Abstract
Karl Marx argued that the preferable starting point for influencing social practices is to understand their workings—not to simply moralize social systems through idealization. This thread in Marx informs contemporary critical social theories such as feminism and critical race theory. Such work attempts to diagnose and analyze internal contradictions, limitations, and dysfunctions in social structures as they actually are in order to connect them to normative dissatisfactions in lived experience. This critical theoretical methodology thus embodies what Charles Mills calls for in nonideal explanatory models that abstract without idealizing. In this chapter I argue that Marx’s theory of society, which informs his critique of political economy in Capital, offers bioethics a nonideal framework through which to analyze normative dissatisfactions in health care practice. What may appear to be moral problems or dilemmas in health care can be the result of, or significantly influenced by, structural patterns in health care’s material production—not its abstract moral content. Therefore, understanding health care structurally, as a set of productive practices within a larger systematic whole of capitalist production, can help diagnose systemic dysfunctions in health care’s material production that produce or make worse normative dissatisfactions of concern for bioethics. I call such morally significant structural dysfunctions social pathologies of health care, and contend that a Marx-informed bioethics can descriptively theorize structural bases of moral discontent and conflict in health care, and therein inform its social and political transformation for the better.
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Notes
- 1.
- 2.
And for a particularly scathing critique of Navarro’s work, see Reidy (1984).
- 3.
See, for instance, Daniels (2008, 18).
- 4.
See, for instance, Radin (1996, 79–83).
- 5.
I use the term “Marxian” to refer to theorization in Marx’s texts themselves, while I use “Marxist” to refer more to work of theorists (and political or state actors) who follow Marx and attempt to elaborate (or realize) his ideas. Among such Marxist theorists are Rosa Luxemburg, Georg Lukács and Vladimir Lenin. To offer an analogy, Marxian is to Marxism as Benthamian is to utilitarianism. The former singles out one thinker’s work (Jeremy Bentham) and interpretations of it, where the latter names the broader movement of which that thinker is considered a founder or foundational. This is a worthwhile distinction to maintain for Marx, given that the theories and politics of subsequent Marxism(s) are often taken to be more or less identical to Marx’s thought. Comparing this to other founder-movement distinctions helps indicate potential errors in such false equivalence for the sake of doing theory.
- 6.
The concept of social structure is increasingly theorized and utilized in work on gender and race, especially, to conceive of oppressive forces as interrelated and semi-independent of individual intentions or actions. Thus understanding racial or gendered oppression requires understanding the raced and gendered individual in relation to a larger set of social forces that work in concert—as a whole—to marginalize, dominate, or constrain. This echoes fundamental feminist insights in Marilyn Frye (1983, 1–16), which are utilized further in Anne Donchin (2010), Iris Marion Young (2011), and Sally Haslanger (2012, 2016). These authors are especially informative in my descriptions of social-relational structures in understanding social phenomena for normative social theory.
- 7.
For a more detailed examination of Rawls’s distinction between ideal and nonideal theory, see John Simmons (2010).
- 8.
Simmons (2010) notes that Rawls invokes Rousseau with this phrase (7).
- 9.
I use such modifiers as “mainstream” in part to acknowledge that there are already bioethics scholars doing alternative nonideal work less subject to my critique. Indeed, the present volume is clear evidence of this, as are my numerous attempts to draw connections to such authors and theories. My critiques of bioethics do not claim to apply universally, but instead more to predominant thinkers and approaches, and to common underlying metatheoretical assumptions.
- 10.
References to Marx’s Capital are often directed only at its first and best-known volume, which was the only volume published in Marx’s lifetime. It is focused primarily on the capitalist process of production. A posthumously published second volume (Marx 1992) analyzes processes of exchange and circulation in markets, and a third volume (Marx 1991) is especially concerned with finance capital and surplus value production in the cyclical workings of the capitalist system as a whole. Marx had originally planned six volumes in total for his Capital project that would include, among others, analyses of landed property, the state, international trade, and the world market (Heinrich 2013, 200).
- 11.
Marx generally avoids outright normative or moral condemnation, in favor of more anormative description. The present chapter does not permit a deeper exploration of this tension, however. For an account of anti-normativity from Marx to Foucault, and a Foucauldian argument against normative political theorizing, see Kelly (2018). See also Seyla Benhabib (1986) on the methodological foundations of Marxist and critical theory, including its anormative dimensions in defetishizing and immanent critique.
- 12.
It is worth noting that, despite not identifying as Marxist, the philosophy of economics might be moving closer to Marx on this claim—even if the field of economics itself is not following suit. In the introduction to the Oxford handbook of philosophy of economics, editors Harold Kincaid and Don Ross (2009) argue: “If it becomes widely recognized in economics, as we think it should, that methodological individualism is an ideological or philosophical prejudice rather than a scientifically justified principle, then an eventual fusion of economics and sociology seems to us more likely than the much-prophecied [sic] merger of economics and psychology” (18, [my emphasis]). Methodological individualism here refers precisely to the claim that social and economic phenomena are properly understood when reduced to individual actions and therein to the cognitive activity of individuals. Thus individual cognition, judgment, and action are taken as the underlying drivers of economics, and thus capitalism and society itself.
- 13.
- 14.
See Althusser (2014) for a more detailed consideration of the Marxian notion of modes of production.
- 15.
For contemporary Marxian approaches to social ontology, see Feenberg’s notion of Marx’s “philosophy of praxis” (2014) and Krier and Worrell (2016). For other contemporary approaches, see Sally Haslanger (2012, 2016) and her interlocutors (I believe that both discourses stand to benefit mutually from greater dialogue with one another).
- 16.
This is significant because Marx’s work is often understood as having turned away from philosophy after his early humanistic work (such as the 1844 Economic and philosophical manuscripts) and turned toward purely descriptive social science in works like Capital. Yet the somewhat recent discovery and 1973 English translation of Grundrisse is widely said to help reveal the truly philosophical nature of his later work and its links to the early humanism.
- 17.
- 18.
I find Marilyn Frye’s (1983) theorization of oppression as analogous to a birdcage (1–16) to be especially insightful regarding this structural notion of gender, understood in Haslanger’s (2012) words as “a social category whose definition makes reference to a broad network of social relations” (86–7), or what I refer to here as a totality. To say that gender oppression is like a birdcage is precisely to say that its oppressive effects are only adequately grasped from a holistic vantage point. This reveals social oppression as a plurality of constrictive social forces working systematically or in concert, which can become invisible when examining only an individual barrier or setback.
- 19.
I should differentiate my use of “naturalize” here from calls to “naturalize ethics” and bioethics. See Alison Jaggar (2000), Margaret Urban Walker (2002, 2007), and Lindemann et al. (2009). One naturalizes gender, race, or disability (in the bad way that I intend here) by depicting them as reflecting biological sex, genetics, or malfunction, respectively. Such moves reproduce a popular tacit claim that what is natural is also what is good—or at least what should be accepted because it cannot be changed. Thus naturalizing capitalism, gender, race, or ability tends to protect the status quo from critical scrutiny. On the other hand, calls to “naturalize ethics” aim to theorize moral understandings or epistemologies together with corresponding and co-producing practices in a critical, self-reflexive, and interdisciplinary accounting for the actual practices of moral categories like blame, responsibility, accountability, etc. The latter kind of naturalizing work in ethics clearly motivates and informs nonideal theory, where the former is precisely the problematic kind of naturalizing to which nonideal theory is largely a reaction.
- 20.
- 21.
See Marx (1990, 163–177, 716; 1993, 157); Lukács (1971); Habermas (1987, 332–73). For explication of alienation in Marx, see Blackledge (2012, 87–91). On reification and Lukács, see Feenberg (2014, 61–89). For an assessment of Habermas’s colonization thesis as a reification concept, see Jütten (2011).
- 22.
For an attempt to theorize alienating effects of social-relational structures as they relate to justice and moral responsibility, see Alison Jaggar (2009) and Iris Marion Young (2011). Another noteworthy work in nonideal theorizing in alienated modernity is Alexis Shotwell (2016). Shotwell notes the nonideal nature of contemporary developed-world existence: “there is no food we can eat, clothing we can buy, or energy we can use without deepening our ties to complex webs of suffering” (5). She asks in response, “what happens if we start from there?” (5). Shotwell’s nonideal aim is “to shape better practices of responsibility and memory for our placement in relation to the past, our implication in the present, and our potential creation of different futures” (8). Her theorizing against purity therefore is an instance of grappling critically and descriptively with actual alienation while deriving normative content.
- 23.
- 24.
To connect a social pathology in health care to structural modes of profit production is not to deny, for instance, their potentially gendered or racial components. It is instead an attempt to begin illustrating their interconnections, amplify motivation for action, and inform transformative strategies.
- 25.
On this distinction between the growth of costs and the rate of growth of costs, and its economic/policy significance, see Chernew and May (2011; especially 317).
- 26.
- 27.
Uwe Reinhardt (2009) echoes this idea.
- 28.
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Neitzke, A.B. (2021). Critical Theoretical Methodology for Nonideal Contributions to Bioethics. In: Victor, E., Guidry-Grimes, L.K. (eds) Applying Nonideal Theory to Bioethics. Philosophy and Medicine, vol 139. Springer, Cham. https://doi.org/10.1007/978-3-030-72503-7_4
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