Hello all! Greetings from the great South. As a part of a class assignment. My doctoral students will be answering the following questions on the blog. Please help me guide them and critique their response. Many thanks!

1. Do you agree or disagree with Pesut and Johnson’s assertion that “philosophical inquiry has yet to be positioned as contributing substantially to the field of nursing’s inquiry.” Why or why not?

2. Do you think that ignoring philosophy in nursing “puts nursing at risk”? Why or why not?

3. What can the historical roots of nursing add to the scientific advancement of the profession?  ¶ 12:06 PM 12 Comments

  Bear:

First, let's consider your point, in the first three paragraphs of your comment, about penectomy. It is correct that penectomy involves transecting the urethra, whereas FGM ordinarily will not. It is not similarly correct to say or suggest that penectomy has no history, and that it would result in death absent modern medical intervention. In fact, penectomy has been performed for thousands of years under circumstances remarkably similar to those attending FGM, as a part of the eunuch process, and it still occurs infrequently in India. See the article in Indian J Urol. 2007 Jul–Sep; 23(3): 317–318 for the grizzly details, along with the accompanying picture. It is instructive, I think, to compare THAT picture to some of the available pictures of female genitalia post FGM, and then compare both of THOSE to one of the innumerable pictures available on the WWW of a circumcised penis. I think my analogy is apt indeed, although like all analogies, it does not achieve a perfect correspondence.

Now, on to your final paragraph. The first two sentences are:

FGM and male circumcision are both barbaric practices with little to justify them. A classic case of culturally defined stupidity and irrational justification in both western and non-western cultures and clear violations of the rights of the victims.

These two sentences make the following claims about MNC: 1) male neonatal circumcision is an elective “cultural” phenomenon or practice not COMPELLED by medical necessity; 2) MNC is stupid and/or irrational; 3) purported justifications of the practice of MNC are “irrational”; and 4) and election by a parent to have a male neonate circumcised violates that neonate's “rights”. I think claim number 1 is true. In Ireland, for example, I gather that a parent will only rarely elect circumcision for a newborn son (Irish readers can correct me if I am wrong about this), and this decision is not irrational. I think it is perfectly rational to elect MNC or to decline MNC. However, I do not think this is true of FGM. A decision to have a daughter “circumcised” is never rational.
Circumcision, a reply to Bear's objections
I flatly deny claims 2, 3, and 4. I suspect the purported truth of #2 depends on the purported truth of #3. That is, I think that if #3 is false, and there are good reasons for a parent to elect MNC, then a fortiori MNC is then neither “stupid” or “irrational”.

I don't see anything in your comment which justifies claim #3, other than characterizations of the research on the topic as just 1) “appearing” to show that MNC confers some benefit, and 2) “thinly veiled rationalizations.” I have, to date, reviewed over 400 published, peer reviewed studies relating to MNC, as did Benatar and Benatar. I have studied research methods, at the graduate level, under the tutelage of one of the best scientists in her field, and am quite sure that I can tell the difference between rational, responsible inquiry and “thinly veiled rationalization.” I am confident Drs. Benatar and Benatar can as well. The corpus of scholarly, scientific study of the practice of MNC is voluminous, and is published in journals that are not in the habit of publishing articles which either a) merely “appear” to show something, or are merely 2) “thinly veiled rationalizations”.

As regards claim #3, I agree with Benatar and Benatar: the evidence supports the following conclusions: men who are circumcised as neonates are at slightly less risk than uncircumcised men of contracting syphilis, gonorrhea and HIV AIDS (if in a high risk group), and at slightly greater risk of contracting canker and non-gonococcal urethritis; they are at a reduced risk for the most invasive forms of penile cancer; and at reduced risk for UTI. Actually, I think most MNG opponents concede that the evidence DOES show what I claim it does. This is especially clear in light of a careful review of the responses to the Benatars' original target article. None of the respondents, even those which were clearly hostile to the practice of neonatal circumcision, argued that there was NO warrant for believing that neonatal circumcision provides (minimal) medical benefits. All of them focused, instead, on whether such benefits were sufficient to justify the practice in light of what various respondents took to be clear contra-indications associated with the practice. Here, I think, absence of evidence equals evidence of absence. Credible arguments against the position that there are minimal medical benefits to neonatal circumcision simply do not exist.

I assume, then, that those who oppose MNG are claiming that there are contra-indications associated with neonatal circumcision which unequivocally and significantly outweigh any medical benefits of the practice that we might have warrant for accepting as real. And, further, that these contra-indications are so significant that the practice should not be permitted. Bear's next to last sentence alludes to one such purported contra-indication – pain.

Pain is yet another informal fallacy – the red herring. Pain is NOT an argument against the circumcision of male neonates. It isn't even a valid argument against FGM, for that matter. It IS an argument against either practice when they are not accompanied by truly effective anesthesia and post-operative analgesia. But pain can be effectively controlled for far more serious operations – it can hardly be an insurmountable obstacle in this instance.

So what other “contraindication” could there be? The only one on offer is that the procedure somehow leaves the individual harmed, or diminished, in some way, and this usually takes the form of one or more versions of the “less pleasure” thesis I have already criticized. Until, and unless, I am offered ARGUMENTS against the position I have outlined regarding the “less pleasure” thesis, and the research which supports my position, I remain unmoved.

I suppose that it is possible that someone might think that only surgery which is medically necessary, as opposed to “in some way desirable”, should be permitted. I cannot imagine why. In fact, surgery is performed all the time for reasons other than “medical necessity.” Here is an example: otoplasty, or ear pinning. The procedure is almost never a medical necessity, since kids with large ears can ordinarily hear perfectly. It is, instead, elected for cosmetic reasons, and to help children avoid inevitable adolescent ridicule. The same is true for cleft palate and other maxillofacial surgery. These are procedures which are not, strictly speaking, medically necessary, but do confer benefits upon those who undergo them. The “not necessary” argument is less than compelling.

Finally, we come to the last sentence, the one about neonatal “rights”. I would argue that neonates do not have “rights” - what they have are interests that adults have a duty to protect and further. For the reasons I have already adduced, I fail to see that any male has an “interest” in either having, or not having, a foreskin, any more than they have an “interest” in having an appendix or tonsils. That is, whether their lives go well or badly in not going to depend to any degree on the presence of these tissues. And this marks the dramatic contrast between FGM and MNC, since every woman has an interest in having a clitoris, and their lives will go less well without their clitoris than they otherwise would.  ¶ 11:58 PM 3 Comments

  Why No Mention of Neonatal Circumcision back in June?

The redoubtable “Bear” Cox has asked why I excluded male neonatal circumcision in my June “capabilities approach” post. I did so for a number of reasons, but let me just mention a few.

First, to equate the two procedures trivializes the horror of FGM. Male
neonatal circumcision (hereinafter MNC) is in no way as invasive as FMG.
The homologous equivalent to female genital mutilation would be amputation
of the entire penis. I assure all reading this post that I am just as
opposed to THAT procedure as I am to FGM. I love my "Mr. Happy," who has been my friend through many adventures. However, penile amputation is almost never performed, whereas FGM happens to millions of young women every year. Since it almost never happens in our patriarchal world, there is no reason to mention it.

Second, I am persuaded that ALL of the COMPETENT peer reviewed studies
regarding MNC, individually and collectively, establish that the procedure
produces a modest medical benefit, to be balanced against modest medical
risk, usually in the form an undetected bleeding disorder. If anyone,
anywhere, is aware of a similar study or studies coming to the same
conclusion about FGM, often termed clitorectomy, please let me know.

An excellent summary of the state of the SCIENTIFIC literature regarding MNC may be found in Benatar and Benatar, "Between prophylaxis and child abuse: the ethics of neonatal male circumcision"; The American Journal of Bioethics - Volume3, Number (2), Spring 2003, pp.35-48. It is magisterial, and much can be gleaned from reading it, along with the decidedly adversarial responses to it from anti-MNC camp.

This leads to my third reason. I am convinced that those who oppose neonatal
male circumcision (in contrast to those who would simply PREFER not to elect
it for their sons) are either uninformed or intellectually dishonest. Here
is an example in the form of a comment on the Benatar study, noted above, by
an individual named "Rio Cruz":

"Benatar and Benatar (2003) conclude that amputating ... protective, and
sexually important tissue from a nonconsenting infant does not constitute
abuse but is rather a matter for parental discretion."

I have never, in 60 years of life, seen a more egregious example of begging
the question. And this is not an isolated instance; every single article I
can find which criticizes the practice contains an example of either the
"strawman" fallacy or the "begging the question" fallacy (usually both),
coupled with a willful refusal to examine the peer reviewed evidence on the
topic with anything remotely resembling an open mind.

Now, to another reason - my main one, actually. Look carefully at what this
"Rio Cruz" person says. He calls the foreskin "sexually important".
Channeling my inner G.E. Moore, I want to know what, exactly, that is
supposed to mean. The anti-MNCers never clearly say, which, following Moore
again, leads me to conclude that they mean nothing whatsoever. But, let's
apply the principle of charity to that statement, and try to say something
meaningful on their behalf. Perhaps what they have in mind is a claim that
the procedure of MNC produces "negative" sexual sequela in later life. I
call this the "Less Pleasure" thesis. Let's take a look at it.

The literature surrounding the possible sexual sequela of neonatal
circumcision focuses on the tactile stimulation that males receive during
sexual activity. Of chief concern is the role that the male foreskin might
(or might not) play in the "sexual pleasure" a sexually active male
experiences, and so the debate seems couched in terms of the "stimulation"
that foreskin tissue might provide, and what loss of "sensitivity"
maturation without a foreskin might cause. This is why one finds so much
discussion (and disagreement) about, for example, how "keratinized" the
glans is, how "sensitive to touch and pressure" the glans is, and how much
"highly erogenous tissue" is removed by circumcision (By "highly erogenous
tissue," I take those using the expression to mean "tissue within an
erogenous zone of the body," and by "erogenous zone" to mean a part of the
body that is associated with sexual pleasure). It is at this point, I
think, that the discussion "jumps the track," and leads to conceptual
confusion.

The discussion "jumps the track" because the analysis seems focused on
"sensation," in the sense of peripheral nerve receptor stimulation, as the
primary focus of investigation and analysis, whereas I maintain that our
best science, and scientifically informed philosophy, suggests that this is
the wrong way (albeit the "folk psychological" way) to think about sexual,
or indeed any other kind, of pleasure.

There is a surprising dearth of recent philosophical analysis on the general
topic of pleasure. Rather, pain seems to be the usual topic of interest.
The great bulk of the modern philosophical literature on the subject of
pleasure generally centers on the work of Gilbert Ryle, produced in the late
1940's and the early 1950's, and the responses of other philosophers to
Ryle's work. This work was done when psychological research was, for the
most part, either strictly behavioristic or, alternatively, introspective.
Psychology at the time had little in the way of research findings to offer
philosophers which could shed light on the subject, so it is perhaps not
surprising that philosophical reflection and analysis on pleasure soon
faded. However, Psychology has advanced considerably in the succeeding
decades, and philosopher Mayat Aydede has revisited the subject fairly
recently and produced a splendid paper, "An Analysis of Pleasure Vis a Vis
Pain," to be found in Philosophy and Phenomenological Research, 61 (3):
537-70, 2000 (hereinafter "Pleasure Analysis.")

The language of the current discussion on the sexual sequela of neonatal
male circumcision leads one, naturally enough, to think about the issue in
terms of some relationship between the number of nerve endings in the penis,
plus or minus the foreskin, and the quantity and intensity of "sexual
pleasure." I maintain that this is the wrong way to conceptualize the issue,
in light of what Dr. Aydede, and the scientific work he cites, can tell us
about how it is that pain and pleasure happen to happen.

Aydede argues that, from a general understanding of the gate control theory
and the phenomenon of reactive dissociation, some clear conclusions can be
reached about pain. We can best understand pain, he argues, in the
following way (as drastically simplified by me.) We "feel" pain, or are "in
pain" when: 1) pain stimuli from peripheral nociceptors (pain specific
receptors, located primarily in the skin and viscera) arrive at the
somatosensory cortex and at various limbic system structures; 2) in the
somatosensory cortex, these nocioceptor generated stimuli (noxious stimuli,
for short) are identified as pain, and measured in terms of intensity and
the spatio-temporal location of the originating nociceptors; and 3)
simultaneously, in the limbic system, affective response to the noxious
stimuli, in the form of an aversive reaction, is generated. That, in a
nutshell, is how pain happens to happen, when all goes as "nature intends."

Contrast this picture, Aydede suggests, with physical pleasure. It some
ways, the process is parallel, in that the "experience" of "feeling physical
pleasure" usually begins when stimuli from receptor sites arrive at the
somatosensory cortex and the limbic system. However, a marked difference is
already at work. The arriving stimuli do not include any "pleasure" stimuli,
for the simple reason that the human body apparently has no "pleasure"
receptors, as such. We have lots of receptors, including proprioceptors,
thermal receptors, pain receptors, receptors for touch, taste, light and
smell; but no "pleasure receptors." Thus, the somatosensory cortex does not
identify anything as "pleasurable." When we "experience" pleasure, the
somatosensory cortex is busy identifing stimuli, but identifying them as,
for example, touch, taste, pressure, smell, sound, or motion; not as
pleasure. So "physical pleasure" simply is, on Aydede's model, the affective
response to those particular stimuli.

To simplify even further, we do not have pleasure experiences; rather, we
have experiences we find pleasurable. Pain is different; we have pain
experiences that we usually find, well, painful, unless someone gives us
morphine. Aydede helps us here by simplifying even further: "Put crudely,
the suggestion is not that we feel...pleasure and then desire it. It is
rather that the very feeling of pleasure metaphysically consists of our
desiring whatever...sensory information we are simultaneously processing or
reacting to." Works for me. How else can we explain what goes on in certain
nightclubs in San Francisco? How else do we explain all of that "birching"
business going on on British television (see several episodes of "Midsomer
Murders" for examples)? My goodness how they carry on over there!

Thus, if either circumcised William or uncircumcised James experiences "less
pleasure" than the other, we are not going to be able to tell by counting
the number of their respective "erotogenic receptor sites," assuming,
without deciding, that there even are such things. Instead, we will have to
determine which of them is most strongly "desiring...whatever sensory
information" they typically process/react to when engaging in sexual
activity. And this sort of study, I am afraid, is not something opponents
of MNC ever cite.

There are some peer reviewed studies which do provide some information about circumcision's sexual sequela in adults. But this evidence, such as it is,
does not reflect negatively, on balance, on male circumcision in general.
There is a study which indicates that men who have been circumcised in
adulthood find sexual activity more satisfying, overall, roughly 70% of the
time, studies which conclude that circumcised men engage in a greater
variety of sexual activities than do uncircumcised men (specifics available
upon request - email me off post, ladies), and studies which conclude that
circumcised men are less prone to erectile dysfunction than uncircumcised
men, especially in later life (more good news!). To me, these studies hardly
provide warrant for characterizing the sexual sequela of neonatal
circumcision as "negative", but I leave the reader to draw her or his own
conclusions in this particular.

Let's end by returning to the capabilities approach. It is entirely clear
to me that women undergoing FGM are deprived of a "capability" needed for a
fully "human" life. Joyce's Molly's "YES" is absolutely never going to
happen for them. In the case of circumcised males, however, YES happens for
them as least as often as it does for their uncircumcised cohorts, and all
of the evidence we have suggests that they yell "Oh My God", or words to
similar effect, at least as loudly, when "knocking boots". So, while MNC in
the USA is indeed a cultural phenomenon, an expression of an aesthetic
preference on the part of middle and upper class protestant women, it
deprives no one of a meaningful capability necessary to enjoy a fully
"human" life. The same cannot be said for FGM.

So I did mention FMG, but didn't mention MNC. Hope this answers Bear's question.

Labels: Capabilities Approach

  ¶ 9:15 AM 3 Comments

 
This last week's discussion about science and epistemology has impressed me. I gather that the class is quite diverse in terms of how much philosophy the participants have taken, but folks appear to be picking up on many important concepts and ideas right out of the starting gate. Good job!


Let me suggest something further to think about. Caveat: what I am about to say is opinionated and contentious, and would not necessarily meet with widespread agreement by “paid up” philosophers of science. Still it might get the discussion rolling in useful directions.


ONE way to think about the big issues in philosophy of science is to organize the discussion around “realism” versus “anti-realism”, and see how that relates to the empiricism versus rationalism versus pragmatism debate. When we organize our thinking in that way, at least initially, we find an argument going on about the status of “theoretical” entities and forces which we cannot see. Take electrons as a simple example. We don't “see” electrons (or do we?). We take eggs to be “real” because we see them, hold them, eat them, etc. But we don't see, hold, taste or eat electrons in the same way. So why take them to be real?


And, why stop with electrons? What about “causes”? Logical positivists read Hume, famously, as being dubious about any claim of the sort “putting poison in his wife's tea caused her death”. Ayer and the positivists thought Hume would allow that we observed the act of putting poison in the tea, and that we observed the death of the little missus thereafter. He would allow that this same sequence of events has been observed many times in the past. He would allow that, so far, this sequence has been “exceptionless”, that is, that every time we have seen poison put in tea, death has followed on the part of the person drinking the tea. He would allow that we expect that death will follow putting poison in the tea if we do that tomorrow. Moreover, he would allow that expecting death to follow poisoning is perfectly natural on our part. It is a “habit of thought”. But that is ALL he (Hume) would allow, because what we see is the events; we don't SEE the cause. Note, please, that not everyone reads Hume this way. Strawson, Craig and Blackburn offer alternate readings. But, for this discussion, let's stick with the “Hume a la Ayer” version, because it is illustrative.


Illustrative, because we can use it to see what was bugging empiricists “back in the day”, and why empiricism classically can lead to anti-realism in science. “Empiricism” writ large is just the idea that “sense experience is the ultimate source of all our concepts and knowledge”, as contrasted with “rationalism”, which holds that “there are significant ways in which our concepts and knowledge are gained independently of sense experience.” As regards “causes”, or “electrons,” the classical empiricist position might be that, since we never actually see them, there is no reason to treat them as “real”.


Kant thought that, at least as to concepts like “cause”, he had put an end to the debate, arguing that “cause” was a “category of understanding”, a sort of operation that the human mind performed upon experience, thereby constructing the “phenomenal world”. We know, then, that putting poison in the tea causes death, but this is knowledge of the phenomenal world, not knowledge of the “noumenal” world, that is, the world not comprehended through the categories of human understanding. De Pierris and Friedman put it this way: “Kant agrees with Hume that neither the relation of cause and effect nor the idea of necessary connection is given in our sensory perceptions; both, in an important sense, are contributed by our mind. For Kant, however, the concepts of both causality and necessity arise from precisely the operations of our understanding—and, indeed, they arise entirely a priori as pure concepts or categories of the understanding.”


Not everyone agrees that Kant succeeded here, or even what all of that meant, exactly. But, even if he did succeed when it comes to “cause”, where does that leave “electrons”, or germs, or...? THEY aren't “categories” or “operations of the mind,” but rather, according to realists, putative “objects”, or things that (allegedly) exist whether there is any “experience” going on or not. So how does Kant have anything to do with this? How does this HELP? Let's take a brief detour through a bit of medical history and and then return to the question. Much of what follows is inspired by Dr. Marc Lange's article “Salience, Supervenience, and Layer Cakes in Sellars's Scientific Realism, McDowell's Moral Realism, and the Philosophy of Mind”, in Volume 101, Numbers 2-3, of Philosophical Studies. However, he might not agree with some, or much, of this, so don't blame him.


Consider Dr. Semmelweis, the Viennese obstetrician who was horrified to discover that, in the Doctors ward of the hospital, women were dying like flies of Puerperal fever, whereas, over in the nurse midwife ward, women got Puerperal fever less than half as often. And, he wasn't the only one to notice. Here in the good old USA, poet and physician Dr. Oliver Wendell Holmes, Sr. (Justice Holmes' father – a distinguished family) had noticed too. He wrote, years before Semmelwies, that
“. . . in my own family, I had rather that those I esteemed the most should be delivered unaided, in a stable, by the mangerside, than that they should receive the best help, in the fairest apartment, but exposed to the vapors of this pitiless disease."


Folks back then understood that diseases could be spread from person to person. They also presumed that bacteria existed, since Antony Van Leeuwenhoek's 1674 observations of “animalcules” through a microscope had been repeated many times for over 150 years. Some even guessed that “disease” could inhere, somehow, on physical objects like blankets, thus giving General Jeffrey Amherst the bright idea of giving native Americans blankets that had been used by small pox victims. Charming. No one, though, thought that “animalcules” could kill you, since they were so tiny. Thus, there was no “germ” theory of disease.


Semmelweis had before him a classic researchers' problem – discover why two groups, “Doctors' patients” versus “Nurses' patients” had different rates of death due to Puerperal fever. So he made Baconian “observations.” Observations of the organs of someone who had died of "cadaverous fever”; observations of the organs of women who had died of Puerperal fever; observations of Nun midwifes and what they did; observations of Doctors and what they did; observations about ward location, temperature, population and crowding; ton-o-observations, in other words, and he wrote these down methodically. Let's call what he wrote down “observation level” statements.


Not everything he observed, though, had anything to do with Puerperal fever. Semmelweis needed to figure out which observations were clues. He needed for some observations to “stand out”. Salience, per cognitive scientist Dr. Laurent Itti is that “which makes some items in the world stand out from their neighbors.”


In the event, the “right” observations were made “salient” for Semmelweis; that is, the right ones “stood out” for him, for the most part, and he ignored those observation level statements of his that didn't matter. What stood out for him were things like “the nuns wash their hands before and after touching the sick,” “the nuns don't go from cutting up corpses to examining women in labor,” “the nuns have clean clothes on that haven't been in contact with rotting corpses,” “the internal organs of people who have died of cadaverous fever look like the organs of women who die of Puerperal fever,” etc. Equally important was what didn't stand out – things like the color of the nuns' habit, the color of the doctors' trousers, the prayers the nuns said, the temperature in the ward.


What made some observation statements salient and others not? How about the THEORETICAL statements (thoughts, conceptual schemes?) in Semmelweis's noggin? His THEORIES, in other words. Note that they weren't the best of all possible theories. In fact, they were pretty much WRONG, consisting as they did of mostly of the stuff he had been taught – the “wisdom” of his day. The theoretical entities in his noggin were things like “miasmas”, and “vapors”, neither of which, in fact, exist. Still, they were good enough, close enough to how things are, to make the RIGHT observations salient for him, after postulating the existence of a new “theoretical entity”, the “cadaverous particle,” which, while not exactly a bacteria, is a step closer than a “miasma”. Based on his theories, he was able to utilize his observations to formulate some “laws of obstetrical ward hygiene”, which are, roughly, the same ones we subscribe to these days.


These laws of obstetrical ward hygiene can be expressed entirely in the terms used in Semmelweis's “observation level” statements. The only “terms” we need are soap, water, hands, wash, etc. So, once we have them, and we confirm the laws inductively – new moms don't get Puerperal fever when we adhere to them – what else is needed? Wouldn't the right thing for nurses to have done back then be to reason as follows: “we nurses will follow the 'laws of obstetrical ward hygiene' as long as they are inductively confirmed, but we will remain agnostics about vapors, miasmas, and cadaverous particles”?


At first glance that SEEMS right – agnosticism would keep researchers from refusing to look at better theories when they came along, like a theory that substitutes pathogenic “animalcules,” or bacteria, for “cadaverous particles”, say. Viewing science historically, with the benefit of hindsight, agnosticism might look sound. There are even respected philosophers of science who counsel something like this attitude today. Constructive empiricists, for example, allow that one can USE theorizing in order to formulate hypotheses and “observation statement” type laws, but are still of the opinion that it is okay to be skeptical, or at least agnostic, about entities and forces which cannot be directly observed by the senses. Perhaps, they say, today's “electron” is tomorrow's “miasma”, and anyone who is not at least open to that possibility is a pig-headed, lab-coated intellectual fascist.


Plausible as this seems, there are problems with it. For one thing, it assumes that there is some principled distinction between that which is “seen” with the naked eye, and that which is “seen” with a microscope, or by means of some other method which augments our senses. Harvard philosopher John Hall finds this highly suspect. It would mean, for example, that some tiny creature that can “see” a bacteria should “believe” in them, whereas we should be agnostic about them because we need microscopes to spot the little rascals. Or what about the moons orbiting the outer planets? Does this mean that we can be agnostic about them as long as we only “see” them through telescopes, but we can “believe” in them after astronauts “see” them through the spaceship's window?


A second problem is this: absent an assumption concerning the truth of our theories, how do we arrive at explanations? We want good laws of obstetrical hygiene, of course, but we also want an explanation for why they “work”. The philosopher Willfrid Sellars used the example of Boyle's law. Why does the equation P=VT work? BECAUSE (theory) heat = molecular motion, and (theory) gases are itty bitty moving particles. If confined, then, as they heat up they move faster, so they bump in to each other more often, so they exert more force on the confining vessel, so pressure rises. COOL!


A true theory, aided by an ASSUMPTION that the fundamental laws of the universe will be the same tomorrow as they are today, permits us to stop relying on inductions from observational statements, and start actually “deducing” things, as J. S. Mill noticed a while back. When our deductions don't work in terms of the observations we make, we go back and revise the theory, expecting (reasonably enough) that it will EXPLAIN not only the observations we do make, but why the old theory SEEMED to work as well as it did.


The miasma theory of disease is a good example to use here. According to that theory, disease was spread by noxious, vaporous things called “miasmas”, which contained tiny bits of rotting stuff called “miasmatas”, and this was the standard theory of disease in the mid 1800's. Nightingale accepted it, for example, at least at the beginning of her career. Accepting it as true lead to changes in public behavior. People started washing stuff that smelled bad (including themselves, thank God), covering sewers, inventing toilets and digging outhouses, and draining swamps so that the bad stinky air wouldn't blow in to town (eliminating the mal aria, in Latin. Isn't that an interesting tidbit?)


The miasma theory wasn't all that great, but it seemed to work. Malaria, for example, virtually ceased to exist in many parts of the industrial world. Public health visibly, measurably, improved. Observations seemed to confirm the theory. It began to be modified/abandoned only when anomalous phenomena were observed, and/or its explanatory power proved inadequate. And, our newer theories of disease explain the successes the miasmatic theory did enjoy. Drained swaps don't harbor mosquitoes, and so malaria disappears. Washed bodies are far less at risk for septicemia than unwashed ones are, due to a lower bacteria count. Cholera is less frequent when people stop throwing poop in to gutters, where it washes in to streams and shallow wells, because fewer vibro cholerae are getting in to the drinking water. In fact, one can go so far as to say that we wouldn't ACCEPT the germ theory of disease if it COULD NOT explain the successes of the miasmatic theory.


So where does this leave us? I think it ought to leave us back with Kant, at least in spirit, if not in detail. Nick Fearn and others have suggested that we think of Kant's BIG idea about categories of understanding as analogous to eyeglasses that we cannot take off, operations that the mind automatically and unceasingly performs on the information it receives, and indispensable to us, since without them we could not THINK at all. Similarly, we might think of theories and the entities and forces they postulate as indispensable eyeglasses which render certain observations salient. Without them, and the presumption that they characterize reality accurately, we cannot proceed.

The late and very much missed philosopher Jay Rosenberg put it much better than I ever could:

“...stories that postulate “theoretical entities” are not merely manageable second-class surrogates for more complicated and unwieldy stories about entities that we have good, i.e., observational, reasons to believe actually exist. Theoretical entities, rather, are those entities we warrantedly believe to exist for good and sufficient theoretical reasons. On this understanding, scientific theories explanatorily “save the appearances” precisely by characterizing the reality of which the appearances are appearances.”


So, don't forget to wash you hands, empiricists. They REALLY have animalcules on them.  ¶ 11:05 AM 8 Comments

  Some readers of this blog have, perhaps, been watching the United States try to devise a rational health care system. I imagine reactions around the globe have varied along a spectrum, from amusement on one end to the sort of pity, mixed with horror, that a classic Greek tragedy produces, on the other. The most vocal opponents over here of any sort of systematic health care planning and reform are being labeled “deathers.” Deathers claim that, under any sort of nationally mandated health care scheme, a lot more old peopled will die a lot sooner than they otherwise would. Those who have been watching from (lucky you!) afar will enjoy this bit of “tongue in cheek” about the “deather” position from the U.S.A. Blogosphere:

'When Obama and the Democrats try to explain how America's health care crisis can be fixed, they often point to our neighbors to the north.

"Canada provides health care to all its citizens, we can too," say the optimists.

Sounds good until you consider this scary fact: at some point after Canada instituted its national health care program, everyone in the country died.

This startling truth emerged today when a group known as the "Deathers" -- sponsored by a consortium of health insurance companies and endorsed by Senator Mitch McConnell (R-KY) -- held a press conference exposing a surprising statistic: according to the most recent census reports, Canada's population is currently zero.

"Near as we can tell, some of them dropped dead right away and some of them were horribly disfigured and stumbled around for awhile and then died," Jordan Gipple, a spokesman for the Deathers, reported "but the bottom line is, from Newfoundland to British Columbia, there's not one single person up there. It's like The Omega Man only without Charlton Heston."

A reporter asked why it was that so many Canadians do seem to be alive and perfectly healthy today. Wayne Gretsky, Seth Rogan and Nelly Fertado were cited as examples. Mr. Gipple responded that these so called "Canadians" actually reside outside of Canada in places like Arizona, Los Angeles and New York. "They're like refugees from the Titanic. Sure, every once in awhile you'll find one floating around, but I bet you five bucks not one person here has seen a real Canadian in the past 24 hours. They've all gone to the great beyond. And you can thank national health care for that!"

"Canada's not the only place. There used to be plenty of people in Norway and Sweden and France. There were even some people in England. But then they went and instituted national health care. And now they're gone too."

Mr. Gipple ended with an impassioned plea that brought tears to the eyes of the press members present, "Yes, America's health care costs are spiraling upwards. Yes, 46 million Americans are uninsured. And yes, about 1.5 million families lose their homes to foreclosure every year due to unaffordable medical costs. But seriously, what are the options? Just look at what happened to these other countries when they tried to "fix" the system. I know I speak for all Deathers when I say we must keep the system we have, absolutely. Don't touch it. We don't want to wind up like Canada or Holland or Denmark or Germany. They're all gone. Now it's up to us, us fortunate few, to keep the candle of mankind burning." '

Recently, a U.S. reichwing opinion writer stated:

“People such as scientist Stephen Hawking wouldn't have a chance in the U.K., where the National Health Service would say the life of this brilliant man, because of his physical handicaps, is essentially worthless.”

Of course, other bloggers jumped on this, and one of them pointed out the blindingly obvious:

... "Stephen Hawking was born and raised in the UK and has lived there all his life. He teaches at Cambridge. That's in the UK. This ranks up there with the French not having a word for entrepreneur."

In sum, the combination of galactic ignorance, Harry Frankfurt Bull Shit, and out and out thuggery (our own Kay Lundy's apt and pithy term) going on over here is truly astounding, until you remember that this is happening in America, where knife fights on the floor of state legislatures happened once upon a time, today's college freshmen can't find Wales on a map, and Sarah Palin thinks she can see Russia when she opens her front door.

Sooner or later, it will occur to someone to look at statistics. The following numbers come from our CIA, so they must be pretty good, right? Canada =81.23 years, Norway =79.95, UK=79.01,USA = 78.11. The US only beats Albania, hands down the poorest country in Europe, by a few months.

So, how are you perfidious Cannucks, Norskies and Brits managing this? Do you come up with a closely guarded secret “target” age, fixed upon by NHS gnomes, to keep the “life expectancy” numbers up to a level that reassures the gullible public, and THEN do granny in? Or, could it be that here in the US of A we are, in fact, doing granny in ourselves, in various and sundry (and often unpleasant) ways, but just lying to ourselves about what really goes on here?

Perhaps, for example, we make routine care out of reach for Granny for most of her life, so that her type II Diabetes, and hypertension, go undetected for years. Then, when we finally do detect it, we prescribe expensive meds she can't begin to afford, when over the counter Humulin R and Lasix, coupled with some patient education, would have done very nearly as well. Or even better. Then, when her kidneys fail, we put the tax payers (and Granny) through the oiive press with dialysis. The cost of the dialysis, it should be noted, will far exceed what a lifetime supply of Humulin R, generic brand Walmart insulin syringes, a few home health visits, and generic lasix would have cost.

After months of this misery, Granny refuses dialysis and dies. Painfully. This happens. In 15 years as a long term care nurse, I have held "Granny's" hand, under exactly these circumstances, more times than I care to remember. I cry each and every time it happens. Sometimes, the Director of Nursing has to send me home. “Pay no attention to the man behind the screen, Dorothy.” Could it be that “deathers,” heaven help us, are right to look, but are looking in the wrong direction?

Labels: Deathers

  ¶ 12:39 PM 3 Comments

 

This list is in danger of suffering from disuse atrophy, which is a bad
thing, as I have reason to know.  So I decided to post something.

I just received an announcement that Martha Nussbaum will be coming to the
southern part of heaven (otherwise known as UNC-Chapel Hill) next spring to
make a presentation (title TBA) to the philosophy department.  I can't pass
up a chance to meet another philosophical rock star.  So, in anticipation of
the coming event, I sat down and read Nussbaum's "Sex and Social Justice,"
one of several of her books that relies on what she calls the "capabilities
approach" to ethical and political theorizing.

Nussbaum writes beautifully, with the goal of engaging not just
philosophers, but all thoughtful people.  Commendably, she doesn't just
theorize in a philosopher's study, but often descends in to the messy world
of day to day life as ordinary people around the world must live it, and, as
one Jesuit reviewer put it, "if you are looking for wisdom, her books are
full of the stuff."

Much of the "wisdom" is derived from her encyclopedic knowledge of the
ancient world, particularly Aristotle and the stoics.  Of course, not
everyone agrees that she "gets them right." I am not competent to
adjudicate, so I just think of it as a case of "Aristotle and Aurelius as
She Understands Them", or AASUT for short (sounds sort of like the "AHH
S..T!" that working nurses exclaim when the vein they are trying to puncture
for a blood sample blows up).

In any event, informed by AASUT, and the work of the economist Amartya Sen,
Nussbaum offers us the notion of "capabilities."  The goal here is to
specify "a life in which fully human functioning, of a kind of basic human
flourishing, will be available."  She attempts, in other words, to meet a
big challenge for eudamonian based ethical theories, that of specifying what
counts as a "good life."  Problems rush in here, for doesn't the very idea
of "basic human flourishing" smack of dreaded "essentialism"?  "Good life"
for me might be a whole different kettle of fish from "good life" for
Hitler.  In fact, I am pretty sure I would mean something different by the
term than he would.

What counts as a good life ought to matter to nursing if anything does,
especially in light of the love affair nursing has had with virtue ethics
over the years.  But, you don't have to be in nursing  very long to discover
that there are differing conceptions of the "good life"  amongst the patient
population. Some nursing scholars are lead to conclude, by the diversity of
views on the subject, locally and globally, that there is simply no such
thing as THE "good life," and any attempt by some
old-fat-white-man-ex-lawyer-now-a-nurse (like, say, me) to define the term
would be an exercise in "colonialism"; a LITTLE better than yelling "bash
the WOGs and Fuzzies, let's have another gin" - but not MUCH better.
Attempting to define "good life" for other folks turns me, apparently, into
a sort of intellectual neo-Clive let loose upon the world once more,
opressing everyone from Dublin to the Ganges (well, not Dublin - I love
Dublin.  Let's abuse them last).  Bob the nabob, minus the opium and dancing
girls (damn it, I was born too late!).

Nussbaum is not unaware of these difficulties, and gamely tackles them.  Her
efforts are impressive, and even the likes of Simon Blackburn (who does not
suffer fools lightly) admires them.  The approach is supposed to be (mostly)
culture neutral because it addresses capabilities as opposed to practices,
and so at some level or another supposedly doesn't  involve telling other
people what to do. Consider the list:

life; bodily health and integrity; senses, imagination and thought;
emotional expression; practical reason; affiliation; play; other species;
and, control over political and material environments.

The idea has initial plausibility - take, say, control over the political
environment.  It doesn't rule out of court an Islamic republic, for example,
provided the folks living there want to live in one and have some say in
choosing that form of life.  But not every "post-colonialist" is likely to
be persuaded.  For instance, some cultures are not too ginned up about
giving women even certain "capabilities."  There are societies which deny
women substantial capabilities viz. affiliation, bodily integrity, thought
and environment.  The capabilities approach would declare them illegitimate,
and therefore is, arguably, "colonialist".

To this criticism from the left flank, there are at least three replies.
First reply: who speaks for the culture in question - the girls who want to
go to school, or keep their clitoris, but who are not allowed to, or the
(male) mullahs, elders and/or warlords who won't let them?  Maybe what the
culture "really" wants IS compatible with the "capabilities" approach.

Second reply: maybe these silly savages are just ignorant.  Maybe they don't
know that women are actually smarter than men, on average, and so OUGHT to
go to school if anyone does, or they've misunderstood their own scripture,
or they don't understand enough about human physiology to comprehend that
eumenorrhea is normal and healthy and occurs for homeostatic reasons, or
that it is a bad idea to mutilate female genitalia with or without antsepsis
and anesthesia for any number of reasons, or ... I could go on for while,
but you get the general idea.  Sort of a Millian style argument, like the
one he gave against Bentham's "equality of pleasures" position.

Third reply: this provides a repugnant conclusion/reductio ad absurdum
refutation of post-colonialist arguments. Simply put, IF post-colonial
theory countenances, in any shape, form or fashion, stuff like female
circumcision, obligatory suicide of widows, "honor" killing of women, etc.,
then so much the worse for post-colonial theory.  What's wrong with the idea
that cultures, like individuals, make mistakes?

Assaults could be mounted from the right flank as well.  While emphasizing
"capabilities" is not AS blatantly egalitarian/redistributionist as say, a
Rawlsian program of equal distribution of all social "goods", it is still
going to involve some "taking from the rich" and "giving to the poor".
Noziak-style libertarians will, therefore, still object.  First reply: a
capabilities approach is consistent with unequal distributions of wealth so
beloved by libertarians - it just assures equality of opportunity to the
fullest extent possible, not equality of achievement. You get to keep, in
other words, what you fairly earn; capabilities approaches are simply trying
to give everyone, to the extent possible, the same chance you have.  It
can't give everyone a great voice and a lucrative concert career, for
example, but it can make it possible for everyone who has a great voice to
have music lessons. After the lessons it's up to you.  How could even Mrs.
Thatcher or Ronald Regan object to that?

Second reply: All the "capabilities approach" is doing is assuring some sort
of compliance with the "Lockean proviso", which says that you, or Bill
Gates, or Madonna can take as much of the world's riches as you want, so
long as you do so fairly and leave "enough and as good" for everyone else.
Most libertarians accept the Lockean proviso.  It is hard to know exactly
what that proviso comes to, in today's world, but maybe some sort of
"capabilities approach" captures the spirit of what Locke had in mind.

Interesting stuff.  But what, one asks, has this got to do with Nursing?
Nothing, if Nursing affords no valuable and unique perspective on questions
such as how should healthcare resources be distributed, o what constitutes
"disease" or "disability".  But, if it does have such a perspective, this
might be one way to articulate it that is in some meaningful sense
"transcultural."

Also, it seems to me that this sort of analysis of social justice and human
flourishing mirrors, in some interesting ways, the ways in which various
nursing processes analyze the individual's health.  The parallels with
Orem's theory are especially striking.  Perhaps Plato was on to something in
suggesting that the healthy person and the healthy society are structurally
similar.

One VERY bright young Don in the UK, Lorella Terzi at Roehampton University,
is doing some interesting work on this approach in the context of education
and learning disability.  See, for example, her ‘Beyond the Dilemma of
Difference: the capability approach on disability and special educational
needs’ in Journal of Philosophy of Education , 39 (3), pp.443-459.

I don't think it is absurd to think that there may be parallels between
questions surrounding  the delivery of educational services to the learning
disabled and the delivery of nursing services to the physically disabled, or
to the care of the sick in general.

Thoughts, anyone?

Labels: Capabilities Approach

  ¶ 8:56 PM 1 Comments

  This Blog has been moribund for quite a while, as most of the folks who are interested in this subject matter at present have made use of the nursing philosophy listserv, kindly maintained by our UK friends. I hope, though, to resurrect it in the near future.

The blog has proved to be quite useful for philosophy in some ways, permitting scholars who work in (relatively) narrow areas to communicate with each other, and providing a vehicle for those new to a field, or just wanting to explore it, to easily access ongoing discussion. And, unlike listserv-type communication vehicles, a blog does not contribute to e-mail inbox overcrowding.

Let's see if we can give this another go.  ¶ 10:21 AM 0 Comments

 
The health issues news service I use, care2.com, had an article posted today that claimed the UK has had a 21% increase in maternal childbirth deaths over the past year. It also claimed that the average salary for physicians in the UK is now higher than in the US, thanks to a new agreement between physicians and the NHS, whereas there is a hiring FREEZE for midwifes.

As the late David Falk would have said, interesting, if true. My problem is that I have found it unwise to take press reports(even those vetted by well-meaning folks like those at care2.com) at face value. After all, the much admired New York Times assured us a few years ago that Iraq possessed weapons of mass destruction.

Are these statistics accurate? Are there interesting issues here (along with the usual costly bout of Humean sympathy I am so prone to) for consideration under the topic of, say, "justice in the distribution of health care resources?" Will this be the occasion on which I loose those rose colored glasses through which I view all things "English?"

Bob Newsom  ¶ 9:20 AM 4 Comments