Thursday, December 29, 2016

Moral Imagination

What is moral imagination, and what role does (or should) it play in moral reasoning? What is its importance in moral decision-making?
      Moral imagination may be described as an ability to devise new or alternative approaches to moral problem-solving, and thus an ability to formulate new interpretations of the meaning of moral actions and situations.
      It may also be described as an ability to conceive of new or alternative moral principles and values, and thus an ability to engage with, and have a fuller understanding of, one’s own moral capacities and those of a given individual, group, or society.
      It may also be described as an ability to develop new or alternative interpretations of the moral motivations of others, and thus an ability to recognize the range of possibilities available for moral behavior.
      For some individuals, moral imagination may take the form of imagining a kind of morality different from conventional morality. It may take the form of an imagining that what is conventionally taken as right is actually wrong, or that what is conventionally taken as wrong is actually right, or that there actually is no right or wrong.
      For those who do not know right from wrong (such as some young children, perhaps, or some cognitively disabled individuals, or some psychiatrically impaired individuals), moral imagination may be an imagining that something is right or wrong because of the responses that it seems to evoke from others. The emotionally immature or cognitively disabled individual may in some cases only discover that something is right or wrong by becoming acquainted with the moral and social responses of others to it.
      Trying to improve our moral conduct, and striving toward a moral ideal, may also to some extent involve our imagining the kinds of people we could be if we were to be live up to all our responsibilities and fulfill all our moral ideals. In order to become better citizens, we may sometimes have to imagine how we could become better fathers, mothers, sons, daughters, brothers, sisters, teachers, students, co-workers, colleagues, teammates, friends, or neighbors.
      To imagine something may be to conceive of that thing without ever having actually seen or experienced it. It may also be to perceive something as present or possible without its ever having actually been present for, or accessible to, sensory perception.
      To imagine something may also be to conceive of an object, person, situation, or condition that does not yet, but could, exist. It may be to evoke, summon, or call forth unrealized possibilities.
      If something engages or captivates our imaginations, we may find it to be particularly intriguing or compelling. We may discover that it presents to us a range of possibilities that we were previously unaware of or were only partially aware of. We may then be drawn to further explore its nature, meaning, significance, and implications.
      Moral imagination may be a power or faculty of producing from current or past perceptions new ideas or concepts that have moral applications, implications, or dimensions. It may involve creative and intuitive, as well as analytic and critical thinking. It may be combined with other moral faculties, such as moral perception, intuition, insight, reasoning, and understanding, in order to produce a more secure and reliable foundation for moral judgment.
      Moral imagination may also enable us to recognize that there may be more than one way of looking at and responding to moral problems.
      The ability to be imaginative may depend on an openness to new thoughts, new impressions, and new ways of looking at things
      Moral imagination may therefore enable us to find creative solutions to moral dilemmas. It may enable us to envision and formulate ideal modes of conduct.
      Supererogatory conduct (actions that go beyond what is morally obligatory) may depend on the power of the imagination to inspire us to perform actions that go beyond the call of duty.
      Imagination may also play an important role in such moral attitudes as sympathy, empathy, and compassion. The ability to feel and express sympathy, empathy, or compassion for others may to some extent depend on the ability to imagine what they are feeling, and thus to imagine the pain, suffering, distress, anxiety, embarrassment, shame, sadness, or despair they may be experiencing.
      A constricted moral imagination may constrict the ability to feel sympathy, empathy, or compassion for others. Failure to respond to the suffering and distress of those who are seen as outsiders or strangers may thus in some cases be due to a constriction, deficiency, or failure of imagination.
      Imagination may also enable us to evaluate our own actions in light of what we think others may think about them. It may help us to recognize that our conduct can always be improved.
      Moral imagination may enable us to exercise capacities for moral decision-making that we did not previously know we possessed or were only dimly aware of. It may enable us to anticipate the possible unintended consequences of our actions, and to judge whether those consequences are desirable or undesirable. In cases in which we are compelled to ask ourselves whether we may have failed to treat others as we ourselves would want to be treated, it may enable us to recognize how we would feel if we were treated by others in the same way that we have treated them.
       Moral imagination may also play a role in, or be incorporated into, other forms of imagination, such as religious, aesthetic, literary, poetic, or dramatic imagination. It may inspire the creation of moral comedy or tragedy. It may provide a foundation for moral aesthetics or poetics, including the poetics of moral possibility.
      As a creative enterprise, moral imagination may also be opposed to mimesis, rote repetition, or mechanical mimicry of conventionally accepted behavior. It may be opposed to rigid and inflexible adherence to moral norms and principles of duty. Thus, it may make possible the perception of a kind of moral truth that transcends conventionally accepted truth, and it may inspire new approaches to, and creative strategies for, moral problem-solving.
      Moral imagination may therefore depend less on the seeing of things as they are (though it certainly does depend on this kind of seeing) than on the seeing of things as they might be. The seeing of things as they might be, or as they could possibly be, is also the awareness of possibility, which may be the essence or most fundamental feature of imagination.
      Moral imagination may be something that makes possible Raskolnikov’s overwhelming sense of guilt in Crime and Punishment, Ahab’s maniacal quest for revenge in Moby Dick, Kurz’s ultimate sense of horror in Heart of Darkness, and Joseph K’s inescapable sense of anxiety and desperation in The Trial.
      It may also be something that makes possible Jane’s faithfulness to her sense of duty in Jane Eyre, Strether’s moral scrupulousness and faithfulness to personal conscience in The Ambassadors, Jay Gatsby’s romantic idealism and sense of hope in The Great Gatsby, Emma’s carelessness and capriciousness in Madame Bovary, Hedda’s recklessness and self-indulgence in Hedda Gabler, Blanche’s disdain for Stanley’s crudeness in A Streetcar Named Desire, Levee’s sense of futility and rage in Ma Rainey’s Black Bottom, Dimmesdale’s agonizing sense of guilt in The Scarlet Letter, and Aschenbach’s hopeless infatuation with Tadzio in Death in Venice.
      Matthew Kieran, in an article entitled “Art, Imagination, and the Cultivation of Morals” (1996), explains that morally significant art may promote imaginative understandings of moral problems, concerns, or situations. Art "may extend or deepen our understanding of the values and commitments that underlie our actions and desires,” and it "may also shape our understanding of what we value by showing us how to act…in morally fruitful or harmful ways.”1
      John Dewey (1922) explains that “deliberation is a dramatic rehearsal (in imagination) of various competing possible lines of action….Each habit, each impulse involved in the temporary suspense of overt action takes its turn in being tried out. Deliberation…. is an experiment in making various combinations of selected elements of habits and impulses, [in order] to see what the resultant action would be like if it were entered upon.”2
      Steven Fesmire (2003) extends Dewey’s conception of the role of imagination in moral deliberation by proposing three interrelated theses: (1) moral character, belief, and reasoning are inherently social, embodied, and historically situated, (2) moral deliberation is fundamentally imaginative and takes the form of dramatic rehearsal, and (3) moral imagination may be conceived as a process of aesthetic perception and artistic creation.Fesmire therefore argues that imagination may provide deliberative resources for moral decision-making that are not provided by rigid adherence to abstract principles of morality.
      Mark Johnson (1993) explains that "moral reasoning is...basically an imaginative activity, because it...requires imagination to discern what is morally relevant in situations, to understand empathetically how others experience things, and to envision the full range of possibilities open to us in a particular case."4 He also says that moral situations may be metaphorically conceptualized in order to more clearly understand them, and that "the metaphorical character of moral understanding is precisely what makes it possible to make appropriate moral judgments."5
      Moral imagination may inspire the construction of moral narratives, and it may promote understanding of the ways in which such narratives can be framed or contextualized. Moral narratives may be those that have a moral content, subject matter, theme, purpose, or meaning. The understanding of moral situations may to some extent depend on the understanding of narrative accounts and explanations that have been provided with respect to those situations. Moral understanding may therefore be to some extent a kind of narrative understanding.
      However, moral understanding may be not only analytic, conceptual, thematic, and textual, but also synthetic, imaginative, empathetic, and experiential.
      Moral imagination may include the capacity to perceive previously unrecognized or poorly understood moral dimensions of our actions. It may also include, as a result of the capacity to think creatively about moral possibility and responsibility, the capacity to perceive those moral dimensions of our actions that are not immediately or prima facie evident. It may therefore enable us to develop a fuller understanding of the morally good, and a clearer understanding of the true nature of morality (whatever that may be).
     

FOOTNOTES

1Matthew Kieran, “Art, Imagination, and the Cultivation of Morals,” in The Journal of Aesthetics and Art Criticism, Vol. 54, No. 4 (1996), p. 345.
2John Dewey, Human Nature and Conduct: An Introduction to Social Psychology (New York: Henry Holt and Company, 1922), p. 190.
3Steven Fesmire, John Dewey and Moral Imagination: Pragmatism in Ethics (Bloomington: Indiana University Press, 2003), p. 4.
4Mark Johnson, Moral Imagination: Implications of Cognitive Science for Ethics (Chicago: The University of Chicago Press, 1993), pp. ix-x.
5Ibid., p. 10.

Saturday, December 10, 2016

Health Care as a Basic Human Right

If every person has, or should have, the right to health care, what are the limits of that right? To what kind of health care is every person entitled, if health care is a basic human right?
      I believe the right to health care is indeed a basic human right, along with the right to life, the right to liberty, the right to personal security, the right to due process of law, the right to work, the right to receive an education, and other basic human rights.
      The Universal Declaration of Human Rights, Article 25, says that “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”1
      I believe there is a moral argument to be made (which I shall not present here) for providing some level of basic health care to everyone who is in need of care, regardless of his or her ability to pay. What then is the level of basic care that should be provided?
       Allen Buchanan, in an article entitled “The Right to a Decent Minimum of Health Care” (1984), argues that the right to health care is not an unlimited right, but rather a right to a “decent minimum” of care.2 However, I would argue that the concept of a “decent minimum” of care is unacceptable for a number of reasons, and that the right to health care is a right to timely and adequate access to medically necessary care, recognizing that (1) access must be reasonable, not unnecessarily impeded, not unduly burdensome, and actual rather than merely theoretical, and (2) the care provided must be respectful of the human and personal dignity of each individual.
      Medically necessary care may be defined as care provided to prevent, diagnose, or treat a medical condition, in accordance with the accepted medical standard of care for that condition. The standard of care for a given medical condition may be defined as the kind of care that would ordinarily be rendered by a competent health care provider in the same community under similar circumstances. Medically necessary care may also be defined as care without which the patient being treated would suffer debilitating symptoms, preventable complications, irreparable injury, or permanent loss of function.
      The right to health care is not a right to unlimited or unnecessary care. Patients do not have the right to demand unnecessary services, and care providers do not have an obligation to provide unnecessary services. Indeed, care providers have an obligation not to provide unnecessary services, because such services may be harmful to patients and wasteful of health care resources.
      What then is wrong with the concept of a “decent minimum” of care? A “decent minimum” may be defined in a number of ways, some of them quite problematic. For example, from the point of view of party A, who thinks that party B is morally and socially inferior and therefore undeserving of the same level of health care available to party A, a “decent minimum” of care for party B may be something quite lower than what party A is entitled to. Also, from the viewpoint of party A, who lives in wealthy country C, a “decent minimum” of care for party B, who lives in poor country D, may be something quite lower than what party A is entitled to, because of the disparities between the economic and health care resources of countries C and D and the consequent disparity between what people of the two countries may see as the “decent minimum” level of care to which they are entitled. Both of these viewpoints may lead to arbitrariness, inequity, and injustice in the way in which the definition of a “decent minimum” of care is decided upon.
      It may also be argued that people have a right to more than a “decent minimum” of care, and that they have a right to the best quality of medically necessary care that can be provided, within the logistical, economic, and technological constraints of the health care system of the society in which they live.
      The financial cost of health care, of course, has to be taken into account in determining what constitutes the best possible care. The best possible care is also the safest, most reliable, most effective, and most cost-efficient care, as well as the care that is least burdensome for patients and most likely to produce the best possible outcomes.
      Buchanan says that debate about the claim that there is a right to a “decent minimum” of health care may center on two issues: (1) the issue of whether there is a more extensive right to health care, and (2) the issue of what health care services comprise the “decent minimum” of care to which there is a right.3 He admits that the claim that there is a “decent minimum” of care usually presupposes that this “decent minimum” is relative to the given society in which it is said to exist, but he argues that the advantages of the concept of a “decent minimum” for all individuals, as opposed to an equality of opportunity (regarding health care) for all individuals, are that (1) the concept of a “decent minimum” enables us to adjust the level of care according to relevant social conditions, (2) it “avoids the excesses of the strong equal access principle” (that everyone has an equal right to the best health care available) , while still acknowledging a substantive universal right, and (3) it recognizes that there must be some limitation to the right to health care, because of the limitations in resources available to any given society.4
      Buchanan thus explains that it’s reasonable to assume that, just as with other social goods and services, the extent of the right to health care services depends on the resources available to a given society.5 He makes a distinction between universal rights claims (which attribute the same rights to all individuals) and special rights claims (which attribute rights to particular individuals or groups).6 He also explains that special rights claims may be based on past discrimination against an individual or group (because that individual or group may have a special right to goods or services they have previously been denied) or may be based on unjust harms suffered by an individual or group (because that individual or group may have a special right to compensation for the unjust harms they have suffered) or may be based on sacrifices made by an individual or group for the good of society as a whole (because that individual or group may have a special right to compensation for the sacrifices they have made).7
      It may be argued, however, that everyone has a right to the best care available within the logistical, economic, and technological constraints of the health care system of the society in which they live, although everyone may not necessarily the same right. Those who are more in need of health care may have more of a right to the best care available. Those who invest their financial resources in order to ensure that they receive the best care available may also have a special right to receive the best care available. However, need should be considered more important than ability to pay in determining who is most deserving of available health care. Individuals should not be prohibited from investing their financial resources in order to ensure that they receive the best care available, but all individuals should be able to receive the best care available if they are really in need, regardless of their ability to pay.
      Another argument against the acceptability of the concept of a “decent minimum” of care is that care providers may have a duty to provide more than a “decent minimum.” They actually have a duty to fulfill a “reasonable standard of care,” which may be more than a “decent minimum.” Moreover, it may be argued they have a duty to provide the best care they can provide within the constraints of the health care system in which they function as providers. Requiring them to provide only a “decent minimum” of care may conflict with their duty to fulfill a “reasonable standard” of care and to provide the best care they can provide within the constraints of the given health care system.
      I would argue that health care providers also have a duty to provide the best possible care for all their patients, regardless of their patients’ socioeconomic status, age, gender, race, nationality, religion, sexual orientation, gender identity, or disability.
      Part of the duty of every health care provider is to function as an advocate for his or her patients in order to help them navigate the health care system, and in order to ensure that they have access to all the care they need. Patients have a right to expect that their health care providers will do their best to ensure that they receive all the care they need, and to ensure that they receive the best care possible.
      The concept of a “decent minimum” of care may therefore become a means to unfairly discriminate against individuals, based on their socioeconomic status or other factors. Those who are seen as being of lower socioeconomic status may be seen as being entitled to only a “decent minimum” of care, while those who are seen as being of higher socioeconomic status may be seen as being entitled to the best care available.
      The supposed obligation to provide only a “decent minimum” of care may also become a “slippery slope” for care providers, leading them to provide less and less care until the concept of a “decent minimum” has hardly any meaning. A “decent minimum” may come to mean almost nothing at all. A “decent minimum” may also come to mean a lower level of care than could reasonably be provided within the constraints of the health care system.  A “decent minimum” may become a kind of “race to the bottom,” rather than an effort to make a higher baseline level of health care available to all individuals.
      Perhaps, instead of trying to explore the content of a “decent minimum of care,” we should try to explore the content of an “adequate baseline level of care.”
      Justice in health care does not require that everyone have the same access to care and receive the same level of care, regardless of whether some are more in need of care than others. It does, however, require that everyone be provided with the health care he or she needs, and that an adequate baseline level of health care be made available to all.
      Kenneth Cust (1997) describes a “just minimum of health care” as a more viable concept than a “decent minimum of health care.” He says that

“Thus far we have taken the phrase ‘decent minimum of health care’ to mean roughly an adequate amount of health care. However, the concept “decent” has normative content as well. It can mean, for example, conformity with a standard of conduct or propriety. On this account, to say that people were entitled to a decent minimum of health care would mean little more than to say they were entitled to only what we choose to give them. If this is what Buchanan meant by a decent minimum of health care, then it may not be sufficient to meet people’s basic heath care needs.”8

      The right to medically necessary care may imply other rights, such as those enumerated in various statements of patient rights and responsibilities. Patient rights implied by the right to medically necessary care may include such rights as (1) the right to be treated with dignity and respect, (2) the right to be treated in a safe and secure environment, (3) the right to be protected from abuse, neglect, and mistreatment, (4) the right to be protected from discrimination on the basis of race, ethnicity, religion, nationality, sexual orientation, or disability, (5) the right to informed consent, (6) the right to privacy, (7) the right to confidentiality of personal and health information, (8) the right to participate in medical decision-making concerning one’s own care and treatment, and (9) the right to timely and understandable communications from health care providers.
      Patient responsibilities, on the other hand, may include (1) the responsibility to provide complete and accurate information about present symptoms, present and past medications, past medical history, and past treatment, (2) the responsibility to cooperate with care providers in order to develop plans of treatment, (3) the responsibility to comply with recommended treatment, (4) the responsibility to return for follow-up appointments in a timely fashion, and (5) the responsibility to respect the rights of other patients.


FOOTNOTES

1United Nations, “The Universal Declaration of Human Rights,” (1948), online at http://www.un.org/en/universal-declaration-human-rights/.
2Allen Buchanan,, “The Right to a Decent Minimum of Health Care” (1984), in Justice and Health Care: Selected Essays (Oxford: Oxford University Press, 2009), p. 4.
3Ibid., p. 17.
4Ibid., p. 20.
5Ibid., p. 20.
6Ibid., p. 27.
7Ibid., p. 27.
8Kenneth Cust, A Just Minimum of Health Care (Lanham: University Press of America, 1997), p. 61.