The Applied Ethics Academic Article Review Assignment Rationale For this assignment, you will be read, analyze, and critique an academic research article written about applied ethics, which is a work of contemporary philosophy (meeting course objective 1). In the summary component of the paper, you will discuss how a contemporary philosopher applies those same concepts and principles that we discussed in class to address moral concerns (meeting course objectives 2, 3, 4, and 5). In the critical analysis component of the paper, you will discuss how someone might reasonably disagree with what they say (meeting course objective 7), as well as how someone might apply what they say to various aspects of life (meeting course objective 6). Assignment Prompt This is a 1000-to-1250-word paper (approximately 4-5 pages) that half summarizes (approximately 500 words) and half critically analyzes (approximately 500 words) a recent academic article (published in 2018 or later) of your choice on applied ethics. This review of an academic article will be written as a professor might write a critical review of an academic book. The word length is important, because 1000 words is the length of a standard academic book review. You will find that minimizing word length and offering restrained criticism of academic work will be increasingly important as you take advanced undergraduate and graduate classes. Success on the paper will largely depend on how well the paper conforms to the formatting and content guidelines included in this document. It must be exactly eight paragraphs, in the same order and with the same content as specified in the guidelines. The review will be graded “like an English paper” in terms of the quality of the writing itself and “like a philosophy paper” in terms of the precision of its ethical content, such as how appropriately it defines and uses philosophical terminology. The paper must be written about a single academic article published in 2018 or later, on a topic applied ethics, or it will receive a zero. Applied ethics refers to the application of the ethical theories to moral issues: the “ethics of” a given topic (for example, the “ethics of” zoos), a given topic’s “ethics” (for example, “zoo ethics”), or specific applications of ethics (for example, ethics of keeping elephants in zoos). This major assignment is 20% of the final grade. You cannot review any of the articles which are reviewed in the samples following this guide. You also cannot review any of the articles reviewed in the sample papers following this prompt. Style Guide Formatting • • The review should be written as a continuous narrative: There are no separate sections. Please observe standard writing conventions of 2-3 paragraphs per page (doublespaced, 12 pt. Times New Roman, 1” margins). Language • • • • The review should be written in academic style. The article should be written in the historical present tense (that is, we know the author “wrote” the article in the past, but you’re presenting it as if the author “writes” now). The author is doing the action, not “the article.” Since you are reviewing an ethics paper, you must incorporate technical philosophical words where appropriate, taking into consideration that different authors may understand those same terms differently and defining those words accordingly. References and Citations • • Do not use any outside sources in the review, other than the article under review. Cite page numbers only if you quote the article directly, e.g. (p. 29). Cite section numbers, e.g. (sec. 3), if no pages are available or when you reference the sections of the article in the first paragraph. Quotes should be used sparingly, if at all. Citations are needed for direct quotes or to point out specific information to the reader. Citations for section numbers are required in the first paragraph. Content • • • Remember, the point of the review is to explain why the article is worth reading to someone who has not yet read the article—but who may be interested in doing so! Better reviews will critique the limitations and strengths of an article in terms of clear examples, rather than generalizations. Perhaps limit your discussion to two points of limitation and two points of strength. A good measure of success is whether someone who has not read the article can answer basic questions about it: How is it structured? Who wrote it? What is it about? What makes it unique and worth reading? What might make it not worth reading? If someone cannot answer these questions after reading your review, you must rewrite and revise the review Content Guide Academic Articles The review must be written about an academic research article. • An article is academic if it is published in an academic journal. An academic journal publishes peer-reviewed articles written by scholars and professionals. Journals dedicated to publishing the work of only undergraduate or graduate students are not true academic journals, and articles published in them are not suitable for the review. • An article is a research article if it defends a thesis. Some academic journals also publish book reviews and opinion-editorials. These are not suitable for this assignment. • Scientific articles written according to the scientific method typically do not make moral points, making most of them unsuitable for this assignment, but there are exceptions. Title The citation of the academic article under review also functions as the title of the paper. This is a citation style that is often used in ethics papers written by professors. • The citation is created using a hanging indent. • Everything, including your name line, is bolded • DOI stands for Digital Object Identifier. This functions as the article’s unique serial number. You must use the direct link to the DOI. If no DOI is available, you will need to link to the article’s digital “home” on the journal’s website. Do not use links to library databases. Title Format Author Last Name First Initial (year in parentheses) Title of article in all lowercase. Title of Journal in Uppercase volume number of the journal:page range of article. DOI link Reviewed by Your First Name and Last Name, undergraduate at Blinn College (or Texas A&M) Title Example White TI (2017) Dolphins, captivity, and SeaWorld: the misuse of science. Business and Society Review 122:119–136. https://doi.org/10.1111/basr.12112 Reviewed by Steve Dezort, instructor at Blinn College Paragraph 1: Structure and Scope • • • • The first three sentences need to 1) Indicate the issue that the paper is addressing, 2) Indicate the author’s research question, in the form of a statement (E.g., “In this article, Thomas White seeks to answer . . .”), 3) Indicate the author’s answer to the research question, the thesis (E.g., “He argues that . . .”). The remainder of the paragraph should describe article’s structure, organization, and sections, referencing those sections in parentheses. For example, “Section 1” of the article would be referenced as (sec. 1). The content should be specific, not what the author is doing, but what the author is questioning, describing, explaining, arguing, etc. All the sections must be accounted for in parentheses. Subsections should not be referenced. • • Refer to the author by both their first and last names at first mention, and by last name only at subsequent mentions. Do not reference the title of the article or the titles of the author. For example, do not refer to the author as Doctor (Dr.), Professor (Prof.), or Mister (Mr.). Paragraph 2: People, Perspective, and Point • • • • • Describe the perspective from which the author writes the article by mentioning the author’s discipline, and the author’s research specialization within that discipline. For example, the author’s discipline might be philosophy, and their specialization within that discipline might be business ethics. You will have to do an “academic background check” to find out the author’s discipline and area of specialization. This “academic background check” will typically lead to a university’s website. You should not reference this as an outside source. It is not plagiarism. You should use the same pronouns that the author uses in their self-description. The author’s place of employment, job title, and degrees are irrelevant and should not be mentioned. Describe the contribution that the author is seeking to make to their research specialization. This is what the author claims they are seeking to contribute. Paragraphs 3 and 4: Thesis and Argument • • • These paragraphs elaborate on the first 3 sentences of paragraph 1 and therefore must match that content. Describe the author’s argument in the article. Summarize their main point (thesis) and sketch their arguments in support of that main point. Paragraphs 5 and 6: Points of Limitation • • • Limit each paragraph to only 1 point of limitation. Examples include: o Evaluate the breadth, depth, scope, and limitations of the article. o Discuss what the author covers and what the author leaves out. o Evaluate whether the author’s claimed contribution is indeed what they make o Evaluate how convincing the author’s arguments are. Including an example or two would be helpful to the reader. Use language such as “Someone might be interested to know more about …” or “One aspect of the issue that readers would like to know more about is …” Paragraphs 7 and 8: Points of Usefulness • Limit each paragraph to only 1 point of strength. Examples include: o Evaluate the strengths of the article. o Discuss the interesting insights the author offers. • • o Comment on the ways the article is useful and who might find the article useful. Specifically discuss how someone might apply what they say to various aspects of life. Including an example or two would be helpful to the reader Paragraph 8 is not a conclusion. The conclusion is the last sentence, so end on a positive note with a sentence on why the article is worth reading and recommended for reading. Lee C Kahle L (2016) The linguistics of social media: communication of emotions and values in sport. Sport Market Quarterly 25:201–211. https://fitpublishing.com/articles/linguistics-social-media-communication-emotionsand-values-sport Reviewed by John Locke, undergraduate at Blinn College Values in sports are communicated through social media and reflected in sport marketing. This raises the question of how values and emotions influence sport marketing on social media, and the additional question of how sport communication is used to recognize fanbase popularity. Christopher Lee and Lynn Kahle argue that effective communication on tweets reflects the values in sport communication and managers should realize their role in consistent language when managing a social media account for fan support. Lee and Kahle first discuss the attractiveness of products in relation to values (“Theoretical Framework”). Next, Lee and Kahle present evidence on comparing the linguistics of four MLB Baseball Teams by tweeting their values during a significant moment in the match (‘Study 1: Teams and Linguistic Context of Tweets”). They subsequently proceed to the study of four sport apparel companies to assess how they communicate their values and emotions through Social Media when not having a minute-tominute variation (“Study 2: Apparel Companies + Linguistic Context of Tweets”). Lee and Kahle conclude a framework to understand the values and sports in order to reveal a new lens, implies sport markets seek to emphasize values and a lifestyle to communicate their desired message to the fans. (“General Discussion”). Lee and Kahle are marketing scholars. Lee’s research interests are consumer behavior, framing, linguistics, and marketing communication, and Kahle’s research interests are sustainability, social values, and marketing communication. They both argue that “Social Media offers marketers the opportunity to communicate specific values to ensure communication is consistent, while analyzing linguistics of messaging” (p. 201). They developed a List of Values (LOV) to specify how tweets are evaluated. The values consist of belonging, excitement, warm relationships, self-fulfillment, peer respect, fun and enjoyment in life, security, self-respect, a sense of belonging, and accomplishment. Lee and Kahle explain how values and emotions are expressed in sport marketing. Social media has been the aspect on how to better interpret values to gradually increase sport marketing. The authors emphasize social media through the first study of four different Major League Baseball (MLB) teams. The LIWC software on individual tweets explores values and emotions communicated in Twitter and applies Kahle’s LOV to investigate communication linguistics to the nine core values. An example is that Yankees and Red Sox tweeted more about the value of self-respect, whereas the Dodgers and Red Sox utilized their tweets more about fulfillment. Lee and Kahle further their evidence by explaining the emotional perspective and explains the Red Sox and Giants carry increased emotional tweets to improve viewers’ attention. This supports the social media of sport markets to reinforce emotional appeals in order to enact strong bonds with fans. Lee and Kahle present their second study on the values and emotions of apparel companies to understand the influence of sports marketing. The study of the four largest apparel companies (Nike, Adidas, Under Armour, and Reebok) and their rhetorical tactics utilizing social media helps understand how values are analyzed. Kahle’s LOV and LIWC are used in the articulation of the values and emotions of each apparel company. An example is that Under Armour invests in popular self-validating and fulfillment tweets stated in the popular slogan “Protect This House.” This encourages consumers to follow their Twitter account (p. 207). Under Armour promotes the most positive and emotional brand overall within the studied arenas which assists in promoting an increased connection with consumers. On the contrary, Nike is the least positive sport apparel brand overall, directing their tweets toward the sense of accomplishment with phrases like, “Just Do It” and “Find your Greatness.” The authors argue that the relationship to values and emotions represented in sport communication is a revealing combination independent of other sport apparels in the study (p. 207). One aspect that Lee and Kahle left out of the article is the significance of the fanbase, and how the fanbase perceives values and emotions. Put differently, one aspect of the issue that readers would like to become aware of is why Lee and Kahle did not analyze the values and emotions of the tweets of the consumers and/or fans. Lee and Kahle observe the tweets of the producers (i.e., the companies) and judge how they appeal to the society but could have also evaluated how consumers react to the tweets to understand collectively and as a sport market, fulfilling how values are expressed through communication in sport marketing. Another example is Under Armour, which combines respect and emotional positivity into one category, but the issue is how those positive emotions affect their followers who support their sport market. Another interesting but neglected aspect is how values and emotions are revealed in social marketing through other sport organizations. For example, Lee and Kahle focus on only four MLB Baseball Teams and neglect the very many other, and different, organizations such as NBA and NFL Teams, which likewise use tweets to communicate values and certain aspects of linguistics. The study’s usefulness, then, while certainly being useful, is nevertheless severely limited in scope. Additionally, lacking are the tweets of individual players, their followers, and the linguists and values each display. Another interesting aspect of the study is Kahle’s creation of the List of Values to compare different organizations and what those values are. It explains how focusing on business expansion is tantamount for producing senses of accomplishment and pleasure and portraying fun and enjoyment. Nike is the highest business company because it has the highest sense of accomplishment in their tweets. Conversely, Adidas produce the volume of pleasure business inducing tweets to convey a sense of enjoyment and fun. One reason Adidas expresses fun and enjoyment is because their clothing lines present a sense of artistic awe to consumers examining the product and how it brings excitement in the store with interesting slogans. Another positive aspect within the paragraph is that Lee and Kahle use Nike as an appropriate example to understand how values and emotions reflect on sport marketing. An importance in Nike is how their tweets are sent out to strengthen a perception of accomplishment towards their fanbase. Another reason that Nike is an important apparel in sports is because more consumers would purchase items due to the value of accomplishment expressed in their sport market. This article would be fruitful for sport managers to read, because they would better understand how different values are portrayed through organizations and gain insight on what values particular tweets would be more likely to increase fanbase expansion. This article is worth reading since Lee and Kahle are writing objectively with facts and figures and demonstrate how other organizations may be assessed based on the tweets they adapt for the purpose of gaining popularity. Wareham CS (2016) Substantial life extension and the fair distribution of healthspans. Journal of Medicine and Philosophy 41:521–539. https://doi.org/10.1093/jmp/jhw021 Reviewed by Thomas Hobbes, undergraduate at Texas A&M Christopher Wareham begins his article by describing the popular desire for humans to maintain their youth and extend their lives. In doing so, Wareham asks whether the distribution of life-extending substances called calorie restriction mimetics (known as CRMs) to the public is fair, knowing that it would be nearly impossible to distribute the substances fairly amongst different groups of people. Wareham argues that, assuming there is a way of ensuring fair distribution of these substances to the public, the distribution of these life-extending substances is more fair than the alternative of not distributing the substances in the name of equality. To make this argument, Wareham presents research data on CRMs (sec. 2), presents the prevailing objection to his argument (sec. 3), argues against a laissez-faire approach as well as the banning of CRMs (sec. 4), discusses equal provision of CRMs (sec. 5), and presents the argument for unequal distribution of CRMs (sec. 6). As an ethics researcher whose focus is bioethics and public health ethics, Wareham writes to discuss the ethical implications of emerging scientific and nutritional discoveries surrounding life-extending substances, as they pertain to public consumption. Wareham uses this background to argue that CRMs should be distributed to the public under the right circumstances, as well as arguing against competing theories surrounding the debate. For example, Wareham’s includes recent studies surrounding the biological effects of CRMs on animals, that are believed to show the positive effects CRMs could have on humans. Wareham argues for the acceptance of CRMs, and that their ability to rectify the disparities that exist in life length and quality would be an ethically acceptable practice. Wareham’s primary argument revolves around the theory that a society in which people have the same length and quality of life is preferable to a society whose people do not. In this sense, an unequal society includes a society in which some people have longer than average lives and some have shorter than average lives, the claim being that the extension of some lives over others is inherently unethical. Wareham then claims that if life extending substances were to exacerbate existing disparities in life length and quality then their use would be unethical. Wareham argues against both the laissez faire approach and the banning of CRMs as he considers them both to be ineffective and immoral. Wareham claims that the laissez fair approach is problematic because it would predominantly enhance the lives of the wealthy, while the poor are preoccupied with more urgent needs. Wareham also maintains that banning the substances would be unethical, one point being that a ban would be difficult to enforce and those with greater resources would likely still have access to CRMs, and secondarily the banning of substances that could improve the livelihoods and ailments of members of the public would be met with great outcry. Instead, Wareham argues that the most effective solution would be a program that distributes CRMs to those in need in order to ensure an equal outcome in terms of life length and quality. While Wareham explores multiple sides of the ethical debate, there are issues involving the distribution of CRMs that were not taken into account. In the case of a government program to distribute CRMs on the basis of need, or what is referred to in the article as unequal provision, this would be funded by the public's tax dollars. While Wareham was thorough in his approach seeking fairness he did not take into account that wealthier areas put more money into tax programs, so their local programs tend to be higher quality than the programs put into place in lower income communities. This would lead to wealthier groups having greater access to the substances that enhance their lives, creating an unethical distribution of resources. When one considers the disadvantages faced by lower income communities as can be seen across the world, but specifically across America, it is easy to see how these would manifest unequal distribution of resources in a program like the one Wareham describes. The monumental differences that can be observed in different jurisdictions when you look into public schools and medical facilities, as well as other public services within communities, it isn’t difficult to imagine how this lack of standardization would affect such an important emerging medical treatment. This of course violates the lockean proviso of which it is based on, because of the unequal distribution and quality of services provided to the public. Wareham’s distinct organizational skills help to make this easy for someone with no prior knowledge of the topic to understand, and retain the most important information well. As he explains complex moral issues and the many faceted arguments surrounding them, Wareham is able to condense massive amounts of information into smaller digestible chunks for the reader to take advantage of. Wareham elaborates on not only the studies that have led to CRMs, but also the precedents that they could set for further medical and nutritional advancements. With Wareham’s experience in bioethics and public health ethics, he is able to provide insight into the processes for coming up with a solution to the ethical dilemmas faced by innovators in the field, and the long term consequences that come along with these innovations. While this may be considered a niche subject, it is more likely to affect our lives in the future than many understand. The general public would be well served to educate themselves on this topic as it may become very prevalent in the coming years, both as it pertains to CRMs, and more broadly as it pertains to the future of technological innovation that we all benefit from. This article is worth reading and helpful to all, and its approach to exploring all facets of the ethical debate make it a well crafted work of ethical and philosophical writing. Persson K Selter F Neitzke G Kunzmann P (2020) Philosophy of a “good death” in small animals and consequences for euthanasia in animal law and veterinary practice. Animals 10:124–138. https://doi.org/10.3390/ani10010124 Reviewed by Mary Wollstonecraft, undergraduate at Texas A&M University Kirsten Persson, Felicitas Selter, Gerald Neitzke, and Peter Kunzmann describe euthanasia in the veterinary practice as a “good death” and further move on to discuss the different factors that may result in a nonhuman euthanasia. The focus of the paper is to bring light to the variety of ethical reasons of why companion animals may undergo euthanasia. They accomplish this by describing a variety of definitions and accounts of the meaning of death as well as laws and guidelines regarding the practice. Persson et al. describe the multiple ethics that pertain to euthanasia (sec. 2), refer to the laws that veterinarians must follow based on human interest and public safety (sec. 3), and describe intermediate interests between the patient’s owner and society (sec. 4). Lastly, they provide a discussion that focuses on the perspective of the veterinarian (sec. 5), and finish with a conclusion to wrap up their final points (sec. 6). Persson et al. share the same discipline in philosophy, while Selter has a discipline in neurophilosophy. Meanwhile, each author specializes in animal ethics, with the exception of Neitzke, who specializes in medical and clinical ethics. The authors aim to write about the moral difficulties that come with euthanization within the small animal practice, as well as attempt to explain and diminish the tension within the end-of-life (EOL) debate. To help support these ideas, Persson et al. provided an Austrian study in which veterinarians said they view euthanasia as an “unavoidable evil” and stated that both the owners and veterinarians feel guilty after having to put down a pet even though they knew it was in their best interest (sec. 5). In order to ease tension with EOL decisions, the authors include different definitions of the meaning of euthanasia. For example, “proper euthanasia” refers to the painless killing of an animal if death is deemed to be the best decision for that pet, whereas “contextually-justified euthanasia” is referred to as the killing of a companion animal who could have had a fulfilling life, though the circumstances, either of the owner or society, are not worthwhile (sec. 2). These definitions both allow for an ethical euthanasia even though the circumstances are different. Persson et al. argue that euthanasia is one of the most burdensome practices in the veterinary field, yet is an unavoidable tool. They explore the moral stress of a veterinarian as a result of the killings of their patients, sometimes having to decide in favor of the owner’s decisions rather than their patient’s well being. With the increasing rate of owners who consider their companion animals as family members, veterinary medicine has evolved to help give their patients longer, more fulfilling lives. However, sometimes this may go against the animal’s best interest if given a negative prognosis. If this is the case, Persson et al. write that the quality of life for this animal may be more detrimental than beneficial. The authors support this claim by stating that death can prevent a life full of suffering (sec. 2). Besides having to euthanize a nonhuman on behalf of the owner's interest, veterinarians must also follow laws and guidelines regarding the practice. For example, Persson et al. write that the painless killing of allegedly dangerous dogs or the surplus of animals in laboratories or animal shelters are in the interest of the public, and therefore justify the killing under the classification of euthanasia. The authors state that there is not yet a definition for euthanasia in terms of public safety, however, provide the term “humane killing” to refer to the death, without pain and suffering, of research and labratory animals. Finally, the authors state that the conflict between the animal’s interest and the owner’s circumstances, like time or money, that result in a euthanasia are a heavy influence of the moral stress in veterinarians. Though the authors briefly touch on the topic of quantity vs. quality of life, readers might be interested to know more about how to improve a companion animal’s quality of life. The authors state that “prolonging life without increasing quality of life may cause more harm than good” (sec. 2), but what does it mean to improve the quality of life? Could it be as simple as physically showing more appreciation for the animal, or maybe rewarding it after completing a given task? The quality of life is based on the animal’s best interests, not the owners, however, many owners may not have the will to put their animal down because of the companionship they bring. If they remain stagnant to improve the animal’s life, they may slowly be hurting their companion animal more. Persson et al. also fail to explain what may bring value to the companion animal’s life. If increasing the quality of life means to increase what a companion animal values most, then we must understand what is necessary to accomplish that. Early in the article, Persson et al. write that judgment for justification of euthanasia for nonhuman animals can be based off of different accounts of the meaning of death. However, when this topic comes up, they fail to explain what these different accounts may consist of. They also fail to describe the meaning of death of an animal, which is what a reader may be interested to learn. What might death look like in an animal's eyes? If not a physical death, could a companion animal ‘die’ from lack of care, meaning, can they mentally overcome the burden of an owner’s neglect? While the authors fail to look further into these specific topics, they provide valid support for the points they make later in the article. Hedonism is a theory that describes pleasure as the highest good, and from pleasure, a good life may be lived. Persson et al. describe this theory very well when they describe narrow and broad hedonism. For example, narrow hedonism is described as the lack of negative events like suffering and pain and broad hedonism suggests to consider both positive and negative states of life in regards to euthanasia. However, narrow hedonism allows for logical criticism stating that if a fulfilling life requires a lack of suffering, then the best option would be to kill every animal since that would ensure the absence of suffering (sec. 2). The authors incorporate this criticism to allow the reader to consider what is truly important in a companion animal’s life and what may lead to an ethical euthanasia. Hedonism is significant because it pertains to the nonhuman’s quality of life, which was previously stated to be a factor decision for euthanasia. Persson et al. describe the theory in a way that is easy to understand and allows the reader to reflect on the topic. Persson et al. provide new perspectives to the meaning of euthanasia in the veterinary practice. They provide detailed information with points and outside references to help support their claim. Though euthanasia is a controversial topic, the authors explain the ethical reasonings behind it while also remaining empathetic to the reader by explaining the moral stress that veterinarians must face. The authors provide an unbiased opinion in the article, which allows the reader to create their own outlook based on the information. This article is worth reading because it strives to reduce criticism that targets a very controversial, yet highly recognized veterinary practice Journal of Medicine and Philosophy, 45: 16–27, 2020 doi:10.1093/jmp/jhz034 Advance Access publicaton on December 16, 2019 DAVID B. HERSHENOV* University of Buffalo, Buffalo, New York, USA *Address correspondence to: David Hershenov, PhD, Philosophy Department, University at Buffalo, Buffalo, NY 14260-4150, USA. E-mail: dh25@buffalo.edu Christopher Boorse is very skeptical of there being a pathocentric internal morality of medicine. Boorse argues that doctors have always engaged in activities other than healing, and so no internal morality of medicine can provide objections to euthanasia, contraception, sterilization, and other practices not aimed at fighting pathologies. Objections to these activities have to come from outside of medicine. I first argue that Boorse fails to appreciate that such widespread practices are compatible with medicine being essentially pathocentric. Then I contend that the pathocentric essence, properly understood, does not prohibit physicians from engaging in actions that are not aimed at combating pathologies, but rather supports an internal morality of medicine that allows medical providers to refuse without penalty to engage in practices that promote pathologies. Keywords: Boorse, medicine’s internal morality, pathocentrism I. INTRODUCTION The idea of an internal morality of medicine is that some acts that are not immoral in themselves are still wrong for medical practitioners to undertake. They are wrong because they are contrary to the nature of medicine, which is usually understood in terms of certain goals being definitive of the practice. One traditional conception is that its essence is to combat disease or pathology.1 Christopher Boorse understands a pathocentric emphasis to fighting disease “as an abbreviation for any of three things: (1) preventing pathological conditions, (2) reducing their severity, and (3) mitigating their bad effects” (2016, 146 n.1).2 Paradigm examples of actions that © The Author(s) 2019. Published by Oxford University Press, on behalf of the Journal of Medicine and Philosophy Inc. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com Downloaded from https://academic.oup.com/jmp/article-abstract/45/1/16/5679183 by 81695661, OUP on 13 January 2020 Pathocentric Health Care and a Minimal Internal Morality of Medicine Pathocentric Health Care and a Minimal Internal Morality of Medicine 17 Downloaded from https://academic.oup.com/jmp/article-abstract/45/1/16/5679183 by 81695661, OUP on 13 January 2020 violate the pathocentric principles guiding an internal morality of medicine would involve physicians participating in torture or execution, even if the external morality of society (the general non-role-based morality) permits torture and executions. Other examples of actions that might be prohibited by a pathocentric internal morality of medicine include abortion, euthanasia, physician-assisted suicide, sex changes, sterilization, and some forms of contraception.3 An internal morality of medicine may even prohibit actions like cosmetic surgery and other enhancements for they do not combat pathologies, even though they do not cause them, like the above list of medical interventions. Some theorists holding pathocentric views about the nature of medicine are absolutists about the internal morality of medicine and would not permit physicians to engage in banned activities, even if the external morality deemed it appropriate (Kass, 1975; Pellegrino, 2001). There are other advocates of an internal morality of medicine that will accept on balance, all things considered, physicians doing some of the items on the above lists (Miller and Brody, 2001). They view such actions as just prima facie wrong for a physician. Boorse challenges the idea that medicine has historically been pathocentric. He draws on a rich historical record of doctors devoting their skills to practices other than curing or preventing diseases. He concludes that such practices prevent a historically sensitive internal morality of medicine from proscribing practices like hastening the deaths of some patients or helping others avoid becoming pregnant by pills or sterilization. Boorse suggests that the rejection of such practices must have its source in moral ideas that originate from outside of medicine. I take issue with Boorse, arguing that he does not recognize that these historical activities of doctors are not at odds with the medical craft being essentially pathocentric. I contend that we can construe medicine’s pathocentric essence in a way that does not exclude doctors from applying their technical skills and knowledge of the body to ends other than thwarting pathologies. Acknowledging a pathocentric essence can instead serve merely to protect medical practitioners, enabling them to refrain with impunity from procedures that cause pathologies in their patients. My account differs from the more conservative pathocentric accounts in that it does not limit doctors to fighting pathologies. I highlight the distinction between acts “contrary to” medicine’s essence and those merely “not entailed by” its essence. Ending a life is contrary to the essence of medicine. Fighting pathologies is entailed by the essence of medicine. Cosmetically enhancing a life is neither contrary to the essence of medicine, nor entailed by its essence. My aim is to allow doctors to refuse to induce pathologies without suffering a penalty. I am not advocating that they be limited to fighting pathologies. 18 David B. Hershenov II. ANCIENT CONTRACEPTION AND VICTORIAN OBSTETRICAL ANESTHESIA Downloaded from https://academic.oup.com/jmp/article-abstract/45/1/16/5679183 by 81695661, OUP on 13 January 2020 Boorse brings attention to the fact that whether one thinks that medicine has its origins in the ancient Greek Hippocratic School or the 19th century with the discovery of germ theory and antiseptic surgery,4 medical practitioners at those times did not restrict themselves to preventing and combating pathology. Boorse points to ancient contraception and modern obstetrical anesthesia. Fertility is not a disease that contraception prevents, and obstetric anesthesia is treatment for normal pain, not a symptom of disease.5 Boorse claims two points are crucial for his argument. First, unfettered access to contraception was not widely condemned, so we can exclude it from Western medical practice only by excluding those ancient physicians who made it available on demand. Second, even if the received view that Hippocratic medicine is the paradigmatic representative of ancient medicine is correct, it does not seem to have placed limitations on the use of contraceptives. The most quoted passages in the Hippocratic corpus do not place any limits on contraception (Edelstein, 1967; Riddle, 1992; Noonan, 1965).6 Nor was contraception dispensed just to prevent pathology.7 Advice was even given to the hetairai, a group of high-class courtesans, so they could practice their trade without interruption. Boorse considers the alternative possibility that scientific medicine originated in 19th century. He draws on Wootton’s work where it is argued that not until the 19th century did “physicians” do more good than harm, that is, the result for patients became better than placebo effects. So scientific medicine, on Wootton’s approach, has a recent origin. Earlier “medicine” was no more medical than astrology was astronomy. But, Boorse points out that even in the 19th century anesthesia during labor achieved near total acceptance. While women suffer great pains in labor because of the size of the fetus’s cranium and torso, and strong contractions and widening of various areas is needed but painful, the pain is normal for delivery and not pathological. The pain is inherent in human design, either as a design flaw or perhaps encouraging women not to give birth alone or, according to psychoanalysis, to help them bond with their children. Boorse concludes that these examples (contraception and obstetrical anesthesia) prove one of two things: either (1) medicine has no essential connection to disease or (2) physicians may practice qua physician something besides medicine. Either way, physicians are not limited to promoting health. There was no Golden Age of pathocentric physicians. So Boorse concludes that no internal morality of medicine offers good reasons to ban controversial actions by doctors such as euthanasia and enhancements. The Boorsian critique seems to be that most defenders of an internal morality of medicine wrongly think that medical providers have wandered away from the essence of medicine that existed at medicine’s origins or during Pathocentric Health Care and a Minimal Internal Morality of Medicine 19 III. PATHOCENTRIC MEDICINE Boorse imagines three responses to the physician being unbound from a focus on the pathological: (1) retreat and reject as unethical all of physicians’ treatments of normal conditions; (2) endorse these as ethical acts by physicians but not as medical since they’re not health directed; and (3) accept them all as medicine, embracing an internal morality of medicine that allows any use of biomedical knowledge and technology for the patient’s benefit.10 Option (1) rejects medical history. If (2) or (3) are accepted, then there are no objections from an internal morality of medicine against voluntary active euthanasia and enhancements because these are either genuine medicine or permissible for doctors to undertake. Thus, there is no objection on the basis of an internal morality of medicine to such practices. We would be left with only objections from general or external morality. Boorse overlooks two other responses. The one that I prefer is that there is a pathocentric essence of medicine, and this provides grounds for why doctors should be able to refuse without penalty to participate in actions that promote pathology, as is obviously the case with suicide, abortion, executions, and torture, as well as live-donor organ removals and sex changes, Downloaded from https://academic.oup.com/jmp/article-abstract/45/1/16/5679183 by 81695661, OUP on 13 January 2020 its prime. But, there was never a time when medicine was so pure, and thus there is no reason to think that such an internal morality of medicine is based on medicine’s essence. So Boorse criticizes pathocentric accounts of medicine. One target is the Oxford English Dictionary that understands a physician to be “a person trained and qualified to practice medicine” and then defines medicine as “the science or practice of diagnosis, treatment and prevention as disease.” Boorse criticizes Pellegrino’s (2001, 569) conception of the internal morality of medicine as one geared toward serving a single end or intrinsic good of healing—“the return of the physiological function of mind and body” and “the relief of pain and suffering.”8 Boorse also laments Veatch’s (2001, 640–641) identification of health and medicine, for that makes it appear that the practice of medicine is the promotion of health.9 Also, Boorse argues against Brody and Miller’s evolutionary theory of the internal morality of medicine on the basis that “it is important to eliminate (their) limitation of medicine to ‘disease and injury’, a phrase which I shall presume amounts more or less to ‘pathological condition’” (2016, 160). Boorse claims that “Miller and Brody are wrong to think that traditional medical care has ever been restricted to health promotion” (2016, 163). Boorse concludes that there is no threat to professional integrity when physicians go beyond health-related goals. Whatever reasons there are to prohibit euthanasia, contraception, or physician-assisted suicide, etc., they will have to come from an external or general morality. One cannot base such bans on the practices or principles inherent in the nature of medicine. 20 David B. Hershenov Downloaded from https://academic.oup.com/jmp/article-abstract/45/1/16/5679183 by 81695661, OUP on 13 January 2020 sterilization, and some contraception. A second possibility, one about which I am not as enthusiastic as the first, is that doctors should be able to refuse without penalty to engage in acts that—while not contrary to medicine’s essence of fighting pathology—are not entailed by the essence. Enhancements are practices that neither promote pathologies nor combat them. Perhaps some contraception avoids being so classified as pathology promoting if it interferes in the way that condoms and diaphragms do without directly killing sperm or damaging the body, as do vasectomies and medications that prevent ovulation cycles.11 My contention is that Boorse fails to appreciate that there is a conceptualanalysis defense of clinical medicine’s pathocentric core. It does not matter that doctors have always prescribed contraception or provided relief for natural pain, or even if they always practiced cosmetic surgery. Such practices might still not be essential or central to medicine, just as it does not matter if the army always helped out with disaster relief, quelling riots, and search and rescues. If the institution known as the “army” did not protect against foreign military threats, then we would say it was not an army, even if it did search and rescues, put down domestic riots, and provided disaster relief. If the institution called the “army” only protected against foreign military threats, we would still say it was an army despite not helping out domestically with riots, disaster relief, or search and rescues. The essence of the army is to protect against foreign military threats. Something structurally similar can be said about medicine. If some people refused to cure the sick or ameliorate the consequences of their pathological conditions, or prevent diseases, but only prescribed contraception, alleviated natural childbirth pains, and removed unattractive wrinkles with creams, we would say they were not physicians. But if such persons only prevented disease, cured the sick, and lessened the effects of the diseased, but refused to prescribe contraception, do cosmetic surgery, or alleviate the pains of childbirth,12 we would still be inclined to label them physicians. Boorse presents a clever challenge to my critique of his writing “On your view, if an anesthetist only gives anesthesia in normal deliveries, is she no longer a physician? Are surgeons who do only cosmetic surgery no longer physicians?”13 My response to Boorse’s objection is two-fold. First, I make a more minor point. Boorse’s asking whether the individuals would be “no longer physicians” suggests that they used to combat pathologies and thus did more than the non-therapeutic procedures that now monopolize their practices. They once were clearly physicians by any standard, so my concern is that their past classification is biasing our attitudes to their present practices, since we may be prone to provide classifications that characterize their entire career. Moreover, there is vagueness about the duration of the period where they must no longer practice pathology-fighting medicine to cease to be classified with the physicians who do. So, it is better if we imagine them never Pathocentric Health Care and a Minimal Internal Morality of Medicine 21 Downloaded from https://academic.oup.com/jmp/article-abstract/45/1/16/5679183 by 81695661, OUP on 13 January 2020 having done anything but cosmetic surgery and non-therapeutic anesthesia. I suspect that we would be more inclined than before to withhold the label of physician from them. We might be more willing to treat those anesthesiologists like hospital technicians who control the climate and lighting of the operating room, making sure the lighting is soft and pleasant, the air is pure, and the temperature is comfortable for the exposed patient. Additionally, we would be more amenable to considering the well-trained persons carrying out only cosmetic procedures their entire career as high-tech beauticians. My main response is that Boorse’s examples may mislead our classificatory efforts because the persons in question are assumed to have the complete medical treatment/skill set that would allow them to engage in the standard procedures of pathocentric medicine. Anesthesia is used for pathocentric surgery as well, and cosmetic surgeons have the skills to do therapeutic surgeries on facial injuries and other appearance-affecting pathologies. It will help to offset the distortional role of their background knowledge upon our classifications if we imagine the cosmetic practitioners having only the set of skills to work on enhancing skin tone and changing in an aesthetically pleasing way the shape and appearance of noses, eyelids, etc. but lacking the know-how to do any plastic surgery combatting pathologies. We would be much more inclined to claim that they were not medical practitioners, if they not only did not want to treat pathologies, but also could not do so effectively if they were so inclined. Contrast our response to such non-pathology fighting technicians with that towards plastic surgeons who only had the skill set to engage in pathologycuring operations and did not know how to tighten aging skin or create swollen (bee sting) lips and produce other cosmetic enhancements. We would not be inclined to doubt they were physicians. So, there is an asymmetry in how we classify those without the abilities to do enhancements and those without the abilities to counter pathologies. Boorse, or the reader, may protest that it is unrealistic and unfair to propose a classification of those who only want to do enhancements and who lack the skills to practice any pathology-combatting medicine. So, let us assume a moderate case where the skill set enabling those solely engaged in cosmetic enhancements also provides them with the skills to reshape noses and tighten skin, which have been damaged due to pathological agents. The procedures for the enhancements would be the same as those of medical treatments. To help us here still resist any pull to include those enhancementonly providers as engaged in the practice of medicine, consider an analogy between security guards and merely cosmetic surgeons. Imagine that the security guard at the sporting goods store uses the skills he learned on the football field to tackle shoplifters with stolen footballs in their possession. He even knocks the ball out of their hands when he tackles them, just as he used to cause fumbles when tackling opponents on the gridiron. We can even imagine him next punting the ball away from the thief or passing 22 David B. Hershenov IV. PROTECTED REFUSALS My approach to conceptual analysis suggests that an essence of medicine exists, even if doctors never in the history of their profession limited themselves to just the essential practices.14 This renders Boorse’s history lessons just defeasible evidence for a non-pathocentric medicine. If there is such an essence, a bioethicist, more conservative than myself, might argue that all acts contrary to it should be banned. Or such a bioethicist might prefer the even more extreme position, that not only are acts that promote pathologies to be banned, but those not entailed by the prevention and treatment of pathologies are also to be prohibited. The latter would include a ban on enhancements that do not produce any pathologies and make people better than normal. I argue in this paper for much less. My position is that once we have a core or essence, we can apply a minimal internal morality of medicine that allows medical practitioners to refuse to act contrary to their profession’s essence. They will be able, without penalty, to refuse acts that conflict with the pathocentric core even if the external (social) morality advocates such acts. So on my pathocentric but minimal internal morality of medicine, it does not follow that physicians are restricted to actions entailed by the fight against unhealthy conditions. Why should medical providers be allowed to avoid certain practices? Well, it is contrary to the nature of the profession that they entered. They did not sign up for such when they became doctors, nurses, or pharmacists. They professed allegiance to the principles of a profession that was devoted to healing and making people whole. In addition, it could very well be that their vocational self-understanding and professional integrity are tied to these ends. They conceive of themselves as tasked with saving the lives of the present generation and preventing the destruction of those of the next. They cannot easily, and should not have to, think of themselves as both healers and killers. They mastered a healing vocation and not another profession. Even if the external morality maintains that it is moral, all things considered, to facilitate abortion, euthanasia, and sterilization, etc., physicians Downloaded from https://academic.oup.com/jmp/article-abstract/45/1/16/5679183 by 81695661, OUP on 13 January 2020 it over his outstretched hand to a fellow employee. Just because there is a narrow description of the security guard’s abilities and movements that is the same as that given of a football player tackling an opponent, that is no reason to claim the security guard is a football player. He is engaged in a goal very different from a football player’s, despite his skills arising from his earlier football playing and those skills still being applicable to success on the football field. The aims of providing security and playing football are very different, as are the aims of enhancement and treatment. We would not classify the practitioners of each pair as being in the same field, despite their skill sets allowing them to do what the other does. Pathocentric Health Care and a Minimal Internal Morality of Medicine 23 Downloaded from https://academic.oup.com/jmp/article-abstract/45/1/16/5679183 by 81695661, OUP on 13 January 2020 have a right to not do so, and may even believe that they have a duty to refrain from these actions, lest they compromise their professional integrity.15 Let us turn now to the main upshot of the operations of minimal internal morality of medicine: protected refusals. My conception of a minimal internal morality of medicine is that once the essence is understood, medical providers (doctors, nurses, and even pharmacists) should be allowed to refrain from carrying out certain requests of an external morality’s requests. That is, they can refuse to abort fetuses, castrate or mutilate willing patients, torture terrorists or execute prisoners, and provide some forms of contraception, even emergency contraception (I am assuming that the latter consists of abortifacients) despite the external morality of society being one that has come to want medical providers to start doing those things. Additionally, they should be protected and their conscience recognized in a way differing from, say, a Jehovah’s Witness doctor in the Emergency Room. The latter should not be allowed in the Emergency Room if she would refuse to provide a patient with a necessary blood transfusion. She loses her job or is prevented from having such a job, for she is refusing to do what is central or essential to medicine—curing patients.16 The internal morality of medicine could be construed as rendering certain actions non-mandatory. On my minimal internal morality of medicine, physicians can legitimately opt out of certain acts by appealing to the nature of their profession. Prison—or army—employed physicians cannot be morally commanded to increase pathologies through, respectively, executions, or torturous interrogations. Hospital and clinic workers should be able, without penalty, to refuse to provide abortions or even contraception that makes organs malfunction.17 The right to refuse should also be extended to pharmacists unwilling to prescribe abortifacients and to Catholic hospitals when governments or insurers insist that they must provide such contraception. I would extend the same protection to a doctor’s refusal to remove a vital organ from a living donor, even a redundant organ like a kidney.18 Importantly, medical schools training the next generation should allow students to refuse to learn how to perform an abortion, contra Allison Jaggar, who insists that ob/gyn training and certification should require abortion training and practice as a matter of respect for women’s equal rights (2009). Of course, nearly every surgical medical procedure will kill some cells, but that might not make patients unhealthy—it merely means they have an unhealthy part. For example, one dead skin cell is a part-pathology but perhaps not a pathology at the macro level. On the other hand, if an unhealthy part means an unhealthy patient, I would still maintain that a pathocentric essence is compatible with creating a minor pathology to prevent a greater pathology. The pathocentric account just demands that, overall, the aim is that the patient’s health be improved. I understand a patient to be unhealthy only if a condition including a part malfunction increases the probability of death or reproductive failure. Removing one kidney raises the probability 24 David B. Hershenov Downloaded from https://academic.oup.com/jmp/article-abstract/45/1/16/5679183 by 81695661, OUP on 13 January 2020 that a donor will have a shorter life, so I consider kidney transplantation to make the donor unhealthy, even if it does not shorten his actual life. I have argued that doctors can refuse to act contrary to the pathocentric essence of medicine. This is not to say that physicians ought to refuse to do things contrary to the essence of medicine, only that they should remain protected when governments or employers want them to do things contrary to the essence of medicine—abortion, executions, torture, and the like. It is a further question if they should be allowed to refuse to do things that are not part of the pathocentric essence of medicine, such as to provide contraception, cosmetic surgery, and sleep medicine for those traveling through time zones. Although I am less concerned with defending an extension of the above internal morality of medicine, other bioethicists could construe it as extending its protection to refrain not only from those acts that promote pathologies but also from any that do not combat pathologies such as enhancements. Nevertheless, such an application is hardly entailed by my argument. Philosophers move too quickly from the view that the core goals of medicine exclude certain actions contrary to its essence to excluding actions not entailed by its essence. It might be fine to alleviate “healthy” birth pain, prescribe contraception, perform cosmetic surgery, etc. It may be that one can allow conscientious objection to giving contraception (condoms and diaphragms) that does not involve damaging reproductive organs or altering their functions, since it is not fighting pathology either. That is different from saying that no doctor should give out such contraception. The sort of conscientious objection that I am now considering is an extension of the minimal internal morality of medicine that I earlier advocated wherein doctors can refuse to act contrary to the essence of medicine. However, this alleged second realm of morally legitimate and legally protected refusals would seem to be very problematic when the issue is, say, pain relief, if the pain relief in question is not considered to be a component of treating disease.19 For example, one would not want a doctor to be allowed to refuse to treat the normal or natural pains of childbirth. Nevertheless, there may be an account of medicine as making people whole that includes pain relief. Perhaps Pellegrino’s defense of healing as restoring wholeness can allow pain relief and suffering reduction20 if wholeness is not meant structurally but functionally. Debilitating pain prevents one from integrating various aspects of one’s life, because it reduces one to a onedimensional pain-fleeing animal or hedonist. Suffering is even defined and developed by Velleman (1999) as something like the distress experienced when collapsing as a person. Perhaps that could be seen as counting as cognitive impairment, that is, dysfunction, when it prevents a range of cognitive and affective activities.21 Still, I am skeptical of the prospect for success here because the labor pain-caused cognitive inabilities resemble those of sleep, which is not a malfunction, but a normal process of rejuvenation. Likewise for the poor mental performance of those who are sleepy right before they Pathocentric Health Care and a Minimal Internal Morality of Medicine 25 fall asleep and immediately after they wake up, these cognitive inabilities are not pathological limitations of one’s thought. V. CONCLUSION NOTES 1. I basically follow Boorse’s later preference for “pathology” over “disease.” While “disease” intuitively excludes injuries, drug overdoses, frostbite, and birth defects, “pathology” does not. Boorse originally used “disease” in an expansive sense to mean any absence of health. He has since switched to “pathology,” which does not seem as strained as “disease” when extended to all instances of the absence of health. 2. I assume that Boorse intends pain to be one of the bad effects to be mitigated. All the citations are from Boorse (2016). 3. Donating organs, tissues, and even blood produces a pathological condition. 4. Boorse relies upon Wootton (2006) for this judgment about the 19th century as being the origins of scientific medicine. 5. Other examples of non-pathology-fighting medicine include the “well baby” care of the normal obstetrician or pediatrician, countering discomfort from menstrual cramps, anesthetizing drugs used by athletes, and adjustment to sleep cycle when traveling. Perhaps even the medical attention given to the declining performances of the elderly is just attending to the normal processes of aging, rather than pathology. 6. “If a woman does not want to become pregnant, give to her in a drink of water moistened (or diluted) copper ore (misy) in the amount of a vicia bean, and she will not become pregnant for a year” (from On the Nature of Women [§98]). I quote from Riddle (1992, 74). 7. While the Hippocratic Oath prohibited some abortions, scholars (Edelstein and Riddle) now believe that Hippocrates did not actually write the oath; rather, it was written by a fringe Hippocratic group. Other Hippocratic writings even provided advice about how to induce abortion. 8. Boorse notes in footnote 17 that “since Pellegrino (2001) believes that ‘health’ means ‘making whole again’ (568), it seems unclear how pain relief, which is merely blocking a sensation, is a case of it, and similarly for suffering in general” (Boorse, 2016, 9). 9. Boorse does note that Veatch in other places allows that health and medicine are not identical and that justified medical treatment might not aim at health and healing. 10. Boorse prefers option (3). He puts forth in the same article an internal morality of medicine with basically one principle regarding patients: that it serves their interests. There may be a failure in Boorse’s Downloaded from https://academic.oup.com/jmp/article-abstract/45/1/16/5679183 by 81695661, OUP on 13 January 2020 Whether an appeal to restoring wholeness can handle normal pain does not matter, for my preferred minimal internal morality of medicine is just the right to refuse to act in ways that cause or increase patient pathologies. Alleviating diseased-caused pain is a proper part of pathocentric medicine as Boorse (2016, 146) understands it and it is certainly compatible with Wakefield’s (1992) account of disorder (pathology) as harmful dysfunction. It just does not cover pains from natural or normal functions like childbirth. Whether doctors have a right to refrain from procedures that do not produce pathologies and thus do not raise the likelihood of death or reproductive failure is another matter. This further refusal is not entailed by a pathologyfighting medicine. It is perhaps there where the external morality’s general demand for benevolence and respect for autonomy will have more force against a physician’s refusal to do something other than fight pathology. 26 David B. Hershenov Downloaded from https://academic.oup.com/jmp/article-abstract/45/1/16/5679183 by 81695661, OUP on 13 January 2020 account to appreciate how patients’ autonomy and interests can collide. There also may be a failure to appreciate that doctors can disregard the patients’ interests for internal reasons, not just external ones like costs to the government. Examples could be not putting someone on an organ waiting list or not providing him with an experimental drug. 11. It is a fine line that differentiates between preventing conception in ways that cause part pathologies versus those that prevent it without directly inducing pathology. Catherine Nolan has made me a little more confident that it can be sustained, for she distinguishes suppressing ovulation and vasectomies, which are pathology-inducing, from a device that traps sperm no longer in the man’s body. The death of such sperm would be a dysfunction of the sperm, but not of the man or woman. 12. Even if they refused to lessen the pain of natural childbirth, we would call them physicians, just callous ones. Keep in mind that Boorse includes mitigating the effects under the heading of fighting disease, so I think he would allow a pathocentric medicine to include pain relief from diseases. He would just insist that obstetrical anesthesia is not a case of disease-caused pain. If someone insists that fighting disease does not include fighting pain caused by it, then one other response is available: that the duty to relieve pain is something anyone should do and thus it is part of an external morality that applies to medical practitioners while at work. One could take the same attitude towards non-pathological obstetrical pain. 13. Personal correspondence. 14. It has been claimed that a pathocentric account of medicine like that which I am defending may not be able to include informed consent as part of the nature of medicine, unlike Miller and Brody’s evolutionary account. I think this is acceptable. There were physicians before the emergence of informed consent in recent decades. It need not even be seen as part of a Brody and Miller evolving internal morality of medicine. Rather, it can be viewed as just an instance of a general principle of external morality that respects consent and autonomy. Medical practitioners were slow to recognize and observe that aspect of a general morality. 15. A referee asked for examples in other fields. Clergy may recognize the state’s legitimate need for information gathering on parishioners who are susceptible to religious-inspired violence. Nevertheless, they should be able to resist with impunity the authorities’ entreaties to themselves be informants as incompatible with their role as confessor, spiritual guide, trusted confident, agent of God, etc. Another possibility is counselors or social workers in a reform school that is committed to rehabilitating juvenile offenders. Imagine that they had taken the job before the state introduced new policies that include incapacitating or merely deterring adolescents. Such reform-minded counselors could have grounds to refrain from participating in such heavy-handed practices geared towards preventing recidivism and copycats as incompatible with their mission of moral cultivation and transformation. A final possible example might be science teachers who firmly believe that science can be demarcated from religious creationist views. They should be able to avoid public school board pressures to teach “creation science” in their classroom. Maybe the school is free to add it to the curriculum and compare its explanatory power with that of science, but if it is not science, then it should not be required of science instructors that they teach it in their science classes as a rival scientific explanatory scheme to evolutionary science. 16. Maybe this minimal internal morality of medicine could be extended to doctors and nurses who did not want to treat certain patients, say of the other sex. Refusing to offer such a treatment would not be tolerated. But, this is trickier since, unlike the Jehovah’s Witness doctor, they are still curing others. Maybe it is just an external morality that prohibits such discrimination. 17. It might be thought that permissibility of doctors’ refusals to perform tubal ligation, vasectomies, and live organ procurement are bullets that I have to bite. However, I do not think they are lethal, painful, or debilitating bullets. Keep in mind that the current practice of the double veto in transplant ethics has been defended as not violating patient autonomy. While the patient may have a right to donate an organ, she does not have a right that doctors take the organ. Transplant teams can refuse to take organs without violating the patient’s autonomy. Likewise, it may be a doctor’s right to refuse to take organs or engage in other pathology-causing practices. 18. Unlike Boorse, I doubt that the internal morality of medicine is just to serve the patient’s interests. 19. Boorse (2016) adds, “In fact, since the pain of disease or injury is a wholly normal reaction to it, one might expect a true purist about medical goals to condemn nontherapeutic pain relief as not true ‘healing.’ Yet no one takes that position” (2016, 171). 20. Pace Boorse’s (2016) claim in footnote 19. Pathocentric Health Care and a Minimal Internal Morality of Medicine 27 ACKNOWLEDGMENTS I would like to thank Christopher Boorse first for delivering his original and stimulating paper “Goals of Medicine” as the keynote address at the Pantc conference that I organized and then for suggesting that I write up my criticisms and submit them to the Journal of Medicine and Philosophy. REFERENCES Boorse, C. 2016. The goals of medicine. In Naturalism in the Philosophy of Health, ed. É. Giroux, 148–77. Basel, Switzerland: Springer. Edelstein, L. 1967. Ancient Medicine: Selected Papers of Ludwig Edelstein. Eds. O. Temkin and C. L. Temkin. Baltimore: John Hopkins Press. Jaggar, A., M. Tooley, C. Wolf-Devine, and P. Devine. 2009. Abortion: Three Perspectives. Oxford, United Kingdom: Oxford University Press. Kass, L. R. 1975. Regarding the end of medicine and the pursuit of health. The Public Interest 40(1):11–42. Miller, F., and H. Brody. 2001. The internal morality of medicine: Explication and application to managed care. Journal of Medicine and Philosophy 26(6):581–99. Noonan, J. T., Jr. 1965. Contraception. Cambridge, MA: Harvard University Press. Pellegrino, E. 2001. The internal morality of medicine: An evolutionary perspective. Journal of Medicine and Philosophy 26(6):559–70. Riddle, J. 1992. Contraception and Abortion from the Ancient World to the Renaissance. Cambridge, MA: Harvard University Press. Veatch, R. 2001. The impossibility of a morality internal to medicine. Journal of Medicine and Philosophy 26(6):621–42. Velleman, D. 1999. A right to self-termination? Ethics 109(3):606–28. Wakefield, J. 1992. The concept of mental disorder: On the boundary between biological facts and social values. American Psychologist 47(3):373–8. Wootton, D. 2006. Bad Medicine. New York: Oxford University Press. Downloaded from https://academic.oup.com/jmp/article-abstract/45/1/16/5679183 by 81695661, OUP on 13 January 2020 21. A referee claimed that “the idea that pain reduces integrated function or is even a cognitive impairment doesn’t seem helpful for labor pain. When those (labor processes) occur, there isn’t anything else the woman is trying to do (or cognize) besides giving birth.” Fair enough. However, she may have to make decisions about the procedure, such as whether to undergo a Caesarean section or some other treatment, and pain can impair that decision. Extreme pain can also make her less able to participate in the delivery—follow directions and relay information, etc. So in that way, thought is unlike the rest of the normal and healthy bodily limitations that occur during a birth. The latter do not impair delivery in the same way great pain can. © 2020 Journal of Medicine and Philosophy Inc. 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