Recent eLetters

Displaying 1-10 letters out of 471 published

  1. Re:Moral value of newborn infants

    Dear Editor,

    Giubilini and Minerva's paper, 'After-birth abortion: why should the baby live?' [1] is a 'thought experiment' expressing old ideas supported by old arguments, [2] with the only innovation being to extend killing of newborns to those who are normal, apart from being unwanted. It is redolent of the almost mathematical approach to human life much favoured by some philosophers, and Giubilini and Minerva have every right to discuss the idea.

    We believe publication in a high-profile medical journal is another matter. It was brought to public notice as headline news, expressed with characteristic journalistic hyperbole in some Australian and British newspapers and was bound, therefore, to elicit maximum repugnance from most readers, yet also to give ammunition to extremists in both directions. We question both the motivation and the act of publishing the paper, which does not add to useful discussion and which exposes bioethicists to ridicule.

    While Giubilini and Minerva correctly identify the infant and the mother as central in the argument, they seem na?ve in regard to the subsequent effects of killing the baby, let alone the fact that such events take place in a society which collectively sets general ethical and legal standards. Their use of the disingenuous euphemism 'after-birth abortion' for infanticide is in the same league as 'collateral damage' for non-combatants killed in warfare. Lacking a clear indication of when it would no longer be OK to kill a newborn baby and how anyone would be able to decide when the baby becomes a person, this paper is mere moral posturing.

    We find the argument that neonates are morally equivalent to fetuses and the whole concept of retrospective abortion morally unacceptable. Neonates who die are dead babies, not products of abortion. We no longer leave newborns with Down syndrome to die of dehydration. We oppose throwing newborn girls in the trash because they are the wrong gender. Additionally, the authors argue that adoption is not in the best interest of people without explaining or justifying this extraordinary statement.

    As paediatricians, we have spent a lot of our lives acting as child advocates and arguing that newborns are morally under-valued. [3] Over a million newborns died last year in the world and newborns are responsible for 40% of all childhood deaths under 5 years, almost all in developing countries. [4] Neonatal intensive care is highly cost-effective and compares favourably with adult intensive care. [5] The Nuffield Council report on bioethics argues convincingly that neonates are morally equivalent to older children and adults. [6]

    If the paper has any value, it should be to stimulate efforts to re- define the true moral value of newborn infants. [3]


    1. Giubilini A, Minerva F. After-birth abortion: why should the baby live? J Med Ethics published online February 23, 2012: doi:10.1136/medethics-2011-100411.

    2. Singer P. Rethinking life and death. New York, St Martin's Press 1994:180-3.

    3. Janvier A, Bauer KL, Lantos JD. Are newborns morally different from older children? Theor Med Bioeth 2007;28:413-25.

    4. Oestergaard MZ, Inoue M, Yoshida S, et al. Neonatal mortality levels for 193 countries in 2009 with trends since 1990: a systematic analysis of progress, projections, and priorities. PLoS Med 2011;8:e1001080.

    5. Doyle LW; Victorian Infant Collaborative Study Group. Evaluation of neonatal intensive care for extremely low birth weight infants in Victoria over two decades: II. Efficiency. Pediatrics 2004;113:510-4.

    6. Nuffield Council on Bioethics. Critical decisions in fetal and neonatal medicine: ethical issues. Oxford, Nuffield Council, 2006. Available on (accessed 29 March 2012).

    Conflict of Interest:

    None declared

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  2. A devil's advocate outflanked by demons: Is it really time to stop talking to anti-vaxxers?

    Brennan offers an interesting strategy in "A libertarian case for mandatory vaccination," though in form it is the common "devil's advocate." The apparently least charitable bases for one's own position (in this case libertarian premises) are granted for the sake of argument; one's position is nevertheless found defensible (mandatory vaccination); and thus the harshest critics are answered without having to pay out a full rebuttal. One need not endorse or condone the "devil" for this to work; it is not sophistry to pick your battles - if libertarianism is right, mandate vaccines; if it is wrong, mandate vaccines by a probably more obvious argument than if it is right. No commitment necessary.

    It should be noted, though, that Brennan's intended "devil" is clearly a pro-vaccine libertarian. The anti-vaxxer audience is lost by assumptions (A)-(D) that take for granted the efficacy, safety, and obviousness of vaccines, plus a quip about Jenny McCarthy.

    The damage here is not in directly insulting a particular reader (I would be suprised if many anti-vaxxers read the JME), but in what such disregard entails. For instance, the author briefly mentions that libertarians can tolerate government advertisement campaigns, but he does not feature this as a serious criticism, presumably because the anti- vaxxer is not only irrational, but unreachable. While it is true that any attempt to persuade a dogmatic believer can backfire and cause further polarization instead, this danger applies also when outreach is forsaken in favor of compulsion. It could be replied that, in the time it takes for outreach to work, we will fail to stop harm to others, but in the time it takes to debate each other about a mandate (and eventually to pass it), there will also be infected. Force is seen as efficacious only after diplomacy has been discarded.

    By disregarding the anti-vaxxer as an agent with potentially revisable beliefs, this article becomes about what "we" are to do about "them." "We" are very diverse (so some devil's advocacy is required), but "they" are demonized with words like "irrational," "stupid," and "self- destructive." "They" aren't invited to this article, where the "them- problem" is discussed and resolved (by government policy, no less). Liberals and libertarians should be the first to get chills, at which point Brennan also loses the very audience he attempts to court, who are particularly wary of government-enforced marginalization.

    So here is a "demon's advocate" portrait of an anti-vaxxer, based on close friends of mine who have not vaccinated their children (though I do not claim how far the portrait can be generalized): They are people. They are firm in belief, and when I finish talking to them, I do have feelings of frustration that one might express through name-calling (I have done so privately). However, they are not those names; they are concerned mothers and fathers who share many premises in common with me and probably with you - for instance, a high regard for the welfare of their children. Their premises diverge from mine on which sources of health information are most trustworthy, as we have both a different religious and educational upbringing, and they have felt (not unjustifiably) estranged from the mixture of impersonal, corporate, and politicized healthcare that differs strikingly from their intuitions on what "health" or "care" mean. They prefer personal relationships with small-town doctors who spend time taking their histories, and who typically engage in preventive, holistic, minimally pharmaceutical, and minimally invasive forms of care (primum nocere). Adverse events and side-effects are judged more heavily than potential gains in health or improvements in one's natural history, so most drug labels are off-putting and some minor maladies shrugged at; preferences sometimes align with what evidence-based medicine would prescribe and sometimes not. Drug and supplement companies who advertise as being all-natural, small-scale (non-PHARMA) businesses have taken the time to understand, magnify, and exploit some of these preferences to share information "that the FDA doesn't want you to know," along with conspiracy theories about FDA, Pharma, and government agendas (only marginally more far-fetched when compared to confirmed events like the Tuskegee or US Radiation studies, which, to use Brennan's phrase, "a minimal amount of research" can easily uncover for any American worried enough to look for it).

    If we are both clever and patient enough to derive government mandates from libertarianism, is our rhetorical distance from this portrait so much greater? Couldn't some of their own premises favoring preventive care and corporate transparency be used to expose the misinformation?

    *The opinions expressed in this letter are personal and do not necessarily represent the views of my institution

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  3. A hierachy of access to information/ knowledge is unethical

    There is a hierarchy of means to access opinions and information published in journals. This is unethical in a democracy which uses citizens' information to contribute to debates- from which they are then excluded. This to some extent mirrors my position that it is unethical to with hold information from clients in therapy. It is taking advantage of vulnerability however it is dressed up but also creates a hierarchy of the informed. There are some prospective clients who will be more informed by reading up on the practice and many others who will rely mainly or only on what is disclosed by the therapist. There is also the problem of the therapist him/herself deciding who will be given how much information. Which can be discriminatory. Withholding information can also be used defensively by therapists to hide their own insecurities.

    The claim that it is acceptable to 'benignly' deceive clients undermines what is the more important component - trust .To deceive as a means to an end is unethical and more likely to be a component which adds to dissatisfaction if the therapy is unsuccessful.

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  4. Response to Roberts

    Dear Editors, I read with interest the recent article on the ethics of doctor's strikes.1 I accept most of the arguments expressed in the article, however, there is one shortcoming to the framework: its under-analysis of the role that the social context can have when evaluating the ethics of doctors strikes.2 I contend that there is a need to contextualise industrial disputes of this nature, namely, reflecting on and evaluating the nature of the healthcare system, its values and vision, and its relationship to the prevailing socio-political landscape. Such an approach would offer a more integrated ethical understanding of doctors decision to strike and extend the value of the ethical framework being proposed. Roberts does attempt to contextualise the strike, by referring to the 'party line' adopted by various government officials and departments that the junior doctor strike exposes patients to serious harm 1(p.3), and how the media can be used to promote the government position. However, the link between the doctors' actions and the social context is not properly formulated. Healthcare systems can be categorised into four basic models- Beveridge model (UK), the social insurance model (e.g. Germany), the national insurance model (e.g. Canada) and a market driven model (e.g. India).3 Each of these systems employ different principles of healthcare. It would be worth incorporating this dimension of health care to an ethical framework for evaluating doctors' strikes. In this article the NHS and the Department of Health are framed as the doctors 'employers'. While this is factually correct, it is worth remembering that the Department of Health and the NHS are also significant social institutions, key apparatuses of the UK welfare state and custodians of its principles of universality, equality and justice.4 In this particular case, it would be appropriate to check the actions of the government and that of the doctors decision to strike against these principles.5 The NHS has undergone a period of profound restructuring and reorganisation under the austerity driven focus of a conservative coalition government (2011-2016) and more recently a majority conservative government (2016-present).6 The 'better outputs with fewer resources'8 logic of austerity calls into question whether equality, access and quality of health services can be achieved when fiscal rectitude rather than universality is the operational mode.7 9 In the UK the annual health spend per capita in real terms is slowly recovering from -1.3% in 2010(compared with 0.1% for the OECD average for the same year). In 2013 the figure was 0.6 %, however, this was still behind the 1.0% average for the OECD. 6 This concerted strategy to underspend in the area of healthcare also included a two year policy of pay freezes and staff redundancies.6 It is clear that these political decisions have had an impact on the delivery of healthcare, impacting of the range of services provided and the working conditions for staff. Austerity then not only amplifies health inequalities of society and but also erodes at the 'the very principle of relatedness and mutuality'10 that defines these public health services and initiatives. Incidentally, this belief in state responsibility for the health of UK citizens has proved a rallying call for some of the striking doctors. During the escalation of the industrial strikes in April 2016, a make- shift banner was posted on the wall of a NHS hospital near my place of work. It read: 'The NHS will last as long as there are folk left with faith to fight for it- Aneurin Bevan'. This poster betrays the striking doctors' sympathy with the ethical vision of the founding father of the NHS and adds further legitimacy to their actions. It would appear that the values of the healthcare system and the type of priority it is given or not by a government are also important factors to consider when evaluating the reasons why doctors strike. I think that this amendment is worth making and highlighting for consideration.

    REFERENCES 1 Roberts AJ. A framework for assessing the ethics of doctors' strikes, J Med Ethics Published Online First: 20 May 2016 doi:10.1136/medethics-2016- 103395. 2 Weinstein BD. Dental ethics. Philadelphia: Lea and Febiger 1993. 3 Physicians for a National Health Program. Healthcare systems-Four Basic Models, resources/health_care_systems_four_basic_models.php (accessed 8 Jun 2016). 4 Weir S. 2015. The welfare state is dead - what is rising from the grave?. dead-%E2%80%93-what-is-rising-from-grave (accessed 7 Jun 2016). 5 Pearse N. 2015. Welfare debate marks opportunity to renew Beveridge's legacy. marks-opportunity-to-renew-beveridge%E2%80%99s-legacy (accessed 7 Jun 2016). 6. OECD. Country Note: How does health spending in the United Kingdom compare? 7 July 2015. OECD Heath Statistics (accessed 7 Jun 2016). 7 Quaglio GL, Karapiperis T, Van Woensel L, et al. 2013. Austerity and Health in Europe. Health Policy 2013; 113: 13-19. 8 Thomas S, Burke S, Barry S. 2014. The Irish health-care system and austerity: sharing the pain, Lancet, May 3, 2014; 383: 1545-1546. 9 Suhrcke M, Stuckler D. 2012. Will the recession be bad for our health?: it depends. Soc Sci Med 2012; 74: 647-653. 10 Lynch, K. 'New managerialism' in education: the organisational form of neoliberalism, Open Democracy, 16 Sept 2014.'new-managerialism'-in-education- organisational-form-of-neoliberalism (accessed 7 Jun 2016).

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  5. Contempt for Conscience, Contempt for the Profession

    A major conceptual problem this paper suffers from is the suggestion that those whose views do not accord with the majority are, by default, not tolerable.

    Such people, whom the authors assume are exclusively religious, are twice said to possess an idiosyncratic view of the universe. These remarks exclude the possibility that there might be good, even non-religious, reasons for conscientious objections. Moreover, they betray a contempt for religious views.

    These people are also said to have "ultimately arbitrary" views, and that because it is "ultimately up to society to determine the scope of professional practice", those who wish to conscientiously object should leave the profession. Two things here are cause for alarm. The first, relating to the previous point, is: the authors suggest that off-beat views are nonsensical. This is a disrespectful posture which colours the entire argument.

    The second is the largely undefended assumption that society defines the scope of the medical profession. This is intellectually untenable. Professions have always enjoyed a degree of independence from the State. This degree of autonomy prevents certain conflicts of interest, and allows a profession to develop its own aims and standards. Professional standards are not determined by plebiscite, but by rational reflection.

    Of course, the professions are accountable to the State and the nation, but not dictated by them. Only tyranny contradicts this. Simply, it is not in the general interest for the professions to be merely a tool of the government. Since the authors appear to suggest the opposite, that the professions should acquiesce entirely to others' demands, their attempted ethical argument is built upon political presuppositions. If their argument is to stand, so must these political assumptions be defended.

    In conclusion, doctors of all stripes and beliefs should be most distressed by the proposals laid out in this paper. Morality and medicine are not issues to be settled, in the final analysis, democratically. The professions should resist unreasonable interference from other bodies. It would be most undesirable for them to bow to the absolutism of public demand or government decree. Though the authors dismiss all analogy with historic totalitarian regimes, they seem to suggest that conscientious objection is never appropriate. And this is manifestly false.

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  6. Proposed FGM 'compromise' illuminates medical complicity with non-therapeutic fee-paying surgery on infants.

    The JME's peer reviewers failed to press the clinical issues before publication of this flawed paper(1). The unoriginal idea of a 'ritual nick' performed by health professionals in a harm limitation approach to female genital mutilation (FGM) was proposed by the American Academy of Pediatrics back in 2010(2), who rapidly replaced their statement(3) in the face of worldwide condemnation(4) by the World Health Organisation, and the UK Royal Colleges of Obstetricians and Gynaecologists and Paediatrics and Child Health, amongst others.(5)

    Many mistakes slipped through: (i) the authors say the prevalence of FGM is stable, but provide figures showing it falling; (ii) they claim to medically recategorise all procedures (amateur, accidental or surgical) - matters beyond the scope of ethicists to judge; (iii) they state the impacts of surgery on male and female genitals can be assumed to be similar - they cannot; (iv) likewise, comparisons with adult surgery (including cosmetic female genital surgery) are not relevant to children; (v) there is no such thing as a "nick that heals completely" without leaving scar tissue; (vi) indeed, they later admit that "de minimus" procedures will involve "tissue being removed", the amount being difficult to regulate; (vii) controversially, they describe asymptomatic healthy children as "patients" thus generating an overweaning sense that doctors owe a duty of care regarding social matters; (viii) despite arguing for autonomy they did not suggest leaving parents with responsibility for performing the 'nick'; (ix) far from seriously considering the utilitarian calculus, they have no insight into the damage their proposal has on trust in the medical profession; (x) the concept of 'harm limitation' need not be applied(6) to justify changing the present global consensus, especially without evidence of rising harm in countries where FGM is illegal; (xi) they neglect entirely physicians' conflicted pecuniary interest when surgically altering healthy children's genitals, even if by request of loving parents for socio-cultural benefits; (xii) revealingly, they use a self-referential test for acceptability based on one gynaecologist's previous defence of male circumcision(7).

    Surgeons should respect the basic ethical principles of 'first of all, do no harm' and informed consent to irreversible surgery on the basis of medical necessity, particularly when performed on children. In the USA (but less so in Europe), there may presently remain a 'liberal' tolerance of male circumcision whose protection appears to be the article's real purpose. The weak arguments presented might lead to the opposite conclusion: far from condoning renamed non-therapeutic procedures (no doubt performed for a fee on defenceless girls), why not turn the spotlight onto medically sanctioned traditional 'ritual' practices on male infants?

    References (1) Arora KS, Jacobs AJ. J Med Ethics Published Online First: 22nd February 2016 doi:10.1136/ medethics-2014-102375 (2) American Academy of Pediatrics. Ritual genital cutting of female minors. Pediatrics 2010; 125: 1088-93. (3) American Academy of Pediatrics. Policy statement: ritual genital cutting of female minors. Pediatrics 2010; 126: 191. (4) MacReady N. AAP retracts statement on controversial practice. Lancet 2010; 376: 15. (5) Joint RCOG/RCPCH statement on the AAP policy statement on FGM. 12 May 2010 policy-statement-on-fgm/

    Conflict of Interest:

    I was involved in setting up an FGM clinic 1996, have publications on FGM, and received a fee for expert advice in the UK's first FGM trial 2014.

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  7. Utilitarianism in disguise will remain unconvincing to many

    The authors submit an ethical theory which rejects categorical conceptions of right and wrong, and adopts a scaled view of rightness, believing that it can depolarise the debate over the use of human embryonic stem cells (hESC) in medical research. I will argue that their proposal is unsuccessful.

    They argue that binary ethics must be forgone in preference of a non- binary understanding of rightness and wrongness: pro and contra reasons cannot be reduced to a binary moral conclusion, and a single pro or contra reason should ever rule out acts which go against it (and vice versa). If it were otherwise, an illegitimate "deontic leap" is made, and a binary conclusion (e.g. action X is right/wrong) is forced. Below I offer one major reason why this theory cannot do what the authors claim it can.

    Crucially, "right" and "wrong" remain (apparently) undefined, though they are essential to the debate. Those who oppose to the use of hESC often assume that embryocide is murder--a belief not easily trumped even by the forceful argument of medical research.1 So, if the means to an end are seen as absolutely wrong, the "non-binary" analysis will mean nothing to those whose ethic includes deontological considerations such as "do not kill".

    The authors do not seem to recognise this. Hence, they imply that "right" and "wrong" are synonyms of "pro" and "con" respectively; they assume a quantitative view of ethics. Thus, they reveal that their ethic is utilitarian. Regardless of whether utilitarianism is valid or not, it is na?ve to think that it could resolve a debate so bound up in religion and politics.2 Simply, it is a different ethical language to that of some of the major voices in the debate.

    Espinoza and Peterson's non-binary ethical theory falls short of its promise to depolarise the ethical debate. Its utilitarian design sidesteps other ethical considerations in order to redefine the terms of the debate, making it unconvincing to many.

    1. Meilaender, G. 2013. Bioethics: A Primer for Christians. Cambridge: Eerdmans 2. Green, R. M. 2008. "Embryo as epiphenomenon: some cultural, social and economic forces driving the stem cell debate". Journal of Medical Ethics, 34, pp 840-844.

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  8. There is still an unethical failure of democracy

    I feel a huge debt of gratitude towards the Journal of Medical Ethics for showing that it can be possible for outsiders to contribute to what can seem like a closed circle of people talking to themselves. Just to point out though that there is not an equality of democracy when the Journal of Medical Ethics and others are still largely unknown to the public; that work carried out in the name of 'the public good' is unknown until it trickles down into policies; that they still has a pay policy which bars many from reading most complete articles and therefore the opportunity of making their own authentic views heard. Is there maybe a fear of 'lowering the tone' of the more academic publications? Funding is an issue but does it need to cap the right to equality of access to debates about issues which effect society as a whole? For outsiders such as myself it can seem at times that specialist publications can act like some exotic society composed of those who can afford to pay, can speak the language of academia - to each other - and /or have free access through institutions from which most members of the public again are excluded.

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  9. More on Moore and moral status

    I look to clarify and reinforce my criticisms of the Moorean defence by Curtis and Vehmas of their proposition that all humans have an equal moral status that is higher than that of all non-human animals. In particular, I point to the relative scope for inventive new arguments against that proposition, and suggest that what misgivings we have about rejecting it are inadequate to make that type of strategy appropriate.


    In 'Having hands and moral status', I made two principal claims about Curtis and Vehmas' Moorean defence of the following proposition:1

    H>A: Humans have an equal moral status that is higher than the moral status of non-human animals.

    The "basic idea" of their Moorean strategy "is that our confidence in the truth of this proposition is greater than our confidence in the propositions that make up those philosophical views that entail that it is false, and that this is sufficient to justify rejecting those views and to continue to believe H>A."3 In other words, any deductive argument for a contrary proposition is really "no more than an invitation to compare plausibility:"4 if it is more plausible that a premise of that argument is false than that its conclusion is true, then "we should not be moved by the argument".1

    My first claim was that although their strategy is logically valid, "it is not powerful." My second, which I labelled "[m]y own view", was that "resort to the argument the authors make reflects too great a pessimism about the class of accounts which are unresponsive to PIDs", or profound intellectual disabilities. In a short rejoinder, Curtis and Vehmas explain why they believe I fail to establish those two claims. Since the authors misunderstand the points of both of them -- and given the significance of the issues our papers cover -- I look to clarify and reinforce those criticisms here.

    Valid, but not powerful

    Arguments 'for' propositions

    The first sense in which the Moorean strategy is "weak"3-- a word I never use -- is general to any issue to which it is applied. This is that "it does not give one any stronger reason than one had" to believe in the proposition defended: "all it does is point out that one's confidence in that position is a reason not to believe in others."1 In that particular sense, it is not an argument for H>A or for an external world: what disagreement we have about that label is in principle purely semantic.

    Curtis and Vehmas also note -- and read a great deal into -- my aside about ghosts: that a conviction in their reality is a reason to doubt attempts to explain them away, but not a reflexive reason to believe in them more. The comment was not a reductio of their argument, not least because I disagree with their assumption that using the Moorean strategy to defend one's ghostly beliefs against empirical attacks "is obviously not something that one would be justified in doing".3 Rather, my point was precisely that a Moorean argument which plays on how strongly you disbelieve a conclusion does not, as I use the label, count as an argument for your disbelief: "[h]aving confidence in the existence of ghosts is a pro tanto reason not to put stock by attempts to explain away ghostly appearances with optics or psychology, but it is not a reflexive reason to be confident in the existence of ghosts."1

    Out of the sceptical context

    The more important sense in which the Moorean strategy is "weak" is specific to its application to the issue of moral status. In my reply to Curtis and Vehmas' paper, I wrote that:

    Moore's original argument from his confidence he has hands to the existence of external things is unusually powerful because the sceptical arguments he opposes tend not to offer reasons to be confident about any alternatives: rather than suggesting just that we do not have hands, scepticism challenges our reasons to be confident about any of the possibilities; there need not be a change to the order of the options we have confidence about.
    The case of moral status is fundamentally different. Each plausible argument for an account which conflicts with all and only humans having full moral status is potentially capable of tipping the balance against that proposition. Such arguments are not sceptical reasons to doubt our confidence in everything: they advance opposition to the defended account relative to it.1

    The authors assert that I misconstrue Moore's argument, which, on the "common interpretation" which they ascribe to Lycan, "is not from [Moore's] confidence that he has hands to the existence of external things, but from his confidence that he knows he has hands to that he knows that external things exist".3 Lycan actually attributes both versions to Moore, with Curtis and Vehmas' reading being a development of what Moore first intended which makes "a rubber arrow" of an objection to any role played by common sense.4 Moreover, my claim that "[t]he case of moral status is fundamentally different"1 remains importantly true regardless of to which level the shared schema is applied.

    A typical sceptical argument asks us to imagine that we are, for example, brains in vats, fed artificial neural signals which generate a convincing illusion of reality. It then invites us to note that we cannot rule this possibility out, since all of our perceptual experiences would be as they are in actuality; deduces that we cannot know that this possibility is not actual; and concludes that, since we would not have hands were we brains in vats, we do not meet the standard for knowledge of whether we do have hands.

    The Moorean insight is that if it is more plausible that we know that we have hands than that it is possible that we are brains in vats, then the sceptical argument need not be threatening: rather than accepting its conclusion, we ought to -- or at least are free to -- deny that it is possible that we are brains in vats. What makes Moore's anti-sceptical position exceptionally secure, or his defensive strategy "unusually powerful",1 is how difficult it is to make it more credible that a sceptical possibility could be real: that we could be brains in vats or be plugged into the Matrix, or be duped by Cartesian demons or locked in vivid dreams.

    That security is not transferrable to questions of moral status. As a project, sophisticated opposition to H>A is still relatively immature. There is plausibly plenty of scope for inventive new arguments for positions with which H>A conflicts, whether drawing on unconsidered intuitions, metaethical innovations, zoological discoveries, or studies of psychological biases. Curtis and Vehmas note in their original paper how the best-known objections to H>A are "based upon a set of theoretical claims, such as the claim that moral status can depend only upon the possession of intrinsic properties," and that new arguments which drew on empirical facts would be "of an entirely different sort than those usually offered".2 The point is that there is ample latitude for such arguments to be developed or publicised, whereas the same is not nearly so plainly true of sceptical opposition to Moorean dogmatism. In this sense, the authors' deployment of the strategy is importantly different and significantly less enduringly effective.

    Reflecting too great a pessimism

    Denying H>A

    Recall that my original second claim was that "resort to the argument the authors make reflects too great a pessimism about the class of accounts which are unresponsive to PIDs."1 The Moorean strategy is one to adopt when none of the positions we can positively defend are anything but barely appealing: when the arguments for them are so uncompelling that we feel free to assume their conclusions are false. With this in mind, I used the final paragraph of my discussion to outline an account on which a being's moral status is proportionate to the "magnitude" of their interests, or more roughly to their capacity for satisfactions and dissatisfactions. Non-human animals -- or at least those of which we know, and then as far as we know them -- plausibly do have a smaller scope of interests than we as humans do.

    That account is "unresponsive to PIDs" in the sense that it does not make any person's moral status directly dependent on their cognitive capacities: that is, to borrow from Curtis and Vehmas, "those capacities to do with conceptual abilities, understanding, problem solving and rational decision-making."2 Instead, the entitlements, rights, or distributive heft of a person depend entirely and exclusively on their capacities for joys, disappointments, excitements and distresses: if PIDs are relevant to moral status, it is via those amplitudes only.

    In their restatement of my claim, Curtis and Vehmas replace "the class of accounts which are unresponsive to PIDs" with "the accounts available that purport to justify H>A", then finding my comments "puzzling" because on my proposal H>A is false.3 The conclusion they should instead have drawn is that I do not think an account needs to vindicate H>A to be compelling enough to make a struthious Moorean strategy inappropriate; it is in that sense that falling back on the strategy "reflects too great a pessimism".1 In particular, I do not think that accounts which satisfy H>A are unique in respecting what we find most troubling about the traditional criteria for moral status, nor that H>A is robust and self-evident enough to be aptly labelled "common sense".2

    What is troubling about those accounts of moral status which follow the liberal Lockean tradition -- making one's status contingent on autonomy, agency, or cognitive capacities -- is not in itself that they are sensitive to real differences within and across species, but rather that they fixate on distinctions which ought not at all to matter. Lacking cognitive capacities does not make a person any less inherently and importantly valuable and dignified: it does not justify inequalities of moral consideration. As Alastair Norcross put it, the fact that beings "can't be moral agents doesn't seem to be relevant to their status as moral patients: moral status "is not some kind of reward for moral agency."5 We agree, I think, in opposing "the view that such intrinsic psychological capacities as rationality and autonomy are requisites for claims of justice, a good quality of life, and the moral consideration of personhood",6 but we part soon after there.

    If one human is ever entitled to less than another, it ought to be because they have less use or need for what is at stake: that they lack some latitude to be satisfied or dissatisfied. That latitude, or that magnitude of interests, plausibly does matter to our dues or to our heft in distributive algorithms, and it plausibly is what creates moral gradations amongst known sentient beings.7, 8 It is not that we are innately unequal as beings or as humans, but rather that our interests are:9 that "a mayfly imago which needs not even feed will also not be fearing homophobia or pondering the frustration of its childhood dreams."1 Provided we keep this distinction in mind, H>A might if anything seem implausible in principle; short of that, it does not just seem "common sense".

    Non-human animals

    Curtis and Vehmas draw attention, however, to the account's implications for those humans and non-humans who share their sentient capacities for joys and disappointments.2, 3 Suppose, to take their example, that equality is true of humans with PIDs and dogs, and that we begin with the credible assumption that the moral status of a humans with PIDs exceeds -- perhaps significantly -- that of a dog. The standard argument is that we then face a trilemma: either acknowledge that dogs have greater moral status than we thought, being equal to that of humans with PIDs; accept instead that the status of humans with PIDs is lesser than assumed, being equal to that of dogs; or endorse, after all, something similar to H>A, and here defend it with a Moorean shift. I have, like many, no attraction to the second option. I will close this paper by both suggesting that the first is favourable to third and attempting to undermine any concerns.

    Many of our thoughts about the moral status of animals relative to humans with PIDs may, firstly, stem simply from a lack of knowledge of what most humans with PIDs are like. Eva Kittay, for example, describes her own daughter -- "diagnosed as having severe to profound retardation" -- as "enormously responsive, forming deep personal relationships with her family ... and friendly relations with her therapists and teachers," and with a discerning taste for "especially but not exclusively classical symphonic music".10 Kittay's daughter is not comparable to any non-human animal as most of us understand them: if there is a dog which matches her for sentience, then that dog is truly exceptional. Our misgivings may not be about genuinely equal cases.

    Secondly, we need to be clear that moral status need not even closely align with how a person should be treated: it is not a guide to whether we can "farm and eat the flesh" of people,2 or an indication of how much we value them. We stand in relations to humans with PIDs which we rarely if ever do with any non-human animals: we care deeply about them and about our relationships with them, and the facts that they matter so much to us, that we identify with them, and that they may depend on us give us perfectly permissible reasons to treat them exceptionally well. It is a fallacy that two beings with equal moral status need to be treated the same, and we should consider how much this accounts for the extent to which we find the first option challenging.

    Thirdly -- and finally -- recall the reasons I gave for thinking the Moorean strategy which Curtis and Vehmas proposed to be, albeit "valid", far from "powerful."1 We must be incredibly careful not to see that strategy as permitting us to be more confident about the truth of H>A: despite the titles of both their papers, it is not an argument for that proposition in the most conventional evidential sense. If H>A was ungrounded before, it remains as ungrounded now: it is a dialectical last resort. I suggest that we have greater reason to adopt an alternative view than we do to maintain H>A in the face of foundational difficulties "that we do not know how to overcome";2 H>A is, at least, nothing like our convictions that we really know that we have hands.


    1. Roberts AJ. Having hands and moral status: a reply to Curtis and Vehmas. J Med Ethics 2016;42:265 doi:10.1136/medethics-2015-103355.

    2. Curtis B, Vehmas S. A Moorean argument for the full moral status of those with profound intellectual disability. J Med Ethics 2016;42:41--5 doi:10.1136/medethics-2015-102938.

    3. Curtis B, Vehmas S. The Moorean argument for the full moral status of those with profound intellectual disability: a rejoinder to Roberts. J Med Ethics 2016;42:266--7 doi:10.1136/medethics-2016-103437.

    4. Lycan WG. Moore against the new skeptics. Philos Stud 2001;103:39+42 doi:10.1023/A:1010328721653.

    5. Norcross A. Puppies, pigs, and people: eating meat and marginal cases. Philosophical Perspectives 2004;18:243 doi:10.1111/j.1520-8583.2004.00027.x.

    6. Kittay EF. At the margins of moral personhood. Ethics 2005;116:100 doi:10.1086/454366.

    7. Singer P. Speciesism and moral status. Metaphilosophy 2009;40:567-81 doi:10.1111/j.1467-9973.2009.01608.x.

    8. DeGrazia D. Moral status as a matter of degree? South J Philos 2008;46:181-98 doi:10.1111/j.2041-6962.2008.tb00075.x.

    9. DeGrazia D. Equal consideration and unequal moral status. South J Philos 1993;31:17-31 doi:10.1111/j.2041-6962.1993.tb00667.x.

    10. Kittay EF. The personal is philosophical is political: a philosopher and mother of a cognitively disabled person sends notes from the battlefield. Metaphilosophy 2009;40:616 doi:10.1111/j.1467-9973.2009.01600.x.

    Conflict of Interest:

    None declared

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  10. Classification of Hyper-parenting

    Although genetic selection has a slew of issues involved with the process, what dictates hyper-parenting? If being a hyper-parent is the same for genetic selection as it is for having an organized schedule for one's child, at what point do you tier different levels of hyper- parenting? If everyone seems to be a hyper-parent in their own right, wouldn't the argument of "gene selector hyper-parents" become moot?

    Conflict of Interest:

    None declared

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