Answering the challenge: moral philosophy and the cognitively disabled Dominic Wilkinson 29/9/08 Does cognitive disability present distinct problems for philosophy and moral philosophy? Until fairly recently philosophers have given precious little attention to the question of the care, the internal experience and the moral status of those human beings whose cognitive capacities are significantly less than the rest of the species. But in the last 2 decades or so there has been increasing focus on the ethical and metaethical questions that relate to the cognitively disabled, particularly those who are most profoundly disabled. These questions were the focus of a conference in New York in late 2008 – “Cognitive Disability: a challenge to moral philosophy”.1 The conference raised a number of interesting questions, and the presentations will be available online as podcasts2, in a special issue of the journal Meta-philosophy, and in a published collection by Blackwell. Here I will briefly outline and draw links between two questions that underpinned a number of the presentations. Firstly, what is the appropriate conception of the good for individuals with severe cognitive disability3? Second, how should we think about and treat individuals with severe cognitive disability (SCD) compared to non-human animals with similar (or greater) cognitive capacities? Is it even appropriate to make such comparisons? Finally I will point to some important distinctions that are relevant to attempts to answer the question of how we should treat humans with SCD. What makes for a good life? This question is one of the most fundamental in philosophy, and great minds have been attempting to answer it for thousands of years without reaching a consensus. One broad way of classifying the answers that are given to this question is into subjective and objective.(DeGrazia 1995) Subjective theories point to the ultimate value of pleasure (hedonistic theories) or the fulfilment of desires (preference-based theories). On such theories things can be good for us insofar as we are aware of them and they lead to positive experiences, or if they satisfy our preferences. These things can be said to be in our interests. On the other hand objective value theories hold that certain activities or features make life good regardless of whether or not they are consciously perceived or preferred. These might include for example the development of deep reciprocating relationships, the pursuit of knowledge, the development and attainment of goals. There can be hybrid theories that include both subjective and objective elements (for example thinking about ‘rational preferences’ as well as actual preferences, or incorporating preference satisfaction into lists of objective goods), and to many, such combined theories are the most plausible accounts of what makes our lives valuable. SCD can be relevant to either of those two broad types of theory.4 The problem facing subjective theorists is firstly epistemic - individuals with SCD are frequently unable to communicate to us the nature of their experiences. We may not be able to tell whether or not an adult or a
    1
    
    18-20th September 2008, Stony Brook University, New York 2 http://www.stonybrook.edu/sb/cdconference/ 3 In this paper I will use the term ‘severely cognitively disabled’ to refer to… 4 Note that these issues are quite distinctive for cognitive disability compared to physical disability, and in particular for severe or profound cognitive disability. It is less clear, for example that moderate or mild cognitive disability affects wellbeing in such profound ways.
    
    child with SCD is feeling pleasure or pain. We may have little or no idea of their preferences, and indeed it may not be clear to what extent they are capable of forming preferences. Secondly, if SCD limits awareness and the development of desires or preferences, it may fundamentally change the range of things that are of value to an individual with SCD. For example, it has been argued that individuals who are not self-conscious cannot have a desire or preference for the future, and that consequently it may be much less of a harm to them to die (if it is a harm at all). (Singer 1993) Objective theories of value are also challenged by SCD, since many of those features that are typically listed as being valuable in human life are dependent upon rationality. Since cognitive capacity and reason are the features that are often noted as being distinctive of human life (as opposed to the life of non-human animals), this is not surprising.(Wilkinson 2006) Yet the implication of such theories is that the lives of those with SCD may contain less that it is of value (to them) than the lives of individuals without cognitive disability. This may give rise to controversial questions about priority when the interests of individuals with SCD conflict with the interests of the cognitively normal. Less controversially it may also have implications for consideration of the interests of patients with SCD who are faced with disorders or medical procedures that are likely to cause the patient to suffer. (Wilkinson 2006) Only one paper in the New York conference explicitly raised the question of value theory in relation to individuals with SCD, though the problem lurked beneath the surface of many points of contention. Leslie Francis and Anita Silvers argued that the aforementioned epistemic problem for subjective theories of the good could be overcome by using family, friends and guardians to help assess what is of value for the individual.5 They saw the trustee acting not by stepping in to the individual’s role, but by serving in a manner akin to a prosthetic limb. The trustee carries out a task, rational reflection, that the disabled individual is not able to perform unaided. Francis and Silvers’ paper was one of several at the conference that attempted to find a way to incorporate individuals with SCD into a liberal theory of justice. They, (as well as several other speakers at the conference), drew attention to the problem that Rawl’s contractualism appears to exclude the cognitively disabled. For Rawls the good was defined by a “rational plan of life”.(Rawls 1999, 380) He argued that individuals should be free to decide upon their own conception of the good, though when deliberating on the form that society should take (in the ‘original position’) they should be ignorant of their own individual values. (Rawls 1999, 347-9) However Rawls’ approach seems to have little to say directly about justice for those with cognitive disabilities; worse, some have argued that it may aggravate the disadvantages of those individuals compared to the rest of society. Martha Nussbaum presented her alternative approach to justice at the conference,6 and several speakers commented on Nussbaum’s book Frontiers of Justice, and the degree to which her
    
    5
    
    Francis L, and Silvers A. (Conference paper) Rethinking “Conceptions of the Good” in Light of Intellectual Disabilities. Cognitive Disability: a challenge to moral philosophy 2008 6 Nussbaum M. (Conference paper) Capabilities and Disability. Cognitive Disability: a challenge to moral philosophy 2008
    
    favoured ‘Capabilities approach’ succeeded in overcoming the limitations of Rawls’ theory.7 Yet Nussbaum and the other speakers remained largely silent on the question of what is of value to individuals with cognitive disability and how that might be different from cognitively normal individuals. Nussbaum’s list of capabilities to be promoted appear to be based upon an Aristotelian idea of human flourishing. During her presentation Nussbaum mentioned that they had emerged from international discussion and consensus. They include being able to “live to the end of a life of a human life of normal length”; being able to use the senses “to imagine, think and reason – and to do these things in a “truly human” way”; “being able to form a conception of the good and to engage in critical reflection about the planning of one’s life”; “being able to participate effectively in political choices that govern one’s life”. (Nussbaum 2006, 76-7) However it was not clear from the discussion whether Nussbaum thinks of these capabilities as being objectively valuable, or whether they are instrumentally valuable in promoting the subjective wellbeing of individuals with SCD. If they are objectively valuable, then in the absence of ways to enhance the cognitive abilities of individuals with SCD their lives appear to be stripped of many of the distinctive values of human life. If they are supposed to be subjectively valuable then it is not clear how some of the capabilities promote the wellbeing of the severely cognitively disabled. One of the implications of Nussbaum’s capabilities approach that she freely acknowledged, was that individuals with cognitive disability or their guardians should have a right to participation in the political and judicial process in terms of voting and involvement on juries.8 There are some reasons why political participation may be of instrumental benefit to adults with SCD.9 Politicians have traditionally neglected the welfare of the disabled. Extending voting rights to individuals with SCD may force political parties to think seriously about the ways in which their policies will affect, and be perceived by, disabled adults and their guardians. This step might also reduce other forms of discrimination against disabled individuals because of its explicit recognition of their place in society. Yet such instrumental justification might also justify granting political representation to others who are traditionally discriminated against in the political process such as future generations or non-human animals.10 Nussbaum explicitly rejected this latter possibility on the grounds that certain goods are valuable only for members of particular species; she claimed that voting would not be of interest or benefit to an elephant for example.11 But why does species membership matter when we are considering how we should behave towards an individual? The question of how we should treat non-human
    7
    
    Berube M. 2008 (Conference paper) Response to Nussbaum; C. Stark. 2008 (Conference paper) Reasons, persons and capabilities; Wong S. 2008 (Conference paper) Duties of justice to citizens with cognitive disabilities. 8 Nussbaum M. 2008 (Conference paper) 9 Nussbaum rejected the idea that her capabilities approach would also require the extension of voting rights to children or their guardians. It was not clear however how this distinction was justified. 10 Singer P. 2008 (Conference paper) Speciesism and moral status. 11 Nussbaum M. 2008 (Conference paper) response to questions
    
    animals compared to humans with SCD came up repeatedly during the conference. Some speakers questioned whether it is appropriate to even ask this sort of question, and the debates about the relevance of species membership for moral status yielded some of the most heated discussions of the conference. Yet in itself the question of whether species membership is relevant to our moral obligations seems not to be one that should generate offence. It is no different to asking whether height, or religion or social class are relevant factors that we should consider. I suspect that the reason that some individuals have such visceral responses to making comparisons between species relates to two factors. Firstly individuals with SCD are related to other humans in ways that non-human animals are not. They are someone’s daughter, someone’s son, someone’s brother or nephew or cousin. We feel strong bonds of kinship with our family in ways that we do not with non-human animals. A number of the speakers at the conference had children or close relatives with disability. Such experience helps to enrich philosophical discussions about disability, but it also makes it hard for those who have opinions that diverge from those of disability advocates to express their arguments without risking causing offence. Eva Kittay, whose daughter has multiple disabilities expressed her palpable “nausea” at being asked to justify a distinction between what we owe to animals such as a chimpanzee, a dog or a pig and cognitively disabled humans. I will return to the question of the ‘relatedness’ of individuals with SCD and whether it justifies treating them differently from non-human animals with similar cognitive capacity. However if relatedness matters, it does not seem to invalidate the question of comparisons between species. The second reason that some may object to comparisons between species is that they lead to conclusions that conflict fairly strongly with commonly held beliefs. Philosophy may offend by taking us to places where we would rather not go. One way to avoid such unpalatable conclusions is to avoid the comparison in the first place – however it is not clear that there is a non-question-begging way of justifying this. Peter Singer presented a familiar argument about moral status and ‘speciesism’.12 Both he and Jeff McMahan13 drew attention to a commonly cited defense of differential treatment of non-human animals ie that they differ in cognitive capacity, rationality, and use of language from humans. Yet some animals at least have cognitive capacities that are on a par with many humans (Singer cited a gorilla able to use and understand 1000 signs, and a parrot able to understand abstract concepts like ‘shape’ and ‘colour’). And some humans with SCD have cognitive capacities that are lower than many non-human animals. Singer argued that cognitive capacity is relevant to interests, and that consequently we should treat individuals with similar cognitive capacities similarly.14
    12 13
    
    Singer P. 2008 (Conference paper) Speciesism and Moral Status McMahan J. 2008 Cognitive disability, cognitive enhancement and moral status. 14 Interestingly Singer was attacked after his presentation for caring more about nonhuman animals than about humans with disabilities, and for supporting better treatment of animals than of individuals with SCD. His reply was he did not advocate, and had never advocated such a difference, and seemed puzzled that his interlocutors had misunderstood his position. One possible explanation for the misunderstanding is a sort of parallax error in interpretation of Singer’s views. He argues for animals to be treated better than they currently are (and than many people think they should be), while also arguing that our moral obligations to individuals with SCD are less than currently held. This conjunction of views might give the impression that he is
    
    Singer did not discuss this, but it should be noted that this does not require equal treatment, since the desiderative interests of individuals may diverge. However it seems to require that the minimum that is morally required of us should be broadly similar. But what does this mean in practice for our treatment of humans with SCD and non-human animals. McMahan has suggested in his book ‘The Ethics of Killing’, that we have three options. (McMahan 2002, 206) We could treat humans with SCD on a par with our current treatment of non-human animals (an option he calls Consistent Elitism); we could improve our treatment of non-human animals to the level that we currently treat humans with SCD (Radical Egalitarianism); or alternatively we could improve the treatment of non-human animals, but at the same time lower the standard for treatment of humans with SCD so that they come together (Convergent Assimilation). McMahan rejects the first two as implausible, and argues that the third option is the only defensible alternative. Yet even if some form of convergent assimilation is accepted, this does not require us to treat identically humans and non-humans with similar cognitive capacity. There are two reasons for this. (McMahan 2002, 231) Firstly, while the interests of an individual may determine what we are morally required to take into account, it is always possible for us to do more than this. There is nothing to say that we cannot treat humans better than non-humans, as long as this does not prevent us from treating non-humans to the minimal standard that their interests require. Such preferential treatment might be thought of as superogatory. However it may also reflect the difference that I noted earlier, that humans with SCD are related to other (cognitively normal) members of the community in ways that non-human animals are not. These relationships may create agent-relative obligations for family members of an individual with SCD. They also mean that there are other significant interests that may be affected by our treatment of humans with SCD that do not need to be taken into account (or are less strong) in the treatment of non-human animals.15 ‘Relatedness’ may justify different treatment of humans with SCD than cognitively similar non-humans. However there are also reasons why some may have qualms about relying on it to justify a kind of speciesism. Firstly, it may imply that where such relations do not hold, it may be justifiable to treat a human with SCD quite differently from the way that they are at present treated. For example, a child who was orphaned, without any available adoptive parents. It may also mean that the level of treatment of individuals with SCD would be contingent upon the degree to which their families care for their wellbeing. Would society be justified in treating less stringently a child or adult whose family had lost interest in them? Secondly it may mean that if there were relationships of a certain strength holding between humans and non-human animals, that such animals should be treated relevantly similarly to advocating preferential treatment of animals, yet in fact there is such a wide gulf between our treatment of humans and non-humans, that his arguments merely represent some narrowing of that gap. 15 Of course most non-human animals are also ‘related’, in the sense that they are the son, daughter, brother etc of other non-human animals. These relationships are important to them, and may historically have been underestimated by humans, however the strength of the future-directed preferences of such relatives are likely to be less (as a rule) than their human counterparts, and this may lead us to think that the corresponding interests are less strong.
    
    humans with SCD. In fact some existing non-humans have very strong relationships with humans, and where those humans are able to afford it, that does lead them to be treated in a way that is substantially greater than other non-humans, and not that differently from humans. Again such comparisons risk causing offence, but there may be good reasons for making them.16 In this paper I have outlined some of the challenges that SCD presents to moral philosophy. I have explored two issues that underpin philosophical debate in this area. The relevance of SCD to wellbeing depends upon our conception of the good. Some disagreements about SCD, and how we should treat disabled individuals turn on this question of what makes a life valuable to that individual. Unless our answer to this question is dependent upon species membership, the question of how we should treat individuals with SCD compared to non-human animals is impossible to avoid. I have argued that even if speciesism is rejected, it may still be possible to justify preferential treatment of humans with SCD over similarly cognitively endowed non-humans. It is beyond the scope of this paper to outline what should be the level of care of humans with SCD. However I will end by listing a number of key distinctions that I believe should be made when attempting to answer this question. When considering the treatment of individuals with SCD we should distinguish 1. Decisions about the lives of individuals with SCD, from decisions about whether they live 2. What we are morally required to do (the minimal standard), from what we are permitted to do, or what may be superogatory to perform 3. What we are required to do by virtue of the intrinsic morally relevant properties of an individual from what we owe to them by virtue of any special relationships that we may have with them, or they may have with other individuals 4. What we actually care about from what we have reason to care about 5. What we should in general do for individuals, from what may be, in certain circumstances, justifiable. These distinctions are sometimes blurred in debates, and were at times during the New York conference. Being clear about these may help to resolve disagreement and answer the challenge that cognitive disability presents to moral philosophy.
    
    REFERENCES DeGrazia, D. 1995. Value theory and the best interests standard. Bioethics 9(1): 5061. McMahan, J. 2002. The ethics of killing: problems at the margins of life. New York: Oxford University Press.
    
    16
    
    There may be some residual asymmetry between human-human and human-animal relations. It is not clear whether the strength of feeling of a human to a dog, or a horse, or other animal can ever reach the same level as the strength of feeling of a parent for their child. It also does not seem that an animal-human relationship would generate the same sort of agent-relative reasons as a parental or filial relationship.
    
    Nussbaum, M. C. 2006. Frontiers of justice : disability, nationality, species membership. Cambridge, Mass. ; London: The Belknap Press of Harvard University Press. Rawls, J. 1999. A theory of justice. Oxford: Oxford University Press. Singer, P. 1993. Practical Ethics. Cambridge: Cambridge University Press. Wilkinson, D. 2006. Is it in the best interests of an intellectually disabled infant to die? J Med Ethics 32(8): 454-9.

Add Comment

To add a comment, you need to login or signup (you can signup without leaving this page)