PB Book Club

Rights and Their Limits by Francis Kamm (Oxford University Press, 2022)

Post Coming Soon!

Health Problems: Philosophical Puzzles About the Nature of Health by Elizabeth Barnes (Oxford University Press, 2023)

Post by Jennifer Blumenthal-Barby, PhD (Baylor College of Medicine)

In her newest book (2023) Health Problems: Philosophical Puzzles about the Nature of Health, Barnes thinks carefully about the issue of health and its philosophical complexities. It is a book that is rich philosophically, but also personally, as Barnes reveals that she wrote the book at the height of the COVID-19 pandemic and as she was diagnosed with young-onset Parkinson’s disease. This book is a crucial read for anyone who thinks about health, tries to promote it, protect it, or measure it—which is to say, almost all of us.

For something so central to our lives, health turns out to be very hard to define.

In Chapter 1 of the book, “Theories of Health,” Barnes systematically marches through the major definitions or philosophical accounts of health and points out their problems and puzzles.

Below, I briefly define each account and then offer Barnes’s major critique.

1. Function-based (biological) theories of health: This family of theories holds that a healthy organism is one that is functioning in a species-typical or species-appropriate way (e.g., a normal functioning immune system attacks pathogens, one that attacks parts of your own body is not normal and as such is unhealthy). What’s the problem with this? As Barnes notes, the major challenge is that we need a way to define what normal/abnormal functioning is. Two major ways to try to do this are explaining normal by way of statistical typicality/variation (e.g., Christopher Boorse’s “biostatistical” view) or by way of natural selection and health’s relationship to the goals of survival/reproduction (e.g., Jerome Wakefield’s view) the goals of survival and reproduction). BUT…according to Barnes, there are statistical variations that are not pathological (e.g., being able to wiggle your ears) and there are many common pathologies that do not reduce lifespan or limit reproduction (e.g., breaking your ankle).

• Teleological theories of health: According to these theories (e.g., Philippa Foot’s theory, relying heavily on Aristotle), there is a “proper or intended form” for members of a given species. For human organisms, there is a pre-set “human form,” and the “end” or “telos” of the human person is to flourish. Foot thought this proper form arose from facts about natural selection. The major problem with this view, according to Barnes is that it is mysterious: in order to make judgments about a “proper form” (vs. a dysfunctional one), we must pre-suppose a theory of health.  

• Well-being based views of health: The World Health Organization (WHO) equates health and well-being (health just is well-being, according to its definition). There are many problems with this. Put simply, health and well-being come apart. Barnes asks us to consider a person with moderate cerebral palsy who considers himself a happy person, has a family he adores, and a job he finds fulfilling, etc. On the well-being view of health, we need to either say that his disability does not substantially compromise his health or that his despite his own appraisal, he is not well and flourishing (both bad options). Barnes is willing to admit that health often has a profound impact on well-being, but it is not the only thing that matters for well-being and it does not perfectly correlate with well-being. She writes in more detail about the relationship between health and well-being in Chapter 2 of the book.

• Phenomenological views of health: The phenomenological tradition in philosophy focuses on first-person experiences or how various things “appear” or “feel”. On this view, a person is healthy if they feel healthy (and vice versa for unhealthy). There is a certain feeling or experience to health—when we feel healthy, we feel at home in our bodies and without struggle. The primary problem with this view is that many things that compromise our health have no symptoms (e.g., advanced ovarian cancer) and that we can sometimes feel not at home in our body without being unwell.

• Social constructionist theories of health express the idea that what determines whether a condition is pathological is how that condition is collectively viewed and treated in a particular society. One problem with this view is that society can be wrong (the classic example is that homosexuality used to be viewed as a disease).

Summing up, Barnes points out that each of these prominent theories of health gets something right, but no one gets everything right, and we can’t just fix this problem by cobbling different theories together. Health is complicated!

For summaries of Chapters 2, 3, 4, 5, and 6, check out the hyperlinks.

Green Light Ethics: A Theory of Permissive Consent and its Moral Metaphysics by Hallie Liberto (Oxford University Press, 2022)

Post by: Jared Smith, PhD (Baylor College of Medicine)

“I will seek explanation of the metaphysical changes that occur in the moral world – both by looking at the change that needs to take place, and the feature of consent that can trigger such a change. I take this to be a conventional approach in analytic philosophy. However, as I argue throughout the book, it has been relatively absent from philosophical investigations into permissive consent.” (p. 26)

Liberto’s recent entry provides a richly-argued contribution to the philosophical discussion about consent. Her primary focus is what she terms permissive consent – the sort relevant in contexts like sexuality, property, privacy, and medical ethics. Liberto points out early on that questions of permission also turn upon questions of authority; who has the authority to permit others to undertake actions that would otherwise be wrong, when, and why? Liberto opts to discuss consent primarily in terms of moral powers and domain rights.

How does Liberto’s theory of permissive consent relate to the existing philosophical literature on consent?

Liberto is clear that many of the ethical issues she highlights early on (such as the Ontological Question) are not new to the discussion of consent, arguing that her approach necessarily treats the fundamental questions of consent in a different order than past theorists (p. 28). She articulates her view in opposition to several distinct ‘camps’ of theorists (such as the Internalists), adopting what she calls the mechanistic approach wherein “we must identify and fully describe the difference (including, perhaps, the minimal difference possible) between the moral world before and after consent and use that comparison as a tool to characterize the wrongdoing prevented by consent,” (p. 30) In this sense, the view presented is as much about practical consent as it is about the ontology, or metaphysics, of consent (p. 8-33): “What happens at the metaphysical level to a moral right when we exercise the moral power of authority-retaining permissive consent?” (p. 30)

What are the ‘wrongs’ involved in domain right violations?

Liberto’s argument becomes increasingly focused across chapters, first on the moral power of “authority-retaining permissive consent” (p. 37-8). Liberto further narrows her argument in chapter 4 where she argues that there are two wrongings that can occur in violations of an agent’s domain rights: divergence strikes and standing strikes. A divergence strike is a wrong that deprives an agent of something she’s entitled to (within her domain) regarding the behavior of others and can range in severity based on the scope of the divergence (p. 95); Perry commits a divergence strike against Samir when he uses his messy chemistry set in Samir’s home (which Samir did not authorize) (p. 97). A standing strike occurs when an agent “degrades the worth” of another’s moral authority in her domain through behavior that denies the agent the authority to which she’s entitled; Peter commits a standing strike against Sarah when he reads her diary (because he devalues her domain right authority over her private diary) (p. 106).

Liberto uses a series of engaging thought experiments (which reappear in later chapters with new variations) to illustrate these strikes and analyze the way an agent with a domain right may permit another to do something within their domain that otherwise would be forbidden (such as Jasper in the Attic, who privately consents to one specific burglar entering his home but not the others, p. 42-3; 125-8, or Mariana and from Measure for Measure who arranges a deceptive tryst). These thought experiments are used to engage with core questions for any theory of consent, such as how private consent (internal/unexpressed) can function to change the moral landscape (p. 131-40).

Green Light Ethics provides a deep dive into the philosophical issues surrounding consent from a distinctly analytic and mechanistic approach. While intended for any audience regardless of background knowledge about consent, veteran readers will appreciate the level of detail and focus in Liberto’s arguments, especially in the closing chapters on coercion and deception.

Liberto’s theory finds perhaps its greatest purchase in examples of nonconsensual sexual wrongs like sexual assault and sex by deception by providing an explanation of the way in which failing to secure an agent’s consent changes the moral landscape, and how devaluing an agent’s authority over that which is hers wrongs her on top of other harms from the violation.

One aspect of domain rights and consent that Liberto does not spend much time discussing is how to negotiate conflicting or overlapping domains, and those domains which belong to no one (i.e. when one is in public). How are my domain rights over my body and person changed when I go from the privacy of my home to the public square? A more curious omission from the discussion is the medical domain since – as Liberto herself notes at the end of the first chapter – the scope of her discussion omits the examples most relevant to bioethicists (p. 34). This is not to say her theory of permissive consent cannot accommodate core biomedical examples, only that this is not Liberto’s primary goal. In fact, the concepts of standing strikes and divergent strikes allow us a kind of flexibility for understanding the wrongs related to violating consent and are fruitful for bioethical inquiry.

Epiphanies: an ethics of experience by Sophie Grace Chappell (Oxford University Press, 2022)

Post By: Jennifer Blumenthal-Barby, PhD (Baylor College Of Medicine)

“As in mountaineering exploration, so, often, in philosophical exploration, the most interesting place to look is where hardly anyone else seems to be looking….Moral philosophers should say more about ethical experience in general, and about epiphanies in particular….In the house of rationality there are many mansions; plenty of other things for human reason to be besides a reductive-deductive system. The idea that ethical philosophy can be nothing except systematizing moral theory is a lazy prejudice….” (p. 55).

Chappell’s bold book encourages analytically trained philosophers to add to their toolkit an ethics of experience. She tells the story of Peter Singer’s turning away from meat-eating, noting that while Singer could provide arguments and theorize with the best of them, what ultimately drove his moral calculus was a sort of “epiphany” about the wrongness of eating meat (p. 51).

What then, is an epiphany? It is a clear and precise seeing (p. 44), a revealing scene or moment (p. 4), which is typically especially motivating (p. 5). Epiphanies are sort of “peaks” in our experience—they can be both good (delight, lucidity) or bad (horror, anger) (9). Put more precisely, “An epiphany is an overwhelming existentially significant manifestation of value in experience, often sudden and surprising, which feeds the psyche, which feels like it ‘comes from outside’—it is something given, relative to which I am a passive perceiver—which teaches us something new, which takes us out of ourselves, and to which there is a natural and correct response. (At least one; possibly more). Often the correct response is love, often it is pity, or again creativity. It might also be anger or reverence or awe or a hunger to put things right—a hunger for justice; or many other things. It might be something that leaders directly to action or new knowledge, but it may also be something that prompts further contemplation or reflection; or other responses again.” (pp. 8-9).

What would it mean for “epiphanies” to be embraced as a more regular part of moral reasoning and knowledge in bioethics or clinical ethics consultation? On the one hand, a powerful moment of moral insight should be embraced if one is so lucky to have it. To have a moment of “seeing,” experiencing, or apprehending value directly seems like something not worth discarding. On the other hand, how can we validate and communicate epiphanies that we or others have? How can we get around concerns about relativism—for example, if Peter Singer has an epiphany that eating animals is wrong but someone else has an epiphany that it is right?

Chappell does not have full answers to these questions (in my view), but she suggests that for any one epiphany someone might have, we can ask (borrowing from Rawls), whether it is “consistent with the republic of conversation” (p. 398). We must be able and willing to enter into a dialogue about our epiphanies and to try to look for the truth together. This leads to the idea of “conversational justice,” which requires speaking and listening in ways that treat others as equal conversational partners (p. 413). None of this promises agreement, but in the least, respectful and peaceful disagreement.

Ways to be Blameworthy by Elinor Mason (Oxford University Press, 2021)

Post by: Benjamin H. Lang, PhD candidate (University of Oxford)

“I think that relationships, both our fairly impersonal relationships with others in our moral community and our personal relationships, are essential to understanding how responsibility attributions and blameworthiness work. If someone is not in our moral community, the way in which we blame them changes, and rightly so. We cannot expect a response from someone who is outside our moral community” ~ (p. 14). 

Mason’s book has a well-defined and tightly maintained pair of guiding questions: what are our actual practices around blame and blaming, and how do they function? For Mason, the key to making sense of who, how, and why we blame lies in the relations we bear with other individuals, our surrounding moral community, and the capital-M Morality upon which that moral community is built. Mason carefully outlines a plausible account of the different functions of blame, which she separates into three categories: (1) ordinary blame, (2) detached blame, and (3) extended blame. For purposes of brevity, I will only discuss the first two, as they are the most common and most important. 

Ordinary blame is attributed by one agent of a moral community to another member of that moral community whenever a moral norm is violated and the agent is responsible for the violation. To be a member of a moral community and thus subject to its blaming practices, an agent must already subscribe to the Morality which governs and informs notions of rightness and wrongness within that community. Importantly, under this view, a person who is responsible (and thus blameworthy) must be subjectively blameworthy or blameworthy “by their own lights.” Mason defines acting subjectively wrongly as “knowingly failing to try to do well by Morality” (p. 25). Mason spends the early chapters discussing what this subjective wrongness looks like, why it is a preferable approach to competing theories of right and wrong action (prospectivism and objectivism), and what determines one’s responsibility (I.e., how hard must one try to live by Morality and what ‘grasp’ of the dictates of Morality is sufficient for being subject to moral responsibility). To illustrate ordinary blame, Mason gives the example of a friend who lets you down by forgetting to turn up for a meeting or failing to stand up for you in front of others (p. 103). 

Detached blame, by contrast, is attributed by one moral agent toward another moral agent who does not belong to the same moral community and thus does not subscribe to the same Morality. For Mason, recipients of detached blame “do not take themselves to be trying (or failing to try) to do well by Morality, because they do not grasp Morality. Perhaps they have some other morality, perhaps they have none. Either way, our communicative blame will not make sense to them” (p 112). Such agents are not ordinarily blameworthy because they have not acted subjectively wrongly, but they have still violated the Morality which the presiding moral community accepts as true, and so they still elicit a blame-like response. In such detached cases of blame, “It is more about the blamer than the blamee—the blamer’s need to let off steam, to signal disapproval to her peers, to manage and manoeuvre around the offending agent” (p. 116). 

Mason’s account of blame, its social practices, and its theoretical underpinnings, is compelling. One remaining question for someone who accepts Mason’s description is normative in nature, namely: how should different moral communities and their members reconcile with one another if they hold mutually exclusive or even antithetical moral beliefs? Are they doomed to forever detachedly blame one another? And if I immigrate to or embed myself within a different moral community, do I have any obligations to assimilate into that moral community? Or to preserve my commitments to my original moral community and its Morality? These normative questions are perhaps an entirely different affair than the project Mason set out to undertake, but her work nonetheless provides fertile soil for bioethics discourse surrounding moral responsibility. Future work may explore how, for instance, the use of artificial intelligence can further complicate the picture of blame and responsibility by having technicians, engineers, physicians, data analysts, and others collaborate with or rely upon non-agential and inculpable machines. 

Morality By Degrees by Alastair Norcross (Oxford University Press, 2020)

Post by: Benjamin H. Lang, PhD candidate (University of Oxford)

“The focus of this book is to argue that consequentialist ethical theories should not be interpreted as theories of either the rightness or goodness of actions, but instead as scalar theories that evaluate actions as better or worse than possible alternatives.” ~ (p. 11).

In this ambitious project, Norcross sets out to demoralize ethics. In demoralizing ethics, Norcross means to strip away explicitly moral concepts that typically structure and inform ethical theorizing, concepts like permissibility, obligation and duty, supererogation, rightness, and wrongness. These concepts are, according to Norcross, potentially of practical significance but no theoretical substance. They may play a role in the practice of scalar consequentialism but do not underpin it.

As an alternative to moralizing theories, Norcross proposes scalar consequentialism. Consequentialism refers to ethical theories for which the consequences of an action are the only normatively significant component. The dominant school of consequentialist theories is utilitarianism, which evaluates the goodness or badness of an action based on the positive or negative net contribution to collective well-being that action results in (or would tend to result in). As Norcross notes, this approach to consequentialism is mired in disagreements which reflect the moral concepts referenced earlier. Does a person have a utility allowance, so to speak? Are they obligated to contribute some quota of utility and is there an amount they may permissibly subtract so long as their net contribution meets a certain threshold? These questions ask how demanding morality gets to be. Moreover, how, on this theory, should I act? Should each action I take aim to maximize expected utility (maximizing act utilitarianism), or should I develop rules of behaviour which tend towards maximizing expected utility (maximizing rule utilitarianism)? This is but a small sample of the tricky questions for a consequentialist theory which hopes to hold on to moral concepts like rightness and wrongness.

By qualifying his consequentialism as scalar, Norcross intends to avoid these problems altogether. On a scalar theory of ethics, an action cannot be right or wrong, it can only be better or worse than alternatives. To motivate this claim, Norcross uses the example of Jones, a wealthy person who can donate 9%, 10%, 11%, or 12% of his annual income to an effective charity. Norcross notes: “A moral theory which says that there is a really significant moral difference between giving 9 percent and 10 percent, but not between giving 11 percent and 12 percent, looks misguided” (p. 23). The scalar consequentialist is equally as invested in the difference between 11 and 12 as between 9 and 10, and to draw a line in the sand such that at 9% would be wrong but 10% would be right seems arbitrary.

Norcross spends considerable time in this book defending the position that scalar consequentialism can be sufficiently action-guiding, which he anticipates as an objection from proponents of moralizing theories. Norcross compares scalar ethical reasoning to prudential reasoning, where we can rationally prefer and decide in favor of certain decisions simply on the basis that we have greater reasons to select those options. He writes: “The fact that one action is better than another gives us a moral reason to prefer the first to the second” (p. 44).

Ultimately, Norcross provides a compelling case for reconsidering the necessity of our moralizing concepts within our ethical theorizing and questioning what is truly required for a theory to be sufficiently action-guiding. One thing I would have been keen to see Norcross address, however, are apparent cases of nonscalar moral commitments. Promises and vows, for instance, are rarely understood in gradable terms. Whether I cheat on my spouse once, or twice, or serially over the course of years, with one or with many other partners, does not seem to affect the badness of the act—the fact that I cheated at all represents complete moral failure relative to the vow of fidelity. Insofar as we judge the serial infidel guiltier or morally worse, it seems attributable to other, more scalar-friendly judgments (i.e., how unremorseful someone is, how frequently or extensively they deceived others, how much time of their partner’s life they potentially wasted under false pretense, etc.). Other examples may be vows of celibacy, pacifism or strict veganism, or substance abstinence. It is unclear to me what Norcross might say about such cases, but this does not diminish the overall merit of Norcross’s project which is worth a read for bioethicists who are interested in consequentialism.