Category Archives: Just Health Care

Questa è probabilmente la notizia più importante del giorno

… e per una volta, non è una brutta notizia:

U.S. Congress Approves Bill to Extend Health Care to Millions

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A definition of talent

This is for use within the context of Rawls’ fair equality of opportunity principle

P=person

A=activity

P’s talent for A at time (t) = P’s capacity at t to acquire the skills required by activity A, at a certain absolute level of excellence, as standardly defined by the social practice to which S belongs, as measured by the hypothetical cost of making P acquire those skills at t,  discounting for costs deriving from the existence of social prejudices against P

With respect to A, P1 is equally talented as P2 at t <–> apart for the costs of removing the adverse effect of social prejudices, the cost of training P1 and P2 to the same level of excellence at all the skills required by A, at t, is the same

social prejudices about P =  false beliefs about P, held only in so far as P is recognized as a member of a certain social groups or community

The definition fits with current usage. Examples:

“At birth, blacks have generally the same level of talent as whites” <–> “for any human activity, apart from the cost of removing prejudice and its consequences, the average cost of training a black man or a white man from birth for the skills required by every human activity (at every level of excellence) is the same”

(some people deny this, because they believe hat blacks can be more easily be trained to become Olimpic runners)

“With respect to all intellectuctual jobs, before means of transportation and buildings are constructed, wheelchair users and normally gifted individuals have the same talents at birth” <–> “for any intellectual job, apart from the cost of removing prejudice and its consequence, and before means of transportation and buildings are constructed, wheelchair users and normally gifted individuals have the same talents at birth”

(This is one the things that disability activists claim when they claim that disability are socially constructred. It is true if building wheelchair accessible buildings and vehicles has roughly the same cost. If true, it could be used as a premise together with Rawls FEO for  claiming that a just society, when deciding to build means of transportation and buildings, ought to choose to build the wheelchair accessible ones)

Some people may believe the following:

“At birth, women and men are not equally talented as chil caretakers” <–> “the average cost of training men and women from birth to the same level of skill as child caretakers is different”

(It may be true if, suppose, women have statistically a higher amount of hormons making the acquisition of certain skills for them easier than for men)”

All reasonable people believe the following:

“at birth, deaf people are on average less talented than the rest of the population with respect to music” <–> “it is more expensive to train deaf people to acquire musical skills from birth than it is to train non deaf people”

Rescuing Justice as Fairness from Norman Daniels

Daniels’ extension of FEO seems unacceptable, for it seems to collapse two issues that ought to remain distinct in any “social structural” account of equality of opportunity, such as the one Justice as Fairness provides.

As I see things, Daniels starts from a good point, but then spoils it. The good point is that you can extend FEO in a plausible way to deal with certain cases where equality in the access to health care is at issue. He spoils it because he wants to extend it to an altogether different type of cases.

Consider:
Case 1. Here we have two individuals with roughly similar “natural endowments” (similar biological constitution) from different sectors of society (e.g. different socio-economic classes): P and R. Suppose that P is born in a poor family, which cannot afford health insurance, and as a result gets sick three times as often as R, who is born in a rich family. Because P gets sick so often, he fails to express and develop his talents to the same degree as R.

Daniels can appeal to our intuition about such cases to claim, quite plausibly,  that FEO extends to access to health care. After all it seems wholly correct to say that, just like unequal access to education, inequality in the access to health care affects opportunities between P and R, so that they end up with different social positions even if the two even if they are equally motivated and endowed .

Consider the second scencario (case 2). Here we have two individuals who are born with different “natural endowments” from the same sector of society: U and L. More precisely, U has a congenitally higher disposition to get sick than  L, and since none of them has access to high quality health care, U actually gets sick twice as often as L. Because of more days free of pain, U has a more successful education and gains access to a more rewarding professional career.

Ought case two figure as a violation of FEO? I think the answer is clearly: no! The case does not differ substantially from that of people born with different talents, for which equal access to opportunity according to Democratic Equality is not an issue. From the point of view of Democratic Equality, inequalities in income and wealth between U and L should satisfy the difference principle.

Daniels disagrees: he wants to extend FEO according to an intepretation that treats case 1 and case 2 as instances of the same scenario, while avoiding the “luck egalitarian” implication of his way of dealing with case 2 by placing a (seemingly arbitrary) constrain: only departures from normal functioning determine a violation of FEO.

I fail to see what could motivate Daniels’ solution, except wanting to respond to Sen’ and Arrows’ criticism of Rawls.

Normal functioning: political not metaphysical (2): the choice of goals. Completely revised.

Revising the BST in the light of political values/ goals.

1. the concept of function

Continue reading

Normal functioning: political not metaphysical (1) The general idea.

We begin this inquiry by assuming that Daniels fails to adequately justify the choice of Boorse’s BST definition of normal functioning as a constraint for society’s obligation to meet the health needs of its citizens. We assume that politically reasonable people may reject the idea that BST delivers a value-free definition of normal functioning. If so, its employment in the context of political theory requires a different justification from the one Daniels provides.

We claim that, however, there can be a notion of normal functioning which can be used for practial polical purposes (e.g. in defining justice-related obligations to meet health needs). This notion must be understood as a political, value-laden notion.

We want apply Rawls’s constructivist approach to the notion of normal human functioning. From the values and ideas embedded in the culture of liberal political and medical institutions we derive,  through a procedure of construction embedding reasonable constraints of equity, a concept of human functioning that, if our conjecture is valid, can form the basis for an overlapping consensus of all reasonable theories/definitions/analyses of health and disease. (A theory of health and disease is reasonable (def) iff it presupposes, at most, the shared political values and ideas of (Rawls’s) political liberalism).

The core notion for the construction is Boorse’s Bio-statistical Theory (BST) of health as human functioning. We choose BST as our starting point. From the formal point of view, the BST provides a type of concept – a normal functioning concept – which, in one form or another, is often implicit in the ideas of health and disease used both in our political culture and in the medical tradition.

We deny that the details of the BST concept of health (the way it defines functions and reference classes, for instance) are the focus of general agreement. But we claim that something like the general form of the normal-functioning concept of the BST must be preserved by any reasonable analysis of health.

The choice of a normal functioning notion is also dictated by the needs of Rawlsian political theory, as Justice as Fairness can be extended to cover health needs only by supplementing it with a concept of normal functioning.

The BST definition of disease involves the following elements:

1. an account of the functional organization of a living being, understood as a hierarchical organization of functions under certain overarching goals (in the BST, survival and reproduction)

2. an account of reference classes, viz. “natural classes of organisms of uniform functional design” (in BST, age group and sex, possibly race)

3. the normal function of a part or process, defined as its statistically normal contribution to the goals of which in (1) within members of a reference class (of which in 2)

4. disease, defined as the reduction of one or more functional abilities below typical efficiency.

5. typical efficiency, defined as “efficiency above some arbitrarily chosen minimun in its species distribution” (p.6 Boorse, Christopher. “A Rebuttal on Health.” BIOMEDICAL ETHICS REVIEWS (1997): 1-134).

We claim that the definition of theoretical parameters of at least 1, 2, and 5 (and derivatively 3 and 4) is value laden. More specifically:

1) the choice of overarching goals if value laden

2) the choice of reference classes is value laden

5) the choice of the cutoff point for typical efficiency is value-laden (as Boorse himself writes, it is an arbitrarily chosen minimum in species distribution)

We arrive at a political definition of normal functioning by revising the BST in the light of the shared political and medical values of liberal democracies. More precisely, we undertake to provide a normative justification of parameters 1, 2 and 5.

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.

Health, Selection and Sex (Some thoughts on Boorse’s “a rebuttal on health” /4)

As in the previous post, here I am concerned with aspects of the “normativity” of Boorse’s account that cannot be considered objections against Boorse’s project, but which still count as objections once Boorsian health is made to play normative work in a political theory. It would be simplistic to assume that, if Boorse can show that his account is naturalistic, in its own terms, then its incorporation in normative theory is unproblematic. The problem discussed here shows why.

When discussing Hare’s “head hear argument”, at p. 71, Boorse writes that

On the other hand, head hair but not leg hair may have a function, in which case the BST predicts Hare’s two disease verdicts. […] Many other possibilities exist, such as that the graying of men’s hair, by indicating age, serves as a fitness indicator in sexual selection. […] Both the above sexual selection hypothesis and Hare himself open a can of worms I wold have liked to avoid: the reproductive effect of appearance. Yet another point about baldness is that many women find bald man unappealing, while few men demand woman with hairy legs. This fact too offers the BST a route to Hare’s two disease judgment, if only baldness impedes reproduction. Yet one cannot let the BST turn ugliness into a disease, especially not moderate or marginal ugliness, since it isn’t one. But baldness, if ugly, is not simple ugliness; it is the absence of a normal body part, a discrete structural anormality. One can see how a structural deviation from species design, coupled with damage to reproduction, might induce a BST-inspired physicial to call a trait pathological. Perhaps, then, this line of thought is one reason major deformities are seen as pathological. Structural defects much worse than baldness can be so hideous as to make reproduction almost impossible, though major structural defects (harelip, cleft palate) tend to involve dysfunction as well as deformity. Still, it seems odd to call attracting the opposite sex a biological (let alone a physiological) function of the mouth, face, scalp, fingers, spine and so on. So perhaps the BST does not, after all, entail that awful structural abnormalities are pathological, despite their antireproductive effect. One should note that this inference could only apply in any case to deformities that block reproduction throughout our species. The BST cannot make any one time’s or culture’s standards of beauty into requirements of health. And no such link between appearance and reproduction offers much confort to normativism anyway, since a fact about what the human race finds intolerably ugly, though a fact about values, is a fact nonetheless.” (71-72)

I have quoted this long paragraph because it gives an indication of the extent to which Boorse’s account runs into trouble when one attempts to apply it thoroughly and across the board. I simply see no way to avoid the conclusion that if an abnormal trait is found to be ugly (by the female sex) thorough our species (i.e. in a statistically normal way), then it counts as a disability, because it is an obstacle to reproduction.

To deny this would be ad hoc, because it would create an unbridgeable gap between pathology in the human and in other species (as Boorse reminds us – p. 15 – BST’s ability to explain disease judgments about plants and animals counts as one of its most important strengths). For it is impossible to account for normal species functioning in the animal world if one disregards those structures and processes whose unique or main purpose is to attract the opposite sex. To take a familiar example, consider the peakock’s tail, whose ipermorphism is solely explained by its capacity to attract the opposite sex. A clause ruling out the “increase partner’s attractiveness function” would imply that a peakock’s born without tail has no disease. Therefore there is no prospect of the BST fitting considered veterinary usage if such clause is included.

Having ascertained that the BST must therefore treat as pathological abnormal structural deviations whose sole functional defects derive from their uglyness in the eyes of the opposite sex, let us turn to the problem whether this makes the account value-laden.

The answer may be no, if one asks whether it makes the account “value-laden” in itself, for the reason that Boorse clearly mentions at the end of the paragraph. But it clearly makes the account too value-laden for the usage Daniels’s wants to make of it. For if health care depends on Boorsian pathology, and Boorsian pathology depends (in a crucial case) on what human individuals find sexually attractive, then health care is tied up by subjective desires and tastes, a conclusion that seems incompatible with  the spirit of a Rawlsian approach (because of its rejection of desire-based utility in political assessments).