Abstract
This paper has two goals. The first is to argue that the field of bioethics in general and the literature on ideal vs. nonideal theory in particular have underemphasized a primary problem for normative theorizing: the role of conditioning principles. I define these as principles that implicitly or explicitly ground, limit, or otherwise determine the construction and role of other principles and, as a result, profoundly impact concept formation, perception, judgment, and action. The second is to demonstrate that ableism is one such conditioning principle and that it undermines the field of bioethics and the practice of biomedicine from achieving the aim of justice as fairness. After briefly addressing the history of principlism in bioethics and its critiques, I lay out my account of conditioning principles. I argue that ableism is one such principle and demonstrate it at work through an analysis of a storied debate between Eva Kittay, Peter Singer, and Jeff McMahan. In conclusion, I contend that the ethical and philosophical dangers of conditioning principles are exacerbated by ideal theory frameworks, and they are especially liable to generate epistemic injustice, especially contributory and hermeneutical injustice.
What it is to be human is not a bundle of capacities. It’s a way that you are, a way you are in the world, a way you are with another.
Eva Kittay (2009, 622).
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Notes
- 1.
Put less diplomatically, bioethics arose to counterbalance the many egregiously unethical and unjust practices and actions carried out under the banner of “medicine” and “scientific progress” across the globe (Washington 2008).
- 2.
Of course, Beauchamp and Childress were drawing and expanding upon the three principles of respect for persons, beneficence, and justice as first laid out in the Belmont report.
- 3.
To be clear, I am sketching a picture that focuses on dominant themes in the literature. The full story is, of course, far more complex and involves the multiple, sometimes conflicting timelines and histories of “bioethics” as the field increasingly expands—and, there is an argument to be made, significantly fractures—from the early 90s onward.
- 4.
As Alica Oulette writes, “despite its many faces, bioethics has as its core a central concern with respect for persons through respect for individual autonomy and good medical care.” (Ouellette 2011, 30). My thanks to Joe Stramondo’s article, “Disabling bioethics: The case for a disability moral psychology and epistemology” for bringing my attention to this quote (Stramondo 2014; cf. Stramondo 2016).
- 5.
To be clear, this critique is less apropos for the field of public health, which often takes the principle of justice and the necessity and nature of caring systems more seriously. Though whether and how it does so in theory as opposed to in practice is a more complicated question. Leslie P. Francis notes that “justice has tended to come last” in the “teaching and practice not only of bioethics but of other fields in applied ethics.” Among other reasons, this is because “justice isn’t a single principle, but a topic area in social, political, and moral philosophy. There is deep disagreement about which principle(s) of justice to adopt, and why” (Francis 2017, 1). The critique of the historical focus of bioethical inquiry on the individual turns on both the scope and application of normative arguments in this domain. Put bluntly, a large swath of bioethical inquiry especially that which occurs inside or in close relation to the field of philosophy, eschews questions of justice in order to focus on narrower concerns. Paradigmatic questions include, for example, “what is an MD in specialist field X to do in situation Y under constraints W and Z given normative theories A, B, or C?”
- 6.
In Peña-Guzmán and Reynolds (2019), we argue that ableism is an epistemic schema. I here argue that ableism is a principle that generates epistemic schemas. We did not discuss the role of the principles in that piece due to the audience and other concerns at hand. I ultimately take these arguments to be compatible insofar as ableism functions as an epistemic schema precisely through its role as a principle.
- 7.
I am not making the argument that epistemic schemas necessarily arise due to a previous (logically or experientially) role as a principle. The larger relationship, causal or otherwise, between principles and epistemic schemas is beside the point here.
- 8.
By construing principles in this manner and by further arguing that ableism is a principle, I am neither defending a generalist, nor a particularist position, nor a position somewhere in between. That is to say, I am neither making an argument concerning the defensibility of moral principles (or other sorts of principles) in general, nor making an argument about their proper role for moral thought or an ethical life. Cf. (Potrc et al. 2010).
- 9.
This is obviously a case of what Elizabeth Barnes’ terms a “bad-difference” view of disability (2016). Note that while I am arguing that ableism understood as a conditioning principle involves a bad-difference view of disability, it does not specify which abilities would be considered central to flourishing and which would not.
- 10.
It is important to note that the concept of ableism borrows part of its force from other pernicious-isms (racism, sexism, cis-sexism, ageism, classism, etc.), but similarly to those terms, ableism is not merely or even primarily a question of individual beliefs or judgments It is instead a complex phenomenon with psychological, material, historical, and many other facets. I take my discussion of ableism as a conditioning principles to build upon such analyses.
- 11.
I am aware of the critiques of Laurie Paul from Agnes Callard, but I ultimately side with Paul.
- 12.
I have learned much from discussions with Lauren Guilmette on the exchange as well as her incisive and insightful analysis of this debate (Guilmette 2016).
- 13.
It is important, I think, to realize that the idea that moral worth arises from capacities assumes that the complexity of certain organisms affords certain capacities that will make life go better. On its face, that idea flies in the face of contemporary evolutionary theory. “If the differential numerical representation of different types in a species occurs not by chance events of life and death, but because the properties of some organisms confer on them greater ability to survive and reproduce in the environment in which they find themselves, might there not be some properties that would confer a general advantage over most or all environments? Such properties, then, ought to increase across the broad sweep of organisms and over the long duration of evolutionary history, putting aside any particularities of history. So, for example, it has been claimed that complexity has increased during organic evolution, since complex organisms are supposed somehow to be able to survive better the vagaries of an uncertain world. Unfortunately no agreement can be reached on how to measure complexity independent of the explanatory work it is supposed to do. It is, in fact, characteristic of directionality theories that organisms are first arrayed along an axis from lower to higher and then a search is instituted for some property that can be argued to show a similar ordering” (Fracchia and Lewontin 1999, 62).
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I am very grateful to the detailed and insightful feedback of the editors, David Peña-Guzmán, and Eva Feder Kittay.
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Reynolds, J.M. (2021). Conditioning Principles: On Bioethics and the Problem of Ableism . 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_5
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