Normal functioning and the treatment-enhancement distinction

Cambridge Quarterly of Healthcare Ethics

Volumn 9, Issue 3, 2000, Pages 309-322

  Daniels, Norman ^a  

^a NONE

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EID: 0034195713     PISSN: 09631801     EISSN: None     Source Type: Journal    
DOI: 10.1017/s0963180100903037     Document Type: Review

References (23)

1. 1. Daniels, N, Sabin, JE. Clarifying the concept of medical necessity. Proceedings of the Group Health Institute. Washington, D.C.: Group Health Association of America, 1991:693-707.
2. 2. Sabin, JE, Daniels, N. Determining "medical necessity" in mental health practice: a study of clinical reasoning and a proposal for insurance policy. Hastings Center Report 1994; 24(6)5-13.
3. 3. See note 2, cases are drawn from Sabin and Daniels 1994.
4. rd ed. Washington, D.C.: American Psychiatric Association, 1993:44.
5. 5. Allen DB, Fost NC. Growth hormone therapy for short stature: panacea or Pandora's box? Journal of Pediatrics 1990; 117:16-21.
6. 6. Using my (1985) account, described in this section, the importance of the need is explained by reference to its impact on an individual's fair share of the normal opportunity range for his society. In an abstract way, this characterizes the expectation of disadvantage an individual may have relative to a baseline of talents and skills. Daniels N. Just Health Care. New York: Cambridge University Press, 1985.
7. 7. Throughout this paper I equate an adverse departure from normal species functioning (or functional organization) with either disease or disability. I allow room for societally relative "construction" by noting that some disabilities (impairments) do not have enough impact on the individual's share of the normal opportunity range for us to consider them morally important disabilities, just as some diseases may not warrant treatment because they have so little impact on us.
8. 8. Boorse C. On the distinction between disease and illness. Philosophy and Public Affairs 1975; 5:1:49-68.
9. 9. Boorse C. Wright on functions. Philosophical Review 1976; 85:1:70-85.
10. 10. Boorse C. Health as a theoretical concept. Philosophy of Science 1977; 44:542-73.
11. 11. Compare with Kitcher P. The Lives to Come: The Genetic Revolution & Human Possibilities. New York: Simon & Schuster Trade, 1996.
12. 12. Engelhardt HT. Disease of masturbation: values and the concept of disease. Bulletin of the History of Medicine 1974; 48:2:234-48.
13. 13. This discussion does not depend on a strong claim about the non-normativeness of judgments about disease of the sort made by Boorse (1976). (See note 9.) Such a claim depends on being able to distinguish genetic variation from disease, and more specifically, on specifying the range of environments taken as "natural" for the purpose of revealing dysfunction. The problem facing this strong claim is that some socially created environments should be counted as "natural" but others not. My discussion turns on a weaker claim. It is enough for our purposes that the line between disease and its absence is, for the general run of cases, uncontroversial and ascertainable through publicly acceptable methods, such as those of the biomedical sciences. It will not matter if what counts as a disease category is relative to some features of social roles in a given society, and thus to some normative judgment, provided the core of the notion of species-normal functioning is left intact. This qualification is made in note 6, Daniels 1985:30.
14. 14. See Rawls J. The basic structure as subject. American Philosophical Quarterly 1971; 14:2:159-65.
15. 15. See Rawls J. Political Liberalism. New York: Columbia University Press, 1993.
16. 16. Rawls defines equal opportunity as follows: "those who are at the same level of talent and ability, and have the same willingness to use them, should have the same prospects of success regardless of their initial place in the social system." (See note 14, Rawls 1971:73.) As Christiano has pointed out, this does not rule out using medicine to enhance the prospects of success of an individual by changing natural qualities of persons that are not directly related to the talents they have. The extension of Rawls's account is thus not incompatible with its initial statement and may be less an extension than it appears. In any case Rawls seems to endorse the extension I propose. See note 15, Rawls 1993:184, note 14.
17. 17. See note 6, Daniels 1985.
18. 18. Some might object that the terminology is misleading: the principle actually supported does not really call for equality in opportunity, but only some adequate range of opportunities. Since protecting normal functioning while leaving a "natural" baseline of talents and skills in place leads to individuals having different "fair shares" of the normal opportunity range for their society, equality in opportunity does not, after all, assure strict equality of opportunity.
19. 19. See note 14, Rawls 1971.
20. 20. See note 15, Rawls 1993.
21. 21. Should we think of the deficiency in capability as giving rise to a defeasible claim, if not ultimately a defensible claim? On the normal function model, if the deficiency falls within the normal range and is not itself produced by disease, disability, or unfair social practices, then we should ultimately recognize no claim here. Is this still a "defeasible" claim, one defeated by these etiological criteria, or should we say that defeasible claims arise only after these criteria are met? For example, reasonable resource limits might still defeat the claim that satisfied these criteria. I am inclined to say that defeasible claims arise only after the criteria that distinguish the theory are met. In From Chance to Choice, Chapter 4, the argument proceeds to show that more radical efforts to level the playing field do not, on close inspection, support eliminating the treatment-enhancement distinction in the way they might seem to at first.
22. 22. See note 12, Engelhardt 1974.
23. 23. See note 11, Kitcher 1996.