Diversity Reading List

Diversifying Syllabi: Thesis: Those affected by mental disorders whose actions are episodically influenced by their disorder are often overlooked by philosophers of moral and ethical responsibility. Allen gives us reasons for thinking it is inappropriate to either:

a) “summarily exclude people with mental problems out of the universe of moral agents, reducing them to the status of rocks, trees, animals, and infants”
b) “include the group on the false assumption that their moral lives are precisely like the paradigmatic moral lives of the epistemically-sound and well-regulated people never personally touched by a mental condition”

We must explore a revised approach to moral and ethical responsibility and obligation for this group.

Comment: This text is useful in teaching in two main contexts: (1) in discussing ethical issues related to mental disorders; and (2) to provide a challenging case in classes on blame and responsibility. The text can be also used in the context of the free will and determinism debate, and as a further reading in classes on moral agency.

Introduction: Doctors, lawyers, and priests have traditionally recog nized the duty of professional secrecy regarding what individuals confide to them: personal matters such as alcoholism or depression, marital difficulties, corporate or political problems, and indeed most concerns that patients or clients want to share with someone, yet keep from all others.’ Accountants, bankers, social workers, and growing numbers of professionals now invoke a similar duty to guard confidences. As codes of ethics take form in old and new professions, the duty of confidentiality serves in part to reinforce their claim to professional status, and in part to strengthen their capacity to offer help to clients.

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Diversifying Syllabi: Bordo claims that the recent increase in women with Anorexia is a symptom of the “central ills” of our culture. Bordo discusses three sources of this “cultural illness” which leads to anorexia: the dualist axis, the control axis, and the gender/power axis. She spends the bulk of the paper discussing each “axis” or problematic component of society which is reflected back to us in the increasing diagnosis of anorexia. These “psychopathogolgies” are expressions of the culture, she claims.

Comment: This text is most readily applicable in teaching feminist theory and social philosophy. However, it is also very useful in at least three other contexts: (1) as a critical approach to mind-body dualism, especially when teaching on Descartes or Plato’s Phaedo; (2) in teaching on the ethics of mental illness and the anti-psychiatry movement, as an example of socially constructed disorders; and (3) more broadly in teaching on personal and collective moral responsibility.

Abstract: Modern medicine is built on a long history of medical experimentation. Experiments in the past often exploited more vulnerable patients. Questionable ethics litter the history of medicine. Without such experiments, however, millions of lives would be forfeited. This paper asks whether all the “unethical” experiments of the past were unjustifiable, and do we still exploit the poorer members of the community today? It concludes by wondering if Harris is right in his advocacy of a moral duty to participate in medical research.

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Content: The paper examines various arguments looking at the responsibility psychopaths bear for their immoral actions, using neurological knowledge about psychopathy.

Comment: Useful in teaching about the ‘mad or bad’ dilemma, and about responsibility and issues in psychiatric ethics in general.

Summary (from Introduction of Autonomy and Mental Disorder, Radoilska ed.): In ‘Mental disorder and the value(s) of autonomy’, Jane Heal identifies and critically examines a form of thought which is implicit in discussions about what we, as a society, owe to people with mental disorder. This form of thought builds upon intuitions which link respect for a person with respect for a person’s autonomy. In light of these intuitions, the issue of how to treat a person with mental disorder may seem to revolve around the question whether or not this person has the capacity for autonomy. However, Heal argues, inquiries that share this logical form are methodologically inappropriate and potentially unhelpful in answering either of the questions they put together: what we owe to people with mental disorder and what is involved in autonomy as a capacity. The reason for this is twofold.
Firstly, the apparent consensus about autonomy as a capacity for self-determination that ought to be protected from interference by a corresponding right to self-determination is too shallow to ground a coherent course of action in terms of respect for autonomy. Even if we work with the assumption that autonomy is part of the Enlightenment project, we face an important dilemma since we have to choose between a Kantian or rationality oriented and a Millian or well-being oriented take on the nature and significance of autonomy. Secondly, even if we were to reach a substantive consensus on the concept of autonomy, it would arguably require an intricate array of mental capacities, outside the reach of at least some people with mental disorder. Getting clearer on what autonomy is will not help us find out what it means to treat these people respectfully.

Comment: This text would be a good candidate for inclusion in a course about autonomy, philosophy of disability, or the ethics or political philosophy of mental health or aging (due to discussion of dementia). If assigned as part of a course on autonomy, students will benefit from considering Heal’s approach to breaking down the logical components of the concept and her nuanced discussion of the limitations of autonomy as a moral principle for understanding our obligations toward people with mental disorders. This second element is the central question of the paper and would be of interest when examining disability or mental health from a philosophical perspective.

Publisher: How, in a secular world, should we resolve ethically controversial and troubling issues relating to health care? Should we, as some argue, make a clean sweep, getting rid of the Hippocratic ethic, such vestiges of it as remain? Jennifer Jackson seeks to answer these significant questions, establishing new foundations for a traditional and secular ethic which would not require a radical and problematic overhaul of the old.
These new foundations rest on familiar observations of human nature and human needs. Jackson presents morality as a loose anatomy of constituent virtues that are related in different ways to how we fare in life, and suggests that in order to address problems in medical ethics, a virtues–based approach is needed. Throughout, attention is paid to the role of philosophy in medical ethics, and how it can be used to clarify key notions and distinctions that underlie current debates and controversial issues. By reinstating such concepts as justice, cardinal virtue, and moral duty, Jackson lays the groundwork for an ethics of health care that makes headway toward resolving seeming dilemmas in medical ethics today.
This penetrating and accessible book will be invaluable to students of sociology and health care, as well as those who are interested in the ethical uncertainties faced by the medical world.

Comment: Particularly useful in teaching is Chapter 10 which discusses abortion, reviewing arguments made by J.J. Thompson and M. Tooley, and enquiring into what makes killing wrong. Chapter 9 looks at distributive justice in medicine, reviewing some problematic cases and distinguishing between bad luck and injustice. Chapter 5 treats on conscientious objection and issues related to toleration and imposition of values.

Introduction: Dworkin puts forth two main arguments to justify adhering to the wishes the patient expressed before becoming demented. As he sees it, this course of action both promotes the patient’s well-being and is required in order to respect the patient’s autonomy. In each argument, while I consider most of the ideas well-founded, I challenge the crucial premise. In the argument focused on the patient’s well-being, I dispute the claim that demented patients are no longer capable of generating what Dworkin calls “critical interests.” In the argument concerning autonomy, I question the premise that demented patients no longer possess the “capacity for autonomy.”7 In each case, I will trace how the problematic premise arises within Dworkin’s argument and then develop an alternative account of the relevant capacity.

Comment: Jaworska asks: ‘Should we, in our efforts to best respect a patient with dementia, give priority to the preferences and attitudes this person held before becoming demented, or should we follow the person’s present preferences?’ (p. 108). The article offers a useful critical overview of the views expressed by Rebecca Dresser and Ronald Dworkin. It is best used as a primary reading in ethics classes focusing directly on medical ethics or autonomy, or as further reading in general ethics teaching on autonomy.

Summary: In this paper, Kittay advances a conception of justice that ‘begins with an acknowledgement of dependency and seeks to organise society so that our well-being is not inversely related to our need for care or to care’ (576). Her motivation for advancing this view is that ideals of citizenship in liberal society, including independence and productivity, perpetuate the victimisation, social exclusion, or stigmatisation of people with mental retardation and their carers. This is because liberal definitions of personhood do not provide resources for responding in a morally adequate way to the mutual dependence of people with mental retardation and their carers/advocates. People with mental retardation are inescapably dependent because of their central need for attentive care. And, carers’ work is so deeply other-directed that they also do not fit the liberal model of the rationally self-interested actor. Thus, both carers and their charges are vulnerable and need to be advocated for so that they can be seen as having important entitlements to public resources and claims to justice. To this end, Kittay proposes a conception of personhood that is based on relationships. Although those with mental retardation are inherently dependent, they still count as persons because they are able to participate in relationships. This makes them entitled to the satisfactions that make life worth living. To achieve the twin goal of achieving justice for familial or paid carers, Kittay advances a new principle of justice, doulia, which calls for larger society to support those who care for the inexorably dependent. Kittay takes her relational conception of personhood and her principle of doulia to ensure that appropriate forms of social organization exist to support all those who become dependent. She claims her view is needed because principles of charity and beneficence are not adequate since they are consistent with the continued stigmatization of mental retardation and care work, and ground only low-priority social obligations.

Comment: This paper, with it’s helpful discussions of the elements of the liberal tradition with which Kittay specifically takes issue and the inadequacies of the Americans with Disabilities Act, would be an appropriate reading for courses about the philosophy of disability or about liberal political theory.

Publisher’s Note: According to the “sanctity-of-life” view, all human lives are equally valuable and inviolable, and it would be wrong to base life-and-death medical decisions on the quality of the patient’s life. Examining the ideas and assumptions behind the sanctity-of-life view, Kuhse argues against the traditional view that allowing someone to die is morally different from killing, and shows that quality-of-life judgments are ubiquitous. Refuting the sanctity-of-life view, she provides a sketch of a quality-of-life ethics based on the belief that there is a profound difference between merely being alive and life being in the patient’s interest.

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Publisher’s Note: Few subjects have generated so many newspaper headlines and such heated controversy as the treatment, or non-treatment, of handicapped newborns. In 1982, the case of Baby Doe, a child born with Down’s syndrome, stirred up a national debate in the United States, while in Britain a year earlier, Dr. Leonard Arthur stood trial for his decision to allow a baby with Down’s syndrome to die. Government intervention and these recent legal battles accentuate the need for a reassessment of the complex issues involved. This volume–by two authorities on medical ethics–presents a philosophical analysis of the subject based on particular case studies. Addressing the doctrine of the absolute sanctity of life, Singer and Kuhse examine some actual cases where decisions have been reached; consider the criteria for making these decisions; investigate the differences between killing and letting die; compare Western attitudes and practices with those of other cultures; and conclude by proposing a decision-making framework that offers a rational alternative to the polemics and confusion generated by this highly controversial topic.

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Abstract: Medical complicity in torture is prohibited by international law and codes of professional ethics. But in the many countries in which torture is common, doctors frequently are expected to assist unethical acts that they are unable to prevent. Sometimes these doctors face a dilemma: they are asked to provide diagnoses or treatments that respond to genuine health needs but that also make further torture more likely or more effective. The duty to avoid complicity in torture then comes into conflict with the doctor’s duty to care for patients. Sometimes the right thing for a doctor to do requires complicity in torture. Whether this is the case depends on: the expected consequences of the doctor’s actions; the wishes of the patient; and the extent of the doctor’s complicity with wrongdoing. Medical associations can support physicians who face this dilemma while maintaining a commitment to clear principles denouncing torture.

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Abstract: Essays on excusing conditions and their correlates, mitigating conditions, usually begin with the assumption that there is general agreement on what the standard excuses are, and on where they are inapplicable. This assumption is justified; criminal law and the history of discussions of excuses have produced accord, though now and then doubts are expressed about particulars. Essays on excuses typically aim not so much to convince one that such-and-such are the general types of excuses but, rather, to show how they work and what their operation reveals about the nature of voluntary acts, full responsibility, etc.

Comment: In a course on moral reasoning
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Publisher’s Note: Onora O’Neill suggests that the conceptions of individual autonomy (so widely relied on in bioethics) are philosophically and ethically inadequate; they undermine rather than support relationships based on trust. Her arguments are illustrated by issues raised by such practices as the use of genetic information by the police, research using human tissues, new reproductive technologies, and media practices for reporting on science, medicine, and technology. The study appeals to a wide range of readers in ethics, bioethics, and related disciplines.

Comment: Parts of this book are an excellent supplement to units on autonomy and informed consent in an intermediate-advanced level medical ethics course. In particular, chapters 1, 2, and 4 would be excellent additions to a unit on autonomy, and chapter 7 would be a similarly excellent addition to a unit on informed consent.

Abstract: Many accounts of informed consent in medical ethics claim that it is valuable because it supports individual autonomy. Unfortunately there are many distinct conceptions of individual autonomy, and their ethical importance varies. A better reason for taking informed consent seriously is that it provides assurance that patients and others are neither deceived nor coerced. Present debates about the relative importance of generic and specific consent (particularly in the use of human tissues for research and in secondary studies) do not address this issue squarely. Consent is a propositional attitude, so intransitive: complete, wholly specific consent is an illusion. Since the point of consent procedures is to limit deception and coercion, they should be designed to give patients and others control over the amount of information they receive and opportunity to rescind consent already given.

Comment: A great introductory text offering a short overview of the problems related to consent. The point regarding the intransitivity of consent is likely to inspire interesting discussions. As the paper is quite short, it can easily be used in conjunction with other texts.