List of Contributors
Lawrence C. Becker is Fellow of Hollins University and Professor of Philosophy Emeritus at the College of William & Mary. His philosophical monographs and articles include work on topics in contemporary ethical theory, stoicism, social, political, and legal philosophy, as well as the role of human agency in practical affairs.
Andrew M. Courtwright received his MD and PhD in philosophy from the University of North Carolina at Chapel Hill. He completed his internship, residency, and fellowship at Massachusetts General Hospital and Brigham and Women’s Hospital. He is currently a transplant pulmonologist at the Hospital of the University of Pennsylvania where he serves on the hospital ethics committee.
Adam Cureton , Associate Professor of Philosophy at the University of Tennessee, works primarily on ethics, Kant, and disability. He co-edited (with Kimberley Brownlee) Disability and Disadvantage (2009) and he is currently co-editing (with David Wasserman) the Oxford Handbook of Philosophy and Disability. He is President of the Society for Philosophy and Disability.
Richard Dean is Associate Professor of Philosophy at California State University Los Angeles. He has published and presented work on normative ethical theory, the history of moral philosophy, and several issues in applied ethics. These publications include The Value of Humanity in Kant’s Moral Theory (2006), “Respect for the Unworthy,” “Does Neuroscience Undermine Deontology,” “Humanity as an Idea, as an Ideal, and as an End in Itself,” and “Stigmatization and Denormalization as Public Health Policies.”
Samuel Freeman , Professor of Philosophy and of Law at the University of Pennsylvania, works in social and political philosophy, ethics, and philosophy of law. He has written books on Justice and the Social Contract (2006) and on John Rawls. He edited The Cambridge Companion to Rawls (2006), John Rawls’ Collected Papers (1999), and his Lectures on the History of Political Philosophy (2008). Freeman’s book, Liberalism and Distributive Justice, is forthcoming in 2018.
Richard Galvin is Betty S. Wright Professor in Applied Ethics in the Philosophy Department at Texas Christian University. His publications include articles in Mind, Philosophical Quarterly, Journal of Politics, Legal Theory, Kant-Studien, History of Philosophy Quarterly, and Journal of Social Philosophy. His areas of interest include moral theory (especially Kant), applied ethics, political philosophy, and philosophy of law.
Thomas E. Hill, Jr. , Professor Emeritus at the University of North Carolina at Chapel Hill, is author of essays in moral and political philosophy collected in Autonomy and Self-Respect (1991), Dignity and Practical Reason in Kant’s Moral Theory (1992),
Respect, Pluralism, and Justice (2000), Human Welfare and Moral Worth (2002), and Virtue Rules and Justice (2012). He co-edited (with Arnulf Zweig) Kant’s Groundwork for the Metaphysics of Morals (2002) and edited A Blackwell Guide to Kant’s Ethics (2009).
Sarah Holtman is Associate Professor of Philosophy at the University of Minnesota, Twin Cities. She holds a JD from the University of Virginia and a PhD from the University of North Carolina at Chapel Hill. A specialist in moral, political, and legal philosophy, her work lies at the borders of these and draws inspiration from Kant’s practical philosophy. Her published articles appear, inter alia, in Ethics, KantStudien, Kantian Review, American Philosophical Quarterly, Utilitas, and The Blackwell Guide to Kant’s Ethics (2009).
Oliver Sensen is Associate Professor and Director of Graduate Studies at Tulane University. He is the author of Human Dignity (2018), Kant on Human Dignity (2011), the editor of Kant on Moral Autonomy (2012), as well as the co-editor of three other volumes and the author of about 50 articles. As co-editor, he also has under contract a collection on “Respect.”
Karen Stohr is Associate Professor of Philosophy at Georgetown University, as well as Senior Research Scholar at Georgetown’s Kennedy Institute of Ethics. She works in normative ethical theory, especially Kantian ethics and Aristotelian virtue ethics. Her publications include numerous articles and a book, On Manners (2011). She is currently working on a second book, tentatively titled Minding the Gap: Moral Ideals and Moral Improvement.
David Sussman is Associate Professor of Philosophy at the University of Illinois, Urbana-Champaign. His principal research interests are ethics, moral psychology, and Kant.
J. David Velleman is Professor of Philosophy and Bioethics at New York University. His papers in bioethics have been collected in the volume Beyond Price: Essays on Birth and Death (2015).
Virginia L. Warren is Professor of Philosophy at Chapman University. Her research and teaching interests lie in ethical issues in medicine, the environment, and race, class, and gender. She has written on autonomy, the ‘medicine is war’ metaphor, and feminist medical ethics. Recently she has returned to the question addressed in her dissertation on Kierkegaard: how to choose between different ways of life and views of the self. She has learned much about living ethically from serving on the ethics committee of the Children’s Hospital of Orange County and, recently, from coaching teams for the Association for Practical and Professional Ethics’ Ethics Bowl competition.
Introduction
Adam Cureton and Thomas E. Hill, Jr.
Everyone is disabled in some respect, of course, at least in the sense that others can do things that we cannot, but significant limitations on pursuing major life activities due to severely limited eyesight, hearing, mobility, cognitive functioning, and so on pose special problems that fortunately have been recognized (to some extent) in our public policies. Public policy is important, as are also the deliberative frameworks that we use to justify it, and the original essays in the second and third sections of this volume have significant implications for public policy and offer new proposals for justifying frameworks. Underlying public policies and their assessment, however, are the attitudes, good and bad, that we bring to them, and our attitudes as well deeply affect our interpersonal relationships. Although some excellent work in the philosophy of disability has been done in this area of attitudes and relationships, more discussion is needed. The essays here, especially in the first section, reveal how complex and problematic our attitudes towards persons with disabilities are when we are in relationships with them as care-givers, friends, family members, or briefly encountered strangers. Our attitudes towards ourselves as persons with (or without) disabilities are implicated in these discussions, as personal relationships are always in some respects reciprocal.
Among the special highlights of this volume, in our view, are its focus on moral attitudes and relationships involving disabilities, its contributors’ recognition of the multi-faceted nature of disability problems, and their serious, critical, but non-polemical manner of examining complex moral questions. The importance of respect for persons as a necessary complement to generosity, beneficence, and charity is an underlying theme in many of the essays, and a deeper understanding of respect is made possible by considering closely its implications for relationships with persons with disabilities. Awareness of the common and uncommon human vulnerabilities makes clear the need for modifying traditional deliberative frameworks for assessing policies, and several essays make constructive proposals for the changes that are needed.
Our contributors are known for their excellent philosophical work in ethics and related areas. Almost all of them have personal experience with disabilities of their own, their relatives, or others close to them, but many of them are writing professionally on disability issues here for the first time. Many of the authors also take a broadly Kantian
perspective, interpreting and applying this broad framework in subtle and sometimes surprising ways. Samuel Freeman and Lawrence Becker, however, take up alternative frameworks, such as contractualism and eudaimonism, modifying and applying them as apparently needed to address adequately the special vulnerabilities and potential contributions of persons with disabilities. For Richard Galvin our philosophical perspectives are what need to be examined, and Virginia Warren too highlights a need to move beyond traditional perspectives to confront the challenges posed by severe cognitive and moral incapacities. Karen Stohr comes to disability issues from previous work in virtue ethics and about good and bad manners. Whatever their philosophical orientation, most of the authors focus directly on the practical choices that are affected by our attitudes towards disability, such as a disabled person’s decision to hide his disability from others, a bypasser’s decision to assist someone with a disability, a scientist’s search for “cures,” a physician’s decision not to intervene when a patient depressed by a recent disability wants to die, and a woman’s choice to end a pregnancy when a severe disability is anticipated.
We, the editors Cureton and Hill, developed our desire to reflect philosophically on disabilities in ways that are different but probably not unusual. As someone who has been (legally) blind since birth but determined not to let this physical limitation matter or even be noticed, Cureton has been especially alert to empowering technologies and aware of the sometimes offensive responses that well-meaning people have when they see others as disabled. Coming to analytical philosophy and the history of ethics from Oxford and the University of North Carolina, he could see the potential and need for philosophical exploration of our attitudes and policies regarding people with disabilities and the deliberative frameworks needed to justify them. Hill came to philosophy of disability after he had been teaching ethics for many years without special attention to disabilities issues, but this changed when he started working with Cureton, sharing time with a nephew who has Down syndrome, and developing his own age-related handicaps. Cureton started up the American Philosophical Association-recognized Society for Philosophy and Disability and together he and Hill have organized several workshops in this area.
We were deeply saddened to lose our friend, Claudia Card, who had shared her experiences and reflections about disabilities with us at our workshop on Emerald Isle, North Carolina, in May 2013. Claudia was working on her paper for this volume when she fell ill and she was unable to complete it.
We are grateful to all of the contributors for their deeply serious, thoughtful, and original discussions, and we hope their essays will inspire the further philosophical reflection that these topics deserve.
Here, in the paragraphs below, are brief summaries of the essays in this volume.
Part I Attitudes and Relationships
These four chapters discuss the attitudes, good and bad, that we can have towards people with disabilities, ourselves as well as others, as we engage with others in personal
relationships of various kinds, including friendship, care-giving, and more casual interactions even with strangers.
One way to explore various informal social attitudes towards disability and some of the ways that these attitudes inform and shape our relationships with disabled people is to take up the perspective of a disabled person and consider whether we might be tempted to hide or downplay our disability from others if we ourselves were disabled. In his chapter “Hiding a Disability and Passing as Non-Disabled,” Adam Cureton, who is legally blind, draws on his own experiences of passing as non-disabled to explain how a disabled person can hide his disability, why he might choose to do so, and what costs and risks he and others might face along the way. Some of the most significant potential benefits of hiding one’s own disability, Cureton argues, include greater social acceptance and inclusion in joint projects, an enhanced sense of belonging and of self-worth, and an easier time forming and maintaining personal relationships. Yet, Cureton explains, hiding one’s disability can also undermine some of these same social values when hiding one’s disability, for example, prevents someone from living up to normal social expectations or from sharing important aspects of himself with others. Hiding a disability, Cureton explains, can also interfere with a person’s self-respect, self-acceptance, integrity, and self-development. Although Cureton does not take a stand on whether hiding a disability is, overall, prudent, wise, or morally justified, he provides a subtle account of some of the informal social attitudes that disabled people face and draws out some lessons about attitudes towards and relationships with persons with disabilities from why someone might want to hide his own disability.
What attitudes should we have towards people with disabilities? We might initially think that a good and sufficient answer is sympathy, kindness, or eagerness to help. But in practice attempts to express these beneficent attitudes can be offensive, and this calls into question our understanding of these attitudes and what they require. Sarah Holtman, in her chapter “Beneficence and Disability,” identifies what is problematic in our common assumptions about when and how to express our caring attitudes and offers a subtle alternative that is sensitive to the moral complexities of these questions.
Her chapter draws on testimony by and about Helen Keller as well as on lesser known aspects of Kant’s moral framework to describe and justify morally appropriate attitudes to have when considering whether and how to help others. “Reciprocal beneficence,” as she calls this attitude, includes three elements. The first, which Holtman labels “fellowship,” is a mutual recognition that human beings, whether disabled or not, have common forms of vulnerability, need, and dependency that bind us together and call for assistance and understanding from one another. The second element of reciprocal beneficence, according to Holtman, is that this attitude of fellowship should be informed and shaped by sympathetic understanding, which involves actively sharing and understanding the particular feelings, goals, values, and needs of others in the contexts in which they arise as well as attempting to learn how we can help others and desiring to do so. Developing and exercising this attitude towards people with disabilities in particular, Holtman argues, requires a willingness to listen to and
learn from them as well as to use our imagination and personal experiences to understand and sympathize with them as best we can. The third element of reciprocal beneficence, according to Holtman, is gratitude to others who help us to develop the kinds of understanding and sympathy towards them that bind us together in respectful relationships of fellowship. These three features compose an attitude of beneficence because this attitude is appropriately engaged when others may need our help; and this attitude is reciprocal because it is toward everyone, it involves sympathizing with and understanding the interests of others as similar to our own interests, and it requires an openness and readiness to appreciate others for what they teach us about ourselves.
Our attitudes—good and bad—are reflected in what we notice; and to a remarkable extent what we notice and attend to about a person is guided and restricted by social conventions. Not noticing a person’s suffering can be wrong, but paying attention to what embarrasses a person can be unkind. As Karen Stohr’s chapter “Pretending Not to Notice: Respect, Attention, and Disability” makes clear, understanding and assessing the relevant conventions is not easy but nevertheless is important when considering what attitudes to take and how to behave with respect to people who have perceptible disabilities.
In her chapter, Stohr explores the nature and moral underpinnings of the complicated social conventions that should govern whether we notice others, what (if anything) we notice about them, how (if at all) we express what we notice, and how (if at all) others respond to us in turn. She begins with a subtle description of our actual social practices about what sorts of things in the world we pay attention to, become conscious of, and potentially think about when our noticing of them in these ways is reasonably apparent to others. She explores conventions about, for example, glancing, staring, making eye contact, prying, shunning, and pretending not to notice. Stohr also explains how these conventions are sensitive to, for example, the space that people share, their expectations of privacy, and their aims and goals. Social conventions of noticing, Stohr argues, help to establish and communicate boundaries among persons by determining, for example, what is a suitable topic of conversation; but they also determine when we should notice that someone is in duress and in need of our help.
These conventions of noticing, Stohr goes on to argue, are not simply rules of etiquette or efficient forms of coordination; they are also justified by moral considerations of respect and beneficence. Working in a broadly Kantian framework, Stohr argues that respect for others involves “keeping our distance” from them, which often gives us reasons not to seek out, pay attention to, or concern ourselves with the personal information of others as well as reasons to act as if we do not notice facts we are not entitled to know if we cannot help but notice them. Beneficence, on the other hand, “draws us closer” to others, which often gives us reasons to notice how others are feeling, how well off they are, and whether they could use our help. Social conventions of noticing, she concludes, are justified and shaped by our potentially conflicting concerns to show respect and love for other people, which helps to explain why those practices are often so complicated and difficult to navigate in particular cases.
Stohr then applies her general discussion of noticing to several issues of disability. Staring at someone’s visible disability, perhaps because we find it surprising or shocking, is incompatible with Kantian respect, in part because our stare includes an implicit demand on the person to, for example, explain her condition and how she came to have it. Yet in other cases, our genuine concern for a disabled person may lead us to notice her disability so that we can help her, justifiably adjust our expectations of her, or express our recognition of her as the person she is. In light of the potentially conflicting reasons of respect and beneficence, moral judgment and sensitivity, Stohr argues, are needed to determine whether we should notice or show that we notice that someone has a perceptible disability.
What attitudes should we have in our interactions with people who have severe cognitive disabilities? Ordinary moral thinking, according to Oliver Sensen, suggests that people with severe cognitive disabilities deserve respect, yet it is difficult to explain why they merit respect and what forms of respect we should have towards them. In his chapter “Respect for Human Beings with Intellectual Disabilities,” Sensen criticizes what he calls ‘third-personal’ conceptions of respect, which hold that some features of a thing, such as its rational capacities or sentience, make it worthy of respect. Such views, according to Sensen, do not adequately capture our commonsense judgments about the many possible objects of respect, which include not just persons, human beings, and sentient creatures, but also deceased people, the environment, flags, traditions, and ideas. Sensen’s alternative, ‘first-personal’ account holds that our reasons to have and show respect are justified independently of any characteristics that the appropriate objects of respect might have. He suggests that having respect for something may instead be justified on the basis of one’s own flourishing, by the ways in which respect tends to promote other moral values, or because respect for various things is a constitutive feature of rational agency. A ‘first-personal’ view of this sort, Sensen claims, stands a better chance of providing a unified explanation for why different kinds of things deserve our respect.
Sensen then explains why his ‘first-person’ account of respect implies that people with severe cognitive disabilities deserve respect, not because of any features of them but because respect for them is a morally appropriate attitude for us to have. Respect, according to Sensen, is best understood as an attitude of accepting that something places limits on us, of leaving something as it is, and treating it as if it is very important. According to Sensen, we respect people with severe cognitive disabilities by, for example, not condescending to them, regarding ourselves and others as equally important parts of a larger society, treating one’s own happiness as no more important than theirs, not mocking, ridiculing, or harming them, and avoiding cruelty towards them.
Part II Attitudes and Policies
The next four chapters focus especially on the implications of moral attitudes, such as respect and love, for social policies, for example, regarding reproductive decisions, research to find “cures” for disabilities, and physicians’ assessments of the
decision-making capacities of newly disabled patients to accept or reject lifesustaining support.
The fact that an embryo or fetus is likely to result in a child with a disability is widely regarded as a strong reason to select a different embryo, abort the fetus, or otherwise prevent the child from coming to exist. Some disability advocates and anti-abortion activists counter that, even if embryos and fetuses are not persons, allowing parents to prevent the birth of a disabled child as such demeans existing disabled people by implying that they are not valuable, that they should not have been born, or that their lives are not worth living. In “Not Alive Yet,” J. David Velleman denies these supposed implications and argues instead that the intrinsic value of personhood provides reasons not to bring people with certain kinds of disabilities into existence as well as reasons to love and respect existing people who live with those conditions.
Velleman begins with the Kantian assumption that persons are “self-standing” ends who, as such, warrant respect as a fitting response to their basic moral value. According to Velleman, respect for persons, which can be directed at people we are familiar with as well as those who are known to us only under certain descriptions, is only a negative constraint on how we may treat them. Because respect for personhood does not require positive actions, Velleman argues, it cannot provide reasons to bring persons into existence.
Respect can provide reasons, however, to refrain from creating persons if doing so is incompatible with the value of personhood. In particular, Velleman claims that respect for personhood requires us not to create children who would lack the capacity for independent and autonomous activity.
Love, Velleman claims, is another fitting response to the intrinsic value of persons. Unlike respect, however, the object of love must be singular, which means we can only love someone we know “in person” rather than as someone who is picked out by some description. Because our potential or future children do not exist, we cannot be acquainted with them in the way that love for them requires. At most, we can know them only under some description, such as “my future child.” Velleman concludes that we cannot love our potential or future children or bring them into existence out of love for them. Only once a disabled child is born, Velleman claims, is she an appropriate object of love. Velleman concludes that prospective parents should sometimes abort or select against embryos or fetuses because the resulting children would be severely disabled even though they should also love and respect existing people who have those conditions.
Velleman goes on to consider whether allowing prospective parents to make such reproductive choices implies that the lives of existing disabled people are not worth living or that they should not have existed. He notes that there are many cases in which it is appropriate for parents to make reproductive choices for the sake of the well-being of their potential children, such as delaying pregnancy until the prospective parents have sufficient income or have traveled the globe, without implying that the lives of
people who are born in the circumstances the parents aimed to avoid are any less worthwhile or that their lives are regrettable.
In “Respect, Regret, and Reproductive Choice,” David Sussman attempts to explain and resolve an apparent inconsistency in the forward-looking and backward-looking attitudes we might have about knowingly and deliberately creating a disabled child. When we are considering what sort of child (if any) to produce, we might come to the all-things-considered judgment that we should not create a disabled child. But, later, when we are the parents of a disabled child that we nonetheless decided to create, we might overall affirm, and not regret, our decision to have him. These two attitudes, according to David Sussman, seem to be in tension with one another: If prospective parents believe they should not create a disabled child, then, were they to intentionally produce one anyway, they would apparently be rationally required to regret their decision after the child is born; and, conversely, if actual parents of a disabled child do not regret having him, then, apparently, their prior judgment that they should not do so was irrational. Drawing on and supplementing prominent discussions by Jeff McMahan, R. Jay Wallace, and J. David Velleman, Sussman offers a novel explanation for why, in many cases, it makes sense for parents of disabled children to affirm their own prior reproductive decisions that, at the time, they themselves thought were unjustified.
According to Sussman, when we love someone, we accept that he has his own values, ends, and concerns; we give him a special standing to make claims on us on behalf of his interests; and we recognize corresponding reasons to take his claims seriously, to answer them, and sometimes to fulfill them. In Sussman’s view, our love for others thus tends to shape our overall conception of ourselves and of what we regard as valuable and meaningful in life by the ways we tend to respond to the perspectives, interests, and claims of those we love. Once we have incorporated the claims and demands of our disabled child, for example, into our sense of self then Sussman thinks that our love for him becomes part of the fixed background from which we can evaluate ourselves and the world. In particular, our love for our existing child precludes any rational assessment about the importance of him or his life because our current perspective takes his value to us as given. Therefore, Sussman argues, the love that parents have for their disabled child prevents them from genuinely forming the belief that they should not have created her, which implies that it is impossible for them to have overall regret for that decision. The parents could have been correct that producing a disabled child would be a mistake for them; but from their current standpoint, they necessarily affirm their decision to have the child because he is now part of who they are.
In “Neurodiversity and the Rejection of Cures,” Richard Dean examines and partially evaluates growing debates about whether we should attempt to ‘cure’ autism. The debate, Dean argues, comes down to whether conditions on the autism spectrum are merely different, and not defective, forms of neurological organization or whether some or all of those conditions are, at least in part, medical deficiencies. If autism is
merely a difference then, in light of historical injustices and continued oppression of autistic people, seeking a cure for those conditions in our society sends a false and disrespectful message that there is something wrong or defective about people who identify as autistic when in fact what is wrong is how they tend to be treated by society. But, Dean argues, if autism is to some extent an inherent medical problem or defect then attempting to correct it would not necessarily send a disrespectful message of rejection to those who are autistic.
Dean proposes an innovative way to assess whether autism is a defect or a mere difference, which is to imagine a fully rational and reasonable person with autism who is living in an idealized society in which autistic people are the dominant group who make up the vast majority of the population. We then try to assess what attitudes an autistic person of this sort would have about attempts at curing conditions on the autism spectrum in a society that is, according to Dean, fully just in its treatment of autistic people. If such a person would oppose searching for a cure for autism as a waste of time and resources then, according to Dean, this would support the claim that autism is not a defect of persons. If, however, she would favor trying to cure certain forms of autism despite the fact that her society treats autistic people justly then this would be evidence that those conditions are, at least in part, defects rather than mere differences. Once we have a better grasp of whether various conditions on the autism spectrum are defects or mere differences, then, Dean argues, we can better determine whether seeking a cure for autism in our world is more akin to trying to cure someone of an addiction or trying to ‘cure’ someone of being gay.
In “ ‘I Would Rather Die than Live Like This’: When the Newly Disabled Refuse Life-Sustaining Treatment,” Andrew M. Courtwright describes and evaluates how current medical practice assesses the decision-making capacities of newly disabled people to accept or reject life-sustaining treatment. Drawing on his own experiences as a practicing physician, Courtwright explains how medical professionals tend to operationalize and apply the idea of respecting the autonomous decisions of their patients. Whether such an assessment is performed in the first place, Courtwright explains, depends on the seriousness of the choice that the patient faces and whether her decision-making capacities have already been assessed in the past. When medical professionals do perform such assessments, they attempt to determine, first, whether a patient’s empirical beliefs about, for example, her medical condition and the risks involved in accepting or refusing the life-sustaining intervention are reasonable, whether the patient can reasonably explain these beliefs and her reasons for affirming them, whether these beliefs are reasonably consistent with the patient’s other beliefs and convictions, and whether these beliefs are reasonably responsive to evidence. Second, medical professionals try to figure out whether the patient’s desires, such as whether she wants the treatment or not and what (if any) goals she aims to achieve in accepting or rejecting the treatment, are reasonably consistent with one another and other things she cares about, whether these desires are best explained by a diagnosable
psychiatric disorder, and whether her desires are reasonably firm. Finally, medical professionals assess whether the resulting decision that the patient makes is stable across several contexts and interactions. In each of these three dimensions, the idea of reasonableness is left vague, which, Courtwright notes, raises problems about different physicians evaluating the decision-making of their patients differently.
This model for assessing whether a patient’s decision to refuse life-sustaining treatment is autonomous, according to Courtwright, should be supplemented by a more expansive view of autonomy as a property of the person making decisions rather than just a property of particular decisions. Respecting the autonomy of a person faced with a choice between accepting or rejecting life-sustaining treatment, according to Courtwright, requires us to regard her as an agent who has capacities to, for example, think for herself, endorse her own set of values, and deliberate on the basis of reasons. Courtwright notes several implications that this broader idea of respect for the autonomy of persons has. First, physicians must engage their patients with reason and argument and be sensitive to the effects of informal social pressures; they should work with their patients over time to evaluate relevant risks and outcomes; and physicians should sometimes offer alternative, perhaps less effective, therapies that are more amenable to the patient. Second, physicians should attempt to alleviate any conditions that are impairing a person’s decision-making capacities; when necessary, they should try to convince patients to change their self-destructive behaviors through rational processes rather than through coercion or force; and physicians should stand ready to revise their assessments of a patient’s decision-making capacities. And third, in extreme cases, physicians should seek surrogate decision-makers for the patient who should in turn try to balance what the patient would want and what is in her best interests.
Part III Justifying Frameworks
The chapters in our last section step back from questions about particular relationships and policies to consider what deliberative frameworks are appropriate for justifying and assessing them. The authors show how basic moral attitudes can be relevant not only in practice but in how we reflect and debate about the justice of our practices and the scope of our moral consideration.
Lawrence Becker’s chapter “Disability, Basic Justice, and Habilitation into Basic Good Health” draws on and extends ideas he developed in his recent book Habilitation, Health, and Agency: A Framework for Basic Justice. Becker proposes a novel conception of the circumstances in which questions of basic justice arise and argues that, on his account, health and disability are central concerns of justice. Rather than conceiving of the circumstances of justice as conditions of conflict among persons, Becker suggests that issues of justice arise when and because all people have necessary interests in acquiring and maintaining certain capacities or functional abilities that they cannot develop or maintain without help or non-interference from others. Normative conceptions of
justice are then needed to explain how these interests in ‘habilitation’ should be secured, whether through interpersonal assistance, cooperative social arrangements, or some other mechanism. This account of the problem of basic justice, Becker goes on to argue, shows that health is a basic concern of justice because the lifelong process of acquiring the capacities and abilities we need to survive and live minimally decent lives requires what Becker calls basic good health. Becker’s conception of basic good health has several interesting features. He defines it in functional terms as reliable and competent physical and psychological functioning in some range of environments; he emphasizes that good health involves not just absence of pathology but also physical and psychological energy and resilience; he suggests a way of operationalizing his definition of good health for practical contexts; and he notes some consequences of his conception for healthcare policy.
The main focus of Becker’s account of the circumstances of justice, which is on coping with the fact that no one can survive and prosper if they or others do not acquire certain abilities and capacities, provides an organizing theme for addressing issues of disability. When our aim is to ensure that people have the abilities they need, our attention is drawn to factors such as basic good health, the structure of the physical and social environment, rehabilitation, and other ways of creating and sustaining abilities in all persons, whether they are disabled or not.
Contractarian conceptions of justice are widely criticized for their apparent inability to justify the claims and rights that people with severe and lifelong cognitive disabilities have against society. Martha Nussbaum, Eva Kittay, Marilyn Friedman, and many others have argued that people who lack any capacity for reasoning, who require extensive protection and care to function, and who are incapable of making social or economic contributions are, for these reasons, not owed duties of justice on contractarian views because these conceptions ground principles of justice in hypothetical agreements among normal and fully cooperating members of society.
Several features of Rawls’ contractarian view, or of his presentation of it, have invited this charge, including Rawls’ use of contract metaphors, his idea of justifiability, his conception of the person as free and equal, his understanding of cooperation as mutually advantageous, his assumption that the contracting parties are normal and fully cooperating members of society, and his postponement of certain questions of justice for severely disabled people.
In “Contractarian Justice and Severe Cognitive Disabilities,” Samuel Freeman defends Rawls’ contractarian framework from the charge that it fails to respect the dignity and equal moral status of severely disabled people. Drawing on and supplementing his previous work, Freeman puts the offending ideas in context, explains how they are often misunderstood, points out the limited role they play in Rawls’ theory, and emphasizes aspects of Rawls’ view that others may have missed. Freeman argues that the main criticisms of moral contractarian views, and of Rawls’ view in particular, are not impediments to justifying the claims and rights of severely disabled people.
In addition to offering various objections to competing conceptions of justice, including Nussbaum’s capabilities approach, Freeman makes some suggestions for how a comprehensive moral contractarian framework can be developed in ways that fully incorporate the interests of severely disabled people. Such views, he claims, should assume as a starting point that all human persons, as such, have dignity, are owed respect as moral equals, and have basic rights and claims against society. Moral contractarian theories should make use of multiple conceptions of the person, including conceptions of severely disabled people that capture and explain their fundamental needs and interests, and incorporate these ideas into different contracting procedures that are appropriate for addressing various moral issues. The basic interests that people with severe disabilities have in being protected and in having their basic needs met, according to Freeman, ground certain basic rights and forbid ignoring or trading them off for the sake of aggregate welfare. Beyond this, moral contractarian frameworks should distinguish between questions of equal justice, which concern equal rights among normal and fully cooperating members of society, and other questions of justice that concern how these rights can be justifiably limited for people with severe cognitive disabilities in order to protect them from harm. Moral contractarian views, Freeman suggests, should also incorporate notions of reciprocity and respect into their ideas of social cooperation and account for moral duties and obligations beyond those of justice. And they should postpone the choice of certain principles, such as those about the special needs of people with severe disabilities, when these issues presuppose prior principles of social organization and depend on particular facts about a society, without assuming that these principles are any less fundamental or important than ones already selected.
According to Richard Galvin in his chapter “Obligations to the Cognitively Impaired in Non-Structured Contexts,” moral philosophers who have seriously reflected on issues of cognitive disability tend to proceed in a ‘top-down’ fashion, by adopting, interpreting, and supplementing traditional moral frameworks and applying them to a narrow set of public-policy and justice-related issues for the cognitively disabled. Galvin contends that these sorts of approaches to thinking about how to regard and treat cognitively disabled people are unpromising because of difficulties they have in explaining why people with moderate or severe cognitive disabilities count as moral persons and in explaining how, in particular, we should regard and treat them in more informal and interpersonal contexts. Galvin proposes an alternative, ‘bottom-up’ way of approaching moral issues of cognitive disability that begins with commonsense moral judgments about how to regard and treat cognitively disabled people in everyday life. Generalizing from these judgments, Galvin argues that participation in cooperative activities, agency and self-respect are mutually supporting moral goods that many cognitively impaired people can achieve to some extent. Non-disabled people have duties to promote these goods for cognitively impaired people who are capable of them, Galvin argues, which not only implies that those people have moral
standing but also provides specific guidance about how to treat them in informal, daily interactions.
Disabilities are usually thought to be impairments that substantially limit one or more ‘major life activities,’ such as caring for oneself, eating, or walking. In her chapter “Moral Disability, Moral Injury, and the Flight from Vulnerability,” Virginia Warren aims to extend our understanding of disability by adding a new ‘major life activity’ to the standard definition of disability, namely the activity of living a full moral life. A “moral disability,” according to Warren, is thus an impairment that significantly limits a person’s ability to live as a full moral person.
What does it mean to live a full moral life? Part of this activity, according to Warren, is engaging in moral reflection and moral decision-making, having the motivation to act morally, and executing one’s moral decisions. These moral abilities in turn depend on other abilities, such as those of attention, self-awareness, empathy, and long-term planning. Certain cognitive or psychological impairments are moral disabilities because they tend to prevent or significantly interfere with these prerequisites that are essential for moral agency. Other kinds of moral disabilities, Warren argues, may be willful, as in certain forms of self-deception or distraction. One form of disabling self-deception that Warren discusses is to distract oneself from the basic and unchanging fact that we are vulnerable creatures by either denying our vulnerability to, for example, illness, domination, or dependence on others or by aspiring to an ideal of invulnerability.
Another part of living a moral life, according to Warren, is having integrity, which can be undermined by, for example, choosing to violate one deeply held moral value for the sake of another. These ‘moral injuries’ that, for example, soldiers suffer in war as a result of the difficult decisions they face, are also moral disabilities because they tend to shatter a person’s sense of herself as a moral person.
Warren goes on to note several implications that her idea of moral disability has for ethical thinking about a variety of apparently unrelated moral issues, such as ones concerning gun control, climate change, and war.
