parenthood, but where some women still preferred to go to avoid the stigma of attending an abortion clinic. Watson tells us how she too considered not using her insurance to pay for her abortion to keep this visit separate from the rest of her life – “but a study I read finding that a large number of women with private insurance still choose to pay for their abortion themselves struck me as a sad, expensive expression of abortion stigma, and remembering that keeps me on track. Pulling out my insurance card suddenly feels like a political statement.” (225)

It’s a fine ending to this book, and one which Watson clearly struggled with whether to include. Although hers is an ‘extraordinary’ abortion, for her, her own decision sits alongside of all those belonging to other women who felt that they were not in the position to parent this child at this particular time in their lives.

From my perspective, I do think we have made huge strides in telling women’s stories – both extraordinary and ordinary – although there is much work still to be done. Stigma silences the voices of the ordinary, but it is also true that when it comes to direct campaigning we do not hang our hats on tales of ordinary abortion. We find the examples we believe most likely to help us achieve our political goals, and which will motivate constituents to lobby their elected representatives for change. This is certainly not problem-free, as Watson identifies, and her book made me reflect on the importance of weaving ordinary abortion into everything we do. But I felt her book was at its most pioneering and thought-provoking in its exploration of the issues and identities of providers, and the particular and pernicious ways in which the current abortion discussion stigmatizes them and undermines the work they do. We have yet to adequately tell the story of the doctors, nurses, and midwives who provide care to women day in, day out – some still unable to tell their own families what it is they do. A key component of the book is the identification of the ‘beneficiaries’ of abortion – the women who receive them, of course, but also their partners, who may go on to establish a much loved family with somebody they want to start a family with, the children both may go on to have, the children they may already have. But Watson also identifies another group of beneficiaries: “all the physicians, nurses, hospital administrators, and other healthcare workers who would be personally devastated to see women harmed by unsafe abortion, and who could provide this service themselves, but choose not to. Like men who benefit from their girlfriend’s choice to have an abortion, these clinicians benefit from their colleagues’ choice to provide abortion.”(192) As put by Dr Lori Freedman, physicians want both distance from abortion and someone skilled to send their patients too. But this has a sometimes considerable cost to those who provide the abortions, who carry the burden of responsibility for an entire abortion service – often leaving little space to carry out other gynaecological or obstetric practices which may bring them professional satisfaction – and become the target of various restrictions and regulations that do not apply to other areas of medical care. Watson highlights how the enthusiasm for accommodating conscientious objection to abortion within a medical practice is accepted as taking precedence over and above any doctor’s conscientious commitment to helping their patient obtain the abortion she wants. Her analysis of the framing of the doctor within the 2007 Supreme Court review of the partial birth abortion ban is superb – these doctors are not identified by medical specialty (obstetrician-gynaecologist, family physician, surgeon) but as abortion doctors, and at issue is whether they could be trusted to provide patients with details of what the partial birth abortion – itself a loaded term – would involve, that this would be a procedure they would undertake for ‘convenience’ to themselves. Watson deftly tracks the narrative of the doctor from Roe v Wade, cast as the hero rescuing the damsel in distress, to the demon of Gonzales v Carhart, where both woman and fetus needed to be rescued from the clinicians’ claws. She rightly highlights the way in which supposedly benign mandatory waiting periods enforce this view of the doctor as untrustworthy, uncaring, at the same time as belittling women. “They insult physicians – your state thinks you are so despicable that is a patient expressed uncertainty in the consent process, instead of suggesting she come back if and when she’s certain, you would herd her through for an abortion anyway.”(187-188) It was depressing to see that Ireland, in its much heralded new abortion legislation written from scratch, also opted for the mandatory waiting period and the continued criminalization of doctors in a way unmatched in any other form of Irish healthcare.

One of the abortion beneficiaries Watson identifies, an interviewee whose girlfriend ended a pregnancy while they were at college, but who has never spoken of it, or the life it has enabled him to live, comments on the need for more people to “come out”(72) about abortion. This attempt to draw parallels with the LGBT movement appears so obvious, and so tempting – particularly in the lights of the gains made on that front. But Watson is right to stress the problems of this approach – abortion is not an identity for the individual women who needs one. It is one event, usually not repeated, that may give her ownership of her own life story but which does not define her. No woman aspires to have an abortion – and on this side of the Atlantic we too are familiar with the philosophy of abortion support which runs “rape, incest, and me”(23), and not infrequently see women who say they are against abortion, but that their circumstances are different to those of the other women waiting. It explains why many of the direct beneficiaries of abortion would not necessarily be guided by that issue when it came to the polls – if it’s a service they have received, they might assume they will never need it again, and if they haven’t, they have no expectation they may need to – particularly in a climate where abortion is routinely stigmatized and exceptionalised. But for providers, not least because of the way abortion services are organized in the US – and also the UK, providing abortion care is their professional identity – and I absolutely share Watson’s view that were there to be a Will and Grace of abortion it would be providers who took center stage.

But while abortion itself as a singular event may never be an identity, there are crucial dots that must be drawn between abortion and other areas where reproductive autonomy is being eroded. I was surprised that Watson, writing from a US context where the relationship between abortion restrictions and persecution of women deemed to pose a risk to or to have harmed their fetus is more obvious than elsewhere, did not pursue this further. Paradoxically in the UK, we see support for women’s access to abortion growing at the same time as we see mounting censorship of women’s behavior in pregnancy – and indeed increasingly pre-pregnancy, including of women who have no desire or intention to get pregnant. Women of childbearing with epilepsy are now refused access to a particular drug, Sodium Valproate, unless they agree to accept a Long Acting Reversible Method of contraception and undergo regular pregnancy testing on the basis that the drug is known to be teratogenic to the fetus. It is important that women are fully informed of the risks to the fetus were they to become pregnant on this drug, but this new policy now effectively curtails women’s right to access the treatment most suited to her over the health of a fetus that does not even exist. It is particularly disheartening to see this recent development at a time when women with uncontrolled epilepsy remain among the most likely to die in pregnancy – often because they have come off medication for fear of harming their fetus. In a climate where obesity is now deemed to pose a risk not just to the fetus, but the future children of that fetus (even though the evidence for this is shaky in the extreme) women with high BMIs can struggle to persuade healthcare professionals to remove IUDs and implants to enable them to get pregnant. Although a case in 2014 seeking to establish that a woman who whose child was born with Fetal Alcohol Syndrome committed a crime by drinking in pregnancy failed, there is a relentless focus on the harms women cause their offspring by alcohol consumption. A new test is being developed in Scotland to establish whether a newborn’s first meconium can be used to accurately establish a woman’s alcohol use in pregnancy. The news of this development, which raises all manner of ethical questions about how it will be used, on whom, and what the consequences will be, was largely met with either indifference or support in a climate where fetuses are increasingly deemed to be at risk from the reckless actions of their mothers.

We may believe these initiatives are all aimed at ensuring the best possible outcomes for babies. Yet the fact that, in the UK at least, where the clear link between folate deficiency and neural tube defects in babies was first made decades ago, we have failed to fortify our flour with folic acid to improve pregnancy outcomes on the basis that we would be interfering in the diets of the entire public, not just women – shows these measures are often not driven by the desire for better outcomes but underpinned by the other social concerns such as obesity and alcohol, and the need to control women and their behavior. Which brings us back to abortion. In the final pages of her book, Watson gives us the image of the Russian Doll. “Nested inside an argument about embryonic and fetal status is a hidden argument about the proper role of women….Conflict is only productive when we’re honest about the real reasons we’re fighting. Let’s transform our political bickering into productive fighting by further unpacking the Russian Doll of abortion, and openly discussing how recent social changes are affecting people both practically and emotionally…if some abortion conflicts are largely about issues like gender, sexuality, and religion, it would be more productive to identify our true disagreements and discuss them directly.”(207)

And this is the real challenge that awaits us. Abortion discussions so often hinge on a wide range of other social tensions. A case in point is the opprobrium over sex selective abortion – where racists, feminists and anti-abortion campaigners unite in a curious alliance to crusade against a practice which largely does not exist in countries where there is not significant gender inequality – and, where it does take place, the answer is not to further restrict women’s already limited reproductive choices but challenge the misogyny that underpins and drives son preferences. Abortion is absolutely wrapped up in perceptions of good women and bad women, and nested inside that – to borrow Watson’s Russian doll analogy – good abortions and bad abortions, often also synonymous with the extraordinary and the ordinary. The role this book plays in bringing ordinary abortion to the fore, telling its story and casting the spotlight on its many beneficiaries, is invaluable to anyone involved in or looking to join the debate about abortion in the 21st Century, wherever they may be.

Clare Murphy

Director of External Affairs

British Pregnancy Advisory Service

London, UK

 

 

References:

Meredith, F. (2016, October 21). ‘The end of a life in the womb doesn’t compare with any other taking of human life’. The Irish Times. Retrieved from https://www.irishtimes.com/life-and-style/people/the-end-of-a-life-in-the-womb-doesn-t-compare-with-any-other-taking-of-human-life-1.2804888