Abstract
Elselijn Kingma maintains that Christopher Boorse and other naturalists in the philosophy of medicine cannot deliver the value-free account of disease that they promise. Even if disease is understood as dysfunction and that notion can be applied in a value-free manner, values still manifest themselves in the justification for picking one particular operationalization of dysfunction over a number of competing alternatives. Disease determinations depend upon comparisons within a reference class vis-à-vis reaching organism goals. Boorse considers reference classes for a species to consist in the properties of age and sex and organism goals to comprise survival and reproduction. Kingma suggests that naturalists are influenced by value judgments and may rely upon implicit assumptions about disease in their choice of reference classes and goals to determine which conditions are diseased. I argue that she is wrong to claim that these choices cannot be defended without arguing in a circular manner or making certain arbitrary or value-driven judgments.
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Notes
Since most people want to reproduce, infertility will typically be considered harmful. However, neither the degree of the harm of infertility nor the number of people for whom it is harmful is as great as the response to early death.
Standard examples include cowpox that protects one during a smallpox epidemic, flat feet that keep one out of a suicidal war, infertility after having a dozen horrible kids and an unhelpful partner, and pneumonia in its capacity as “the old man’s friend.”
My discussion of metaethical issues here is indebted to a referee.
This claim can be extended to hybrid accounts like Jerome Wakefield’s, which entails that disorders consist of two necessary (and jointly sufficient) conditions—dysfunction and harm [3]. See Neil Feit [6] for a careful analysis of the problems that overdetermination and preemption of harm pose for packing harm into the definition of disease.
Readers could insist that there are other prima facie harms like the loss of the goods of friends and family. My response is that one can imagine that unending, untreatable pain or coma has already severed the patients in question from those goods prior to the fatal disease. Alternatively, one can imagine an unhappy hermit or orphan. (Keep in mind that since the current exercise is conceptual analysis, all that is needed is one counterexample to undermine normativism.) Considerations like these suggest another counterintuitive aspect of normativism—that there could be a cause of death that is a disorder for one group but not for another due to differing attitudes toward continued life. One population might regret that a fatal disease should shorten their lives, while another welcomes the same disease because they are bored or rendered miserable by the prospect of more life.
Kingma occasionally states that a value-free account cannot be provided [11, p. 128; 12, p. 370], but a referee points out that she needs only the weaker claim—that one has not been provided. In this way, the onus is on Boorse to show that the choice of reference class is value-free, but she argues that he has not yet done this.
Boorse does leave open that people with homosexual orientation, like sterile working insects, can play a role in kin reproduction [2, p. 99].
Likewise, if one were to choose depressedness rather than sex as a reference class component, the grief of the depressed would not be pathological.
Terminators like Eric Olson [18], Peter van Inwagen [19], and me [20] believe that we pass out of existence at death. Anti-terminators believe that we can become corpses and remain so until there is too much decay. But even anti-terminators are likely to assume that we come into existence as living beings even if we are able to persist without continuing to be alive. They would accept that something becomes a part of an organism only when it is caught up in life processes, though it can remain a part as long as sufficient structure remains. So my point below in the main text—that the xs are parts of an organism in virtue of their being caught up in life processes that contribute to survival—provides a reason for survival to be an organism goal even if anti-terminators are correct that corpses are identical to the earlier living organisms. The parts of the corpse are considered parts because they were earlier caught up in life processes. The anti-terminator does not allow the corpse to acquire new parts.
Some biologists are misled by the fact that survival serves reproduction from an evolutionary perspective and thus fail to see how survival is part of our essence and reproduction is not. I contend that conceptual analysis and thought experiments show that we would be essentially living entities even if we did not reproduce, did not evolve given an inability to mutate, or remained alive long after we ceased to serve any reproductive function, even to our grandchildren. Surely one does not want to insist that it is metaphysically impossible for the first living organisms to have existed without being able to reproduce. Olson also provides support for this position [18]. For views that evolution is essential to life, see Mark Bedau [21] and John Maynard Smith [22]. If I am wrong and we are essentially reproducing entities, then my thesis is actually stronger insofar as survival is just a necessary means to reproduction. Then I could get the goal of survival as an intermediate goal toward reproduction which is disposable when reproduction is served by loss of life.
Other accounts of personal identity may appeal to value judgments. See Lynn Rudder Baker’s defense of our uniqueness in the animal kingdom [23]. Her awe of our rationality and first-person perspective drives her claim that we must be ontologically distinct in virtue of those impressive traits. Animalists like me think our most valued traits are irrelevant to our essence. So we cannot easily be accused of relying on value judgments in our choice of theory of personal identity. Of course, there are philosophical and scientific values involved in theory choice, but those are just the standard comprehensiveness, accuracy, explanatory power, consistency, fruitfulness, and perhaps simplicity.
An organism can replace most, if not all, of its parts. There are some parts it can survive the loss of without replacing because of either redundancy or lack of involvement in essential life processes. If there are any parts that an organism cannot lose without going out of existence, then these are essential parts. So, for example, if one defends the brain death criterion of death, then the brain must be considered an essential part of the organism as it is the central integrator, responsible for making the xs parts of a living body. Replace the brain and you replace the human being. But there is a second sense in which parts are generically essential, which allows them to be lost and replaced (unlike the aforementioned brain) without the original organism’s going out of existence. These parts must contribute to the organism’s continuous realization of its essence (i.e., staying alive), but any qualitative duplicate will do. So while any particular microscopic part (e.g., any cell or carbon particle) is not essential in the first sense, it or a duplicate thereof may be essential in the second generic sense insofar as it is there because parts of its kind are essential to keeping the organism alive and instantiating its essence.
A referee points out that my part theses do not seem necessary for the claim that organisms are essentially living and so have survival as a goal. So even if I am wrong about parts only being parts because of an event whose nature is to preserve the organism, I can argue that it is natural to judge parts by their contribution to an essential goal of the whole.
That is not to say that homosexuality could not become a form of reproduction in the future if people with homosexual orientation were to form a class that reproduces by, say, gene splicing.
Usually, our goals are not only compatible but also complementary, given that all organisms must survive to reproduce, that successful reproduction produces offspring that survive, and that most multicellular organisms will seek to continue to survive after reproducing.
I understand Kingma to be attacking naturalism, believing her critique to be not limited to Boorse and his followers but problematic for naturalists who reject his biostatistical theory. They too will appeal to reference classes for even if they explain functions in terms of selection, it is women of certain ages that are selected to be capable of pregnancy, not young males. I see my paper’s project as defending naturalism, not just Boorse’s version of it. So I think it is permissible for me to consider drawing upon etiological accounts to support reference class factors. Evidence that Kingma intends her critique of value-free reference classes to extend beyond Boorse’s BST to other naturalist accounts can be found in the sections entitled “Naturalists’ Burden of Justification” and “Naturalism and Pluralism” [12, pp. 370–371]. After objecting to Boorse with her hypothetical XST theory, she writes:
The earlier argument has wider implications for naturalist accounts of disorder: it increases their burden of justification. Naturalists’ central claim is that disorder is not a reflection of social values or norms, but a feature of the natural world. … But the earlier argument suggests that this is not enough; giving a definition or account of the concepts “health” and “disorder” in value-free terms does not suffice for proving that these concepts are completely value-free. As the example of the XST demonstrates, accounts stated in value-free terms can still embody deeply held social values. It follows that if naturalists are to defend their main claim, they have to meet an additional challenge: demonstrate that there is some value-free justification for employing the particular naturalistic concept they define, rather than another one. … Whatever the right account of function turns out to be—we end up with a problem very much similar to the one the BST faces: any particular account of disorder as dysfunction, whilst describing disorder in value-free terms, has to choose and employ a particular way of carving up functional architecture, rather than another one, to determine what are disorders. [12, pp. 370–371]
So I do not think that Kingma would be satisfied with the conclusion that only Boorse-style naturalism fails to provide non-normative justifications for reference classes.
A standard example used to elucidate the determinable/determinate distinction is that of red as a determinable and any type of red as a determinate (e.g., scarlet, crimson, or burgundy). The determinable/determinate classifications are sometimes contrasted with the genus/differentia classifications, in which the genus animal, say, may be qualified by the differentia of rationality. There is no qualifier to add to red to explain why crimson is different from scarlet.
See Leon Kass for an account of the ontological significance of sexual reproduction [28], which lends support to the claim that sex is an appropriate reference class. Asexual reproduction is found in only the lowliest of beings. Kass writes, “Sexuality brings with it a new and enriched relationship to the world … with desire for union, the animal antecedent of human eros and the germ of sociality. Not by accident is the human animal … the most aspiring, the most social, the most open and the most intelligent animal” [28, pp. 21–22]. So much of our culture is a consequence of our pursuit of mates. Even the activities of lower animals are determined greatly along sex lines. The same cannot be said for any of the proposed alternative reference classes.
I admit that some diseases are pervasive in that they show up in every cell. But being pervasive in the sense of being present in every cell is different from being phenotypically pervasive.
This point can be extended to age as well. The differences between embryos and adolescents is greater than any differences between those who are in the reference classes that Kingma offers, such depressed people, and those who are not.
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I would like to thank two very knowledgeable anonymous referees, a Romanell Center workshop audience, and Katelyn MacDougald.
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Hershenov, D.B. A naturalist response to Kingma’s critique of naturalist accounts of disease. Theor Med Bioeth 41, 83–97 (2020). https://doi.org/10.1007/s11017-020-09526-9
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DOI: https://doi.org/10.1007/s11017-020-09526-9