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In a hypothetical situation that could possibly have real-life implications, how

In a hypothetical situation that could possibly have real-life implications, how should one decide between helping a small group of extremely sick individuals with only a small possibility of benefits (e.g., caring for AIDS patients without knowledge of whether or not your treatment will allow them to live) or helping many who have a greater chance of surviving (e.g., spending more time with individuals with proven treatable illnesses)? With either choice, it seems that there is a serious quandary. Should one elect to help the many, neglecting to care for those who are most likely to perish anyways? If so, is this justifiable by helping cure more while leaving those few sick individuals to fend for themselves?

According to the utilitarian approach, you should do the most good (or, what is likeliest to lead to the most good). And if you really are a utilitarian, you should look at all options, not just the two you mentioned (include options such as sending all your money to UNICEF, or becoming a Mother Teresa).

Non-utilitarians approach such questions differently. They are more likely to consider what you WANT to do in the discussion about how to lead a moral life.

An 11-year-old child lies on the operating table, dying from an accident. He

An 11-year-old child lies on the operating table, dying from an accident. He asks his doctor if he is going to die. The doctor says "no", knowing the child will be dead in minutes. I say the doctor (it is not me) did nothing wrong. What good does it do for a child to be told he will be dead in a few minutes. This beloved family doctor has been conflicted over this 40-year-old problem and teared up when telling someone (me) for the first time.

The salient feature of this question is that the dying person is an 11-year old child, rather than an adult. Our sympathy is aroused and we wish to protect the child from pain, especially the pain of knowing that s/he is about to die. I think it is important to first ask the question: if the dying person was an adult, would it be appropriate to lie about the prognosis? And I think the answer is "No. The adult has a right to be told the truth about their prognosis if they ask." So, if an adult has that right, why not a child? Some would say that a child "can't handle the information." But I think that depends on the child, and many 11-year olds might be able to handle the information as well as adults, and might use it to e.g. make final statements or requests. The work of anthropologist Myra Bluebond-Langner on dying children shows that children often handle the topic of their own death as maturely (or more maturely) as adults do. The beloved family doctor could probably have made a better decision.

Is it ethical to "cure" a mentally disabled/disturbed person if they might

Is it ethical to "cure" a mentally disabled/disturbed person if they might actually be unhappier when they are "healthy" than they were before when they were living in their own "world"?

The first problem is in knowing whether being "cured" would make them unhappier or otherwise, and how one would find out. Then there is the issue of autonomy, which we value even if it makes someone miserable, or more miserable than they might be otherwise. After the "cure", presumably the individual has greater ability to take their own decisions etc. and this can lead to problems of one sort or another. It is the old question of whether it would be better to be a contented pig or an unhappy Socrates, although it seems to me that Socrates often appeared to be rather cheerful, and pigs do occasionally look rather mournful, especially when something tasty is out of reach.

Your question does raise the issue of how important happiness should be to us, as opposed to other valuable human aims such as freedom of choice, knowledge, a variety of experence and so on. What sorts of life are worth living, and more worth living than alternatives? These are the issues that are relevant here.

The following dilemma has arisen in my work as a health professional. I suppose

The following dilemma has arisen in my work as a health professional. I suppose it is more of an ethical conundrum than anything else. Imagine the following scenario: Someone is seeking help because they believe they may be at high risk of developing condition X. Our assessment suggests that they are in fact at high risk of developing condition X. Part of the reason they are high risk is BECAUSE they are worried they may develop condition X. As you can imagine informing the person of the results of their assessment can actually lead to that high risk person developing condition X. Health professionals have a clear duty to respect autonomy (including telling people the truth), balanced with a duty not to cause harm, and a duty to do good. Bearing this in mind, what should we tell the clients about the results of their assessment? NOTE: They would still be at high risk of developing condition X if we didn't assess or treat them. What we appear to do currently is assess them, but when communicating...

This is an interesting problem, very crisply stated. Variants of it occur in other life contexts as well. Thus truthful reporting of information can be counterproductive, for example, in the work of Human Rights Watch or Amnesty International in situations where such information may undermine the reputation of a political party or faction that, all things considered, is better than its rivals. This case is different from yours in that the responsibility for being truthful is primarily to third parties: to those who rely on the NGO to report the whole truth and nothing but the truth about the various governments, parties, or factions and their conduct.

In your case, where the responsibility is basically to the patient, the practice you and your colleagues have developed seems entirely right to me. Maybe your slight doubts about this practice can be mitigated by a brief further thought about autonomy. Contrary to what you suggest, I do not think that respecting autonomy requires being entirely candid. Rather, respecting autonomy requires deferring to the patient's judgments about how she ought to be treated and what she should be told. If she wants health professionals to be entirely candid with her -- and many patients do want this and will tell you so -- then respecting autonomy means being entirely candid. But in the absence of such an insistence on hearing the whole truth, you can make your own judgment about what the patient would want. (Directly asking her how much honesty she wants is tricky because it deprives her of what may be for her the best option: being uncertain about how honest you are with her while trusting that you will make decisions about what to tell her in a way that you judge is best for her.) And you may well conclude -- correctly -- that the patient is scared and would rather be firmly reassured than hear the full litany of risks and disclaimers.

When a patient really presses you for the truth, then you can -- in addition to the obfuscations you mention in your last two sentences -- also say truthfully that the condition does have an important psychological component and is most likely (ambiguity intended) to remain latent if one worries about it as little as possible.

Some friends and I have been debating the question of state mandated vaccination

Some friends and I have been debating the question of state mandated vaccination. There are actually several different pieces to this. First, forcing someone to undergo a medical procedure seems to be a major violation of their individual rights. Or is it? Second, there are always risks with any medical procedure, including vaccination. Does the value to the group of controlling infectious disease trump the right of the individual to free choice of risk? Some people might prefer the risk of disease. Third, what about parental responsibility? How far does the state have the right to force medical procedures on minors, against the parent's objections? Thanks for your help!

Vaccinations protect the vaccinated person. But they also protect others (who would come into contact with the vaccinated person if she were to be infected) and the population at large (as the disease has less of a chance to spread if there a fewer usable carriers).

Given this situation, a classic collective action problem can arise. The cost and risk of getting vaccinated are mine alone, while much of the benefit is dispersed. So it is quite possible that it is better for each not to get vaccinated (regardless of what others do) even while it is also better for all that all get vaccinated than that none do. (In numbers: Suppose the cost and risk of getting vaccinated is 6 and the benefit to oneself is 3 and the benefit of another person getting vaccinated in a 101-person community is 0.05. Then, if all get vaccinated, everyone gains: 3 + 100*0.05 - 6 = +2. But each can reason this way: The first term is +3, the second is whatever it is independently of what I do, and the third term is -6. So I will lose 3 if I get vaccinated, whatever others do.) The sad outcome is that no one will choose to get the vaccination.

What can be done to overcome the problem? We can reciprocally agree to get the vaccination. But if this reciprocal agreement is voluntary (a "coalition of the willing"), then any individual has reason not to join for the reason canvassed above. So the only way to overcome the collective action problem is by agreeing, through a democratic decision, to enforce the vaccination on all . In that democratic vote, the two possible outcomes are yes (all are forced to get vaccinated and everyone is better off) or no (no one is forced and none or very few get vaccinated).

The best justification for allowing such votes with consequent coercion here is, in my view, that they offer the only way of overcoming the collective action problem. Letting people's individual rights be decisive here would frustrate the point of these rights: our protecting our interests. We fail to do this when we get stuck in a collective action problem.

About your second point. Yes, there are risks. Some may die as a consequence of getting vaccinated (albeit fewer than would have died without the vaccination program). How do we justify the program to them? We can say that the vacination was beneficial to them ex ante, that everyone's risk of premature death was diminished by the vaccination program (relative to its non-existence).

But there is a problem. Some may be known to be especially likely to die from being vaccinated. (For them the cost and risk may be 9 in the above numerical example, say, so they would be better off without the vaccination program.) I think these people should have the option to exempt themselves. Fortunately, they are generally only a few, and their non-vaccination therefore has little impact on the benefit the others achieve.

Your third question poses no special difficulty. If it's OK democratically to overrule the expressed preference of an adult with regard to her own body in this case, then it should be alright to override her preference with regard to her child's body in the same case. We can say to her that it is better for all children, including hers, that they all are compelled to get vaccinated than that their parents have discretion (and thus predictably veto the vaccination of their children). It's in the best interest of the children that we do not allow any parent to do what's in the interest of her own child.

Do you think that volunteer organ donors should get preferential treatment over

Do you think that volunteer organ donors should get preferential treatment over non-organ donors in regards to receiving organs?

I'm not sure if this is a question of principle or policy. Let's start with the question of principle. Certainly, volunteer organ donors deserve moral kudos, but should they get to move ahead of others in line to receive organ transplants? That really depends on what the principles should be guiding the distribution of this scarce resourse. Should it be responding to the most urgent medical need? Maximizing life expectancy? Maximizing contribution to social happiness? Something else? If, say, it was giving priority to most urgent medical needs, then I don't see why preference should be given to volunteer donors. Perhaps the thought is that the benefits of a practice should go disproportionately to those who contribute to the practice, for, according to this principle, volunteer donors contribute more to the practice of organ doantion and transplant and so deserve priority. Perhaps being a volunteer donor could serve as a tie-breaker among transplant candidates who were otherwise equally well qualified (along whatever other dimesnions are relevant). But I find it hard to believe that the practice of orgna donation and practice should distribute benefits according primarily to contributions. It seems more like a charitable scheme meant to respond to need than an insurance scheme. A different consideration is that of creating an incentive to potential donors to agree to volunteer their organs after death. But there are many ways to incentivize conduct. Rarely, do we need the incentive to be the same kind of good as the very good we are trying to promote. But these claims about principle are complicated and contestable and don't yet address directly matters of policy design.

Do you think cosmetic surgery performed by a surgeon is a form of art?

Do you think cosmetic surgery performed by a surgeon is a form of art?

Yes and no, though perhaps most importantly no. Saying that something is an art is sometimes a way of saying that it's an exercise of skill, not least of a skill that isn't simply a matter of following a set of instructions. In that sense, cosmetic surgery is an art. Cosmetic surgery also has an obvious aesthetic dimension and no doubt calls on many of the same skills that a good sculptor needs. So all of that is on the "yes" side.

But there's another obvious sense in which cosmetic surgery isn't an art, or better, perhaps, an Art. Painting, sculpture, poetry, etc. are Arts in this sense not just by virtue of being skills whose practitioners may have aesthetic goals. They also fit into a familiar set of cultural practices and institutions (museums, galleries, performances, reviews, critical studies, sales, auctions...) that determine what we count as "Art" with a capital "A." Cosmetic surgery isn't an "Art" in that sense, and this is almost certainly a very good thing.

Is the rise in the western world of 'mental illness' such as 'depression' a

Is the rise in the western world of 'mental illness' such as 'depression' a reflection of language usage or some more substantive reason(s)?

As Sally Haslanger writes, proper answers to your question do need to feed on some empirical, in this case historical data. But I suggest that these data can only yield answers through some philosophical unpacking.

The category of mental illness is itself a cultural product, insofar as it depends on the notion that 1) our minds can be ill just as our bodies can; 2) and so that they are instantiated, most probably, by the brain. Note, however, that to restate the concept of mental illness in such terms is not to say that it is merely a cultural product, that truths are relative to cultures, that if some people believe our mind is instantiated by our feet then so be it. I say this because the kernel of your question seems to address the matter of whether it is useful to imagine a clear-cut distinction between language use - that is, broadly, culture - and a "substantive" reality.

To this I would answer No: what is described by the expression "mental illness" must correspond to a reality which must always have existed. To note the historical genesis of a concept is not to deny the existence of a reality designated by that very concept, by those cultural terms. Historians can go beyond older uses of language to tell us how that reality was perceived, understood, conceptualized. What we need to remember, then, is that culturally produced terms are not exhaustive of their conceptual object. "Mental illness" designates something real, but that reality can only be named in the way that it is at any given time, via the existence of further cultural constructs.

"Depression" is a relatively novel term; but it designates a number of conditions that doctors and philosophers had recognized even in Antiquity. One notion to which "depression" corresponds is that of "melancholy", an infamous term, central to western culture, believed from the 5th century BC to be the counterpart of creativity, inspiration, insight, and so on, but also of sadness, despondency, love-sickness, and madness in various guises. Its history has been told many times, in books, compilations, most recently an exhibition in Paris called Mélancolie: Génie et Folie en Occident. Melancholy has a much broader range of meanings than does depression: it is a category that encompasses states of extreme disturbance, from what we call mania to what we call schizophrenia and beyond, to the gentler sort of everyday "blues" all of us experience. Only a serious melancholic - someone who could not function in society - would have been considered in need of medical care (and medical care was not very gentle). A case of mild melancholy was nothing dramatic.

Literally, melancholy is Greek for "black bile", one of the four humours that corresponded to temperaments, to states of health and illness from the Greeks for two millennia on. But its meaning, significance and aetiology gradually ceased to be tied to that very precise physical substratum. (You could browse Robert Burton's Anatomy of Melancholy, published in the 1620s, to get a profound sense of the concept's fate.) In that sense, the term "melancholy" remained a cultural container in the same way that "depression" is today: we might assume that depression is aetiologically reducible to neurotransmitters, whose explanatory structure is akin to that of a humour like black bile. Yet there must exist cultural conditions for attaching a meaning or value to this putative reducibility: it isn't a stable given. In fact, the sliding scale between full-on madness and bluesiness, once covered by the concept of melancholy, no longer exists: today we must be either healthily content or depressed.

And so, one hypothesis for the rise in diagnoses of "mental illness" is that we tend not to accept natural states, which can be unpleasant: instead we are quick to turn them into pathologies that then justify the resort to medication. It is hard to gauge whether there has been a rise in cases of evident psychoses, or in cases of manic depression and so on, all of which have always historically been perceived as illnesses that necessitated a cure - and one can only be grateful today for the medications that do help those in acute distress. But I imagine far more people are diagnosed as "mentally ill" than is warranted. We like short-cuts to well-being, easy answers to painful questions, so we pop pills. We forget that no one quite knows the criteria, other than those provided by symptoms themselves (categorized in the DSM), by which one can define the border between a mentally ill patient in need of medication and someone suffering from common melancholy, in need of introspection and consolation. And we lose sight that we make a fallacious inference when we say that, if our mind is our brain, then all mental distress is simply a medical ailment. A hernia, a collapsed lung or a broken leg are clearly medical issues; but mental matters, that is, matters of psychology, are less obviously unpacked by the appeal to medicine. (Incidentally, psychology is a word that used to denote what its etymology indicates: knowledge, or for us science, of the soul, or for us mind.)

Many doctors in the past used to be philosophers, precisely because it is so hard to establish what exactly is the province of medicine; and today, good doctors and good psychiatrists still know that diagnosis is in part a philosophical act.

I am a baseball coach/manager. In my stepson's baseball league, another team

I am a baseball coach/manager. In my stepson's baseball league, another team has a child (these are pony league players - 13 & 14) who has some arm problems. I know he has had an MRI (know the MRI tech) and also that his doctor instructed him never to pitch again. The coach and parents are aware of this too - yet the coach still pitches him in games. Other parents discuss this problem, yet no one seems willing to step up and do something about this. Since I know the story, would it be ethical if I anonymously informed the league? There may be a potential liability issue at stake here too. This kid is going to ruin his arm before he gets to high school. I am also trying to balance the confidentiality of the medical relationship vs. the kid's welfare. Should I even be considering this?

I agree with Thomas Pogge's remarks, but I also have a couple of cents to add.

First, consider very seriously and act in light of the fact that your information comes to you second hand (from a lab tech and not the child's physician or parent)--unless, of course you are the MRI technician. Second hand reports are notoriously inaccurate, and so I suggest proceeding with caution and when you act qualifying your comments with the acknowledgment that your information may be inaccurate. The tech may be exaggerating the physician's instructions or otherwise distorting them.

Secondly, it's worth pointing up front that (again unless you are the technician) that it was probably unethical for the technician to have given you medical information about the boy. Medical information is by law, custom, and moral principle extremely private material. The technician's poor conduct in providing you with medical information about the child further calls his or her credibility into question.

Thirdly, while I think Dr. Pogge is correct that the best first route is through the technician--or, better, directly through the physician--if that route doesn't achieve results that satisfy you, you should consider speaking with the parent. Your having this knowledge does give you a moral burden, I'm afraid. Your being a coach/manager magnifies that burden. If you find speaking to the parent uncomfortable or unsatisfying, you may consider informing the league. Now, the parent may deny that a physician has given the child such an instruction--at which point you will likely have no way of proving your claim, and the parents' claim will rightfully trump yours. Remember you will be reporting to the league third hand and, anyway, who is one to believe, the tech or the parent or you? If you somehow have access to hard evidence (and I mean really hard evidence, as overriding a parent is no small matter), you may wish to discuss the matter with a social worker.

Is it ethical for surgeons to use economic considerations when setting their

Is it ethical for surgeons to use economic considerations when setting their fees? For example, is it ethical for a surgeon who is known to have better results for a certain operation to charge more than a surgeon who has worse results? Likewise is it ethical for a surgeon who has a scarce skill in a region to charge exorbitant fees for that skill simply because it would be unaffordable for most patients to travel to another region to attend another surgeon?

It may also matter what sort of operation we are talking about. If this is cosmetic surgery (beautifying belly buttons, say), then the service does seem quite similar to other commodities (face cream), and the reasons against the surgeon's charging what she will seem quite weak.

As we move to the other end of the spectrum -- to operations that are a matter of life and death -- Peter Fosl's points become ever more compelling. Such operations should not be rationed on the basis of wealth: A medically important operation that is routinely available to the wealthy should also be available, in roughly the same quality, to the poor. Call this the medical equity principle (MEP).

It does not follow from the MEP (here comes my second point) that it is unethical for the best surgeons to charge more. Societies that have organized themselves around the MEP need to have enough high-quality doctors to take care of the medical needs of all. To attract people into the profession of surgeon, and to entice them to become really good surgeons, such a MEP society may arrange itself so that the income of surgeons reflects their level of skill. Why should not a top surgeon who lives in a MEP society take the high remuneration available to her just as other surgeons with her outstanding skills are also doing in this society?

G. A. Cohen gives a reason against her doing this. See e.g. If You're and Egalitarian How Come You are so Rich?. But this reason applies to all highly-paid professionals. It is quite different from the ones Peter Fosl advances, which seem to me to be as inapplicable to a MEP society as they are to cosmetic surgery.

Our society -- not to speak of the world at large -- is very far from realizing MEP. Millions are spent on small improvements and extensions of the lives of the affluent even while poor uninsured Americans lack access to important medical services and millions of child deaths abroad could be avoided each year at the cost of a few Dollars per case.

These grotesque violations of MEP are a very grave injustice, in my view. An important aspect of your questions is then how one ought to behave in a context of grave injustice. By demanding from every patient what the market will bear for a medically important operation, a highly skilled surgeon would be both contributing to and taking advantage of a grave injustice: She would be contributing to the unjust segregation of patients by wealth, and she would be taking advantage of the fact that the social context is one in which patients must bid for top-flight medical treatment. What such a surgeon should plausibly do is to earn her living by charging the affluent what the market will bear and then giving equally good service to poor people for what they can comfortably afford (which may sometimes be $0).

Last point. It is not only top surgeons who, in an unjust social context, have responsibilities to shield people from grievous effects of injustice. Affluent citizens should understand that, if our society were just and thus in reasonable compliance with MEP, then people like themselves would have lower net incomes (as more of the social product would be spent on ensuring that all have access to important medical care). Understanding this, affluent citizens should not just pocket the fruits of injustice, but should spend some of their wealth on supporting political reforms or on protecting the victims of injustice. We all should help put access to medical care on the political agenda this primary season and help elect politicians who are firmly committed to moving this country and the world closer to MEP compliance.

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