Can Norman Daniels Help You Get a Wheelchair? A Commentary on Durocher et al.

Durocher and colleagues (2019) argue that Norman Daniels’s notion of just health could provide a useful framework for decreasing inequities in access to assistive technology. I argue that it would provide limited help for two reasons. First, Daniels’s reliance on normal species functioning as the goal of health care and his assumptions regarding the impact of normal species functioning on reasonable life projects create substantial difficulties for application to assistive technology. Second, although Daniels’s requirements for distributive justice provide a critical starting point for any discussion of health equity, these requirements appear already met within current assistive technology funding schemes.     

Health care need: three interpretations

The argument that scarce health care resources should be distributed so that patients in 'need' are given priority for treatment is rarely contested. In this paper, we argue that if need is to play a significant role in distributive decisions it is crucial that what is meant by need can be precisely articulated. Following a discussion of the general features of health care need, we propose three principal interpretations of need, each of which focuses on separate intuitions. Although this account may not be a completely exhaustive reflection of what people mean when they refer to need, the three interpretations provide a starting-point for further debate of what the concept means in its specific application. We discuss combined interpretations, the meaning of grading needs, and compare needs-based priority setting to social welfare maximisation.     

Building Leadership,Capacity, and Power to Advance Health Equity and Justice through Community‐Engaged Research in the Midwest

The Health Equity Advancement Lab (HEAL) at the University of Iowa College of Public Health began in 2012 to support students, researchers, and community members interested in tackling persistent health inequities through a community‐based participatory research (CBPR) approach. Using concepts from critical consciousness theory, we developed an approach to building students’, faculty members’, and community partners’ capacity to engage in CBPR to promote health equity that involved immersion in developing CBPR projects. Our paper describes the evolution of HEAL as a facilitating structure that provides a support network and engages diverse stakeholders in critical reflection as they participate in research to advance health equity, and resulting political efficacy and social action. We describe one HEAL‐affiliated research project that employs a CBPR approach and has a strong focus on providing transformative learning experiences for students, faculty, and community members. We highlight challenges, successes, and lessons learned in the application of critical consciousness as a framework that engages diverse academic and community partners seeking to promote health equity. We argue that critical consciousness is a relevant theoretical framework to promote transformative learning among students, faculty, and community partners to promote health equity research in diverse communities.     

Indeterminacy and the principle of need

The principle of need—the idea that resources should be allocated according to need—is often invoked in priority setting in the health care sector. In this article, I argue that a reasonable principle of need must be indeterminate, and examine three different ways that this can be dealt with: appendicizing the principle with further principles, imposing determinacy, or empowering decision makers. I argue that need must be conceptualized as a composite property composed of at least two factors: health shortfall and capacity to benefit. When one examines how the different factors relate to each other, one discovers that this is sometimes indeterminate. I illustrate this indeterminacy in this article by applying the small improvement argument. If the relation between the factors are always determinate, the comparative relation changes by a small adjustment. Yet, if two needs are dissimilar but of seemingly equal magnitude, the comparative relation does not change by a small adjustment of one of the factors. I then outline arguments in favor of each of the three strategies for dealing with indeterminacy, but also point out that all strategies have significant shortcomings. More research is needed concerning how to deal with this indeterminacy, and the most promising path seems to be to scrutinize the position of the principle of need among a plurality of relevant principles for priority setting in the health care sector.     

Who Do We Treat First When Resources Are Scarce?

In a health service with limited resources we must make decisions about who to treat first. In this paper I develop a version of the restoration argument according to which those whose need for resources is a consequence of their voluntary choices should receive lower priority when it comes to health care. I then consider three possible problems for this argument based on those that have been raised against other theories of this type: that we don't know in a particular case that the illness is self‐inflicted, that it seems that all illness is self‐inflicted in the sense used in my argument, and finally that this type of approach incorporates an unacceptable moralising element if it is to avoid giving those like fire‐fighters a lower priority for treatment. I argue that the position outlined here has the resources to respond to each of these objections.     

Just health care (II): Is equality too much?

In a previous essay I criticized Engelhardt's libertarian conception of justice, which grounds the view that society's obligation to assure access to adequate health care for all is a matter of beneficence [1]. Beneficence fails to capture the moral stringency associated with many claims for access to health care. In the present paper I argue that these claims are really matters of justice proper, where justice is conceived along moderate egalitarian lines, such as those suggested by Rawls and Daniels, rather than strong egalitarian lines. Further, given the empirical complexity associated with the distribution of contemporary health care, I argue that what we really need to address the relevant policy issues adequately is a theory of health care justice, as opposed to an all-purpose conception of justice. Daniels has made an important start toward that goal, though there are some large policy areas which I discuss that his account of health care justice does not really speak to. Finally, practical matters of health care justice really need to be addressed in a ‘non-ideal’ mode, a framework in which philosophers have done little.     

Rationing just medical care

U.S. politicians and policymakers have been preoccupied with how to pay for health care. Hardly any thought has been given to what should be paid for--as though health care is a commodity that needs no examination--or what health outcomes should receive priority in a just society, i.e., rationing. I present a rationing proposal, consistent with U.S. culture and traditions, that deals not with "health care," the terminology used in the current debate, but with the more modest and limited topic of medical care. Integral to this rationing proposal--which allows scope to individual choice and at the same time recognizes the interdependence of the individual and society--is a definition of a "decent minimum," the basic package of medical treatments everyone should have access to in a just society. I apply it to a specific example, diabetes mellitus, and track it through a person's life span.     

Lost in the Market, Saved at McDonald's: Conversion to Christianity in Urban China

Protestant Christianity has been growing very fast in China under communist rule. This article shows that the converts are not all marginalized individuals deprived of material and social resources. An increasing proportion of the converts are well-educated young people in urban China. To explain this conversion to a nontraditional religion, the micro-level factors of individual crisis, individual choices, and personal bonds are inadequate. The meso-level institutional factors of organizational strengths and competitiveness are important, but religious organizations are severely constrained by restrictive regulations in China. I argue that the macro-level contextual factors are very important to understand the phenomenon of large-scale conversion to Christianity in China today. The crucial contextual factors are the increasingly globalized market economy under political repression. Christianity provides peace and certainty in facing wild market forces. The Christian faith is liberating amid a stifling political atmosphere. McDonald's is a prominent symbol of the globalized market, which, like Christianity, is perceived as modern and cosmopolitan within the Chinese context.     

The harms of ignoring the social nature of science

In this paper I argue that philosophers of science have an obligation to recognize and engage with the social nature of the sciences they assess if those sciences are morally relevant. Morally-relevant science is science that has the potential to risk harm to humans, non-humans, or the environment. My argument and the approach I develop are informed by an analysis of the philosophy of biology literature on the criticism of evolutionary psychology (EP), the study of the evolution of human psychology and behaviour. From this literature, I tease out two different methods of scientific critique. The first I call the “truth-detectional” approach. Those who take this approach are first and foremost concerned about the truth of EP claims as that truth can be determined by evidence. The second I call the “social-dimensional” approach. Those who take this approach talk about the production and truth of EP claims but within a social framework. On this account, the legitimacy and perceived legitimacy of EP claims are not separate from the institutional and social processes and values that lend to their production. I show that the truth-detectional approach risks harms to society and to the philosophy of science, but that the social-dimensional approach avoids these harms. Philosophers of science, therefore, should take a social-dimensional approach to the assessment of morally-relevant science.

     

RIGID DESIGNATION, DIRECT REFERENCE, AND MODAL METAPHYSICS

Abstract:  In this paper I argue that questions about the semantics of rigid designation are commonly and illicitly run together with distinct issues, such as questions about the metaphysics of essence and questions about the theoretical legitimacy of the possible-worlds framework. I discuss in depth two case studies of this phenomenon – the first concerns the relation between rigid designation and reference, the second concerns the application of the notion of rigidity to general terms. I end by drawing out some conclusions about the relations between rigid designation, semantic frameworks, reference, and essence.     

Accountability and team care

Although we normally have no difficulty with holding individuals accountable for the effects of their actions, we are still confused about holding a health care team accountable. I argue that we can hold teams accountable in the same way that we hold individuals accountable. In constructing this argument, I first examine the nature of a “team,” then look at the consequences of team decision and action, in particular, the problem of synergistic decisionmaking. Finally I relate this philosophical discussion to patient care decisions by teams.     

Enactivism,other minds,and mental disorders

Although enactive approaches to cognition vary in terms of their character and scope, all endorse several core claims. The first is that cognition is tied to action. The second is that cognition is composed of more than just in-the-head processes; cognitive activities are (at least partially) externalized via features of our embodiment and in our ecological dealings with the people and things around us. I appeal to these two enactive claims to consider a view called “direct social perception” (DSP): the idea that we can sometimes perceive features of other minds directly in the character of their embodiment and environmental interactions. I argue that if DSP is true, we can probably also perceive certain features of mental disorders as well. I draw upon the developmental psychologist Daniel Stern’s notion of “forms of vitality”—largely overlooked in these debates—to develop this idea, and I use autism as a case study. I argue further that an enactive approach to DSP can clarify some ways we play a regulative role in shaping the temporal and phenomenal character of the disorder in question, and it may therefore have practical significance for both the clinical and therapeutic encounter.

     

Agency,Thought, and Language: Analytic Philosophy Goes to School

I take as my starting point recent concerns from within educational psychology about the need to treat the conceptual and philosophical underpinnings of empirical research in the field more seriously, specifically in the context of work on the self, mind and agency. Developing this theme, I find such conceptual support in the writings of P. F. Strawson and Donald Davidson, two giants of analytic philosophy in the second half of the Twentieth Century. Drawing particularly on Davidson’s later work, in which he seeks to integrate key claims about subjectivity, objectivity, belief, truth and knowledge, within what he refers to as a triangular framework of two speakers and a common world, I find support for pedagogic and classroom organizational structures based on collaborative thinking and dialogue. While Davidson did not write about education, I argue that his framework has much to offer, most particularly in view of the priority it affords language and dialogue as the necessary and sufficient conditions for reason, belief and thought—in short, for being a person in the world.     

Truthfulness,risk, and trust in the late lectures of Michel Foucault

This paper argues that Foucault's late, unpublished lectures present a model for evaluating those ethical authorities who claim to speak truthfully. In response to those who argue that claims to truth are but claims to power, I argue that Foucault finds in ancient practices of parrhesia (fearless speech) a resource by which to assess modern authorities' claims in the absence of certain truth. My preliminary analytic framework for this model draws exclusively on my research of his unpublished lectures given at the Collège de France between 1982–84. I argue that this model proceeds in three stages: the truth‐teller is first established as independently authoritative, he is subsequently tested under conditions of risk, and the encounter concludes by generating trust and a relation of ‘care’ with the audience. Foucault's model results in an ‘aesthetics of existence’ organized around a set of ethical practices, and thus offers an alternative to other forms of ethical subjectivity. In so doing, this model also critiques the place for risk in liberal political institutions.     

Aggregating with reason(s)

Judgment aggregation is naturally applied to the modeling of collective attitudes. In the individual case, we represent agents as having not just beliefs, but also as supporting them with reasons. Can the Judgment Aggregation help model a concept of collective reason? I argue that the resources of the standard judgment aggregation framework are insufficiently general. I develop a generalization of the framework that improves along this dimension. In the new framework, new aggregation rules become available, as well as a natural account of collective reasons.     

The Significance of the Concept of Disease for Justice in Health Care

In this paper, I want to scrutinise the value of utilising the concept of disease for a theory of distributive justice in health care. Although many people believe that the presence of a disease-related condition is a prerequisite of a justified claim on health care resources, the impact of the philosophical debate on the concept of disease is still relatively minor. This is surprising, because how we conceive of disease determines the amount of justified claims on health care resources. Therefore, the severity of scarcity depends on our interpretation of the concept of disease. I want to defend a specific combination of a theory of disease with a theory of distributive justice. A naturalist account of disease, together with sufficientarianism, is able to perform a gate-keeping function regarding entitlements to medical treatment. Although this combination cannot solve all problems of justice in health care, it may inform rationing decisions as well.     

Response to Michael Sells

In an era when lies and misrepresentations about historical events easily become firmly rooted, Michael Sells's discussion illustrates the importance of careful historical research as a moral enterprise. In addition to the skills of the historian, however, there is also room in this enterprise for those of the ethicist. In particular, I warn against confusing the truth or falsity of claims about one narrow historical period with larger questions about the moral meaning and significance of those claims. Illustrating this, I argue one cannot assess the legitimacy of competing nationhood claims solely on the basis of the deeds of specific actors. Nor should the actions of a single individual like the Grand Mufti of Jerusalem be converted into a totalizing claim about the rights of the Palestinian people.     

A Multilevel Approach for Reducing Mental Health and Substance Use Disparities Affecting Bisexual Individuals

Despite bisexual individuals being at increased risk for mental health and substance use problems, clinicians’ ability to provide affirmative and competent care to bisexual clients is limited by their lack of bisexual-specific training. To address this common gap in training, this article provides a brief review of bisexual health disparities and the factors that influence them. Then, we describe a multi-level approach for improving the health and well-being of bisexual individuals. This approach addresses factors that influence health at the micro-level (e.g., strategies that clinicians can use to help bisexual clients cope with stigma-related stressors), mezzo-level (e.g., adaptations to clinical environments and training programs that promote bisexual-affirmative care), and macro-level (e.g., advocating for political change and implementing strategies to reduce prejudice against bisexual individuals at the population-level). Specifically, we describe how clinicians can adapt evidence-based interventions to tailor them to the needs of their bisexual clients. Additionally, we discuss the need for bisexual-affirmative clinical training and provide recommendations for how clinical training can be adapted to prepare clinicians to work effectively with bisexual clients. Finally, we describe how population-level interventions can be used to reduce prejudice against bisexual individuals in order to reduce bisexual health disparities. Given the striking health disparities affecting bisexual individuals, there is a critical need to develop, test, and disseminate interventions to improve the health of this population and to prepare clinicians to provide bisexual-affirmative care.     

Equity but not Equality: Commentary on Lachance-Grzela and Bouchard

Lachance-Grzela and Bouchard (2010) review the research concerning the division of household labor that has been published between 2000 and 2009, with special emphasis placed on micro-level and macro-level perspectives and on methodological considerations. This commentary suggests that perceived fairness is an important factor that cannot be separated from the impact of division of household labor. Women perform the majority of household labor, yet the majority of both men and women view this unequal division to be fair. In the past, perceived fairness has been linked to both mental and relationship health. Perceived fairness is discussed from a micro-level and macro-level perspective and in terms of methodological considerations using research primarily published within the last decade.