A London lunch brainstorm… some afterthoughts

The veil of ignorance as a model for defining a value laden and political notion of normal functioning: some problems.

At the London lunch brainstorm we discussed the idea of keeping a normal function model of disease for political purposes (e.g. in Daniels’s theory of health care), while rejecting (Boorse and Daniels’s) idea that the definition of normal functioning can and ought to be naturalistic or value-free. I mentioned the idea of deriving a value-laden, political notion of normal functioning as a free-standing political notion, reflecting shared values of political life and medical ethics. This political notion can become the focus of an overlapping consensus about our obligations to cure and prevent disease. The other partecipant suggested employing Rawls’s idea of a choice behind the veil of ignorance as a procedure of construction for defining this value laden idea of normal functioning. In this post, I develop the idea and discuss what I see as its main difficulty.

We want to define a procedure to select those human characteristics that belong to normal functioning. Can a suitable constructed original position do that for us?

In his A Theory of Justice. (2° ed. Cambridge, MA: Harvard University Press, 1999) John Rawls describes a procedure for selecting social institutions. It appeals to choices made under a “veil of ignorance”. The veil of ignorance deprives choosers of all information about

1) their own place in society (rich or poor, religious or atheist, in the moral majority or free thinker, man or woman, white or black, etc.)

2) society’s characteristics (primitive or industrial, culturally homogeneous or multicultural, big or small)

Choosers must choose a system of institutions for society on the basis of general facts about human nature (including laws of sociology, economics, psychology)

This is referred by Rawls as the “original position”.

Rawls argues that rational (that is, economically rational and self-interested) parties in the original position would choose a system of institutions involving a principle of equal liberty, a principle of fair equality of opportunity and the so-called difference principle. We are interested to see if a procedure which is structurally analogous to the o.p. can be used to derive criteria of quite a different nature.

We want to define a procedure able to tell us if a human characteristic should be considered as a normal variation or as a form of impairment.  Let us define the procedure (PR1) as follows: parties have to choose physical and mental characteristics for the people they represent.  As in Rawls, parties are conceived as self-interested rational chooser of economic theory. The veil of ignorance is defined as in Rawls’s o.p. Let us also assume that, since parties have no way of knowing in what kind of society the people they represent are situated, they will assume the same probability of ending up in any society.

The following definition suggests itself:

P1: x counts as an impairment if and only if x  and the absence of x would be chosen in the original position

P1 seems a good criterion. Why? Because it tracks some important distinctions most of us make, intuitively, between impairments and “disabilities” that are completely “socially constructed” (by which I means, obtain as a result of arbitrary discrimination).

To see why, consider the choice the parties would make. They would probably choose to avoid deafness. They will not choose to avoid black skin.

Why? They are under the veil of ignorance, not knowing the characteristics of  the societies of the people who they represent. However, if they consider deafness, they will conclude that it may very often result in disadvantage, in all or most possible social arrangements and cultures. On the other hand they cannot say that black skin would be a disadvantage (for all they know, the people they represent might be living in an African country where the majority of the population is black and white are discriminated).

Hence P1 seems to track most people intuitions concerning normal functioning, namely that black skin belongs to normal functioning, while deafness constitutes impairment. The veil of ignorance forces the evaluators to abstract from contingent features of society, thus sorting out the naturalistic component of disability from the social one, or at least it gives us a way to think how this distinction can be conceived.

There are two problems with this straighforward approach, though.

The first is that we do not start from a “normality type” concept, so it fails to distinguish between impairments and the low extremes in the distribution of talents. For instance, rational parties would not choose a low level of physical strenght (or intelligence, if you prefer), although a low level of physical strenght may result a disadvantage in most societies. But a low level of physical strenght is not necessarily an impairment (it may be simply a undesirable condition).

The other problem is that it does not seem to deal adequately with certain traits that produce a disadvantage through arbitrary, but in a sense “natural” stigmatization phenomena. Perhaps the stigmatization of people with certain characteristics  is “natural”, in the restricted sense that it tends to occurr thorough a wide range of different possible social arrangments.

As an example, take homosexuality and suppose, as the suggestion goes, that homosexual people are stigmatized in most societies, and that this can be known by appealing to general facts about social psychology. Rational and self-interested parties acting as representativies of unknown citizens may prefer to confer the people they represent the guarantee of not being homosexual, for the purpose of avoiding the disadvantage resulting from stigma. Thus the procedure classifies homosexuality as an impairment of normal functioning, which I think is a politically undesirable result.

Now the case of homosexuality is not an isolated counterexample but highlight a characteristic (perhaps a defect) of the procedure.
For the procedure does not “filter” the effect of morally worthless attitudes like stigma.

For both reasons, we may try to develop a more complex approach that avoids these problems, by embedding the idea of a choice under the veil of ignorance in a more complex conceptual structure, provided by the BST definition of health.


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