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new interesting blog

Il nuovo blog del mio amico e collega Alex Grossini

http://lamorale.wordpress.com/

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(only for those who can read Italian)

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Angelo Angarano

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USA towards universal health care

I paradossi del riconoscimento.

Vorrei mettere su bianco alcune riflessioni che mi sono venute in mente collegando le questioni sul riconoscimento, di cui ci ha parlato la filosofa Elisabetta Galeotti, e i temi di filosofia della medicina e della disabilità dei quali mi sto occupando. Il titolo di questo post è “i paradossi del riconoscimento”, perché ritengo che trattare le caratteristiche particolari degli individui come basi del rispetto porti a conclusioni paradossali.  Caratteristiche particolari degli individui sono quelle caratteristiche che ci permettono di distinguerci gli uni dagli altri, come il colore della pelle, il credo politico o religioso, o l’orientamento sessuale. Non sono caratteristiche particolari invece, caratteristiche come la sensienza, la capacità di provare dispiacere per qualcosa, o di prendere decisioni con un certo grado di autonomia, che sono invece ampiamente condivise e dunque non adatte a tale scopo.

Per prima cosa, metto nero su bianco che ho molte difficoltà a capire che cosa voglia dire rispettare un individuo in quanto tale: secondo me il rispetto è sempre rispetto per una caratteristica, o almeno, è rispetto per qualcuno in virtù di una sua caratteristica. Questo perché il rispetto ha sempre una natura concettuale e intenzionale: se uno mi dice che rispetta un individuo in quanto individuo privo di caratteristiche, io non riesco proprio a capire quello che mi sta dicendo.

Mi pare di capire che la filosofa Elisabetta Galeotti concepisca il rispetto come un atteggiamento che si ha, e che si dovrebbe avere, anche per le caratteristiche particolari (o addiritura, distintive) degli individui. Fino a qui, sento di essere d’accordo con lei. Mi pare che sia giusto rispettare egualmente, ovvero conferire eguale dignità a caratteristiche quali: essere uomo o donna, bianchi o neri, eterosessuali o omosessuali.

Aggiungerei quanto segue: quando noi riconosciamo eguale dignità a determinate caratteristiche umane, smettiamo di considerare gli svantaggi che derivano da tali caratteristiche come un problema dell’individuo, e iniziamo a vederli come un problema della società nel suo complesso. Ad esempio, se riscontriamo che il sesso, il colore della pelle, o l’inclinazione sessuale di un individuo è correlato a diseguaglianze di opportunità o benessere, riteniamo che sia giusto modificare la società in modo da porre rimedio a tali diseguaglianze.

Ma questo non è tutto: oltre a impegnarci moralmente a cambiare la società al fine di ottenere  la scomparsa di tali diseguaglianze, consideriamo inaccettabile ottenere tale risultato attraverso l’eliminazione delle caratteristiche in questione dalla nostra società. (Per i più puntigliosi: l’eliminazione delle loro esemplificazioni).  Ad esempio, non riterremmo accettabile eliminare lo svantaggio correlato alla pelle scura perseguendo una politica che porti alla scomparsa di individui con tali caratteristiche.  Questo principio vale a prescindere da considerazioni attinenti alla sfera della protezione dei diritti individuali: se in una società si dessero le condizioni che porterebbero la maggiorparte dei neri a desiderare di avere un figlio bianco, e i mezzi sufficienti a realizzare tale proposito, troveremmo discutibile (a dir poco) la concessione di tale liberta, almeno fino a quando non avremmo rimosso le condizioni alla base di tale desiderio.

Il problema sorge quando iniziamo a considerare caratteristiche come la sordità o altre correlate a disabilità varie. In base all’analogia con il colore della pelle, l’eguale rispetto per la sordità implica non solo la volontà di riformare la società in modo da scongiurare le diseguaglianze dovute al possesso di tale caratteristica, ma anche quella di impedire che tale obiettivo venga raggiunto attraverso una politica eugenetica, o la semplice concessione di una libertà che porti a risultati equivalenti.

(Mi si risponderà che l’analogia non ha senso, in quanto la sordità è una malattia, la pelle scura no. Eppure non è affatto chiaro che sia possibile distinguere la malattia dalla salute senza fare appello a considerazioni di valore. (Io non credo sia possibile). Inoltre il valore che ci permette di distinguere la malattia dalla salute non è neppure quello del benessere, o delle opportunità. Se da un lato è vero che la sordità incide negativamente sul benessere di un individuo, lo stesso può essere detto a proposito della semplice bruttezza, non dovuta a malattie. Inoltre, se da un lato è vero che la pelle scura è compatibile con una vita felicie, dignitosa e foriera di oppotunità, in un contesto sociale adeguato, lo stesso vale a proposito della sordità.)

Veniamo al dunque. Personalmente, sono portato a ritenere che non vi sia niente di illecito nel favorire, o almeno nel permettere, pratiche eugenetiche che portino alla scomparsa sulla faccia della terra degli individui sordi. Se il ragionamento precedente è valido, devo dunque concludere che, per me, la sordità non abbia pari dignità rispetto all’udito normale, a qualsiasi inclinazione sessuale, a qualsiasi colore della peele? Non vedo come possa evitare tale conclusione.

Arriviamo dunque al seguente paradosso: che sia necessario fornire distinzioni potenzialmente controverse tra differenze che sono degne di eguale rispetto e differenze che non lo sono. Si tratta di una conclusione per alcuni aspetti paradossale, dato che le persone tendono a identificarsi con le loro caratteristiche distintive, e quindi sembra che nel mancare di rispettare tali caratteristiche, noi gli facciamo un torto.

Occorre distinguere, naturalmente, il nostro atteggiamento nei confronti del sordo dal nostro atteggiamento nei confronti della sua sordità. Qualcuno penserà di evitare il paradosso sostenendo che sia possibile conferire eguale rispetto a sordi e normalmente udenti, senza con questo adottare lo stesso atteggiamento verso sordità e udito normale.

Ma questa soluzione mi lascia insoddisfatto, per il motivo esposto all’inizio. Infatti secondo me “rispettare il sordo” non vuole dire assolutamente niente, a meno che non venga indicato il fondamento di tale atteggiamento, che è sempre una caratteristica di tale individuo  ( ad esempio, la capacità di agire autonomamente o di provare dolore, o dispiacere per qualcosa). Ma a questo punto, siamo tornati al modello Kantiano, nel quale la base del rispetto è una caratteristica piuttosto comune, con la quale è molto improbabile che qualcuno si identifichi a fondo.

Viva Kant?

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.

Some thoughts on Boorse’s “a Rebuttal on Health” 2

Another point. Many criticisms (and rebuttals by Boorses) revolve around the idea that there is no such thing as a “species design” and a “species-typical functioning” because phenotipes change under evolutionary pressures.

Boorse’s  rebuttal is first, (pp.28-41) to stress that people who see a difficulty in the variability of human species design miss the forest for the tree, or in other words, that evolutionary change is irrelevant, because it takes place at the wrong “order of magnitute” (37). Through non evolutionary times, human phenotypes are remarkably stable; if it were not so, standard anatomy textbooks would contain only lies.

Another, but related reply, is to say that these authors miss the distinction between adaptation and disease (41).

“Being black in Trondheim or white in the Sahara is neither a disease nor pathological, though each condition raises the risk of disease, as Engelhardt observes. His examples, far from being cases where maladaptation is disease, are instead clear cases of the contrast between health and adaptation” (41)

The point is further developed in the section “dynamic equilibrium and environmental disease”.  Here Boorse’s point is that “organisms, including man, have evolved many adaptive mechanism to maintain normal physiology against environmental variation” (79). Therefore

“Some of this pattern is shown by Engelhardt’s Norwegian in Africa. White skin in Africa is not itself a disease. But if the Norwegian is transported suddenly and left in the equatorial sun, he will get at least a severe sunburn, which is pathological. However, if his level of sun exposure had changed gradually, his skin would have tanned, allowing him to stand much more sun without injury. To use HTC’s terminology (p.553), both his original white skin and his tan are intrinsically healthy; the tan is also instrumentally healthy in protecting him from injury. That is, neither tan nor lack of tan is disease, but the latter makes disease more likely in a certain environment” (80)

My impression concerning these passages is that Boorse is escaping the real problem. This I would put it in the following way:

Problem: the efficiency of a structure/process in accomplishing its function depends upon the environment where it operates. Let us now imagine a future in which people ceased to reproduce by usual means and employ only artificial insemination. Let us suppose, for the sake of the argument, that the practice gets culturally stable, and “natural” reproduction becomes a taboo. In this environment, erectile dysfunction does not detract from the goal of reproduction, as there is no goal to which the erection of the penis contributes.   Let us also suppose that this practice lasts for a sufficiently large number of year, sufficient to counterbalance the millions of year during which humans reproduced in the traditional way, so that artificial insemination counts by the numbers as statistical  normality with respect to reproduction.  When this scenario will becomestrue (as in many science fiction novels) the BST must say (at that point in time) that erectile dysfunction is not a disease, in that it does not detract from the typical (species normal) efficiency of erection. (On the interpretation of “typical efficiency”, see the previous post). For at this point, the typical efficiency of erection is null, as erection plays no role in the (statistically speaking) normal environment.

Notice a further oddity, the worse of all: suppose that after eons in which humans reproduced only through non-natural means, old-fashioned sex becomes suddenly (let’s imagine, by violent cultural revolution) the rule again. At that point in time, the BST would still treat people with erectile dysfunctions as healthy.

This odd feature results from a necessary feature of the theory: in order to avoid the relativization of “efficiency” to the specific envirnoment in which the organism operates (which Boorse conceptualizes as “adaptation”), Boorse must average out spatially and temporally over the whole natural history of the species homo sapiens. It cannot be further amended.

This result counts as a reductio ab adsurdum of the theory.  Or doesn’t it? And I haven’t still found a cogent rebuttal by Boorse. Am I missing something?

Reflections on Boorse’s “a rebuttal on health”

P. 18 lexical ambiguity in the explanation of the environmental clause

“Betchel (like HTC) goes on to note that the above idea makes universal diseases impossible, and that I proposed an environmental clause to handle this problem. He quotes my disjunctive summary from DI and complains. […] As for a “hostile” environment, it is one that disrupts something in the hierarchy of statistically normal species-normal part-functions, i.e., reduces a part’s typical contribution to a physiological goal (see Specific Terms) – that is the “state,” as explained in WF and HTC. “

The expression “a part’s typical contribution to a physiological goal” is ambiguous between:

A. typical (=species-normal) in the type of contribution

B. typical (=species-normal) in the degree of contribution

if A, then a hostile environment is one which reduces the efficiency of a structure/process (relative to its typical/species-normal function), simpliciter

if B, then a hostile environment is one which reduces the efficiency of a structure/process (relative to its typical/species-normal function) in comparison to the typical (species-normal) efficency. What’s weird is that what Boorse says makes no sense to me on either reading (am I failing to understand something?).

Let me explain:

Suppose that A. Then for any structure/process in any given environment x1, one can imagine a further environment x2 where the same structure/process performs its function with an increased efficiency . For example, suppose that in our present circumstances, a given amount of collagens (the stuff which keeps bones resistant) is produced, at age 70, by the bone cells. We can imagine an environment which includes medical technologies (e.g. drugs) which stimulate the cells of 70 year old people to produce more collagenes, which would increase he efficiency of those cells. Since in this interpretation the theory counts as disease the decreased efficiency of a biological function relative to any conceivable standard, the theory would entail that 70-year old people that by present medical standards are perfectly healthy are indeed unhealthy. This amounts to a counterexample to Boorse’s theory

Suppose that B. Take the case of a universal disease: caries. If a hostile environment is one that reduces the efficiency of a structure in comparison to typical efficiency, then caries is not due to a hostile environment, because the typical efficiency of teeth surface is compatible with getting caries sooner or later. Under the interpretation B, the environmental cannot help solving the problem of universal diseases.

Rawls on natural talents

Rawls writes that “the extent to which natural capacities develop and reach fruition is affected by all kinds of social conditions and class attitudes” (TJ 2nd ed 164).
What are natural capacities in Rawls?
It is tempting to think that natural capacities are those characteristics whose development is influenced in a minimal part by ordinary external interventions such as education and training and in a major part by a person’s genetic endownment. In this sense, a natural talent for music would be that part of or factor in a person’s characteristic way of playing music which could have not been created by ordinary external interventions.  

Notice the implication of this interpretation for Rawls’s principle of fair equality of opportunity. According to Rawls, his own principle implies that people with equal natural capacities, and willingness to develop and use them, end up in similarly good positions. (ibid. p. 63, assuming equivalence between “natural assets” and “natural capacities to be”.)

In the light of this interpretation (which is wrong, as we shall see), fair equality of opportunity obtains when there is a rough correspondence between the genetic endowment of persons and the social positions they end up in, assuming equal efforts for cultivating and using those genetic resources.
Now it might be argued that there is a different interpretation of natural talents, that matches the role that the concept of a natural capacity plays in Rawls’s theory better than the former . According to this second interpretation, what makes a human capacity a natural one is its not resulting in a systematic and predictable manner from intentional human acts or from the working of human institutions.

Hence the fair equality of opportunity principle would be satisfied when (assuming equal willingness and efforts to cultivates those characteristics which are abilities and which do not result from systematic and predictable manner from intentional acts or human institutions) there is a rough correspondence between positions and possessions of such characteristics.

The two conceptions differ in relation to genetic interventions. According to the first conception a personal quality deriving from genetic enhancement or genetic screening technologies would still count as a natural talent, while on the second it would not.
Arguments against the first interpretation and in favor of the second:
1. the second interpretation is more plausible in the light of our judgments of fairness about a society which would make extensive usage of genetic interventions.
What would we think of a society were the best social positions (meaning those characterized by a high level of income and prerogatives of power) were occupied by people whose parents could afford expensive genetic treatments? This would be a society were individuals who – for no faults of their own – are born in low-income families are deprived of any significant chance to end up occupying privileged positions. I think that we would not say that these institutions guarantee equal opportunities in a fair sense.
Unfortunately, according to the first interpretation of “natural talents”, the first society could be fair. It would be enough that people characterized by similar genetic endowments and similar efforts end up occupying positions of similar wealth and autority. This is perfectly compatible with all positions of wealth and responsibility being occupied by people whose parents could afford expensive genetic treatments.
According to the second interpetation, however, this would not be the case, as the qualities granting access to privileged social positions would not count as natural anymmore.

This blog.

Here I write my first spontaneous reactions to philosophical arguments I read and hear about and my philosophical ideas in an embryonal form. Anyone feel free to discuss and correct them.