This essay replies to critics since 1995 of my “biostatistical theory” of health. According to the BST, a pathological condition is a state of statistically species-subnormal biological part-functional ability, relative to sex and age. Theoretical health, the total absence of pathological conditions, is then a value-free scientific notion. Recent critics offer a mixture of old and new objections to this analysis. Some new ones relate to choice of reference class, situation-specificity of function, common diseases and healthy populations, improvements in population (...) health, the practice of pathologists, “Cambridge changes” in health status, and comparative vs. absolute health concepts. I make no changes in doctrine, except to consider treating “normal aging” as pathological by taking young adults as the standard for all adults. (shrink)

In 2012, the symposium "Christopher Boorse and the Philosophy of Medicine" was held at the University of Hamburg. The initial ideas presented at this event, which celebrated Chris's contribution to the development of what is now a vibrant area of research, especially to the theory of disease, form the core of the papers published in this issue. Similarly to what Robert Nozick once said about John Rawls's work, it can be demanded that philosophers of medicine must now either work within (...) Boorse's theory or explain why not. It is simply the main contender in the so-called naturalist camp of contributions to the theory of disease. All of the papers in this issue address his approach in some respect, and all of them are friendly toward his theory up to a point. In this brief introduction, I try to extract common threads. In doing so, I focus on three issues that have the capacity to determine future debates. The first is the methodology of developing a theory of disease, especially what conceptual analysis amounts to and what it may achieve. The second is the issue of value-ladenness of the concepts of health and disease, a topic that has been at the forefront of the philosophical debate, but which -- to my mind -- has often been misunderstood. The third issue is the problem of the unity of medical terminology. We can ask whether there is only one core medical concept, be it "disease," "pathology," "disorder," "malady," or something else. Alternatively, we might propose different concepts for different purposes. (shrink)

Similarly to other accounts of disease, Christopher Boorse’s Biostatistical Theory (BST) is generally presented and considered as conceptual analysis, that is, as making claims about the meaning of currently used concepts. But conceptual analysis has been convincingly critiqued as relying on problematic assumptions about the existence, meaning, and use of concepts. Because of these problems, accounts of disease and health should be evaluated not as claims about current meaning, I argue, but instead as proposals about how to define and use (...) these terms in the future, a methodology suggested by Quine and Carnap. I begin this article by describing problems with conceptual analysis and advantages of “philosophical explication,” my favored approach. I then describe two attacks on the BST that also question the entire project of defining “disease.” Finally, I defend the BST as a philosophical explication by showing how it could define useful terms for medical science and ethics. (shrink)

In this essay, we focus on the moral justification of a highly controversial measure to redress medical brain drain: the duty to stay. We argue that the moral justification for this duty lies primarily in the fact that medical students impose high risks on their fellow citizens while receiving their medical training, which in turn gives them a reciprocity-based reason to temporarily prioritize the medical needs of their fellow citizens.

This article seeks to reframe the ethical discussion of genetic enhancement, which is the use of genetic engineering to supply a characteristic that a parent might want in a child that does not involve the treatment or prevention of disease. I consider whether it is likely that enhancement can be successfully prohibited. If genetic enhancement is feasible, it is likely that there will be demand for it because parents compete to produce able children and nations compete to accumulate human capital (...) in skilled workers. If some parents or nations begin using genetic enhancement, this will change these competitions in ways that increase the incentives for others to use it. Therefore, a ban on genetic enhancement would be unstable, because once the ban was breached by defectors the motivation of others to uphold it would weaken, making the ban liable to collapse. The argument provides a new perspective on slippery slopes to dangerous technology. Keywords: genetic enhancement, slippery slope argumentation CiteULike Connotea Del.icio.us What's this? (shrink)

THE ARTICLE DEMONSTRATES FOR SOMATIC MEDICINE AS WELL AS PSYCHIATRY AND PSYCHOTHERAPY THAT THE CONCEPT OF DISEASE IS AT LEAST PARTIALLY DEPENDENT ON IDEOLOGICAL CONSIDERATIONS. THE PAPER SURVEYS REPRESENTATIVE VIEWS AND EXPLORES THE BEARING OF THE CONCEPTS OF NORMS, FUNCTIONS, VALUES ON THE SPECIFICATION OF DISEASE.

Winner of the 1975 National Book Award, this brilliant and widely acclaimed book is a powerful philosophical challenge to the most widely held political and social positions of our age--liberal, socialist, and conservative.

Now available in a Harper Colophon edition, this classic book has revolutionized thinking throughout the Western world about the nature of the psychiatric profession and the moral implications of its practices. Book jacket.

After distinguishing two different meanings of the notion of a morality internal to medicine and considering a hypothetical case of a society that relied on its surgeons to eunuchize priest/cantors to permit them to play an important religious/cultural role, this paper examines three reasons why morality cannot be derived from reflection on the ends of the practice of medicine: (1) there exist many medical roles and these have different ends or purposes, (2) even within any given medical role, there exists (...) multiple, sometimes conflicting ends, and, most critically, (3) the ends of any practice such as medicine must come from outside the practice, that is, from the basic ends or purposes of human living. The paper concludes by considering whether these ends external to medicine are universally part of the moral reality or whether they are socially constructed. The paper argues that, even if various cultural accounts of the common, universal morality are socially constructed, they may, nevertheless, be reflections, however, imperfect, of a more universal common morality that should be thought of as real. Therefore, the morality of medicine must come from a more fundamental morality external to medicine. That external morality will be socially constructed, but may nevertheless reflect an underlying common morality. (shrink)

This paper argues that the medical conception of health as absence of disease is a value-free theoretical notion. Its main elements are biological function and statistical normality, in contrast to various other ideas prominent in the literature on health. Apart from universal environmental injuries, diseases are internal states that depress a functional ability below species-typical levels. Health as freedom from disease is then statistical normality of function, i.e., the ability to perform all typical physiological functions with at least typical efficiency. (...) This conception of health is as value-free as statements of biological function. The view that health is essentially value-laden, held by most writers on the topic, seems to have one of two sources: an assumption that health judgments must be practical judgments about the treatment of patients, or a commitment to "positive" health beyond the absence of disease. I suggest that the assumption is mistaken, the commitment possibly misdescribed. (shrink)

Narrative medicine is predicated on the importance of narrative to human life. Although that in itself is not controversial, an extension of this principle that has sprung up in narrative psychiatry—namely, that by coming to imagine a different life story one can become a different person—ought to be. One reason one cannot remake one’s life in the image of a story is that life is not to be mistaken for a story in the first place. The seminal study of psychotherapy, (...) Persuasion and Healing, although recommending that the demoralized absorb more uplifting stories about themselves, appears to recognize some limit to the possibility of modeling life on story. The same study likens therapeutic stories to placebos, but as it happens, placebos themselves have their limits, alleviating symptoms but not curing or “healing.” In order for someone to become a different person through the agency of the placebo effect, it would have to be more robust than it is. The argument that life follows narrative is an ironic one for a discipline devoted to narrative to make, given the salience in the tradition of the novel, from Don Quixote forward, of works that explore the fallacies of that presumption. In keeping with its attention to narrative, this article challenges the use of a short story by Chitra Divakaruni as an illustration of the principles of narrative psychiatry. (shrink)

This volume is the first ever English translation of Kant's last major work, the so-called Opus Postumum, a work Kant himself described as his 'chef d'oeuvre' and as the keystone of his entire philosophical system. It occupied him for more than the last decade of his life. Begun with the intention of providing a 'transition from the metaphysical foundations of natural science to physics,' Kant's reflections take him far beyond the problem he initially set out to solve. In fact, he (...) reassesses a whole series of fundamental topics of transcendental philosophy: the thing in itself, the nature of space and time, the concept of the self and its agency, the idea of God, and the unity of theoretical and practical reason. Though never completed, the text reaches a logical albeit not fully developed, conclusion. (shrink)

In this essay I examine the formal structure of the concept of futility, enabling identification of the appropriate roles played by patient, professional, and society. I argue that the concept of futility does not justify unilateral decisions to forego life-sustaining medical treatment over patient or legitimate surrogate objection, even when futility is determined by a process or subject to ethics committee review. Furthermore, I argue for a limited positive ethical obligation on the part of health care professionals to assist patients (...) in achieving certain restricted goals, including the preservation of life, even in circumstances in which most would agree that that life is of no benefit to the patient. Finally, I address the objection that professional integrity overrides this limited obligation and find the objection unconvincing. In short, my aim in this essay is to see the concept of futility finally buried, once and for all. (shrink)

Most discussions of medical futility try to answer the Futility Question: when is a medical procedure futile? No answer enjoys universal support. Some futility policies say that the health care provider will answer this question when the provider and patient cannot agree. This raises the Decision Question: who has the moral authority to decide what to do in cases where futility is disputed? I look for a procedural answer to this question, an answer that does not turn on whether a (...) given party happens to answer the Futility Question correctly. I argue that these policies get it right; the provider should decide because providers have a right of conscientious refusal that extends to refusing procedures on grounds of futility. This is a procedural answer because providers have this right even if they are sincerely mistaken about whether a procedure is futile. (shrink)

It is plausible that what possible courses of action patients may legitimately expect their physicians to take is ultimately determined by what medicine as a profession is supposed to do and, consequently, that we can determine the moral acceptability of voluntary euthanasia and physician-assisted suicide on the basis of identifying the proper goals of medicine. This article examines the main ways of defining the proper goals of medicine found in the recent bioethics literature and argues that they cannot provide a (...) clear answer to the question of whether or not voluntary euthanasia and physician-assisted suicide are morally acceptable. It is suggested that to find a plausible answer to this question and to complete the task of defining the proper goals of medicine, we must determine what is the best philosophical theory about the nature of prudential value. (shrink)

The United Nations Scientific, Education and Cultural Organisation (UNESCO) Universal Declaration on Bioethics and Human Rights (UDBHR) expresses in its title and substance a controversial linkage of two normative systems: international human rights law and bioethics. The UDBHR has the status of what is known as a ‘non-binding’ declaration under public international law. The UDBHR’s normative foundation within bioethics (and association, for example, with virtue-based or principlist bioethical theories) is more problematic. Nonetheless, the UDBHR contains socially important principles of technology (...) transfer and transnational benefit (articles 14, 15 and 21). This paper is one of the first to explore how the disciplines of bioethics and international human rights law may interact in the UDBHR to advance the policy relevance and health impact of technology transfer and transnational benefit principles. It investigates their normative ancestry in the UDBHR, as well as relevant conceptual differences between bioethics and public international law in this respect and how these may be relevant to their conceptual evolution and application. (shrink)

It is an imperative within health care, medicine, and public health to restore, preserve, and enhance health. Therefore, it is important to determine what kinds of enhancement are increases in health and what kinds are not. Taking as its point of departure two conceptions of health, namely, “manifest health” and “fundamental health,” the paper discusses various means used to enhance ability and well-being, and if those means, such as wheelchairs, implants, medicines, stimulants, or narcotics, enhance health. The fact that some (...) means that enhance ability or well-being are not usually considered health enhancing, for example, narcotics, constitutes a problem. The paper ends with a discussion of some suggestions about how to distinguish between those enhancements that are health related and those that are not. One plausible idea holds that an enhancement is health related when the substance, or aid, increases ability or well-being, is integrated into the body, and does not harm the individual’s fundamental health. (shrink)

This review essay examines H. Tristram Engelhardt, Jr.'s The Foundations of Bioethics, a contemporary nonfeminist text in mainstream biomedical ethics. It focuses upon a central concept, Engelhardt's idea of the moral community and argues that the most serious problem in the book is its failure to take account of the political and social structures of moral communities, structures which deeply affect issues in biomedical ethics.

The fundamental claim that the practice of medicine is essentially a moral enterprise remains highly contentious, not least among the dominant traditional moral theories. The medical profession itself is today characterized by multicultural pluralism and moral relativism that have left the Hippocratic moral tradition largely in disarray. In this paper, I attempt to clarify the ambiguity about practicing medicine as a moral enterprise and echo Pellegrino’s call for a phenomenologically and teleologically derived philosophy of medicine. I proffer a realistic trifocal (...) matrix in which the virtuous moral agency and the teleologically derived moral imperative of the physician are comprehensively integrated with an action-guiding practical analytical framework for the resolution of ethical dilemmas in medicine. I argue that this trifocal perspective points us towards an authentic philosophy of medicine that is not only verifiable through Lonerganian self-appropriation, but also authentically objective through the possible moral self-transcendence of the good physician. (shrink)

There is wide agreement that communities in lower-income countries should benefit when they participate in multinational research. Debate now focuses on how and to what extent these communities should benefit. This debate has identified compelling reasons to reject the claim that whatever benefits a community agrees to accept are necessarily fair. Yet, those who conduct clinical research may conclude from this rejection that there is no reason to involve communities in the process of deciding how they benefit. Against this possibility, (...) the present manuscript argues that involving host communities in this process helps to promote four important goals: protecting host communities, respecting host communities, promoting transparency, and enhancing social value. (shrink)

With Western cultures becoming more pluralistic, the question of "truth" in politics has become a game of interpretations. Today, we face the demise of the very idea of truth as an objective description of facts, though many have yet to acknowledge that this is changing. Gianni Vattimo explicitly engages with the important consequences for democracy of our changing conception of politics and truth, such as a growing reluctance to ground politics in science, economics, and technology. Yet in Vattimo's conception, a (...) farewell to truth can benefit democracy, exposing the unspoken issues that underlie all objective claims. The end of absolute truth challenges the legitimacy of policies based on perceived objective necessities—protecting the free market, for example, even if it devastates certain groups or classes. Vattimo calls for a truth that is constructed with consensus and a respect for the liberty of all. By taking into account the cultural paradigms of others, a more "truthful" society—freer and more democratic—becomes possible. In this book, Vattimo continues his reinterpretation of Christianity as a religion of charity and hope, freeing society from authoritarian, metaphysical dogmatism. He also extends Nietzsche's "death of God" to the death of an authoritarian God, ushering in a new, postreligious Christianity. He connects the thought of Martin Heidegger, Karl Marx, and Karl Popper with surprising results and accommodates modern science more than in his previous work, reconciling its validity with an insistence that knowledge is interpretive. Vattimo's philosophy justifies Western nihilism in its capacity to dispense with absolute truths. Ranging over politics, ethics, religion, and the history of philosophy, his reflections contribute deeply to a modern reconception of God, metaphysics, and the purpose of reality. (shrink)

Patients who are imminently dying sometimes experience symptoms refractory to traditional palliative interventions, and in rare cases, continuous sedation is offered. Samuel H. LiPuma, in a recent article in this Journal, argues that continuous sedation until death is equivalent to physician-assisted suicide/euthanasia based on a higher brain neocortical definition of death. We contest his position that continuous sedation involves killing and offer four objections to the equivalency thesis. First, sedation practices are proportional in a way that physician-assisted suicide/euthanasia is not. (...) Second, continuous sedation may not entirely abolish consciousness. Third, LiPuma’s particular version of higher brain neocortical death relies on an implausibly weak construal of irreversibility—a position that is especially problematic in the case of continuous sedation. Finally, we explain why continuous sedation until death is not functionally equivalent to neocortical death and, hence, physician-assisted suicide/euthanasia. Concluding remarks review the differences between these two end-of-life practices. (shrink)

What has been the fate of Christianity since Nietzsche's famous announcement of the "death of God"? What is the possibility of religion, specifically Christianity, thriving in our postmodern era? In this provocative new book, Gianni Vattimo, leading Italian philosopher, politician, and framer of the European constitution, addresses these critical questions. When Vattimo was asked by a former teacher if he still believed in God, his reply was, "Well, I believe that I believe." This paradoxical declaration of faith serves as the (...) foundation for a brilliant exposition on Christianity in the new millennium -- an age characterized by a deep uncertainty of opinion -- and a personal account of how Vattimo himself recovered his faith through Nietzsche and Heidegger. He first argues that secularization is in fact the fulfillment of the central Christian message, and prepares us for a new mode of Christianity. He then explains that Nietzsche's thesis concerns only the "moral god" and leaves room for the emergence of "new gods." Third, Vattimo claims that the postmodern condition of fragmentation, anti-Eurocentrism, and postcolonialism can be usefully understood in light of Joachim of Fiore's thesis concerning the "Spiritual Age" of history. Finally, Vattimo argues for the idea of "weak thought." Because philosophy in the postmetaphysical age can only acknowledge that "all is interpretation," that the "real" is always relative and not the hard and fast "truth" we once thought it to be, contemporary thought must recognize itself and its claims as "weak" as opposed to "strong" foundationalist claims of the metaphysical past. Vattimo concludes that these factors make it possible for religion and God to become a serious topic for philosophy again, and that philosophy should now formally engage religion. (shrink)