This is a review article of Elizabeth Barnes’ new book, Health Problems. In this article, I try to offer a sense of where this exciting sub-discipline of philosophy of medicine has got to. I do that in three ways. First, I make a few comments on the general idea that there are theories of health competing in the field of philosophy of medicine; second, I offer specific comments on the phenomenological approach; and finally, I comment on Barnes’ claim that health (...) is messy. I do not provide an overview of the book but a response to some of its themes. (shrink)

1. In her latest book (Jefferson, 2022), “Are Mental Disorders Brain Disorders?”, Anneli Jefferson (AJ) argues that mental disorders can be considered brain disorders when they involve brain dysfun...

The authors of the articles in this issue of The Journal of Medicine and Philosophy address a wide variety of topics, from definitions of disease to bioenhancement. Each author, however, draws out the importance of careful use of language. Over the years, philosophers of medicine and bioethicists have debated questions such as what qualifies something as a disease, whether disease language is evaluative, whether the term “person” encompasses more than just human beings, and what language ought to be used to (...) best convey complex information to patients. Among a great deal of disagreement on these topics, one thing emerges distinctly: that clarity and careful attention to language is paramount in medicine. The articles in this issue contribute to that conversation, presenting complex arguments and illustrative examples of why it is so important to use clear and well-defined terms in medicine, and of the reality-altering power that our language carries. (shrink)

The first National Health Service (NHS) was introduced in the United Kingdom providing free universal health care (UHC) at the point of use. Within decades, increasing European countries adopted the same intervention to improve the health of citizens on the entire life span. Today, several reasons put at risk (1) empirically, the sustainability and fairness of these systems, (2) theoretically, the same consistency of solidarity, as vulnerable patients struggle most to receive essential care. Preserving solidarity from the pressure of modern (...) medicine and society needs to identify a fair and sustainable type of coverage at the same time. This paper aims (1) to describe the short circuit of solidarity in European NHSs; (2) to discuss alternative versions of UHC and support redistributive neo-universalism; (3) to promote the role of medical humanities in implementing this solution. (shrink)

In this article, I side with those who argue that the debate about the definition of “disease” should be reoriented from the question “what is disease” to the question of what it should be. However, I ground my argument on the rejection of the naturalist approach to define disease and the adoption of a normativist approach, according to which the concept of disease is normative and value-laden. Based on this normativist approach, I defend two main theses: (1) that conceptual analysis (...) is not the right method to define disease and that conceptual engineering should be the preferred method and (2) that the method of conceptual engineering should be implemented following the principles of Alexandrova’s account of social objectivity in the context of the definition of disease. (shrink)

Brain age prediction is a relatively new tool in neuro-medicine and the neurosciences. In research and clinical practice, it finds multiple use as a marker for biological age, for general health status of the brain and as an indicator for several brain-based disorders. Its utility in all these tasks depends on detecting outliers and thus failing to correctly predict chronological age. The indicative value of brain age prediction is generated by the gap between a brain’s chronological age and the predicted (...) age, the brain age gap (BAG). This article shows how the clinical and research use of brain age prediction tacitly pathologizes the states that it is sensitive to. It will be argued that the tacit character of this transformation conceals the need for its explicit justification. (shrink)

It is widely accepted that children enjoy some form of a right to bodily integrity. However, there is little agreement about the precise nature and scope of this right. This paper offers a conceptual analysis of the child's right to bodily integrity, in order to further elucidate the relationship between the child's right to bodily integrity and considerations of autonomy. Following a discussion of Leif Wenar's work on the structure and justification of rights, I first explain how the adult's right (...) to bodily integrity can be distilled into separate elements that may plausibly be justified by different moral considerations. In particular, I claim that this analysis suggests that whilst the adult's right to bodily integrity is not wholly reducible to bodily autonomy, autonomy nonetheless remains entwined with our understanding of this right in a number of ways. On the basis of this discussion, I go on to outline three important complexities that arise when we consider the child's right to bodily integrity, before particularly focusing on the question of how third parties should determine whether or not to perform a physical interference upon a child who lacks decision-making capacity. Here, I raise some objections to Earp and Mazor's recent attempts to answer this question, before briefly defending an ‘autonomy-based interests’ account of permissible interference, an account that shares in what I take to be the spirit, if not the precise letter, of these earlier views. (shrink)

Despite what many critics see as an inability to deliver much in the way of therapeutic value (Hunter and Drazen 2019), genetics remains a bottomless source of fascination, trepidation, and reflect...

There is little debate regarding the acceptability of providing medical care to restore physical or mental health that has deteriorated below what is considered typical due to disease or disorder (i.e., providing “treatment”—for example, administering psychostimulant medication to sustain attention in the case of attention deficit disorder). When asked whether a healthy individual may undergo the same intervention for the purpose of enhancing their capacities (i.e., “enhancement”—for example, use of a psychostimulant as a “study drug”), people often express greater hesitation. (...) Building on prior research in moral philosophy and cognitive science, in this work, we ask why people draw a moral distinction between treatment and enhancement. In two experiments, we provide evidence that the accessibility of health-related interventions determines their perceived descriptive or statistical normality (Experiment 1), and that gains in descriptive normality for such interventions weaken the moral distinction between treatment and enhancement (Experiment 2). In short, our findings suggest that the tendency to draw a moral distinction between treatment and enhancement is driven, in part, by assumptions about descriptive abnormality; and raise the possibility that normalizing novel biomedical interventions by promoting access could undermine people’s selective opposition toward enhancement, rendering it morally comparable to treatment. (shrink)

The dual role of microbial communities as either beneficial/functional or harmful/pathogenic involves two issues concerning causality in physiology and medicine, etiology of disease, and the notion of function in biology. Causal explanation formulated by the germ theory of disease and the Koch postulates connects the existence of a specifically identified microbe to disease by the isolation and identification of a pathogen from an organism with the disease and the successful infection of a healthy individual. Similarly, microbiome research in medicine centers (...) on taxonomic composition in correlation with physiological conditions and germ-free mice experimentations to establish causal connections. However, because the microbiome is an ecological community, it lacks the specificity of identification assumed in the germ theory. Furthermore, the ecological aspects within and between microbiomes such as background conditions, microbial interactions, and interdependence, are treated as confounding. Looking at ecological studies, the causal explanations are less specific regarding complex systems with their processes of interactions. This article makes the following two points: One is that microbiome causality in the host should be understood similarly to the microbiome causality in an ecosystem. The second is that if considering a microbiome’s causality in the host as an ecosystem, its etiological explanation needs to be revisited to include a heterogeneous and mutual notion of interactions. Finally, according to the second point, the notion of function in ecology with its relevant notion of causality should be considered accordingly. (shrink)

In the philosophical debate on aging, it is common to raise the question of the theoretical definition of aging in terms of its possible characterization as a disease. Understanding aging as a disease seems to imply its medicalization, which has important practical consequences. In this paper, we analyze the question of whether aging is a disease by appealing to the concept of disease in the philosophy of medicine. As a result of this analysis, we argue that a pragmatist approach to (...) the conception of disease is the best alternative to highlight the relevance of the medicalization of aging. From this pragmatist perspective, it can be seen that the notion of aging is going through a conceptual change, and aging can today be understood as a not radically different process from any other condition that is usually considered a disease. (shrink)

As an alternative to linear and unidimensional perspectives focused mainly on either organic or psychological processes, the enactive approach to life and mind—a branch of 4-E cognitive theories—offers an integrative framework to study mental disorders that encompasses and articulates organic, sensorimotor, and intersubjective dimensions of embodiment. These three domains are deeply entangled in a non-trivial manner. A question remains on how this systemic and multi-dimensional approach may be applied to our understanding of mental disorders and symptomatic behavior. Drawing on Gilbert (...) Simondon’s philosophy of individuation, we provide some enactive conceptual tools to better understand the dynamic, interactive, and multi-dimensional nature of human bodies in mental disorders and psychopathological symptoms. One of such tools cursiva is sense-making, a key notion that captures the relational process of generating meaning by interacting with the sociomaterial environment. The article analyzes five aspects related to sense-making: temporality, adaptivity, the multiplicity of normativities it involves, the fundamental role of tension, and its participatory character. On this basis, we draw certain implications for our understanding of mental disorders and diverse symptoms, and suggest their interpretation in terms of difficulties to transform tensions and perform individuation processes, which result in a reduction of the field of potentialities for self-individuation and sense-making. (shrink)

The status of risk factors and disease remains a disputed question in the theory and practice of medicine and healthcare, and so does the related question of delineating disease boundaries. I present a framework based on Bernard Lonergan’s account of emergent probability for differentiating (1) generically distinct levels of systematic function within organisms and between organisms and their environments and (2) the methods of functional, genetic, and statistical investigation. I then argue on this basis that it is possible to understand (...) disease in terms of biological or higher intra-level dysfunction, risk factors—including genetic risk factors—in terms of statistical inter-level conditioning of a given stage or developmental sequence of systematic functioning, and the empirical boundaries of disease in terms of the limits of both functional categorization (from an epistemic standpoint) and upper-level integration of lower-level processes and events (from an ontological standpoint). (shrink)

The paper engages Christopher Boorse’s Bio-Statistical Theory. In its current form, BST runs into a significant challenge. For BST to account for its central tenet—that lower-level part-dysfunction is sufficient for higher-level pathology—it must provide criteria for how to decide which lower-level parts are the ones to be analyzed for health or pathology. As BST is a naturalistic theory, such choices must be based solely on naturalistic considerations. An argument is provided to show that, if BST is to be preserved, such (...) parthood choices are based on non-naturalistic considerations. We demonstrate that even when parthood choices are based on the best way to preserve BST, there are counterintuitive results which bring the central tenet of BST into question. (shrink)

The notion of harm has been a recurring and a significant notion in the characterization of mental disorder. It is present in eminent diagnostic manuals such as DSM and ICD, as well as in the discussion on mental disorders in philosophy of psychiatry. Recent demotion of harm in the definition of mental disorders in DSM-5 shows a general trend towards reducing the significance of harm when thinking about the nature of mental disorders. In this paper, we defend the relevance of (...) the notion of harm in the characterization of mental disorder against some of these attacks. We approach this issue by using the method of conceptual explication pioneered by Rudolf Carnap. Within this framework, we argue that keeping the notion of harm not only helps to discriminate what is pathological from the nonpathological but also prevents potential misuses of psychiatric authority. (shrink)

Metaphilosophy, Volume 53, Issue 1, Page 25-37, January 2022.

The COVID-19 pandemic once again confirmed that zoonotic diseases are a serious threat to humanity. These infectious diseases, transmitted from animals to humans, have the power to cause a global health crisis. Over time the risk on these outbreaks has increased. Some of the main drivers are global population growth, urbanization, worldwide transport, increased demand for animal protein, unsustainable agriculture, and climate change. This development has fueled a renewed interest in the relation between human, animal and environmental health. This was (...) framed in the concept of One Health: the integrative effort of multiple disciplines working locally, nationally, and globally to attain optimal health for people, animals, and the environment. At present, One Health is the worldwide standard to combat zoonotic diseases. In an ideal world such a strategy should lead to a better health for humans, animals and our environment. However, in practice it is not self-evident that a One Health approach in zoonotic disease control is actually in the interest of animals or the environment. From a holistic One Health perspective it can be difficult to accept the culling of healthy animals to protect public health. The same goes for long term confinement of free-range poultry, whose housing systems are often not suitable for this purpose, to prevent avian influenza outbreaks. Or antimicrobial reduction policies that lead to higher disease incidence and mortality in animals. These ethical considerations formed the start of this thesis. The aim of my research is to clarify the ethical assumptions of a One Health approach in zoonotic disease control, to explore how these can be coherently understood and justified and to indicate what this implies for policymaking. The outcome of my research contributes to the development of an ethic of One Health and will hopefully lead to a more socially acceptable zoonotic disease control. This project is related to the interdisciplinary Wageningen UR strategic research theme ‘Global One Health’. From my conceptual analysis, it follows that there is no universal interpretation of the One Health concept nor of a One Health approach in zoonotic disease control. Nevertheless, One Health has produced several successes in zoonotic disease control, surveillance and research. Due to its ambiguity, the One Health concept functions as a boundary object: by leaving room for interpretation to fit different purposes it facilitates cooperation. In many cases this results in the promotion of health of humans, animals and the environment. However, there are also situations in which this mutual benefit of a One Health approach is not that evident. For instance, when healthy animals are culled to protect public health. To address these moral dilemmas, it is important to develop an ethical framework. Such an ethic of One Health starts with acknowledging the moral status of animals and the indirect moral obligations we have towards ecosystems. Furthermore, it is necessary that we find an appropriate definition of health, which encompasses all three components of One Health. In chapter 3, I present the results of an empirical study on normative presuppositions of health professionals involved in zoonotic disease control policies in the Netherlands. This study reveals that in theory these professionals adhere to a holistic view of the One Health concept. However, in practice an anthropocentric approach was dominant. The study identified public health as a trumping moral value, which reveals an inherent field of tension with the core of One Health thinking. Furthermore, a lack of ethical expertise in control systems for zoonotic diseases can lead to misconception of ethical principles, like the precautionary principle. In chapter 4, I discuss that within a One Health strategy, that requires us to balance public health benefits against the health interests of animals and the environment, unrestricted use of the precautionary principle can lead to moral dilemmas. It must at least be clear that there is a harm and some scientific evidence for a cause and effect relation. Furthermore, precautionary measures should be effective, consistent, proportional and not counterproductive. An assessment of their effect should be integrated in the standard decision-models of public health authorities. Moreover, to ensure societal support these considerations should be transparent and open for dialogue. I present two possible conceptions of the precautionary principle. First, it is noticeable that because of the unpredictable nature of zoonotic diseases, public health authorities focus on the idea of ‘precaution as preparedness’. This reactive response leads to difficult trade-offs between human and animal health. I therefore argue that this policy should always be accompanied by a second policy: ‘precaution as prevention’. Addressing the underlying drivers of zoonotic diseases is a necessary condition to justify disease control measures that harm animals and ecosystems on the basis of the precautionary principle. In chapter 5, I elaborate the responsibilities of veterinarians within the One Health framework. Veterinarians are professionally responsible for the health and welfare of the animals under their care. Moreover, society expects veterinarians to safeguard food safety and public health. These societal expectations are sometimes overdemanding. A holistic perspective on One Health offers veterinarians a way out of the dichotomy between public and animal health, that is at the basis of many moral dilemmas in zoonotic disease control. This is explained with the ‘encapsulated health’ argument: the best way to safeguard human health is to promote the health of animals and the environment. In chapter 6, I conclude that before we decide to implement certain disease control measures, an ethic of One Health requires that we choose those interventions that have the least impact on the health of animals and ecosystems, while still effective enough to stop the disease. My research indicates that the contemporary conception of One Health is necessary but insufficient to address moral dilemmas related to emerging zoonotic diseases. A holistic interpretation of the One Health concept confronts us with underlying value conflicts but will ultimately promote human health more than the current anthropocentric conception. (shrink)

The recurring claim that the construct of psychopathy is value laden often is not qualified in enough detail. The chapters in this part of the volume, instead, investigate in depth the role and significance of values in different aspects of the construct of psychopathy. Following these chapters, but also by offering a background to them, we show how certain values are involved in the characterisation of psychopathy, inform societal needs satisfied by this construct, and have a central role in determining (...) whether psychopathy is a mental disorder. Moreover, we relate this description to our criticism of the view that the entrenchment of the notion of psychopathy with values in principle renders it irreconcilable with sound psychiatric theory and practice. However, we also recognize that the value-ladenness of psychopathy leaves open other important challenges. Meeting them needs addressing interdisciplinary interrelated issues that have empirical, normative, and theoretical dimensions. (shrink)

This paper explores the impact that developments in the field of neuroprosthetics will have on the ethical viability of healthy limb amputation, specifically in cases of Body Integrity Identity Dis...

The landscape of addiction is dominated by two rival models: a moral model and a model that characterizes addiction as a neurobiological disease of compulsion. Against both, I offer a scientifically and clinically informed alternative. Addiction is a highly heterogenous condition that is ill‐characterized as involving compulsive use. On the whole, drug consumption in addiction remains goal directed: people take drugs because drugs have tremendous value. This view has potential implications for the claim that addiction is, in all cases, a (...) brain disease. But more importantly, it has implications for clinical and policy interventions. To help someone overcome addiction, you need to understand and address why they persist in using drugs despite negative consequences. If they are not compelled, then the explanation must advert to the value of drugs for them as an individual. What blocks us from acknowledging this reality is not science but fear: that it will ignite moralism about drugs and condemnation of drug users. The solution is not to cleave to the concept of compulsion but to fight moralism directly. (shrink)

What are the worst conditions under which someone can be virtuous and happy? In this paper, I argue that a minimum threshold of favorable circumstances is necessary for moral virtue and human flourishing or happiness. Stoic and Aristotelian traditions make different and important claims about the role of external circumstances in our moral lives. Retrieving the ancient dispute benefits contemporary ethics. For one, the relevance of external circumstances is an important question for the development of present-day virtue ethics. For another, (...) identifying the minimal ingredients for virtue and happiness is helpful for wider ethical concerns such as discussions of our moral obligations to future generations. After explaining the ancient dispute, I describe categories of circumstances that seem intuitively relevant to virtue and happiness. Then, I investigate which are necessary and examine commonsense examples. I conclude that a minimum threshold of favorable circumstances from the following categories is necessary: the necessities for biological life, cognitive ability, and moral education. (shrink)

The “One Health” initiative promises to combine different health-related issues concerning humans and animals in an overarching concept and in related practices to the benefit of both humans and animals. Far from dismissing One Health, this paper nevertheless argues that different veterinary interventions are determined by social practices and connected expectations and are, thus, hardly compliant with only one single conceptualization of health, as the One Health concept suggests. One Health relies on a naturalistic understanding of health focusing on similar (...) bodies that show a similar etiology. However, logics, normativity, and practices exhibit differences when it comes to combatting infectious diseases, maintaining productivity of livestock animals or preventing companion animals from suffering. Therefore, drawing from Charles Rosenberg’s groundbreaking texts on framing disease, we suggest to conceive of health as dispersed in different frames. Thus, this paper proposes to interpret health as complex and multi-layered concept. We distinguish and introduce an objectivist, a functional, and a sentientistic frame of health. Instead of reducing the differential veterinary practices to one paradigmatic understanding, health is seen as a model case of Wittgenstein’s concept of family resemblance. Different and distinct perspectives on veterinary medicine show sufficient overlapping that allows for a common conceptualization, but there is not one single underlying logic suitable to understand and ethically reflect all veterinary interventions. This differentiability promises to reduce moral stress in veterinary professionals since it allows the interpretation of various, seemingly contradicting practices as dependent on multi-layered and socially determined scopes of responsibility. (shrink)

I explore the role that values and interests, especially ideological interests, play in managing and balancing epistemic risks in medicine. I will focus in particular on how diseases are identified and operationalized. Before we can do biomedical research on a condition, it needs to be identified as a medical condition, and it needs to be operationalized in a way that lets us identify sufferers, measure progress, and so forth. I will argue that each time we do this, we engage in (...) epistemic risk balancing that inevitably draws upon values and interests, often including social and ideological values. My main interest here is in the conceptualization of infertility as a disease. Infertility is a rich test case for exploring the interplay between interests and epistemic risk management. There is no uncontested or standardized definition of infertility. The various definitions of it are internally ambiguous and tension-ridden, and in spectacular contradiction with one another. Many interest groups who are invested in framing infertility as a pressing problem deserving of social and medical redress are quick to insist that it is a legitimate ‘disease,’ but they cannot agree on which disease it is, what its symptoms or diagnostic markers are, or even what its basic ontology is. I suggest that there are political explanations for this epistemic mess. Indeed, I contend that there are good scientific and ethical reasons to reduce away the category of ‘infertility,’ especially understood as a scientific or medical category; I argue that we should excise the concept from our research and clinical practices. (shrink)

The general definition of mental disorder stated in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders seems to identify a mental disorder with a harmful dysfunction. However, the presence of distress or disability, which may be bracketed as the presence of harm, is taken to be merely usual, and thus not a necessary requirement: a mental disorder can be diagnosed as such even if there is no harm at all. In this paper, we focus on the (...) harm requirement. First, we clarify what it means to say that the harm requirement is not necessary for defining the general concept of mental disorder. In this respect, we briefly examine the two components of harm, distress and disability, and then trace a distinction between mental disorder tokens and mental disorder types. Second, we argue that the decision not to regard the harm requirement as a necessary criterion for mental disorder is tenable for a number of practical and theoretical reasons, some pertaining to conceptual issues surrounding the two components of harm and others pertaining to the problem of false negatives and the status of psychiatry vis-à-vis somatic medicine. However, we believe that the harm requirement can be maintained among the specific diagnostic criteria of certain individual mental disorders. More precisely, we argue that insofar as the harm requirement is needed among the specific diagnostic criteria of certain individual mental disorders, it should be unpacked and clarified. (shrink)

Patient-reported outcomes are frequently used for medical decision making, at the levels of both individual patient care and healthcare policy. Evidence increasingly shows that PROs may be influenced by patients’ response shifts and dispositions. We identify how response shifts and dispositions may influence medical decisions on both the levels of individual patient care and health policy. We provide examples of these influences and analyse the consequences from the perspectives of ethical principles and theories of just distribution. If influences of response (...) shift and disposition on PROs and consequently medical decision making are not considered, patients may not receive optimal treatment and health insurance packages may include treatments that are not the most effective or cost-effective. We call on healthcare practitioners, researchers, policy makers, health insurers, and other stakeholders to critically reflect on why and how such patient reports are used. (shrink)

The philosophy of medicine is an area that has experienced significant growth and change in the last decade or so. While usually thought to be distinct from bioethics, the philosophy of medicine addresses a wide range of questions having to do with epistemology, metaphysics, and values. In this survey, I use the concept of the reference class to draw connections between a number of questions of longstanding and of more recent concern in the philosophy of medicine. By focusing on the (...) way in which the reference class plays a role in questions and approaches that sometimes seem to be at odds with one another, I hope to illustrate the ways in which these oppositions are less complete than they might at first appear, and to show how the connections between different problems are being redrawn. (shrink)

Current advances in assisted reproductive technologies aim to promote the health and well-being of future children. They offer the possibility to select embryos with the greatest potential of being born healthy (eg, preimplantation genetic testing) and may someday correct faulty genes responsible for heritable diseases in the embryo (eg, human germline genome modification (HGGM)). Most laws and policy statements surrounding HGGM refer to the notion of ‘serious’ as a core criterion in determining what genetic diseases should be targeted by these (...) technologies. Yet, this notion remains vague and poorly defined, rendering its application challenging and decision making subjective and arbitrary. By way of background, we begin by briefly presenting two conceptual approaches to ‘health’ and ‘disease’: objectivism (ie, based on biological facts) and constructivism (ie, based on human values). The basic challenge under both is sorting out whether and to what extent social and environmental factors have a role in helping to define what qualifies as a ‘serious’ disease beyond the medical criteria. We then focus on how a human rights framework (eg, right to science and right to the highest attainable health) could integrate the concepts of objectivism and constructivism so as to provide guidance for a more actionable consideration of ‘serious’. Ultimately, it could be argued that a human rights framework, by way of its legally binding nature and its globally accepted norms and values, provides a more universal foundation for discussions of the ethical, legal and social implications of emerging or disruptive technologies. (shrink)

The article examines the relationship between a trait’s effect on survival and reproduction and the notion of functional efficiency underlying the biostatistical theory of health. BST faces the problem of how to measure a trait’s joint effect on survival and reproduction in its account of function. If one measures the joint effect by means of the biological notion of fitness, examples such as the hereditary breast and ovarian cancer syndrome do not count as a disorder. If one does not invoke (...) biological fitness, it is unclear how to measure the joint effect while keeping to BST’s naturalist credentials. (shrink)

Volume 19, Issue 7, July 2019, Page 45-47.

The range of opportunities people enjoy in life largely depends on social, biological, and genetic factors for which individuals are not responsible. Philosophical debates about equality of opportunities have focussed mainly on addressing social determinants of inequalities. However, the introduction of human bioenhancement should make us reconsider what our commitment to equality entails. We propose a way of improving morally relevant equality that is centred on what we consider a fair distribution of bioenhancements. In the first part, we identify three (...) main positions in the debate on bioenhancement and equality, and we show how each of them fails to meet the demands of a serious commitment to equality. In the second part, we formulate a new proposal that we think better promotes equality of opportunities: people from disadvantaged socio-economic backgrounds should be given access to bioenhancements while people from privileged socio-economic background should be prohibited from using them. We argue that those who are concerned about the inequality implications of bioenhancement should embrace this solution, rather than reject bioenhancement. (shrink)

Developments in Non-Invasive Prenatal Testing (NIPT) and cell-free fetal DNA analysis raise the possibility that antenatal services may soon be able to support couples in non-invasively testing for, and diagnosing, an unprecedented range of genetic disorders and traits coded within their unborn child’s genome. Inevitably, this has prompted debate within the bioethics literature about what screening options should be offered to couples for the purpose of reproductive choice. In relation to this problem, the European Society of Human Genetics (ESHG) and (...) American Society of Human Genetics (ASHG) tentatively recommend that any expansion of this type of screening, as facilitated by NIPT, should be limited to serious congenital and childhood disorders. In support of this recommendation, the ESHG and ASHG cite considerations of distribution justice. Notably, however, an account of justice in the organization and provision of this type of screening which might substantiate this recommendation has yet to be developed. This paper attempts to redress this oversight through an investigation of Norman Daniels’ theory of Just health: meeting health needs fairly. In line with this aim, the paper examines what special moral importance (for Just health) screening for the purpose of reproductive choice might have where concerning serious congenital and childhood disorders in particular. The paper concludes that screening for reproductive choice where concerning serious congenital and childhood disorders may be important for providing women with fair opportunity to protect their health (by either having or not having an affected child). (shrink)

In their paper “Is psychopathy a mental disease?”, Thomas Nadelhoffer and Walter Sinnott-Armstrong argue that according to any plausible account of mental disorder, neural and psychological abnormalities correlated with psychopathy should be regarded as signs of a mental disorder. I oppose this conclusion by arguing that at least on a naturalistically grounded account, such as Wakefield’s ‘Harmful Dysfunction’ view, currently available empirical data and evolutionary considerations indicate that psychopathy is not a mental disorder.

There has been much debate about whether the concept of disease articulated in Boorse’s biostatistical theory is value-neutral or value-laden. Here, I want to examine whether this debate matters. I suggest that there are two basic respects in which value-ladenness might be important: it could threaten either scientific legitimacy or moral permissibility. I argue that value-ladenness does not threaten the scientific legitimacy of our disease-concept because the concept makes little difference to the formulation and testing of scientific hypotheses. Likewise, even (...) if our disease-concept is value-laden, this does not show it is morally impermissible. To determine its permissibility, we must regard it as a tool to structure social institutions. Seen in that way, whether our disease-concept is morally permissible is a consequentialist matter and depends exquisitely on unanswered empirical questions. (shrink)

Philosophical analyses of scientific concepts are legion. However, this literature is replete with methodological errors that have largely gone unnoticed. Five distinct projects are conflated which has led to faulty inferences, ambiguities, and mischaracterizations. There has also been some recent enthusiasm for approaches that attempt to rectify problematic scientific concepts but the motivations for these approaches are questionable. I am hopeful that by bringing these various issues to light that it will lead practitioners to be more explicit about their aims (...) and subsequently result in better analyses. (shrink)

Abstract:This article provides a critique of the monolithic accounts that define justice in terms of a single and often inappropriate goal. By providing an array of real examples, I argue that there is no simple definition of justice, because allocations that express justice are governed by a variety of reasons that reasonable people endorse for their saliency. In making difficult choices about ranking priorities, different considerations have different importance in different kinds of situations. In this sense,justice is a conclusionabout whether (...) an allocation reflects the human interests and priorities that are at stake. The article describes how several principles of justice have a legitimate place in medical allocations. To achieve justice within medical practice, professionals should focus on the human interests and compelling reasons for prioritizing specific principles within their specific medical domain. (shrink)

A satisfactory account of the nature of health is important for a wide range of theoretical and practical reasons. No theory offered in the literature thus far has been able to meet all the desiderata for an adequate theory of health. This article introduces a new theory of health, according to which health is best defined in terms of dispositions at the level of the organism as a whole. After outlining the main features of the account and providing formal definitions (...) of ‘health’, ‘healthy’, and ‘healthier than’, I present the main strengths of the proposed account. I argue that the proposed dispositional theory accounts for all paradigm cases of health and pathology, that it circumvents a number of problems faced by rival theories, and that it makes for a naturalistic theory of health with a rigorous metaphysical underpinning. 1Introduction 2The Dispositional Account 3Further Specification of the Dispositional Account 3.1Reference classes 3.2Comparison classes 3.3Which dispositions? 4Advantages of the Dispositional view 5Three Objections and Replies 5.1Objection 1: Counter-examples 5.2Objection 2: Issues with holism 5.3Objection 3: Expediting medicalization 6Final Remarks. (shrink)

Placebos are commonly defined as ineffective treatments. They are treatments that lack a known mechanism linking their properties to the properties of the condition on which treatment aims to intervene. Given this, the fact that placebos can have substantial therapeutic effects looks puzzling. The puzzle, we argue, arises from the relationship placebos present between culturally meaningful entities, our intentional relationship to the environment and bodily effects. How can a mere attitude toward a treatment result in appropriate bodily changes? We argue (...) that an ‘enactive’ conception of cognition accommodates and renders intelligible the phenomenon of placebo effects. Enactivism depicts an organism’s adaptive bodily processes, its intentional directedness, and the meaningful properties of its environment as co-emergent aspects of a single dynamic system. In doing so it provides an account of the interrelations between mind, body and world that demystifies placebo effects. (shrink)

Although it is intuitively obvious that having health problems makes people vulnerable, neither bioethics nor the philosophy of medicine has paid much attention to the relationship between vulnerability and health or illness. In this paper, I draw on work by Erinn Gilson on the nature of vulnerability in order to address this lack, showing that attending to vulnerability illuminates the relationship between health and illness.

In recent years, neuroscience has been a particularly prolific discipline stimulating many innovative treatment approaches in medicine. However, when it comes to the brain, new techniques of intervention do not always meet with a positive public response, in spite of promising therapeutic benefits. The reason for this caution clearly is the brain’s special importance as “organ of the mind”. As such it is widely held to be the origin of mankind’s unique position among living beings. Likewise, on the level of (...) the individual human being, the brain is considered the material substrate of those traits that in combination render each person unique. In view of this preeminent significance of the brain, it is understandable that, in general, interventions into the brain are considered a delicate issue and that new techniques of intervention are scrutinised with particular care. However, in doing so it is important not to go to the opposite extreme and shy away from promising new therapeutic approaches for debilitating disorders of the brain. With respect to the new techniques of brain intervention a broad interdisciplinary perspective is required to discern irrational fear from justified concern. Hence, the Europäische Akademie established a project group consisting, on the one hand, of experts from different fields of medicine who have got first-hand experience of applying the techniques at issue and, on the other hand, of philosophers and a legal expert. The task of this team was to review the state of the art with respect to each single technique of intervening in the brain, to indicate future developments, and to address the ethical and legal issues common to all of them. The project’s outcome is the book at hand. (shrink)

Author Information: Paul Tubig PhD Philosophy Student, University of Washington - Seattle [email protected] Submission Title: The Place of Health in the Liberal Theory of Justice: The purpose of this paper is to articulate the relationship between health and justice. Ethical claims, such as the World Health Organization’s assertion that health is a fundamental human right or that global health inequalities are normative inequities, require a conceptual analysis of the meaning and value of health within a particular framework of justice. Working (...) from the liberal conception of justice as developed by John Rawls, I will argue that the political significance of health is derived from the Rawlsian democratic conception of persons. In developing this thesis, I will first argue against the traditional biomedical approach of defining health within the political context and instead, advocate a conception of health that comprises of a normative dimension to derive moral rights and responsibilities. I will then argue that the most reasonable conception of health as a public value is derived from Rawls’ democratic conception of persons. By understanding the public identity of citizens as persons who possess a specific set of moral powers and highest order moral interests to develop and exercise these powers, we can derive the political significance of health as a necessary background condition to serve these interests. Therefore, structural arrangements should promote public health to the extent that the two moral powers are developed and sustained. Key Words: Justice, Health, Rawls, Liberalism, Healthcare Justice, Political Bioethics. (shrink)

Teaching ethics in public health programmes is not routine everywhere – at least not in most schools of public health in the European region. Yet empirical evidence shows that schools of public health are more and more interested in the integration of ethics in their curricula, since public health professionals often have to face difficult ethical decisions.

This study is a contribution to the bioethical debate about new and possibly emerging reproductive technologies. Its point of departure is the intuition, which many people seem to share, that using such technologies to select non-disease traits – like sex and emotional stability - in yet unborn children is morally problematic, at least more so than using the technologies to avoid giving birth to children with severe genetic diseases, or attempting to shape the non-disease traits of already existing children by (...) environmental means, like education. The study employs philosophical analysis for the purpose of making this intuition intelligible and judging whether it is justified. Different ways in which the moral problems posed by reproductive technologies are often framed in bioethical debates are criticised as inadequate for this task. In particular, it is argued that the intuition cannot fully be made sense of in terms of harm to the children that such technologies help create. The study attempts to elaborate an alternative to that broadly consequentialist approach, by drawing on Martin Heidegger’s philosophy of technology, Hans Jonas’s ethics, and Aristotle’s practical philosophy, as it has been received and developed in the hermeneutical tradition. It is suggested that reproductive choices, unlike decisions for already born children, are characterised by a peculiar one-sidedness: the future child appears to the parents as something wholly theirs to decide about, not as a concrete other with whom they must interact in a responsive and attuned way. This is problematic because it means that such choices cannot call upon the particularised moral understanding only gained in interpersonal encounters. In particular, it makes them easily shaped by various tendencies, to which parents are always susceptible, to relate to children in instrumentalising ways, and at risk of reinforcing such tendencies. However, this does not mean that all uses of reproductive technologies are equally troubling. When selecting against severe disease the parents can rely on a widely shared illness experience to escape the dangers that one-sidedness involves. It is concluded that the intuition under discussion, thus explicated and in some ways qualified, makes sense morally. (shrink)

Christopher Boorse’s Biostatistical Theory of Health has been the main contender among naturalistic accounts of health for the last 40 years. Yet, a recent criticism of this theory, presented by Elselijn Kingma, identifies a dilemma resulting from the BST’s conceptual linking of health and statistical typicality. Kingma argues that the BST either cannot accommodate the situation- specificity of many normal functions or cannot account for many situation-specific diseases. In this article, we expand upon with Daniel Hausman’s response to Kingma’s dilemma. (...) We propose that recalling Boorse’s specification that health is an intrinsic property of its bearers and explicating this intrinsic property in relation to the concept of homeostasis can illuminate how proponents of naturalistic accounts of health should deal with the situation- specificity of normal functions. We argue that beyond what Boorse and Hausman have delineated, the situation- specificity of normal function cannot be fully captured in a simple dichotomy between normal and abnormal environment or between relevant and irrelevant situations. By bringing homeostasis to the fore of the analysis of health, we set out a richer picture of what the various situations that affect living organisms’ functional performance can be. Accordingly, we provide a broader classification of these various situations which, we contend, better accounts for the main intuitions that philosophers of medicine have sought to accommodate than previous naturalistic theories of health. (shrink)

Some people are now quite optimistic about the possibility of treating psychopathy with drugs that directly modulate brain function. I argue that this optimism is misplaced. Psychopathy is a global disorder in an individual’s worldview, including his social and moral outlook. Because of the unity of this Weltanschauung, it is unlikely to be treatable in a piecemeal fashion. Recent neuroscientific methods do not give us much hope that we can replace, in a wholesale manner, problematic views of the world with (...) more socially desirable ones. There are, therefore, principled reasons that psychopathy is so singularly treatment resistant. (shrink)