There has been growing interest among ethicists in the theme of vulnerability. Some have gone as far as to suggest that vulnerability could serve as a new principle in bioethics. In a recent edition of the journal Theoretical Medicine and Bioethics, a number of leading bioethicists explored the topic of ‘human vulnerability in medical contexts’. This recent journal edition – a first among any of the leading bioethics journals –provides significant insight into the notion of vulnerability and its relevance to contemporary clinical practice. Xavier Symons, the deputy editor of Bioedge, recently spoke with guest editor Stephen Matthews about the key themes discussed.
Stephen Matthews is a senior research fellow at the Plunkett Centre for Ethics and a member of the Centre for Moral Philosophy and Applied Ethics at Australian Catholic University. Steve co-edited the special edition with Bernadette Tobin, Director of the Plunkett Centre for Ethics.
Steve Matthews: Yes, it’s absolutely relevant. An implicit assumption of those whose moral position is quite permissive of the technologies of human enhancement is a kind of perfectionism, or at least a maximising kind of attitude that can tend to swamp moral contemplation regarding vulnerable traits, the possession of which is not undesirable.
This is the idea expressed in John Quilter’s very thoughtful piece, and I take it that something like this is being expressed for the medical context in the article by Wendy Rogers and Mary Walker.
Actually there is a background fundamental question to all of this and it’s about whether certain vulnerable traits we have as subjects are desirable to our moral identities as human beings. If we think there are such traits, this would inform the treatment vs enhancement question from the outset. It may be that we possess such traits and we should be concerned not to enhance ourselves to eliminate them. It may be, also, that we should not be jumping in to treatment occasioned by the slightest deviation from the path of a happy life.
We mention in the introduction the case of grief. Those who have experienced a period of grieving know that it can involve an extremely unhappy time, very disruptive and even destructive. Nevertheless there are strong arguments for thinking this is something that marks the value of the connections we had, and not something to be eliminated.
But let’s not be too glib about this. If there are such traits it does require a philosophical defence to state what they are and to understand the extent to which such (not undesirable) vulnerability should be retained. In the case of grief, this can tip over into a state of extraordinary dysfunction and pathology, in which case, a trip to one’s physician is obviously in order.
XS: How important do you think trust – which I take is archetypal kind of vulnerability in human life – is for a well-functioning healthcare system?
Matthews: This is a very good question. Without trust the compliance costs of any human institution, where relationships are governed by rules, would be prohibitive. For a defining feature of trust is that I may rely on a trusted party without the need to monitor them constantly, or even at all. Trust is highly enabling for a well-functioning healthcare system then, just measured in the banal terms of cost as just stated.
But you’re right, if A trusts B, then A is made vulnerable to B in case B turns out to be unreliable or untrustworthy. The inference is then very clear: systems, including the healthcare system, conceptually depend on levels of vulnerability. The vulnerability goes both ways. Patients are just the obvious case, and not even the best system of informed consent can really compensate for the fact that the doctor-patient relation is one of imbalance: an epistemic imbalance and a power imbalance.
But as both Justin Oakley and Mayes et al argue, the medical fraternity, in various ways and in virtue of their positions of responsibility are vulnerable in so far as they must trust each other and the systems they operate within.
XS: Much of the role of palliative care involves helping ailing patients to come to terms with their vulnerability. Are there other areas of medicine where vulnerability is particularly important?
Matthews: The most vulnerable patients are those whose (autonomy) competence is diminished. The limit case of this is a severely injured person who comes into a hospital unconscious and who cannot be identified. No one can speak on their behalf, and so initially healthcare workers must make, and take responsibility for, all decisions pertaining to their care.
Other groups include dementia patients, the very young, or those with a mental illness. Very depressed patients, for instance, are known to have highly limited capacities in the estimation of risk and benefit and what should be done to assist them.
Another vulnerable group is those with drug dependence issues. The United States is currently going through an opiates epidemic. In 2014, there were 47,000 overdose deaths from prescription and street opiates there. These patients are particularly vulnerable for two reasons. Often medical staff have little understanding of addiction and little sympathy for drug dependent persons who they blame. Secondly, addiction is a chronic condition, which means that over time the drug dependent person becomes resigned to their drug dependent status, and this leads to lost hope, and a sense of ineffectiveness.
Chronic conditions such as this are a great burden on healthcare systems and represent an important challenge to medical staff who may not view such people as the vulnerable types they really are.
XS: Australia has a relatively strong social security net. Is ‘vulnerability’ a justification for a universal healthcare system?
Matthews: Good question again. The conception of a government-supported healthcare system as providing a safety net I think frames the idea of universal healthcare incorrectly. Such a conception runs the risk of making care available only to those who need the net – those vulnerable types who have fallen, and but for the net, would crash to the ground.
And this leaves open an argument that healthcare should be made available only for those whose vulnerability is unpredicted. Then we enter a range of familiar debates about whether, for instance, smokers or risk takers generally deserve the safety net – paid for by all – when other more responsible people are not smokers, risk takers etc. That is a dangerous debate, as we know, and only leads to adversaries digging themselves into positions that tend not to shift.
Now, having said that, I think there is wider philosophical conception of vulnerability – wider than the folk idea that excludes (say) smokers – that could be used to justify the establishment and maintenance of a universal healthcare system. Variations on this conception are outlined in the introduction to the special issue.
On this view, human vulnerability is fundamental, pervasive, shared and possessed by all, independently of perceived power imbalances. Of course there are special cases as well, and obviously some groups are more vulnerable than others, but on the wider conception, no one, as it were, escapes.
Under that view, we can run a line of argument which says that a universal healthcare system is rational because vulnerability is a universally held human trait. On this view the idea of a safety net is almost trivialised, and that is because the understanding is that a healthcare system is a rational response to recognising a fact about our natures, our natures as embodied, social, interdependent creatures.
XS: One theorist who wasn’t mentioned in your introduction to the issue was Alasdair MacIntyre. To what extent do you think MacIntyre’s writings on human dependency overlap with the ideas advanced in this issue of Theoretical Medicine?
Matthews: It would take us beyond the scope of this interview to deal in depth with MacIntyre’s writings. I can at least say this much: In Dependent Rational Animals MacIntyre asserts that “an ethics independent of biology” is impossible. He argues that vulnerability and dependency are constants in the lives of human beings, regardless of what stage of life they are at. This idea is similar to what I said in answer to your first question.
Many philosophers claim that certain vulnerable traits we have as subjects are desirable to our moral identities as human beings. MacIntyre is one such philosopher. According to MacIntyre, to develop our capacity as moral agents means to achieve a certain measure of independence, but this should not come at the expense of acknowledging our constant and continued dependence. In one sense, such an acknowledgement is constitutive of moral development. Insofar as dependency is very closely related to vulnerability, MacIntyre’s ideas overlap significantly with the themes of this journal edition.
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Vulnerability: An interview with Steve Matthews