Romney, Freedom, and Abortion

Jonathan B. Wight

Mitt Romney seems like a nice guy. He clearly is a natural-born leader in the sense that he rises to top of his cohorts, whether in the Mormon Church, the Olympics, and the political scene. But he reeks of falsehood about his core beliefs; he seems a chameleon willing to say whatever he thinks will sell. A huge example is his successful health care reform in Massachusetts requiring mandates that now he disavows. A second is his former commitment to libertarian ideals of freedom and small government when it affects women's health, which again he now disavows.

Slate has a fascinating account of Romney's flip-flops on abortion policy and the personal and political calculations that likely lay behind it. The Mormon Church is mainly pro-life, with exceptions for rape and health of mother. As a bishop in the church Romney counseled a woman in her hospital bed not to have an abortion even though her life was endangered.

Later, when running for the Senate in liberal Massachusetts, Romney hired a consultant who told him he would never win unless he switched to pro-choice. In 1994 Romney and his wife attended Planned Parenthood fundraiser and donated to it. Here is Romney in 1994 supporting his pro-choice stance and justifying it based on his own moral sentiments:

"Many, many years ago, I had a dear, close family relative that was very close to me who passed away from an illegal abortion. It is since that time that my mother and my family have been committed to the belief that we can believe as we want, but we will not force our beliefs on others on that matter. And you will not see me wavering on that."

Later, running for governor of Massachusetts in 2002, Romney pledged a commitment to liberal ideals:

"Believing in people is protecting their freedom to make their own life choices, even if their choice is different than yours. That choice is a deeply personal one, and the women of our state should make it based on their beliefs, not mine, not the government's."

Romney now says that in 2006 he had a conversion back to pro-life because of his consideration of stem-cell research with embryos. That is probably about the same time he began to plot his national ambition to reach the presidency.

Abortion and stem-cell controversies are painful and difficult. Liberal intellectual reasoning leads people to their own mountains of conceit and prejudice against those who hold a more primitive moral sentiments (and Catholic view) that human life begins at conception. In the future we will learn much more—and it would not surprise me if science comes to find that some consciousness exists in an embryo or even in a sperm and egg. The Catholic intuition may turn out to be closer to the truth.

That does not mean its abortion stance is the correct one; Romney's 1994 and 2002 position on abortion may be the best we have at the moment, given all hard and bad choices.

Is health or health care a public concern, a right, or a need?

Mark D. White

One of the topics that fascinates me, but which I never seem to have time to catch up on, is the moral/political status of health and health care. In most cases (other than particularly infectious or contagious diseases), I consider health and health care to be matters of personal choice and responsibility, but I'm eager to hear the arguments on the other side as well.

JLMETwo articles in the latest issue of The Journal of Law, Medicine & Ethics (40/2, Summer 2012), part of a symposium on pharmaceutical firms and the right to health, address this issue:

"Health as a Basic Human Need: Would This Be Enough?" by Thana Cristina de Campos

Although the value of health is universally agreed upon, its definition is not. Both the WHO and the UN define health in terms of well-being. They advocate a globally shared responsibility that all of us — states, international organizations, pharmaceutical corporations, civil society, and individuals — bear for the health (that is, the well-being) of the world's population. In this paper I argue that this current well-being conception of health is troublesome. Its problem resides precisely in the fact that the well-being conception of health, as an all-encompassing label, does not properly distinguish between the different realities of health and the different demands of justice, which arise in each case. In addressing responsibilities related to the right to health, we need to work with a more differentiated vocabulary, which can account for these different realities. A crucial distinction to bear in mind, for the purposes of moral deliberation and the crafting of political and legal institutions, is the difference between basic and non-basic health needs. This distinction is crucial because we have presumably more stringent obligations and rights in relation to human needs that are basic, as they justify stronger moral claims, than those grounded on non-basic human needs. It is important to keep this moral distinction in mind because many of the world's problems regarding the right to health relate to basic health needs. By conflating these needs with less essential ones, we risk confusing different types of moral claims and weakening the overall case for establishing duties regarding the right to health. There is, therefore, a practical need to reevaluate the current normative conception of health so that it distinguishes, within the broad scope of well-being, etween what is basic and what is not. My aim here is to shed light onto this distinction and to show the need for this differentiation. I do so, first, by providing, on the basis of David Miller's concept of basic needs, an account of basic health needs and, secondly, by mounting a defense of the basic needs approach to the right to health, arguing against James Griffin who opposes the basic needs approach.

"A Right to Health Care" by Pavlos Eleftheriadis

What does it mean to say that there is a right to health care? Health care is part of a cooperative project that organizes finite resources. How are these resources to be distributed? This essay discusses three rival theories. The first two, a utilitarian theory and an interst theory, are both instrumental, in that they collapse rights to good states of affairs. A third theory, offered by Thomas Pogge, locates the question within an institutional legal context and distinguishes between a right to health care that results in claimable duties and other dimensions of health policy that do not. Pogge's argument relies on a list of “basic needs,” which itself, however, relies on some kind of instrumental reasoning. The essay offers a reconstruction of Pogge's argument to bring it in line with a political conception of a right to health care. Health is a matter of equal liberty and equal citizenship, given our common human vulnerability. If we are to live as equal members in a political community, then our institutions need to create processes by which we are protected from the kinds of suffering that would make it impossible for us to live as equal members.

CoggonBut what I most look forward to reading is What Makes Health Public?: A Critical Evaluation of Moral, Legal, and Political Claims in Public Health by John Coggon, whom I had the pleasure of meeting and listening to at the "Regulating Bodies and Influencing Health" symposium in Rotterdam in June.

John Coggon argues that the important question for analysts in the fields of public health law and ethics is 'what makes health public?' He offers a conceptual and analytic scrutiny of the salient issues raised by this question, outlines the concepts entailed in, or denoted by, the term 'public health' and argues why and how normative analyses in public health are inquiries in political theory. The arguments expose and explain the political claims inherent in key works in public health ethics. Coggon then develops and defends a particular understanding of political liberalism, describing its implications for critical study of public health policies and practices. Covering important works from legal, moral, and political theory, public health, public health law and ethics, and bioethics, this is a foundational text for scholars, practitioners and policy bodies interested in freedoms, rights and responsibilities relating to health.

The Generational Divide: Shocking but Not Surprising

Jonathan B. Wight

Via Mark Frum comes a link to a Stephen Marche article in Esquire that captures the essence of the ethical and medical dystopia in America:

There may be no white America and no black America, no blue-state America and no red-state America, but one thing is clear: There is a young America and there is an old America, and they don't form a community of interest. One takes from the other. The federal government spends $480 billion on Medicare and $68 billion on education. Prescription drugs: $62 billion. Head Start: $8 billion. Across the board, the money flows not to helping the young grow up, but helping the old die comfortably. According to a 2009 Brookings Institution study, "The United States spends 2.4 times as much on the elderly as on children, measured on a per capita basis, with the ratio rising to 7 to 1 if looking just at the federal budget."

Personally, I think those of us who are entering the growing elderly class have to voluntarily cut back on the extravagance of dying, paid for by other people's (e.g., Medicare's) money. And I think Medicare can help us do that. Since most of health care is spent on heroic but failed attempts to keep a dying person alive a few more months in a hugely expensive intensive-care hospital rooms, think of some practical alternatives. One is a short vacation to Oregon, but I have reservations about doctor-assisted suicide.

But a second idea is to have Medicare make an attractive offer to elderly persons on their last legs:

Insurance Offer: Treating you (the patient) for the next five months before you die will cost us $500,000 using the grandiose and highly expensive crisis medical system. However, if you agree to go into a hospice, where you'll get all the pain medicine you need, our cost will be only $50,000. Medicare (and society) will save $450,000, and we're willing to split that and give you an inheritance to your estate of $225,000.

Now, does this sound like a good deal? Readers: has this been tried anywhere?

[Problems: An elderly person could feel coercion—that they are being shunted off to a nursing home so the greedy kids can get a fat check. But I'd rather think this offers a clear-headed dying person a chance to give their offspring a much-needed bequest at little personal cost. The relatives I've seen who've spent their last months in a hospital have had a pretty miserable quality of life. A hospice may offer greater solace, love, and the opportunity of death with dignity than the advanced medical approach. The key thing is—this would be a voluntary program, and elderly people, while still fully rational, could make the decision ahead of time that "Less is more."]

Several fascinating new bioethics articles in January 2012 journals

Mark D. White

The January 2012 issues of Bioethics (26/1) and Cambridge Quarterly of Healthcare Ethics (21/1) recently came out, with some particularly interesting articles (some of which I actually had a chance to read during my finals!). Here's a sampling:

Whoopie Pies, Supersize Fries: "Just" Snacking? "Just" Des(s)erts?, Leonard M. Fleck

Liberals generally deny that any one ordering of values should govern all individual lives. Some individuals might make maximizing their health their highest value, but that obligates no one else. Still, if some individuals daily indulge in rich desserts, this will have consequences for others in the form of high health costs for diabetes or heart disease. What should a just, liberal, egalitarian society do by way of tolerating, discouraging, regulating, forbidding, or punishing personal health choices that impose costs on others? This is our central question. A related question is whether a just, liberal, egalitarian society should use judgments of personal responsibility for ill health to impose those costs on individuals in order to control escalating healthcare costs for society.

"Please Don't Tell Me": The Right Not to Know, Jonathan Herring and Charles Foster

Knowledge is generally a good thing. People who know lots of bits of information are generally admired. Some of them win prizes in TV competitions. If you were offered the gift of having an entire encyclopedia wired into your brain, you would probably accept, without thinking. But we should be wary of assuming that all knowledge is good. Too much knowledge can inhibit rather than enable thought.

One of the requirements in the Dutch regulation for euthanasia and assisted suicide is that the doctor must be satisfied ‘that the patient's suffering is unbearable, and that there is no prospect of improvement.’ In the notorious Chabot case, a psychiatrist assisted a 50 year old woman in suicide, although she did not suffer from any somatic disease, nor strictly speaking from any psychiatric condition. In Seduced by Death, Herbert Hendin concluded that apparently the Dutch regulation now allows physicians to assist anyone in suicide simply because he or she is unhappy.

In this paper, I reject Hendin's conclusion and in particular his description of Mrs Boomsma as someone who was ‘simply unhappy.’ After a detailed narration of her lifestory, I turn to the American philosopher Harry Frankfurt's account of volitional incapacity and love for a more accurate characterization of her suffering. Having been through what she had, she could only go on living as another person than the one she had been when she was a happy mother. That would have violated her integrity, and that she could not bring herself to do.

Risk and Mid-Level Moral Principles, Nicolas Espinoza and Martin Peterson

We discuss ethical aspects of risk-taking with special focus on principlism and mid-level moral principles. A new distinction between the strength of an obligation and the degree to which it is valid is proposed. We then use this distinction for arguing that, in cases where mid-level moral principles come into conflict, the moral status of the act under consideration may be indeterminate, in a sense rendered precise in the paper. We apply this thought to issues related to pandemic influenza vaccines. The main conclusion of the paper is that on a principlist approach some acts may be neither right nor wrong (or neither permissible nor impermissible), and we claim that this has important implications for how we ought to make decisions under risk.

Assessing Competence to Refuse Medical Treatment

Mark D. White

Last night I read a wonderful and concise article by Jillian Craigie (King's College London) from the latest issue of Bioethics (25/6, July 2011) titled "Competence, Practical Rationality and What a Patient Values." The abstract follows:

According to the principle of patient autonomy, patients have the right to be self-determining in decisions about their own medical care, which includes the right to refuse treatment. However, a treatment refusal may legitimately be overridden in cases where the decision is judged to be incompetent. It has recently been proposed that in assessments of competence, attention should be paid to the evaluative judgments that guide patients' treatment decisions.

In this paper I examine this claim in light of theories of practical rationality, focusing on the difficult case of an anorexic person who is judged to be competent and refuses treatment, thereby putting themselves at risk of serious harm. I argue that the standard criteria for competence assess whether a treatment decision satisfies the goals of practical decision-making, and that this same criterion can be applied to a patient's decision-guiding commitments. As a consequence I propose that a particular understanding of practical rationality offers a theoretical framework for justifying involuntary treatment in the anorexia case.

Craigie argues for assessing the procedure--in this case, practical judgment--by which a person comesto the decision whether to refuse treatment, rather than applying external standards to the decision itself or the reasons that led to it. She emphasizes that in the past, simply exhibiting a behavior and expressing a preference that was characterized as or associated with a mental disorder was taken as evidence that the patient was "irrational." In the case of anorexia nervosa (on which she focuses in the article), if the patient expressed an overwhelming desire to be thin, this was judged to be irrational simply because that was one of the hallmarks of the disorder. Craigie correctly identifies this as circular reasoning, akin to listing homosexuality as a disorder and then "concluding" that homosexual desires are "pathological" (or interpreting denial of a problem as evidence of the problem--for one of the most disturbing instances of this that I've read, see Deirdre McCloskey's Crossing: A Memoir).

Instead, Craigie recommends looking into the quality of the reasoning by which the patient forms the value or preference that leads to the treatment refusal. She considers several approaches of evaluating the process by which the patient comes to a particular conclusion rather than simply judging the decision itself, or the value or preference that led to it. I was gratified to see this approach, because that is what I argue in much of my work on paternalism and welfarism: assuming that paternalism is justified in cases of involuntary behavior, involuntariness must be assessed procedurally--based on how the individual came to "act" in a certain way--rather than judging the value, prudence, or wisdom of the act itself. Whatever external evalutors think of an action is irrelevant--all that matters is how she came to that decision, and if she acted voluntarily.

Craigie argues that there is some evidence--though perhaps not enough at this point--to suggest that anorexics form their overwhelming desires for thinness in ways that compromise their true autonomy, and compares this case to Jehovah's Witness who refuses blood transfusions, in which case she recognizes that the religious value leading to that decision may be a core value of the individual, and is therefore less questionable. This is in line with what I have argued elsewhere (including chapter 5 of Kantian Ethics and Economics), we should assume that individuals make decisions in their own interests, as complex and multifaceted as they are, and interference with them is only justified if there is evidence that a decision (or action) was not made (or taken) voluntarily. (And yes, I realize that voluntariness is a topic of discussion all in itself, but I think the point stands even without specifying it further.) Refusal of medical treatment is  fantastic application of this, and I am very happy Craigie raised these issues.

The Virtue Ethics Approach to Bioethics

Mark D. White

The new issue of Bioethics (25/4, May 2011) is out, and among several articles is one that stands out for obvious reasons: "The Virtue Ethics Approach to Bioethics" by Stephen Holland.

This paper discusses the viability of a virtue-based approach to bioethics. Virtue ethics is clearly appropriate to addressing issues of professional character and conduct. But another major remit of bioethics is to evaluate the ethics of biomedical procedures in order to recommend regulatory policy. How appropriate is the virtue ethics approach to fulfilling this remit? The first part of this paper characterizes the methodology problem in bioethics in terms of diversity, and shows that virtue ethics does not simply restate this problem in its own terms. However, fatal objections to the way the virtue ethics approach is typically taken in bioethics literature are presented in the second section of the paper. In the third part, a virtue-based approach to bioethics that avoids the shortcomings of the typical one is introduced and shown to be prima facie plausible. The upshot is an inviting new direction for research into bioethics' methodology.

Methodology in Philosophical Bioethics (in the Cambridge Quarterly of Healthcare Ethics)

Mark D. White

Rat-genetics The latest issue of the Cambridge Quarterly of Healthcare Ethics (20/2, April 2011) contains two fascinating symposia, the first on methodology in philosophical bioethics and the second on global bioethics. Here are the chapter titles (and links to abstracts and paper)in the first, all of which use Matti Häyry's book Rationality and the Genetic Challenge: Making People Better? as a starting point for discussion. (I'll post on the global ethics symposium later.)

Considering Organ Donation Euthanasia

Mark D. White

An upcoming article in Bioethics (apparently open access for the time being) asks the question...


Dominic Wilkinson and Julian Savulescu


There are not enough solid organs available to meet the needs of patients with organ failure. Thousands of patients every year die on the waiting lists for transplantation. Yet there is one currently available, underutilized, potential source of organs. Many patients die in intensive care following withdrawal of life-sustaining treatment whose organs could be used to save the lives of others. At present the majority of these organs go to waste.

In this paper we consider and evaluate a range of ways to improve the number and quality of organs available from this group of patients. Changes to consent arrangements (for example conscription of organs after death) or changes to organ donation practice could dramatically increase the numbers of organs available, though they would conflict with currently accepted norms governing transplantation.

We argue that one alternative, Organ Donation Euthanasia, would be a rational improvement over current practice regarding withdrawal of life support. It would give individuals the greatest chance of being able to help others with their organs after death. It would increase patient autonomy. It would reduce the chance of suffering during the dying process. We argue that patients should be given the choice of whether and how they would like to donate their organs in the event of withdrawal of life support in intensive care.

Continuing current transplantation practice comes at the cost of death and prolonged organ failure. We should seriously consider all of the alternatives.

The Ambiguity of "Dignity" in Embryo Research and Judicial Decisions

Mark D. White

An article in the new issue of Bioethics (25/1, January 2011) by Inmaculada de Melo-Martín titled "Human Dignity in International Policy Documents: A Useful Criterion for Public Policy?" examines several EU documents governing enbryo research to see if their regulations motivated by proecting human dignity are useful, informative, and/or effective.

From the abstract:

I argue that by using human dignity as a criterion to determine the permissibility of particular human embryo research practices, these documents cannot aid in identifying research that would be contrary to human dignity. Thus, they fail to guide public policy on embryo experimentation. Their use of human dignity as a criterion makes their task of offering guidance unfeasible because the concept as used in these documents is too vague and is applied in contradictory ways. I discuss the main goals of these documents and their claims in relation to human embryo research. I then discuss how they have influenced public policy in several countries. Finally, I show that although these Council of Europe treaties attempt to serve as public policy guides in the area of embryo research, they fail to do so.

She concludes that given the vagueness of the conception of dignity, the uncertainty of whether dignity applies to embryos, and the different cultural value systems in the constituent countries, the concept of dignity has little use and may lead to a least cmmon denominator effect in which the term is reduced to whatever weak meaning the member countires can agree on:

My arguments here are thus concerned not with the usefulness of this concept, in helping us to reflect on a variety of issues that arise with the development and implementation of new biotechnologies, but with its value as a criterion for public policy in this area. For the concept to be helpful in assisting public policy-makers to decide what types of biomedical practices to prohibit or rigorously to control, one must have a clear understanding of what human dignity is, what entities are bearers of human dignity, and how human dignity is at stake.

It might be that, at least in international public policy documents, such clarity and specificity cannot be offered. International documents call for the support of a variety of countries often with very different values for their provisions to be effective. Given the controversial nature of the concept of human dignity, however, and the existence of various and inconsistent understandings of such a concept, it seems unlikely that a clearly defined concept would attract such necessary international support. It might be wise then simply to discard the concept of human dignity as a public policy criterion in biomedical research decisions. In international settings, an insistence on using the ill-defined concept as a way to help institutions to promote polices determining what kinds of biomedical practices should be allowed or forbidden seems not just ineffective, but actually counterproductive. Different States will certainly interpret human dignity in diverse ways and as a consequence are likely to enact legislation that conflicts with other States’ legislative efforts. If human dignity turns out to be consistent with a number of conflicting policies that different countries can adopt, then it fails to guide; thus it fails to serve as a criterion. Doubtless, such a failure poses the possibility that the concept will become empty and without relevance. Given the good that can come of considering human dignity when discussing new biomedical developments, this would be a significant loss indeed. (p. 45)

This conclusion reminds me of Helen Knowles' paper "Courting Dignity," in which she examines the use of the term dignity in U.S. Supreme Court decisions, and Michael Dorf's 2008 blog post "Give Me Dignity or Give Me Death," which is critical of the ambiguous meaning of the term in (then) recent judicial opinions.

It's easy for Kantians (like me) to proclaim dignity to be, at bottom, the ultimate foundation for all legal and policy decisions, but we must be mindful that ours is not the one and only accepted meaning of the term; Alan Gewirth's sense of dignity is much more supportive of positive welfare rights, for instance. (See my paper "Kantian Dignity and Social Economics" for more.) But it would be tragic, given its central importance to so many systems of thought, if some common ground cannot be found to guide decisions in policy and law, especially since the disputes in which dignity is likely to be invoked are also likely to be among the most morally critical ones.