Abstract
In the previous chapter, I introduced and elaborated the teaching and psychotherapeutic models of genetic counseling. The models were located within larger narratives from which they inherited distinct views of communication. I claim that the teaching model of genetic counseling is underwritten by the technical vision of communication; the psychotherapeutic model by the therapeutic vision of communication. Both are broadly situated in what John Durham Peters’ calls the spiritualist tradition. In this chapter I develop an alternative view that has been offered in the genetic counseling literature that places responsibility at the center of its approach. After introducing the responsibility model, I elaborate it in reference to a different philosophical story about communication whose details are worked out in Robert Brandom’s pragmatic model of conversational scorekeeping. These additional expressive resources are then used to flesh out the theses of the responsibility model.
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- 1.
M. T. White, ““Respect for Autonomy” In Genetic Counseling: An Analysis and a Proposal,” J Genet Couns 6, no. 3 (1997): 298–99. White acknowledges that nondirectiveness has many meanings . Her criticisms are most consistently applied to a version of nondirective counseling that resembles the teaching model presented in Chap. 2.
- 2.
Ibid., 304.
- 3.
H. Richard Niebuhr , The Responsible Self; an Essay in Christian Moral Philosophy, [1st] ed. (New York,: Harper & Row, 1963), 68.
- 4.
As White acknowledges , this is an area of heated debate. For an extended discussion of these issues see Parens and Asch.
- 5.
M. T. White, “Making Responsible Decisions. An Interpretive Ethic for Genetic Decisionmaking,” Hastings Cent Rep 29, no. 1 (1999): 18.
- 6.
D. Armstrong, S. Michie, and T. Marteau, “Revealed Identity: A Study of the Process of Genetic Counselling,” Soc Sci Med 47, no. 11 (1998): 1653–8. Arrmstrong and others report how genetic counseling constructs a genetic identity .
- 7.
Immanuel Kant , “An Answer to the Question: What Is Enlightenment?,” in Kant : Political Writings, ed. Hans Siegbert Reiss (Cambridge ; New York: Cambridge University Press, 1991). Robert Brandom asserts that one of Kant ’s most important insights is the relationship between judgment and normativity . Brandom draws a sharp contrast between Kant ’s and Descartes’ accounts of judgment .
- 8.
Whether knowing a fetus has a condition confers benefit to a pregnant woman that is not considering termination is a real question. I observed two OB/GYNS who had different stances on the issue. One stated that if a woman would not consider termination then, she should not undergo amniocentesis . The other said to patients that knowing whether a baby has Down syndrome can help parents and health care provider prepare for the delivery.
- 9.
The debate about the status of norms as regularities or proprieties cannot be sorted through in the confines of the project. The position that norms are proprieties is the one undertaken here and depends largely on Robert Brandom ’s work.
- 10.
Peters , Speaking into the Air: A History of the Idea of Communication , 109.
- 11.
Ibid., 65.
- 12.
Ibid., 112.
- 13.
Georg Wilhelm Friedrich Hegel, Arnold Vincent Miller, and J. N. Findlay, Phenomenology of Spirit (Oxford: Clarendon Press, 1977), 111–19.
- 14.
Peters , Speaking into the Air: A History of the Idea of Communication , 51, 206.
- 15.
Ibid., 34.d
- 16.
Ibid., 159.
- 17.
In philosophical circles, the choice of Brandom over Jurgen Haberma s might be scrutinized. Two reasons justify this decision . First, Habermas’s work focuses more on communicative norms within procedural contexts of ‘ideal speech’, whereas Brandom ’s applies to a broader range of communicative contexts . Second and more important, Brandom ’s account supplies the details to Habermas’s pragmatic stance. Habermas recounts a letter he received from Richard Rorty that recommended Brandom ’s work as working out the pragmatics of communication that Habermas intends. For reference to letter, see Jürgen Habermas, Ciaran Cronin, and Max Pensky, Time of Transitions (Cambridge, UK ; Malden, MA: Polity, 2006). and for a helpful comparison of Brandom and Habermas, see Kevin Scharp, “Communication and Content: Circumstances and Consequences of the Habermas-Brandom Debate,” International Journal of Philosophical Studies 11, no. 1 (2003): 43–61.
- 18.
Every theory has limits and this one is no exception. As Brandom indicates, his theory is an “artificial idealization” that oversimplifies and schematizes what we do but at the same time we should be able to recognize our own linguistic practices in this account. Brandom correlates his term ‘commitment ’ with ‘obligation ’ and ‘entitlement ’ with ‘permission’ and explains his resistance to these correlates as disrupting the picture that authority necessarily depends on hierarchy. Commitments and entitlements are normative statuses for Brandom and one of his central contributions is the development of these normative statuses in reference to assertional responsibility. One possible consequence of his development is that ethical theories must begin at the level of the norms of discursive practice.
- 19.
Brandom acknowledges that placing the practice of giving and asking for reasons at the core of linguistic practice is an intellectualist move away from Wittgenstein ’s notion that language has no downtown. Wittgenstein insight is that we use language for all kinds of purposes and thus there is no core or ‘downtown’ use for language. Brandom ’s insight is that linguistic practice cannot be understood at all without the practice of giving and asking for reasons.
- 20.
Robert Brandom , Making It Explicit : Reasoning, Representing, and Discursive Commitment (Cambridge, Mass.: Harvard University Press, 1994), 142.
- 21.
Ibid., 159–62.
- 22.
Ibid., 162. Brandom elaborates that this practice was justified as a way to confer commitment to illiterate citizens but in actuality it was a highly abused practice that involved disguised recruitment officers circling taverns where drunken citizens with empty pockets would take the queen’s shilling.
- 23.
Ibid., 34–46. The relationship of sanctioning to deontic scorekeeping deserves brief attention because it is a crucial feature for understanding how normative practices work. Positive and negative sanctions provide one explanation of what it means to assess performances as correct or incorrect. Sanctions can consist in withholding rewards or distributing punishment for incorrect performances and the provision of rewards or withholding of punishment for correct performances . Brandom divides sanctions into two kinds: nonnormative or normative . The first kind involves responses to performances that ultimately depend on the disposition of the sanctioner. Imagine a household where the behavior of lying has been designated as wrong but no specific punishment has been specified. Thus, when a child lies the parent might be disposed to spank the child one day and yell at the child the next day. This kind of sanction seeks to negatively reinforce the disposition that produced the performance without yet normatively defining what sanction is appropriate. What makes this sanction nonnormative for Brandom is that it can be explained in purely naturalistic terms by an observer without reference to a normative specification. Normative sanctions consist of responses to assessments that are defined by further changes in normative status, i.e. withholding of subsequent entitlements or removing preexisting obligations , and thus must be defined in reference to the internal workings of the normative practice. When the child lies, he loses his or her entitlement to give reports that will be taken as true by his parents. Normative sanctions do not have as direct a relationship to the reinforcement of a disposition in the ways that nonnormative sanctions do: “In such cases one is rewarded or punished for what one does “in another world” –by a change in normative status rather than natural state.
- 24.
For Brandom , a practice becomes more sophisticated as it become further defined by normative statuses. One only has to think about how policies evolve within an organization to specify additional commitments and entitlements related to it.
- 25.
Wilfrid Sellars, “Some Reflections on Langauge Games,” Philosophy of Science 21, no. 3 (1954): 204–28.
- 26.
Brandom , 590.
- 27.
Brandom is not claiming that every sentence is uttered to provide a reason or every sentence ascribed should be challenged but only that they have the potential to be a reason for some further claim or action and the potential to be challenged .
- 28.
Brandom , 168.
- 29.
Brandom gives the example of a well made match and the entitlement to the inference that when struck against the appropriate surface it will light. He notes extremely cold circumstances in which such an inference could be challenged .
- 30.
J. R. Korenberg and others, “Down Syndrome Phenotypes: The Consequences of Chromosomal Imbalance,” Proc Natl Acad Sci U S A 91, no. 11 (1994): 4998.
- 31.
D. S. Mazzoni, R. S. Ackley, and D. J. Nash, “Abnormal Pinna Type and Hearing Loss Correlations in Down’s Syndrome,” J Intellect Disabil Res 38 (Pt 6) (1994).
- 32.
For a longitudinal study comparing persons with Down syndrome to perform ‘activities of daily living, see M. A. Maaskant and others, “Care Dependence and Activities of Daily Living in Relation to Ageing: Results of a Longitudinal Study,” J Intellect Disabil Res 40 (Pt 6) (1996).
- 33.
The effect a child with Down syndrome has on a family is complex. For a population study that compares divorce rates between Down syndrome families, families with other birth defects and families with no known disabilities , see R. C. Urbano and R. M. Hodapp, “Divorce in Families of Children with Down Syndrome: A Population-Based Study,” Am J Ment Retard 112, no. 4 (2007): 261–74.
- 34.
For a journalistic article discussing the conflict of interests between Down syndrome advocates and OB/GYNs, see Amy Harmon, “Prenatal Test Puts Down Syndrome in Hard Focus,” New York Times, 9 May 2007, 1. Adrienne Asch has been a consistent and forceful critic of the prenatal testing. See A. Asch, “Disability Equality and Prenatal Testing: Contradictory or Compatible?,” Fla State Univ Law Rev 30, no. 2 (2003): 315–42. There is also evidence that counselors are not having undue influence: van den Berg, Matthijs, Danielle RM Timmermans, Johanna H Kleinveld, Jacques Th M van Eijk, Dirk L Knol, Gerrit van der Wal, and John MG van Vugt. “Are Counsellors’ Attitudes Influencing Pregnant Women’s Attitudes and Decisions on Prenatal Screening?” Prenatal diagnosis 27, no. 6 (2007): 518–524. More recently, qualitative attention has revealed a lack of attention to disability , Ellyn Farrelly and others. “Genetic Counseling for Prenatal Testing: Where Is the Discussion About Disability?” Journal of genetic counseling 21, no. 6 (2012): 814–824.
- 35.
The model does not claim that both do it equally well.
- 36.
Brandom endorse an I-Thou social model of linguistic practice rather than an I-we account. In the latter, the communities position on a matter is the truth of the matter ; in the former, the truth of the matter is a negotiated status between individuals who constitute a linguistic community (p.590): “Mutual understanding a communication depend on interlocutors’ being able to keep two sets of books, to move back and forth between the point of view of the speaker and the audience, while keeping straight on which doxastic substitutional and expressive commitments are undertaken and which are attributed by the various parties. Conceptual contents, paradigmatically propositional contents can genuinely be shared, but their perspectival nature means that doing so is mastering the coordinated system of scorekeeping perspectives, not passing something nonperspectival from hand to hand (mouth to mouth).
- 37.
The possibility that P could affect every commitment is evidence of Brandom ’s endorsement of semantic holism, the position that meanings cannot be easily divided into analytic and synthetic distinctions.
- 38.
Robert Brandom , “Hermeneutic Practice and Theories of Meaning ,” SATS - Nordic Journal of Philosophy 5, no. 1 (2004): 23.
- 39.
Ibid.
- 40.
Ibid., 24.
- 41.
For a more thorough discussion of this specific example, see L. de Crespigny, “Words Matter: Nomenclature and Communication in Perinatal Medicine,” Clin Perinatol 30, no. 1 (2003): 17–25.
- 42.
Brandom , “Hermeneutic Practice and Theories of Meaning ,” 26.
- 43.
Ibid., 24–25.
- 44.
Perception is a term used by Brandom to refer to noninferential commitments expressed in observation reports. Noninferential commitments are triggered by what Brandom calls reliable differential responsive dispositions. On Brandom ’s view, we share these dispositions with land mines and thermostats but the latter do not undertake noninferential commitments . To explicate the important relation between noninferential commitments and inferential ones, Brandom compares a parrot that can be taught to say ‘red’ and the use of red by a competent language user. The parrot may be able to differentiate when to say, ‘That is red’ but has no understanding of the inferential significance of this move. When a competent language user claims , ‘That is red’, he or she knows the significance of the utterance, i.e. it is not a patch of green. If Debbie is implicitly or explicitly aware that she is anxious, then this attitude can be attributed as a noninferential commitment that has clear inferential significance for understanding P.
- 45.
See Donald Davidson, “Actions, Reasons, and Causes,” The Journal of Philosophy 60, no. 23 (1963). Donald Davidson claims that action can only be understood in relation to a ‘primary reason’ defined as the pairing of a belief and a pro-attitude. When giving explanations for our actions (Why did you open the umbrella? …because it is raining), we often leave out the pro-attitude (I want to stay dry.).
- 46.
White, “Making Responsible Decisions. An Interpretive Ethic for Genetic Decisionmaking,” 20.
- 47.
L. R. Churchill and D. Schenck , “One Cheer for Bioethics: Engaging the Moral Experiences of Patients and Practitioners Beyond the Big Decisions,” Camb Q Healthc Ethics 14, no. 4 (2005): 393–98.
- 48.
Patricia T. Kelly, Dealing with Dilemma: A Manual for Genetic Counselors, Heidelberg Science Library (New York: Springer-Verlag, 1977).
- 49.
This question does not necessarily mean that the patient wants to abdicate responsibility for decision making .
- 50.
Brandom , Making It Explicit : Reasoning, Representing, and Discursive Commitment.
- 51.
Ibid., 486.
- 52.
For examples of arguments for the importance of restating, see Baker and others, 55–74. and de Crespigny: 17–25.
- 53.
See Kessler and Levine, “Psychological Aspects of Genetic Counseling. Iv. The Subjective Assessment of Probability.”; A. Lippman-Hand and Fraser, “Genetic Counseling – the Postcounseling Period: I. Parents’ Perceptions of Uncertainty .”, A. Lippman-Hand and F. C. Fraser, “Genetic Counseling: Parents’ Responses to Uncertainty,” Birth Defects Orig Artic Ser 15, no. 5C (1979).
- 54.
Jeffrey Stout , Democracy and Tradition , New Forum Books (Princeton, N.J.: Princeton University Press, 2004), 188. Stout ’s examples are based on Brandom , Making It Explicit : Reasoning, Representing, and Discursive Commitment, 245.
- 55.
Brandom , Making It Explicit : Reasoning, Representing, and Discursive Commitment, 252. Brandom acknowledges that moral philosophers tend to reduce moral reasoning down to one type of pattern. For example, Hume reduces moral reasoning to desire whereas Kant prefers to reduce moral reasoning to unconditional obligations .
- 56.
Stout , 188.
- 57.
For an exchange that makes explicit Haberma s’s emphasis on mutual understanding and Brandom ’s critique of Habermas’s stance, see Jürgen Habermas, “From Kant to Hegel: On Robert Brandom ’s Pragmatic Philosophy of Language,” European Journal of Philosophy 8, no. 3 (2000): 322–55. and Robert Brandom , “Facts, Norms, and Normative Facts: Reply to Habermas,” European Journal of Philosophy 8, no. 3 (2000): 356–74.
- 58.
The relationship between Levinas ’s and Brandom ’s positions is not well understood and more research needs to be done in this area. Levinas ’s emphasis on inscrutable otherness and the role of embodiment , i.e. ‘faces,’ in founding the ethical relationship stands as a critique against an emphasis on social practices, i.e. linguistic practices, that bind us and allow us to identify with one another through language. I think Brandom and Peters partially avoid this critique in their resistance to cheap claims of mutual understanding.
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Fanning, J.B. (2016). A Responsibility Model of Genetic Counseling. In: Normative and Pragmatic Dimensions of Genetic Counseling. Philosophy and Medicine, vol 124. Springer, Cham. https://doi.org/10.1007/978-3-319-44929-6_3
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