Ethics and Philosophy of Future Medical Technologies (2005, Barcelona)


Ethics and Philosophy of Future Medical Technologies, Aug 2005, BCN. Thursday 2pm

Life Extension Session

What does the community think? An Empirical base for philosophical and ethical debates about life extension Lucy Carter, Jayne Lucke, Bree Ryan & Wayne Hall (Australia)

T science - successful life extension in model organisms - suggestion of human applications within 10-20 - possible of pharma therapies to extend life span (strong life extension) - biomedical advances to treat disease and maintain health (weak life extn)

caloric constriction – reduce calories by 30-50% extn life by up to 30% in mice -    if we promote thi, not good for adolescents -

maximum life expectancy has not advanced at all

Policy implics -    global, popn and fertility control, work and employment, superannuation and pensions, health and life insurance, regulation of antiageing industry, health and social (disability) services, end of life issues

Public Opinion

Assumptions -    people are repulsed by the prospect -    huge demand for life extn

no empirical data available despite t importance of public opinion in policy development

this study -    examined public ustdgs of life extn -    aiomed to provide empirical data to controbitute..

Questions

How do members of t public understand t possible for inc life expecracny How likely is gen publ likely to take up What are the mpotivations that influence intentions

Method

Structured indiv interviews

Sample -    31 men and women, research registrer for over 50s -    11male, 20 female -    18 aged 50-65, 13 over 65; -    14 had tertiary ed

Do you think that new technology will be successful in extending life span? -    ‘Yes’ this has already occurred o    sources: •    biomedical devevlops eg spare body parts •    research eg. Genetics, applic of model org findings •    lifestyle improvements, eg diet and activity

Limit to life extn? ‘ as a mortal being you are programmed to die at a certain time. Despite what technology might b able to do wof you to make you healthier, there comes a cetain point where that’s it”

Concern about cost “ I would be concerned abgout being a drain on t economy of t country – living on handouts – and this is t b

influ of family and friends ‘ I would like to extend my life because I married late and I’m not going to see my grandchildren;…

If you were offred some technology that made you live longer, would you use it -    95% declined

ME: what comparative qs and studies could be used here?

Comments from older pop seemed more concerned about quality, younger still concerned about the way they looked

Qual of Life -    health is paramount

looks not a high priority -

findings show 1.    people are concerd about issues to do w life extension and eager to talk 2.    range of opinions, but QoL paramamount 3.    intervention that did not enhance health less popular 4.    looks not important

Limitations -    small sample, characs of sample, exploratory qualitative study -    confirmation reqd in larger study

Who wants to live forever? 3 args against interventions in biological ageing Carlo Leget nd Martien Pijenburg Radboud University Medical Centre, Nijmegen, NL

Distinctions

Chronological ageing – calendar time Biological ageing – process of decline

Goals 1.    prolonging natural life span 2.    combating defects and disease that re intrinsically connected  w biological ageing

Args so far

1.    risks/dangers 2.    financial burden 3.    social injustice 4.    risks of overpopulation 5.    societal side-effects (medicalisation, pressure, evasion, genetics)

observations

never positive args, only rebuttal of negative args treat of args is separate ‘more of the same’

this paper: coherent alternative viewpoint – 3 args against

1.    dimension of time 2.    social nature of human 3.    value of global justice

1.    the time dimensions

time is seen as an object – more one has, happier one is

but time is not an object

we do not exp time, merely ourselves and the world around us

ME: no, it is brought into being – revealed – through systems of measurement. We do have these systems

Paradox: more life is expd as meaningful, more one’s perception of time vanishes – when completely absorbed, time flies

We don’t seek more time, only more meaningful experiences

ME: who needs to many os?

Spiritual

Decentrered self

Meaaningufl life as eternal

Decentred = no interest

2.    the social nature of human

life = living w others meaning of ‘with’? -    indep, stand-alone indivs (liberalism) -    members of a community (communitarianism)

liberal -    negative freedom ‘absence of barriers’ -    self-interest -    negotiations -    instrumental value of t other / t community -    goof life FOR ME

communitarian -    positive freedom: possibilities to act -    common good -    social context as precondition for a human life -    t good for me includes for us

ethical justif -    liberal: autonomous choice -    communitarian o    social network as condition sine qua non for human life o    morally good life includes living in communities and meaningful relations

quality v quantity

- life-extending e only valuable if it benefits all – our – networks - unrealistic perspective since networks exist in diversity and worldwide

‘People do not want to bury their children, so should be  open to all!!’ -    ME: this statement draws from a well known popular view and completely takes it out of context so as to be meaningfless

3.    ethical dimension: global justice

expectancy

Canada: 80; Malawi: 40 -ME : yes, but Malawians have sex a lot more! Under-five mortality Norway: 4/1000; sierra leone: 316/1000 75% HIV infected in Africa (more than 27 milions) 12 million orphans

What moral obligations follow from justice?

“If immortality or increased life is a good it is doubtful ethics…. Harris, 2004)

Objections -    immortality only a good as a life in meaningful time and relations -    life extending technology is not an available benefit yet -    question is whether we should choose to develop it

Global justice -    including equitable access for all and promotion of the common good -    broadinig t moral agenda towards justice of institutions

life expectancy as a moral challenge

discussion

1.    to improve t life expectancy of millions that die at 40 outweights by far t relevance of expanding t life o 80yrs old people 2.    how balance between broading and limiting t agenda of bioethics

Conclusions -    3 args against, stressing social nature of humans -    args against interventions in biological aging -    also relevant for other medical technologies

Living LongeR: Ethical aspects of age retardation

Elisabreth Hildt

Intro Age-retard ethics Age retard and autonomy -    informed consent -    self-creation -    determ of course of ones life conclusion

Intro Age-retard ethics -    risk benefit ratio, beneficience snd non-mal -    autonomy and freedom from time constraints -    biological life cycle -    atts towards ageing, death and morality -    chang in family rels -    aging of soc -    justice

Age retard and autonomy -    informed consent o    info transfer; freedom of choice o    adult and competent persons -    self-creation o    transformation of the self o    personality traits and personal identity o    authenticity -    determ of course of ones life o    creation of a full and active life o    some drawbacks •    sense of time •    extended period of old age •    implics of widespread use o    family structure •    growing up and role of family •    formative influ of older generations •    role of trads •    independence o    structure of soc •    concentration of power and authority •    flexibility to change •

Age retard and autonomy -    autonomy does not solve question, might even be arg against techniques -

Controlling Human Ageing: Alternative Rationales and Impications Robert Binstock, Jennifer Fishman, Eric Jeungst

Grant from NIH on implics of anti-ageing interventions

The Politics of Presentation -    how one presents what one is upto in antiageing science can shape regulation/funding/priority

The Fountain of Youth: A Perennial -    today: o    anti-aging entrepreneurs and longevity practitioners (medicine) o    biogerontologists (science)

why is antiage med flourishing? -    Post WWIII baby boom -    Only light regulation on anti-aging prods and services -    Internet sites for marketing -    Dozens of antiaing how to -    Market 64bilion in 2007

Youngevity.com -    the anti-aging -    Patenting Antiaging miracle minerals are called -    ‘The Vlicabamba mineral essence’

American Academicy of Anti-Ageing Medicine (A4M) -    provides board certif. for practitioners of longevity med -    13000 members -    70 international and national conferences -    2million hits per month on website -    net asserts from $65k to $3.5m

RRonald M Klatz ‘Ten Weks to a Younger You’

Biogerontologists -    40% extn In av life expect and mx life in dietary caloric restrictuions (CR) expts -    development of CR mimetics -    genetic interventions

scientific legitimacy of biogerontologists is shakey -    little better than charlatans -    gerovital, anna aslant and nikita kruschev -    in US, National Instititue on Ageing (NIA) in mid-1970s path to legitimacy, but still fragile

War by gerontologists on Anti-Aging Medicine -‘No truth to the fountain of youth’ - published online (CHECK!) - SILVER FLEECE AWARDS TO A4M – for misleading public - continuing publications and media appearances - boundary work to disting themselves from t illegitimate antiaging med movement ‘Those who have legitimate…. R. Miller’

Similarly A4M seeks legit -    denigrates ‘gerontologist estab’ -    files lawsuits against specific …

Ideal models of aging seniors

Imagery beyond boundary work -    the politics of presentation has important social implics -    3 rhetorial strates for defining aims of anti-aging prods, etc o    1. Med tratement o    2. Enhancement o    3. Prevention

1.    med treatment

eg. A4m: reating maldadeies of aging -    moral authority and prof autonomy of med prof

renews debate over whether aging pathological or risk factor

2.    enhancements

‘stay young’ restore mental and phys capacities that decline w age politically, this rhetoric takes enterprise out of biomed realm -    outside of med prof and gov reg

provokes criticism from bioethicists’not natural’ and tf unethical

beyond therapy (2004)

3.    prevention

forestall chronic health probs, associated w aging for as long as possible strategy avoids criticisms of unethical enahcnement skirts debate over whether aging is a disease

embraced by gerontologists

want to be seen as ‘the good buys who favor…..R.Miller essential for maintaining and enhancing funding for further research

internecine warfare against propoent of enhamcenent – Aubrey de Grey, ‘virtual immortality’ is achievable – claims possible to only die from apoptosis - European Journal of ‘Resistance to debate on how to postpone ageing’

‘We are gradually, much too gradually ….’

The Politics of Presentation: Issues for Empirical Research

Tretment -    will treatment rhetoric by anti-aging entrepreneur and clinicians lead to control by org med? -    Or, will org med engage in boundary work, as t biogeront

Enhancement -    will enhance rhetoric lead to political movement to curtail interventions?

Prevention - does prev rhet succeed in strengthening scientific status of bioger

Friday 26 Aug

Therapy & Enhancement Ruth Chadwick

Disagree with Bayliss definition of enhancement, must disting between improvement

Inevitability thesis is incomplete

Moral argument fails to account for context

Instead, improvement should be focus, but wheth enhancement is improvement depends on context

Eugenics revisited

Negative v positive

Enhancement just eugenics repackaged

Disting between germline and non

Eubionics: the pursuit of bodily perfection – negative and positive -    McNally

Negative eubionics – elimination of body Positivev – pursuit of bodily perfections

Case by case?

Beyond therapy US Pres council -    argue for case by case

enhancements 4 approaches -    beyond therapy -    additionality view -    improvement view o    if qualitative, but if enhance to such an extent that X (human) no longer exists as a category -    umbrella view – enhancement just convenient label for number of interventions

limitations of enhancement/therapy distinct -    enhancements likely to arise from therapeutic med -    this will be difficult o    ME: why?  Drug regulation

Beyond therapy probc definition -    Therapeutic intentions? -    Therapeutic effects -    Evidence based therapy -    Proper scope of medicine -    Indiv vs species issue

Norman Daniels: eliminating shyness relies on understanding cause, which is complex

Why should we be more concerned w cause of condition than suffering

Enhnancement and the self

Baylis and Robert -    ‘the resulting alterations may be conservative (ie used to normalise the self), liberal (i.e used to liberate the self) or radical (used to fashion a self that effectively challenges others’ conception of oneself)’

what would count as a preventive therapeutic intervention? -    preventive mastectomy for woman with strong family history -    since we don’t know whether it would arise, can argument is therapeutic, but also as reassurance -    main aim is to reduce risk status -    counterintuitive to speak of mastectomy as enhancement -    need more to concept of enhancement that just beyond therapy

Norman Daniels, Species typical functionign

While enhancement is always characteristic specific, whether something is improved or not requires a judgement -    good eg. Is height -    depends on what we are trying to achieve – context

improvement should not be included in any definition of enhancement

the inevitability thesis

baylis and roberts -    contemporary Western democracies have no experience with permanently halting the development and use of any enhancement technology on ethical grounds.

What doesit mean that it is inevitable -    if simply that someone will try it, not interesting -    ‘despite the likely failure of particular genetic enhancements, there are some among us who will inevitably attempt to engineer the human genome8 for the purpose of improving Homo sapiens.’ Bayliss and Robert

rape and murder doesn’t stop but doesn’t mean not worth trying

they distance themselves from empirical slippery slope argument -    not clear that views will become more liberal

Ithe future is ours for the shaping, tf genetic enhancement inevitable -    an ‘avant garde’ portayal of human nature o    ME: what not merely health improvement?

Perfectibility different from enhancement

Moral Arguments -    boutique model (individual) -    species approach (collective)

boutique model -    Abdul Adah

Central question is whether medicine resources should be used here

Spectrum of positions -    wrong in itself -    injustice arises -    not a priority -    morally required

Habermasian concern not mentioned

My view is that enhancement permissible in certain conditions

From an impartial position, if can improve, we should make it -    but judgement about what is improvement not easy

no gains without compensating losses

consider context

sport

Aristotle -    if ten pounds are too much for a particular person to eat and two too little, it does not ffollow that t trainer will order six pounds; for this is perhaps too much for the person who is to take it, or too little too little – too little for Milo, too much for the beginner in athletic exercises

whether improvement first depends on context of sport, then internal good of sport

with human ‘improvement’ overall

3 areas in need of consideation

1.    enhancements which undermine t possible of moral agency are not morally permissible

but does either the fact of design or the nature of a given enhancement have this effect?

2.    wht si the relationship between moral permissibility and improvement

is improvement a necessary and/or sufficient condition -    if enhancement did not improve, but did not worsen, might also be permissible -    not sufficient, since issues about distrib

3.    priority should be given to enhancements which reduce existing inequalities

morally required?

Important issue not disting between therapy and enhancement, but whether is improvement -    depends on context and purposes

does thinking about whether it is an improvement overall contradict the context specific position?

There has been a huge trend towards public engagement about ethics -    ME: what does she mean by this?

Nordenfelt, L Honorary Session

Nordenfelt

Health goal as medicine

Edmund Pellegrino and David Thomasma in their book Philosophy as t basis of medicine 14, p.26 -    medicine is an activity whose essence lies in t clinical event, which demands that scientific and other knowl be particularised in t lived reality of a particular human for t purpose of attaining health or curing illness through the direct manipulation of t body and in a value-laden decision matrix

other goals exist – saving lives and QoL, health is central goal

task of interpreting health remains

contemporary philosophy of health determ from scientific point of view -    some argue they are value free and descriptive

Christopher Boorse and Thomas Schramme

BST -    ‘a disease is a type of internal state which is eitheran impairment of normal functional ability, eie a reduction of one or more functional abilities below typical efficiency, or a limitation on functional ability caused by environmental agents’ Health is identical w t absense of disease (Boorse, 1997). -    Ill if probability of survival lowered, or…..

‘health is a state in which we neither suffer from any evil nor are prevented from t functions of daily life’ (galen Ars Medica 193AD)

main rivals – in positive tersms

boorse health bst -    A is completely health, iff , all organs of A function normally, ie if they, given a statistically normal enviro, make at least their statistically normal conttrb to t surviaal of a -    A has a disese, iff, there is at least one organ o As which fns subnormally, given a statistically normal enviro

Holistic theory -    A is completely health, iff, a has t ability given standard cicrcums, to reach all his or her vital goals -    Notion of a vital goal is crucial -    Standard circumstance = different from statistical o    related to a cultural norm -    ‘A has a disease, iff, A has at least one organ which is involved in such a state or process as tends to reduce t health of A. t disease is identical w t state or process itself.’ -    Tends to reduce t health of A – sleected since not all diseases compromise health in relationship to vital goals -    Some maladies can be aborted before they have influenced the bearer

How reconcile these defns?

2 stories

genuses of probable health by considering illness and disting between illness and disease -    percevived problem

in the beginning…

illness recognitionand illness communication the illness language illness experts – doctors did not rely on stories from people who were ill, but looked for causes doctors found regular connections between states and symptoms and fourmed hypotheses designates causes as diseases

disease recognition

a quasi-historical sketch

concept of illness primary to disease

problem to be solved

causes assumed to exist within b or m

illness need not entail threat to reproduction

often concerns pain, suffering or disability subject often believes internal cause thus, human disease relationship to suffering and disability, not inc probability of death

3.    standard medical encounter today

john, pain stomach, sees doctor, presumes illness, pain  indicates this, and observes he is prevented from working

doctor examines, when convinced of nature, will find cause in organic function – organic disease, but not for own seek, not any old malady, needs cause of problem, then treats it in relationship to contemporary art, when successful john is healthy – no longer feels pain and can work as usual

thus: health concept used is variant of holistic – -    estab of fact that he is ill does not rely on diagnosis, john can establish through his own exp of illness -    ME: is he not doing what the doctor does? -    In favour of hgh

Endorse idea of reverse theory of disease XXXX - Josh Congilen? 1943 – Wilford 1989

illness recognition essential, but to avoid misunderstanding, illness need not have occurred in individual case, but disease not discovered unless someone in history who had similar case

Disease (holistic) = bod or ment process which is such rthat it tends to cause an illness (understood as a state of suffering or disability expd by the subject)

ME: presumes sincerity on behalf of subject

Gaylin and Resnik – illness caused by suffering or disability

Ability/disability relevant concepts than well-being/suffering -    pluralist notion of health? -    Do not deny relevance of well-being or suffering, but philosophical technique requires that Ockham’s razor (simple and as universal as possible), ability and disability most potent

Differences

In bst, health is entirely internal In holistic (hth) – goals and other abilities (not just intentional), but ability to perceive, feel, etc

In bst

In hth – extr

In bst – health identical w absence of disease, hth health is compatiable w t presence of disease. T concept of disease is, however, logically related to t concept of ill health (or illness) and also according to t hth. A malady is defined as a state or process which tends to reduce its bearer’s health

Hth – whether person as whole, whether can achieve goals -    goals differ: survival, QoL,

Thomas Schamme

2 theories of health of importance to philosophy of medicine, nordenfelt and boorse

defence of naturalist is critical discussion of nordenfelt

nordenfelt includes too many phenomena in definition of ill health

conclusion: analytical framework of naturalistic view should obtain conceptual priority

nordenfelt focus on concept of health, instead of its contraries – illness, etc

starts with health, which is unusual since typically easier to agree on disease, whereas health more contested

Fullfort focuses on illness, Nordenfelt on health

Cannot identify illnesss unless have view of positive health (nordenfelt)

Critique of N, say something of conceptual priority, but Fulford’s argument is non-starter

Fact that we usually observe illness before seeking explanation has no bearing, merely epistemological effect, -    priority in this case not about temporarlityu

dubious to ground medicine on particular goal (individual health) without idea bout what that signifies

must disting between fullfulling positive health

we might mean positive or direct definition of health – not a lack of something

eg. Boorse says absence of disease, but also positive definition of health

or give more than minimum

other examples, such as freedom – different between positive or negative -    state an ideal, not just minimum -    or ideal/true freedom

if apply this to health, WHO definition states both positive definition and positive conception

nothing depends on wherther we give a positive definition of term -    eg. WHO definition as negative, does not lose positive ideal definition o    ie. Health is merely t absence of disease and infirmity, disease and infirmity are states when complete phys and mental .. is lacking’

common mistake to want to talk about positive health, but then people talk about ideal health, which is different

is N ideal or positive?

N might open way to positive, because includes criterion of individual goals, but he adds a restriction by clarification – ‘vital goals whose aspiriation for minimum happiness…so to count as healthy…good health does not imply ability to become completely happy’ – is less extensive than WHO

But still too wide since coveres disabilities that are not ill health

Paradigmatic eg. – -    Lily, an athlete who struggles to becom accomplished high jumper, but does not succced, wants to jump over 2m, not to succeed means not minimally happy, but even sad, though N says minimal happiness not sufficient, but disability is crucial. Lily is unable to realise at least one vital goal. Still, we would not call her unhealthy or in state of ill health, since not a disease, which would be indep of ambitions.

3 possible responses from N - 2 ambitious goals are ruled out by theory. If goal is unreasonable, cannot count as necessary. N opts for objective accounts, but discusess counter productive and trivial goals. - ME: doesit change if Lily wants to be a doctor? - 2. Must lack a second order ability,ie. We could help her by training or education. - 3. Let’s accept she is not unhealthy. But must not discuss as counter intuitive, because is a welfare theory. Nothing left to argue about. Nothing wrong with this definition, but state reluctance to accept. Welfare theory not approp since health is a medical term – end up with medicalisation of all problems

cannot refer to all people who are unhappy just because cannot fulfil goals as ill

must rely on medical normality

we need distinc between 2 interprets of health 1.    taking account medical science (boorse) 2.    grasping eval of medical conditions (normativism)

since normative is logically prior for N, cannot understand why healthXX

from perspective of medicine science people w same condition are both unhealthy

N proposes ideal which leads to medicalisation

We need scientific perspective to restrict

Defence of naturalism qualified by restriction of particular perspective of science -    naturalism must be supplemented by normative, but cannot be removed

G Khushf

Situate health concepts debate in slightly different state

Beginw observation of the debate which is puzzling -    urge to return to Boorse -    Boorse’s work seems to be situated in theoretical biology, but in theoretical biology, nobody cites boorse -    Why does Boorse play such a role in this debate

Need to see how health concepts have been a lens for models in medicine science

Use debate as a lens and look at background context, to suggest that we have real traction.

It is now moving forward

N has made t contribution that enables us to go forward

Rather than argue with Boorse, argue w N.

Science depends on social conditions, but these conds remain implicit

Division of labour between administrators and practitioners of science

Sustain myth of fact/value divide -    colour all features of scientific landscape

medicine not immune to this divide -    in hyperform

consider division between clinical practitoeners and adminitstrators of health care

inc role of administrators

implied that scientifically based practitioners determine what is medically indicated, then negotiate treatment in accord w patients values – this is essential

contrast, admin provide economic circums – estab the conditions

but they are not supposed to influence

these are manifest in ethical deliberations

eg. How are patient’s views Integrated in medical decision making

patient autonomy does not mean equality with physician’s view

physicians are masters of means

eg. Medical futility – approp and inapprop domains of patient autonomy

thus, fact value divide in 2 features of modern medicine -    admin (value)/physician (fact) -    patient autonomy (value)/clinical interaction (fact)

health and disease

appreciate importance of boorse

examine core features of boorse account -    value free and scientific -    broad social and individual patient values are second strand influencing treatment -    socio-economic factors should not play rolein determining disease o    historically problematic: eg masturbation, etc

if focus on these rubricks, we find his position compelling

Nordenfelt -    appreciated predicament fasced by critics of Boorse -    shows why disease canot be value free, but understand sympathy for Boorsian project -    not coincidental that Boorse has taken the BST term from N and uses it to characterise his own theory

focus on deep resonance between Boorse and N and suggest they are much closer

N view of medical science - health concepts tied to human ends, not survival and reproduction - both he and boorse share fundamental assumptions - both think we can tease out the factual and evaluative and applied science involves reasoning and guard against values - N argues health conceptsa re PARTLY evaluative so must speific where they end - onec we do this, can use as basis for empirical eval - does not question purely empirical investigation what marks of end of the domain -    once end is given can apply to realise that end

can understand why health concept is primary -    allows clarification of the end, which is necessary tyo estabg proper role of medicine

health concepts functional analogue of medicine -    mark of legit from illegit

N’s wants based notion of happiness -    focus on: ends integral to medicine are individually relative -    approp values are thus this or that patient, not patients in general -    ends of clinical encounter specified by patient/physician interaction – allows specification approp treatment -    health concept specifies role of…. -    N upholds core features of Boorse, but sustain value ladenness of Health and disease

Nordenfelt should be seen as biomedical ideal

1.    contrast classes for situating the debate

in one of Boorses early aarticles, presents naturalist, weak naturalist, and strong normativist (pure constructivists) -    these are linked to Boorses health concept -    wanted to disting legit (weak) from illegit (storng

but this clouds the debate hard to find anyone that does not have no descriptive -    everyone is a weak normativist

core difference between N and B

new definition of weak and strong -    weak: can disting between fact and eval components (medical v non-medical), while see values as integral, share w naturalist role of descriptive -    strong: not possible to disentangle fact and value in this way. Seek to show how diverse values configure health concepts

Conclusion: new context

In current context, see shift in whatmakes debate important Until now, has been disconnected from trends in medical practice Health concepts incl’y important

Changes in medicine

Eg. Manage care and total quality review

Now being incorporated into standards of care Overlap between admin and pract

Some see as distortion of medicine – economic

Challenge to classical jurisfictions of medical practitioners

Debate also reframed -    is it possible to disting sociopoliticaland economic from microethic of clinical encounter?

Strong normativist is best? (ME: did he say this?)

Cannot sustain neat fact/value distinc in classical form

How to appropriately address in management strategies?

Nordenfelt Reply

Reply to Schramme -    priority of health -    S says order is solely epistemological not logical priority, so fact that we observe before diagnosis says little. Hwr, purpose was not about logical priority, it is health that is logically prior. The observation temporal priority that Bill fulford has argued, not just epistemology, also bearing on conceptual substance. In doctor patient case, we have paradigm case of HC. Tells us what is at stake in the encounter  - patient’s disaibity and suffering. Fact that we label that as disease, tells us something about concept of disease. -    2 arguments: o    1. Ought to be able to explain why someone canbe medically abnormal, without being badly off •    answer: do not claim that all diseases produce suffering. Consider various stages of disease. But for it to be called a disease in the first place, must in some if not most, result in some suffering. o    2. Must be able ot explain why someone is ill and not simply sufferinf from other impairments, such as loneliness, etc. idfs that we include too much. Someone hwo is sad or unhappy will be labelled ill. EG. Lily the athlete, who cannot jump 2ms. She is obviously healthy, says Schramme, so theory inadequate •    answer: talks about health and illness in contradictory, but also in complete. He also says it is a dimension. So when lily does not achieve and when this is a vital goal, it is not automatically that she is ill. It is merely that her complete health is reduced. She can realise her basic vital goals.  Though S would not admit that her health is somewhat reduced, he would maintain that she is completely healthy. Her is an unrealistic goal. If she should be helped, cure is not to turn to orthopaedics, but in ‘goal care’. We should try to convince lilly about the unrealistic nature of her goal. She can set a utopian goal, but be emotionally prepared for its failure. She has a hidh degree of health. Do not enter into people’s lives when they do not call for it. Unrealistic goal setting.

S accuses of including too much, I say he includes too little

Response to George

Constructivist strong normativism

Present concrete eg to test

Need there be a profound shift in concept of health or that we will constantly reconstruction

Distinc between reconstruction and operationalisation

Eg. If clinic accepts ground of someone as unhealthy because cannot go to work – this is operational

What could be reconstructions of health concept

Eg. Measuring health and divising instruments for such measurements. E. sickness impact profile, euroqual, Nottingham health profile -    all contain critieria for measuring health -    they indicate concepts of health -    perhaps the instrument makers construct different concepts of health -    these are postmodern measures of health -    we might have 1000 withiin a decade -    a good state of affairs? I doubt it, descriptively and normatively -    descriptive: o    instrument makers might claim they are merely trying to describe an aspect of health, eg. Mental or dental, or to measure technologies, so not all aspects are accounted for – practical purpose. o    Evaluative: doubt hey would be happy that theya re constructing new concepts of health. They want to measure ordinary understanding – just a partic way of measuring o    May be 150 defns, but from this does not follow that there are 150 good or adequate concepts. Few have derived from careful conceptual analysis o    Thus, maqy find dubious claims within them. Eg Nottingham health profile ‘I lie awake for most of the night’ – explanation? Not just ill health o    We have some intuitive understanding of health and make good judgements. But this does not mean we or they are constructing new concepts of health o    But is there only one concept of health? •    No. like all abstract concepts, health vague. Borders fuzzy. From conceptual analysis only, cannot define sharply.  Must stipulate minimal. But is, at least, a conceptual torso that is given in conceptual language which tells us what dimensions are relevant to health. •    Cconsider Aristotle or gaylen.

Debate

ME: If I cannot work, I am ill. If I cannot be the best worker, I am not ill.

4.2 Future of Medicine

The moral significance of future ‘persons’ G. Papagounous

Question: role of personhood in ethics in relationship to specific entities, namely human beings

In ethics, should not evaluate natural phenomena -    eg. Earthquake, tsunami are neither good nor bad, but consequences can be described in such terms

what is the different between a pilot and a volcano?

Person

Personhood delimintes 2 things

1.    limits of the act. 2.    Allocatrion of the possibility of an act

Warnock – personhood – consciousness, reasoning, self-motivated, communication, self-awareness

Not complete -    if replace ‘raven’ with 2 yr old child, stil theft of ring? – fits personhood as Warnock

must modify personhood

ME: not harm to future persons – they are not harmed. Rather, environmental actions are worsening the conditions within which future persons will exist

Is transferred parental responsibility legitimately enforceable. Matti Hayry matti.hayry@manchester.ac.uk

Premises -    You have (or want to have ) children -    I do not -    You have not been coerced into having (or wanting to have) children by force, threats, deception, or lack or competence or info -    Your children can have children of their own, and so can your possible grandchildren, and so on

Questions

Are you responsible forr t wellbeing of your progeny, including t future generations in your direct family line Are you resposnib for t ewellbeing of other members of t future gen Ami i Are you entitled to coerce me into securing t wellbeing of t future gens?

Are you respon sible for your own? -    box of surprises o    inherited sealed box, cannot open, may contain valuable material or explosive, but smaller chance for latter. Choice: never open box, or give to stranger as give. If give it away, can open it, but no knowledge of contents. Should you give box to stranger

are you responsible for your own?

Conditions for giving t box -    if ou can you can ask t potential recipient. Free informed consent might provide justif -    if not, consider her current sitn. Abject povery might be a factor -    you should be prepared to assume responsib for t conseqs if they are adverse.

Are you responsible for your own? -    the gift of life o    when consider having children, you consider creating indivdwho does not exist yet and giving her a box of surprises o    you  have metaphorically inheretned t gift of life as an heirloom, and you are thinking of

received cannot but open box life might be good or bad

are you responsib for your own conditions for passing on gift -    cannot seek consent of receiver, can only assume -    cannot argue for t situation of t receiver – can only assume life’s value -    must recog your responsib for wellbeing of the (non-voluntary) receiptients -    you must try to guarantee that t lives of your children etc are as good as they can be

are oyu responsib for your own -    answer to first question o    you are responsib for wellbeing of progency, because commitment to this responsib is moralc ond of having kids

are you responsib for others?

How t parental contract comessa bout -    as a prarent you must ask yourself: o    ‘who will take care of my children and my children’s children if I cannot? o    And the natural answer is o    ‘parents of other children. We make a deal. They take care of my progeny if I cannot and I take control of theirs -    how t parental contract is binding o    because by reproducing you have taken on duty to guarantee wellbeing of offspring o    your mutuial contract is not morally binding to anyone else (nonparents) -    answer to this question: o    ou are responsib to other members o t future generations beasides yourown

am I responsib for your children? -    why would I be? o    Because I have made a parental commitment? NO o    Parental contract? No o    Because a need exists, and I should respond to it? •    3 layers •    immediate need in an emergency sitn: your existing child drawoning in a pond? Only I can help. Should i?-yes •    longer term, non-emergency needs: your children need an education, should I contribuite? – probably (prudential), but you first: ME: WHY? SO, REJECT A NATIONAL EDUCATION SYSTEM? •    the needs of your non-existing progeny: why would I sacrifice my worthwhile goals to promote your reproductive aspirations? •    INVOLUNTARY PRODUCED OFFPSRING: should I respond to needs of future children whose existence is due to force, devception or lack or competence or info, of course, but you should join me in preventing such reproduction •    Saving resources to future generations: 5 generations down t line you have burdened t natural enviro 5 units against my one. Could I have double portions, please? •    ME: is he setting up an us and them that is false? •    Answer to 3rd question o    I am not responsib for wellbeing of your distant progeny, or for t wellbeing of other voluntarily produced members of the future gens because I am in no way responsible for their existence

Can you justifiably coerce me? -    possible grounds o    do I have moral duty that you re entitled to make me dispense by coercion or force? No o    have I made a commitment that you are entitle to hold b to by coercion orfoce? No o    have I entered a contract that you are entitled ot make me honour, by coercion or force? No

possible grounds for coercion? -    doyou represent a dominant protective agency which is entitled to coerce me? NO -    if everyone acted like me humanitiy would cease to exist. NO CHANCE. (and voluntarily, what’s the problem) -    if many peoplea cted like me there would be too few tax payers (MOST UNLIKELY) (revise immigration policies)

answer? -    not entitled to coerce me because no valid moral, social or political grounds for such an entitlememnt (I may chip in from time to time voluntarily)

Soren response -    everyone might trace their roots to involuntary creation -    contractarianism: why no contract between procreator and non-procreator to take care of latter

reply -    yes, some involuntariness, but my first duty as non-reproducer is to change world where every reprod choice is voluntary -    wider contract issue with society? Yes, perhaps, but I acknowledged that immediate needs will be met.

Question: the discourse is liberal, but narrow concept of responsibility -    alternative: necessity of action in face of evil.thus responsible for future generations, because the evil exists. Eveil is beginning of responsibility

Question: if you don’t want responsibility, you don’t have responsib for others and if you have your own, you have sole responsibility. But this is not true. Even if you

ME: parental responsibility does not convey, in its entirety, responsiibilty towards children. Parents do not have sole responsibility over their children.

Responsibility for future generations F. Turoldo (Italy) university of Venice.

Why is t term responsibility not t common term in ancient and modern philosophy? -    why contemporary?

Rotation of meaning of responsibility

Initially a juridicial concept – a consequent way – I am responsible for an action and its consequences

2 conditions 1. individuality (I am responsible) 2. consequent (towards past actions)

respondre – to answer for

moral concept of responsibility -    inner judge

T problem of allocating health care resources considering future generations M Igoumenidis

Is it fair to spend mony on moon trips and cloning sheep when could use money to save present people’s lives?

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