Wild justice and fair play: cooperation,forgiveness, and morality in animals

In this paper I argue that we can learn much about ‘wild justice’ and the evolutionary origins of social morality – behaving fairly – by studying social play behavior in group-living animals, and that interdisciplinary cooperation will help immensely. In our efforts to learn more about the evolution of morality we need to broaden our comparative research to include animals other than non-human primates. If one is a good Darwinian, it is premature to claim that only humans can be empathic and moral beings. By asking the question ‘What is it like to be another animal?’ we can discover rules of engagement that guide animals in their social encounters. When I study dogs, for example, I try to be a ‘dogocentrist’ and practice ‘dogomorphism.’ My major arguments center on the following ‘big’ questions: Can animals be moral beings or do they merely act as if they are? What are the evolutionary roots of cooperation, fairness, trust, forgiveness, and morality? What do animals do when they engage in social play? How do animals negotiate agreements to cooperate, to forgive, to behave fairly, to develop trust? Can animals forgive? Why cooperate and play fairly? Why did play evolve as it has? Does ‘being fair’ mean being more fit – do individual variations in play influence an individual's reproductive fitness, are more virtuous individuals more fit than less virtuous individuals? What is the taxonomic distribution of cognitive skills and emotional capacities necessary for individuals to be able to behave fairly, to empathize, to behave morally? Can we use information about moral behavior in animals to help us understand ourselves? I conclude that there is strong selection for cooperative fair play in which individuals establish and maintain a social contract to play because there are mutual benefits when individuals adopt this strategy and group stability may be also be fostered. Numerous mechanisms have evolved to facilitate the initiation and maintenance of social play to keep others engaged, so that agreeing to play fairly and the resulting benefits of doing so can be readily achieved. I also claim that the ability to make accurate predictions about what an individual is likely to do in a given social situation is a useful litmus test for explaining what might be happening in an individual's brain during social encounters, and that intentional or representational explanations are often important for making these predictions.     

On Cloning: Advocating History of Biology in the Public Interest

Cloning – the process of creating a cell, tissue line or even a complete organism from a single cell – or the strands that led to the cloning of a mammal, Dolly, are not new. Yet the media coverage of Dolly's inception raised a range of reactions from fear or moral repulsion, to cautious optimism. The implications for controlling human reproduction were clearly in the forefront, though many issues about animals emerged as well. On topics of public interest such as cloning, historians of biology have the opportunity to make a unique contribution. Such debates are often aired as if they have no precedents, either in biology or in the ethical, moral, and social concerns arising in the public arena. The technology leading to Dolly draws on strands of research going back to the 1890s, and the cycle of public response has been repeated often in the past century. What can we learn from examining these events historically, and how can we – or should we even try – to inform public opinion? I think we should try and will outline briefly some of the ways that can work.     

Rationing fairly: programmatic considerations

Conclusion: I conclude with a plea against provincialism. The four problems I illustrated have their analogues in the rationing of goods other than health care. To flesh out a principle that says "people are equal before the law" will involve decisions about how to allocate legal services among all people who can make plausible claims to need them by citing that principle. Similarly, to give content to a principle that assures equal educational opportunity will involve decisions about resource allocation very much like those involved in rationing health care. Being provincial about health care rationing will prevent us from seeing the relationships among these rationing problems. Conversely, a rationing theory will have greater force if it derives from consideration of common types of problems that are independent of the kinds of goods whose distribution is in question. I am suggesting that exploring a theory of rationing in this way is a prolegomenon to serious work in "applied ethics."     

Spreading disease: a controversy concerning the metaphysics of disease.

This article concerns the metaphysics of disease. Is disease a fixed feature of the world or a social value or preference? I argue that disease is not a value-laden concept and thus debates concerning it differ fundamentally from debates concerning health, harm, or suffering where evaluative judgements are central. I show how the so-called social constructionist view of disease has been motivated both by ethical concerns with medical practices and general theoretical doubts about scientific naturalism. If I can show that ethical concerns about medical treatment can be answered without adopting social constructionism, that leaves only the broader theoretical question of naturalism. I cannot completely answer those theoretical doubts, but I show that the theoretical motivation is less convincing when it is separated from the moral challenge often accompanying it. I conclude that a convincing defense of the non-naturalistic conception of disease is rarely attempted and proves more difficult and counter-intuitive than its proponents assume.     

Threshold considerations in fair allocation of health resources: justice beyond scarcity

Application of egalitarian and prioritarian accounts of health resource allocation in low-income countries have both been criticized for implying distribution outcomes that allow decreasing/undermining health gains and for tolerating unacceptable standards of health care and health status that result from such allocation schemes. Insufficient health care and severe deprivation of health resources are difficult to accept even when justified by aggregative efficiency or legitimized by fair deliberative process in pursuing equality and priority oriented outcomes. I affirm the sufficientarian argument that, given extreme scarcity of public health resources in low-income countries, neither health status equality between populations nor priority for the worse off is normatively adequate. Nevertheless, the threshold norm alone need not be the sole consideration when a country's total health budget is extremely scarce. Threshold considerations are necessary in developing a theory of fair distribution of health resources that is sensitive to the lexically prior norm of sufficiency. Based on the intuition that shares must not be taken away from those who barely achieve a minimal level of health, I argue that assessments based on standards of minimal physical/mental health must be developed to evaluate the sufficiency of the total resources of health systems in low-income countries prior to pursuing equality, priority, and efficiency based resource allocation. I also begin to examine how threshold sensitive health resource assessment could be used in the Philippines.     

Justice and equal opportunities in health care

The principle that each individual is entitled to an equal opportunity to benefit from any public health care system, and that this entitlement is proportionate neither to the size of their chance of benefitting, nor to the quality of the benefit, nor to the length of lifetime remaining in which that benefit may be enjoyed, runs counter to most current thinking about the allocation of resources for health care. It is my contention that any system of prioritisation of the resources available for healthcare or of rationing such resources must be governed by this principle.
This can have apparently paradoxical conclusions in that it can seem wasteful to give someone with a very slim chance of a lifesaving treatment the same priority as someone with a much better chance. In an important and thoughtful recent paper, Julian Savulescu has concentrated on this apparent weakness and has argued for a particular conception of the good or benefit to be achieved by a healthcare system which purports to demonstrate the inadequacies of an equal opportunities approach to prioritisation and to replace it with an altogether better account. This paper will show that a rational 'reasons based consequentialism' is more in line with the equal opportunities approach, which I defended some time ago in these pages, than with that of Savulescu. I shall then examine more closely the conception of equal opportunities in health care and show that if we give weight to an individual's reasons, and what is expected to be good for them, we will opt for exactly the equality based account of distributive justice that I have recommended.     

EQUALITY AND THE DUTY TO RETARD HUMAN AGEING

Where does the aspiration to retard human ageing fit in the ‘big picture’ of medical necessities and the requirements of just healthcare? Is there a duty to retard human ageing? And if so, how much should we invest in the basic science that studies the biology of ageing and could lead to interventions that modify the biological processes of human ageing? I consider two prominent accounts of equality and just healthcare – Norman Daniels's application of the principle of fair equality of opportunity and Ronald Dworkin's account of equality of resources – and conclude that, once suitably amended and revised, both actually support the conclusion that anti‐ageing research is important and could lead to interventions that ought to be considered ‘medical necessities’.     

PALLIATIVE CARE, PUBLIC HEALTH AND JUSTICE: SETTING PRIORITIES IN RESOURCE POOR COUNTRIES

Many countries have not considered palliative care a public health problem. With limited resources, disease-oriented therapies and prevention measures take priority. In this paper, I intend to describe the moral framework for considering palliative care as a public health priority in resource-poor countries. A distributive theory of justice for health care should consider integrative palliative care as morally required as it contributes to improving normal functioning and preserving opportunities for the individual. For patients requiring terminal care , we are guided less by principles of justice and more by the duty to relieve suffering and society's commitment to protecting the professional's obligation to uphold principles of beneficence, compassion and non-abandonment. A fair deliberation process is necessary to allow these strong moral commitments to serve as reasons when setting priorities in resource poor countries.     

RETRACING LIBERALISM AND REMAKING NATURE: DESIGNER CHILDREN,RESEARCH EMBRYOS,AND FEATHERLESS CHICKENS

Liberal theory seeks to achieve toleration, civil peace, and mutual respect in pluralistic societies by making public policy without reference to arguments arising from within formative ideals about what gives value to human life. Does it make sense to set aside such conceptions of the good when it comes to controversies about stem cell research and the genetic engineering of people or animals? Whether it is reasonable to bracket our worldviews in such cases depends on how we answer the moral questions that the use of these biotechnologies presuppose. I argue that the moral language of liberal justice – of rights and duties, interests and opportunities, freedom and consent, equality and fairness – cannot speak to these underlying concerns about what the human embryo is, why the natural lottery matters to us, and whether ‘animal nature’ is worth preserving. I conclude that liberal theory is incapable of furnishing a coherent or desirable account to govern the way we use our emerging powers of biotechnology.     

Deciding on Death: Conventions and Contestations in the Context of Disability

Conflicts between bioethicists and disability theorists often arise over the permissibility of euthanasia and physician assisted suicide. Where mainstream bioethicists propose universalist guidelines that will direct action across a range of effectively disembodied situations, and take for granted that moral agency requires autonomy, feminist bioethicists demand a contextualisation of the circumstances under which moral decision making is conducted, and stress a more relational view of autonomy that does not require strict standards of independent agency. Nonetheless, neither traditional nor feminist perspectives have fully engaged with the critique of disabled people that they are consistently subjected to discriminatory, even life-threatening, practice and policy in biomedical and health care. The paper revisits some of the issues that drive the often highly polarised debate between bioethicists and disability theorists around the question of end of life decisions involving disabled people. While many bioethicists have doubtless been indifferent to the difference that disability makes, I am also concerned that the very proper demand of disability activists and theorists to scrutinise all end of life decisions for signs of discrimination and even violence has segued into something damagingly restrictive that silences internal dissension and stifles external debate. Given that euthanasia and physician assisted suicide may be issues where conventional argument on either side will founder on deeply felt convictions, I make the radical move to speculate on an entirely different, quasi-Deleuzian, approach to the value of life in order to shake up entrenched positions, and begin to think differently.     

Beyond accountability for reasonableness

This paper is a critique of Norman Daniels' and James Sabin's 'Accountability for Reasonableness' framework for making priority-setting decisions in health care in the face of widespread disagreement about values. Accountability for Reasonableness has been rapidly gaining worldwide acceptance, arguably to the point of becoming the dominant paradigm in the field of health policy. The framework attempts to set ground rules for a procedure that ensures that whatever decisions result will be fair, reasonable, and legitimate to the extent that even those who would be adversely affected will have reason to abide by them. I argue that the framework's four conditions are inadequate to this task. While we certainly require a fair and legitimate procedure for making priority setting decisions in health care despite a lack of consensus on relevant ethical and political issues, we must significantly revise the four conditions, and we cannot avoid facing our substantive disagreements head on if we hope to arrive at decisions that would (and should) be acceptable to everyone. I offer two suggestions. First, there is need for greater public involvement in all stages of deliberation. Second, we should give up on the idea that we can simplify the task of democratic deliberation by disallowing particular kinds or reasons and types of reasoning. Reasons of all kinds should be on the table, but then should be judged on their merits, such as consistency, plausibility and explanatory power, without any regard for their alleged sources of authority.     

Consequentialism, reasons, value and justice

Over the past 10 years, John Harris has made important contributions to thinking about distributive justice in health care. In his latest work, Harris controversially argues that clinicians should stop prioritising patients according to prognosis. He argues that the good or benefit of health care is providing each individual with an opportunity to live the best and longest life possible for him or her. I call this thesis, opportunism. For the purpose of distribution of resources in health care, Harris rejects welfarism (the thesis that the good of health care is well-being) and argues that utilitarianism in general may lead to de facto discrimination against groups of people needing health care. I argue that well-being is a superior theory of the good of health care to Harris' opportunism. Harris' concerns about utilitarianism can be better addressed by: (i) relating justice more closely to reasons for action; (ii) by conceptualising the relationship between reasons for action and the value of the consequences of those actions as a plateau rather than scalar relationship. Justice can be understood as satisfying as many equally rational claims on resources as possible. The rationality of a person's claim on health resources turns on the strength of that person's reasons to promote certain health-related states of affairs. I argue that the strength of that reason does not track the expected value of that state of affairs in a fully scalar fashion. Rather a person can have most reason to promote some state of affairs, even though he or she could promote other more valuable states of affairs. Thus there can be equal reason for a distributor of public resources to save either of two people, even though one will have a better and more valuable life. This approach, while addressing many of Harris' concerns about utilitarianism, does not imply that doctors should give up prioritising patients according to prognosis altogether, but it does allow that patients with lower but reasonable prognosis should have a share of public resources.     

Allocating resources for health and social care in England.

The fair allocation of resources for health and social care in relation to the needs of the population in different parts of the United Kingdom has become particularly important since the implementation of the new arrangements for community care in April 1993. These depend on close collaboration between health authorities and local authority social services departments. Yet funding reaches these authorities by different means and according to different criteria. Most health authority funds come through a weighted capitation formula that overemphasises the effects of age, while family health services funding is largely not cash limited and hence demand led. Funds to local authorities for community care are being transferred from the social security budget but on a basis that partly reflects past provision of residential and nursing home care. None of these mechanisms responds to underlying needs that give rise to demands on the health and social care system as a whole, and none makes any attempt to compensate for defects in the others. The solution includes better research and a unified weighted capitation system for all sources of funding.     

Compulsory moral bioenhancement should be covert

Some theorists argue that moral bioenhancement ought to be compulsory. I take this argument one step further, arguing that if moral bioenhancement ought to be compulsory, then its administration ought to be covert rather than overt. This is to say that it is morally preferable for compulsory moral bioenhancement to be administered without the recipients knowing that they are receiving the enhancement. My argument for this is that if moral bioenhancement ought to be compulsory, then its administration is a matter of public health, and for this reason should be governed by public health ethics. I argue that the covert administration of a compulsory moral bioenhancement program better conforms to public health ethics than does an overt compulsory program. In particular, a covert compulsory program promotes values such as liberty, utility, equality, and autonomy better than an overt program does. Thus, a covert compulsory moral bioenhancement program is morally preferable to an overt moral bioenhancement program.     

Reassessing insurers' access to genetic information: genetic privacy, ignorance, and injustice

Many countries have imposed strict regulations on the genetic information to which insurers have access. Commentators have warned against the emerging body of legislation for different reasons. This paper demonstrates that, when confronted with the argument that genetic information should be available to insurers for health insurance underwriting purposes, one should avoid appeals to rights of genetic privacy and genetic ignorance. The principle of equality of opportunity may nevertheless warrant restrictions. A choice-based account of this principle implies that it is unfair to hold people responsible for the consequences of the genetic lottery, since we have no choice in selecting our genotype or the expression of it. However appealing, this view does not take us all the way to an adequate justification of inaccessibility of genetic information. A contractarian account, suggesting that health is a condition of opportunity and that healthcare is an essential good, seems more promising. I conclude that if or when predictive medical tests (such as genetic tests) are developed with significant actuarial value, individuals have less reason to accept as fair institutions that limit access to healthcare on the grounds of risk status. Given the assumption that a division of risk pools in accordance with a rough estimate of people's level of (genetic) risk will occur, fairness and justice favour universal health insurance based on solidarity.     

Ethics consultation as moral engagement

I will begin by presenting some doubts about what might be called the "received view" of the role of the moral expert as a health care consultant. Then I will review the literature on moral experts and moral expertise and proceed to apply the results of that review to the notion that there are some who are expert in ethical decision making in health care. I will try to show that certain conclusions that can be drawn from this rather circumscribed topic have implications for the very conception of the relationship between moral theory and clinical ethics.     

Casting a wider net for countermeasure R&D funding decisions

Among potential bioweapons attacks, endemic infectious diseases (that is, those naturally occurring diseases that afflict us every year), and a potential influenza pandemic, how should we apportion funding and resources for basic research and countermeasure development? To address this question, I argue for a "combined risk assessment" that considers bioweapons attacks with natural pandemics and endemic infectious disease. At present, risk assessments for bioweapons attacks are carried out separately from the assessments long carried out for endemic infectious diseases to make public health and medical care decisions. One result of this separation is that funding decisions may be unduly influenced by an overblown fear of a big bioweapons attack and by political whim. The result of the simplified combined risk assessment presented here argues for more funding and resources for endemic infectious disease and for placing biodefense against anthrax and other bioweapons in a place lower in the risk hierarchy. Since the assessment here considers only fatalities to make the point that our priorities are skewed, the conclusions are only a "first word" on the subject, far from the last. Furthermore, the impact of other issues on priorities, such as national and international policy, is not considered. It is a call for a debate on the public stage of the policy and other rationale and the quantitative risk assessment arguments that now place bioweapons attacks at the top of our risk ranking.     

Public preferences for health care: prioritisation in the United Kingdom

The Government in the UK is encouraging consumerism within health care and is requiring Health Authorities to consult with the public on prioritisation of resources. Public consultation within the National Health Service (NHS) has had limited success in the past. Many of the techniques used are flawed. Despite the limited scope of the public surveys conducted so far, a number of themes have emerged: a willingness to pay for experimental, 'high-tech' life-saving treatments rather than more cost-effective treatments which will improve quality of life, which are more likely to maximise utility from the scarce resources available; preference for treating the young rather than the old; preference for treating patients with dependents (e.g. spouse, children) rather than those who have none; a willingness to discriminate against those patients who were partially responsible for their illness due to choice of 'unhealthy' lifestyle (e.g. smoking cigarettes, drinking excess alcohol). These public preferences raise ethical problems. For example, is it just to spend more on heroic treatments which are likely to fail? Is there a right to health care irrespective of whether you have had 'a fair innings' or whether a patient is in part responsible for their illness due to an unhealthy lifestyle? If there are ethical concerns about these preferences, should health authorities consult with the public at all? Is human life and suffering incommensurable, and hence is it impossible to prioritise anyway? Some of the ethical consequences of using empirical data on public preferences are discussed.     

Public Preferences for Health Care: Prioritisation in the United Kingdom

The Government in the UK is encouraging consumerism within health care and is requiring Health Authorities to consult with the public on prioritisation of resources. Public consultation within the National Health Service (NHS) has had limited success in the past. Many of the techniques used are flawed. Despite the limited scope of the public surveys conducted so far, a number of themes have emerged:
— a willingness to pay for experimental, 'high-tech' life-saving treatments rather than more cost-effective treatments which will improve quality of life, which are more likely to maximise utility from the scarce resources available;
— preference for treating the young rather than the old;
— preference for treating patients with dependants (e.g. spouse, children) rather than those who have none;
— a willingness to discriminate against those patients who were partially responsible for their illness due to choice of `unhealthy' lifestyle (e.g. smoking cigarettes, drinking excess alcohol).
These public preferences raise ethical problems. For example, is it just to spend more on heroic treatments which are likely to fail? Is there a right to health care irrespective of whether you have had 'a fair innings' or whether a patient is in part responsible for their illness due to an unhealthy lifestyle? If there are ethical concerns about these preferences, should health authorities consult with the public at all? Is human life and suffering incommensurable, and hence is it impossible to prioritise anyway? Some of the ethical consequences of using empirical data on public preferences are discussed.