Tag Archives: Daniels

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.

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In dialogue with John Harris. Part 2.

Pp. 19-20

“I wonder how many readers of this book, like me, use spectacles? All who do are using an enhancement technology.  Now you might say “yes, but that restores normal functioning or repairs or corrects disease, damage, or injury.” So it does.

Those who say this will probably know of the work of Boorse and Daniels, who have each defined health and, hence, illness, in terms of departures from normal functioning or departures from species-typical functioning.

Now consider the use of a telescope or pair of binoculars orr a microscope. These tools are not used to restore normalcy or treat disease or injury. They are done to enhance powers and capacities.

Again I wonder how many of those who have ever used binoculars thought they were crossing a moral divide when they did so? How many people thought (or now think) that there is a moral difference between wearing reading glasses and looking through opera glasses? That one is permissible and the other wicked?”

Commentary:

The reasoning is misleading in that it tacitly assumes that the moral boundary in question  must be one between permissible and impermissible (wicked) actions. But not everybody who thinks that there is a moral difference between restoring normal functioning and the enhancement of normal functions thinks that the moral difference in question consists in one being permissible and the other not so.

Another important moral boundary is the one between what we owe to each other, as a matter of justice, and personal desires (or needs) whose being unfulfilled does not impose an obligation on other people. Some people, perhaps many people, think that enhancing capacities and restoring normal functiong differ as a matter of justice. In this perspective, the rethorical question to ask should have been:

“How many people thought, or now think, that there is a moral difference between government funding of  reading glasses and government funding of opera glasses?”

The answer to this question is “many”. As a matter of fact, many countries – such as Germany – fund reading glasses as part of a comprehensive and largely state subsidized health care program for all German citizens. No state in the world has ever dreamed of funding opera glasses or binoculars.

Hence there is at least a superficial difference between enhancing normal functioning and restoring it, one that many people have reflectively endorsed (as it is reflected in the laws that several communities have adopted).

Whether this difference is only “superficial”, that is to say, one that can be explained by deeper moral principles and distinctions which may produce a justification for funding enhancements, is, of course, a different question.

(A counterexample to what I just wrote is provided by considering reading glasses against presbyopia, a difficulty which, being almost universal among humans over 40, may be regarded to be “part of normal functioning”. For it is not obvious that, if reading glasses are to be funded at all as part of a comprehensive program for health care, reading glasses against prebyopia should be excluded.

This objection raises difficult issues that I have discussed in other posts, such as the one whether the concept of “normalcy” that produces meaningful social obligation should be defined in a way that makes it age-group-relative. This is a serious difficulty for those who, like Boorse and Daniels, thinks so, and moreover think that the concept of health as normal functioning must be defined in this precise way, for reasons that are, broadly speaking, scientifically objective and naturalistic. But perhaps the present objection can be avoided by developing an alternative conception of citienzes’ health as normal functioning.)

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).

SOME THOUGHTS on Boorse’s “rebuttal on health” /3

Boorse’s discussion of the alleged normativity of the “choice of goals” directly relates to the argument I talked about yesterday, the argument about the “perspective of the gene” (DeVito). This is how the objection is formulated by Miller Brown:

“How are we to determine those highest -level goals of organisms which lower-level processes function to acheive? … It may be true that what interests the physiologist is what promotes individual surivial and reproduction. But Boorse’s account was designed to show that the concept of disease is non-normative. At best, what he has shown is that given such a choice of highest-level goals, “function statements will be value-free …” But such “empirical matters” are significant only in terms of the goals chosen. What assurance do we have that these are the goals of tthe system whose “species design” we have determined?” (25)

Boorse answers that

“… his point is clear: The BST makes a normative choice, from a whole class of biological goals, of individual survival and reproduction. My answer, again, is that there is no choice here – that is simplyl what disease is, as the concept is best reconstructed from medical classifications. The real normative choice is medicine’s commitment to combat disease, rather than to promote it, to enrich doctors at any cost, to advance world socialism, preserve planetary ecology or biodiversity, or serve infinitely many other possible goals. Unquestionable medical   practice rests on a normative choice to combat disease. But that does not show that the meaning of disease rests on a normative choice unless one assumes that the meaning of “disease” is fixed by medical practices” (25)

What to say about this wonderfully written and striking reply?

Boorse is reminding us that he is concerned primarily with conceptual analysis, not normative theory. More precisely, his goal is to provide the best conceptual analysis of pathology (not doctors!) considered usage. All that’s claimed is that pathology’s considered usage best fits with the analysis “disease = abnormal deviation in the efficiency of a causal contributor (function) to the two goals of reproduction and survival”. The normative choice is made by doctors, when they  choose to combat  what in their pathology texts figures as “pathology” (that is abnormal deviations in the efficiency of a causal contributor to the goals of reproduction and survival).  Notice that Boorse is not claiming that the choice of the dual goals of reproduction and survival is read off the facts of nature (in the usual sense). Rather, he is claiming that it is “read off” facts about considered usage of language by a specific category of people. The choice of the two goals results from conceptual analysis, not from natural necessity.

As far as Boorse goes, this rebutall of the problem of the normativity of the choice of functions might be Ok. But we are actually interested in how Daniels employs Boorse, for the sake of clarifying the content of a normative claim.  We are interested in Daniels’s normative position, and we turn to Boorse because Daniels accepts Boorse’s analysis of health.

To see if the choice of the two goals of physiology matters we must turn to Daniels’ argument concerning the political importance of health – or better, about the political importance of health-as-seen-by-pathology-as-seen-by-Boorse.  We must turn our attention to the claim that society ought to restore  “standard causal contribution to the two goals of reproduction and survival”, which is the real content of Daniels’ claim, obtained by substituting the term “pathology” with its Boorsian analysis.

To evaluate this, we must read Daniels’s justification of the moral and political importance of health care just as a thesis about the moral and political importance of restoring species typical contributions to the two goals of reproduction and survival. If we do this, I bet, Daniels’ arguments become less persuasive.

Daniels’s master argument concerns the relation between health and equality of opportunity. If stated as a thesis about the relation between standard causal contributions to the dual goals of reproduction and survival and equality of opportunity, it loses some of its original intuitive appeal. If our target is fair opportunities, what’s so special about the deviations from this biological standard? Isn’t the standard too biological? The correlation between this standard and opportunities is at best indirect. From the point of view of strenght of correlation, Daniels should have not focused on “pathologist’s disease” (deviation from species -typical ability with respect to reproduction and survival) but on “economists’ disease” : “extreme deviation from the species-typical norm with respect to all-purpose abilities to achieve primary goods”.

The moral of the story is, I think, that the choice of the pathologist’s standard is based on another sort of considerations: epistemic considerations (a point stressed in the discussion by Roberto). The only reason which justifies the choice of the “overall goals” characteristic of physiology (reproduction and survival, if Boorse is right) is that physiology is in better shape than economics (or cultural anthropology) as a science, and therefore less controversial.

So the real argument in favor of disease as an indicator of missing opportunities, as opposed to subnormal capacity to achieve primary goods, is the (alleged) more controversial status of human claims about who is abnormal with respect to the anthropological/economic capacity to achieve primary goods. [Marx?]

How good is this argument? I think it is quite bad for two reasons: 1) mental functions: it is not easier to establish how mental function contribute to the species-typical goals of reproduction and survival than how mental functions contribute to the ability to acquire primary goods; 2) the fact of agreement: if there is a consensus on the moral importance of disease, it does not regard what Boorse calls the “theoretical” concept of pathology, but the more practical notion of illness or clinical pathology that, as Boorse concedes, is heavily value-laden.