Applying Nonideal Theory to Bioethics : Living and Dying in a Nonideal World

This book offers new essays exploring concepts and applications of nonideal theory in bioethics. Nonideal theory refers to an analytic approach to moral and political philosophy (especially in relation to justice), according to which we should not assume that there will be perfect compliance with principles, that there will be favorable circumstances for just institutions and right action, or that reasoners are capable of being impartial. Nonideal theory takes the world as it actually is, in all of its imperfections. Bioethicists have called for greater attention to how nonideal theory can serve as a guide in the messy realities they face daily. Although many bioethicists implicitly assume nonideal theory in their work, there is the need for more explicit engagement with this theoretical outlook. A nonideal approach to bioethics would start by examining the sociopolitical realities of healthcare and the embeddedness of moral actors in those realities. How are bioethicists to navigate systemic injustices when completing research, giving guidance for patient care, and contributing to medical and public health policies? When there are no good options and when moral agents are enmeshed in their sociopolitical viewpoints, how should moral theorizing proceed? What do bioethical issues and principles look like from the perspective of historically marginalized persons? These are just a few of the questions that motivate nonideal theory within bioethics. This book begins in Part I with an overview of the foundational tenets of nonideal theory, what nonideal theory can offer bioethics, and why it may be preferable to ideal theory in addressing moral dilemmas in the clinic and beyond. In Part II, authors discuss applications of nonideal theory in many areas of bioethics, including reflections on environmental harms, racism and minority health, healthcare injustices during incarceration and detention, and other vulnerabilities experienced by patients from clinical and public health perspectives. The chapters within each section demonstrate the breadth in scope that nonideal theory encompasses, bringing together diverse theorists and approaches into one collection. Contents About the Contributors Part I: Nonideal Theory Chapter 1: Introduction to Nonideal Theory and Its Contribution to Bioethics 1.1 History and Background: Ideal and Nonideal Theory 1.2 The Nonideal Approach to Bioethics 1.3 The Future of Nonideal Approach to Bioethics 1.4 Nonideal Theory and Bioethics in the Time of COVID-19 1.5 Contents of the Volume References Chapter 2: Ideal and Nonideal Theories: The Challenges of Decision-Making in an Imperfect World 2.1 Introduction 2.2 Ideal and NonIdeal Theories 2.2.1 Conceptual Distinctions 2.2.2 Ideal Versus NonIdeal 2.2.3 Good and Bad Idealizations 2.2.4 Different Views of Ideal Theory 2.2.5 The Decision-Making Process: Requirements and Deliberation 2.3 Ideal and Nonideal in Bioethics 2.3.1 Case 1: Conscientious Objection and Abortion 2.3.2 Case 2: Research with Pregnant Women 2.4 Conclusion References Chapter 3: The Positioning of Moral Agents and Its Relationship to Nonideal Bioethics 3.1 Bioethics Methodology and Moral Positioning 3.1.1 Strongly Idealized Methodology 3.1.2 Strengths and Limitations of Several Popular Approaches to Method in Bioethics 3.1.2.1 Pluralistic Principlism 3.1.2.2 Non-Particularist Casuistry 3.1.2.3 Morality as a Public System 3.1.2.4 Idealizing Assumptions About the Common Morality and Moral Principles 3.2 Naturalized Moral Epistemology and the Common Morality 3.2.1 Naturalized Common Morality I: Shared Ecological Predicaments 3.2.2 Naturalized Common Morality II: Shared Evaluative Spaces 3.2.3 Naturalized Common Morality III: External Coherence 3.3 Conclusion References Chapter 4: Critical Theoretical Methodology for Nonideal Contributions to Bioethics 4.1 Nonideal Theory and the Paradox of Ideal Theory’s “Realism” 4.2 Marx’s Critique of Political Economy (and Ideal Theory) and Accounts of Structural Alienation 4.3 A Nonideal Marx-Informed Critique of Bioethics 4.4 Social Pathologies of Health Care as a Nonideal Theoretical Model for Bioethics References Chapter 5: Conditioning Principles: On Bioethics and the Problem of Ableism 5.1 Medicine, Bioethics, and Justice 5.2 Principles, Epistemic Schemas, and Normative Force 5.3 The (Problem of the) Principle of Ableism 5.4 Ableism and Ideal Theory 5.5 Ableism and Epistemologies of Ignorance References Chapter 6: Bioethics Education and Nonideal Theory 6.1 Bioethics Education 6.2 Nonideal Theory 6.2.1 Three Approaches to the Ideal/Nonideal Distinction 6.2.2 Shared Commitments of Nonideal Theory 6.3 Race and Medicine 6.3.1 Race as Social Construction 6.3.2 The Maintenance of White Supremacy 6.3.3 Applying Nonideal Theory 6.4 Mental Health 6.4.1 Stigma 6.4.2 Coercion 6.4.3 Applying Nonideal Theory 6.5 Practical Implications References Part II: Applications in Bioethics Chapter 7: Individual Moral Responsibility in the Anthropocene 7.1 Introduction to the Problem 7.1.1 Environmental Justice as a Complex Moral Problem 7.1.2 Moral Intuitions: Is the Idea of Individual Responsibility for Group Harm Quixotic? 7.2 Nonideal Theory 7.2.1 Ideal Endpoint Principles and Idealized Social Conditions 7.2.2 Enduring Empirical Conditions and Normative Pre-conditions 7.2.3 Some Shortcomings of Ideal Theory 7.3 Making a Market Difference 7.3.1 The Basis for Sarah’s Food Consumption Decisions 7.3.2 The Example of Factory-Farmed Chicken 7.4 Making a Climate Difference 7.4.1 How Climate Harms Are Produced 7.4.2 The “Share of the Total” View 7.4.3 Risking and Wronging 7.4.4 Triggering Non-linear Climate Risks 7.4.5 Salience and Unacceptable Risk 7.5 Making a Relational Difference 7.5.1 Moral Indifference and Business as Usual 7.5.2 Reciprocity References Chapter 8: An Institutional Ethic of Care 8.1 Care Theory 8.1.1 Situating Care Ethics 8.1.2 Care and Justice 8.1.3 Care Justice and Health Care 8.2 Nonideal and Ideal Theory 8.2.1 Care Theory as Nonideal Theory 8.3 An Institutional Ethic of Care 8.3.1 From a Public Ethic of Care to an Institutional Ethic of Care 8.3.2 Institutional Care Ethics in Health Care 8.4 Conclusion: Nonideal Theory Informing an Ideal One? References Chapter 9: Power, Identity, and Liminality in an American Hospital 9.1 Patient Identity as Trauma 9.1.1 The Trauma of Hospitalization 9.1.2 The Trauma of Post-hospitalization 9.2 Medical Practice and Liminality 9.3 Holding Each Other’s Gaze: Narrative Medicine and the Power of Stories 9.4 Conclusion References Chapter 10: “Being at Home”, White Racism, and Minority Health 10.1 A Metaphor: Two People Walking Down a Path 10.2 Racism and Microaggressions 10.3 Microaggressions’ Contribution to Stress 10.4 Ideal and Nonideal Theory 10.4.1 Being at Home 10.5 How Minority Persons Should Respond to Microaggressions 10.6 On the Limitations of Health Disparities as a Proxy for Levels of Overall Inequality References Chapter 11: Black and Sleepless in a Nonideal World 11.1 The Problem of Racial Disparities in Sleep Sufficiency 11.2 Sleep Hygiene 11.3 Ideal Theory 11.3.1 Ideal Theory: Sleep Hygiene 11.4 Sleep Sufficiency and Nonideal Theory 11.4.1 Housing Discrimination 11.5 Concerns About Sleep Hygiene at the Micro and Macro Level 11.6 Conclusion References Chapter 12: Thin or Thick, Real or Ideal: How Thinking Through Fatness Can Help Us See the Dangers of Idealized Conceptions of Patients, Providers, Health, and Disease 12.1 What Is Ideal Theory, and How Is Our Dominant—and Working—Conception of Health an Example? 12.1.1 Health as an Ideal Theory 12.1.2 You Can’t Get There from Here: Navigating the Gap from the Real to the Ideal 12.1.3 We Don’t Work Like That: Idealizations of Agents and Conditions/Methods 12.1.4 Ideals as Utopias, Utopias as Dystopias 12.2 Ideal Theory Fails at Fatness 12.2.1 Biostatistical Theory (BST) of Health as Ideal Theory, and the Construction of Obesity as a Disease 12.2.2 Healthism and Ideal Theory 12.2.3 It’s Not Even Healthy to Make Health About Body Size 12.3 Nonideal Theory and Method 12.3.1 Nonideal Theory and Health: Humility, Intersectionality, and Social Determinants of Health 12.3.2 Nonideal Theory, Health, and Fatness 12.4 Conclusion: Imperfectionist Health in a World That Will Never Be Ideal References Chapter 13: Incarceration, Health Harm, and Institutional Epistemic Injustice 13.1 Aging in Prison: The Data 13.1.1 Sentencing, Policies, and Criminalization of Mental Illness 13.1.2 Health Inside and Outside of Prison 13.2 Epistemically Oriented Approaches to Nonideal Theory and the Embodiment of Injustice 13.2.1 Ideal-as-Idealized: The Epistemic Components of Nonideal Theory 13.2.2 Institutional Epistemic Injustice 13.2.3 Institutions and Bodies 13.2.4 An Embodied Account of Institutional Epistemic Injustice in Prisons 13.2.5 Punishment on Top of Punishment 13.2.6 Health Harm and The Institutionalization of Prison Health Care Workers 13.3 Epistemic Practices for Resisting Health Harm 13.3.1 Epistemic Deferral and Epistemic Advocacy 13.3.2 Overt and Covert Epistemic Operations 13.3.3 Mingling of tactics 13.4 Conclusion References Chapter 14: A Nonideal Approach to Truthfulness in Carceral Medicine 14.1 Veracity in Bioethics 14.2 Carceral Medicine and Collective Struggle 14.2.1 Comments Regarding the Mutual Imbrication of Policing and Health Care Institutions 14.2.2 Comments Regarding Interactions Between Health Care Providers and Patients 14.2.3 Comments Regarding Pregnancy and Childbirth During Incarceration 14.3 Conclusion References Chapter 15: Dying in Detention: Where Are the Bioethicists? 15.1 Migrants Keep Dying in US Custody 15.2 Why Are Bioethicists Absent from Debates About Detainee Health Care (or Lack Thereof)? Some Ideas 15.3 A Potential Solution: Wilcox’s Nonideal Theory of Immigration Justice 15.4 A Wilcoxian Bioethical Case Study Analysis 15.4.1 Harm 1: U.S. Government Infringement on Migrant’s Right to Health Care 15.4.2 Harm 2: Lack of Oversight over Detention Facilities 15.4.3 Harm 3: U.S. Has Contributed to Why They Must Flee in the First Place 15.4.3.1 United States as Directly Responsible for Creating Conditions that Migrants Flee 15.4.3.2 United States as Indirectly Responsible for Creating Conditions that Migrants Flee 15.5 Where Bioethicists Should be References Chapter 16: Medical Deportation, Non-Citizen Patients 16.1 Medical Deportation 16.2 The Need for Nonideal Theory 16.3 Contractualism as Nonideal Theory 16.4 Applying Principles 16.5 Other Stakeholders References Chapter 17: Nonideal Theory and Ethical Pragmatism in Bioethics: Value Conflicts in LGBTQ+ Family-Making 17.1 Ideal vs. Nonideal: The Distinction 17.2 Against Ideal Theory 17.2.1 Ideal Theory as Ideology 17.2.2 The Pragmatist Objection to Paradise Island 17.2.3 Pragmatic Nonideal Theory 17.3 Case Study: LGBTQ+ Family-Making and Reproductive Technology 17.3.1 The Case 17.3.2 A Nonideal Pragmatic Approach to Family/Reproductive Ethics 17.4 Conclusion References Chapter 18: Huntington’s Disease Testing in a Nonideal World 18.1 Huntington’s Disease 18.2 Genetic Testing for Huntington’s Disease 18.3 Deciding to Test, or Not 18.4 The Role of Genetic Counseling 18.5 Sen’s Approach to Justice 18.6 Accounting for the Lived Experience of HD Patients 18.7 Patients’ Capabilities and the Role of Institutions 18.8 Conclusion References