At the risk of appearing churlish, I found ProfessorKottow’s thoughts on the philosophy of health andbioethics more puzzling than enlightening (Kottow2002). For me, philosophy is about demystification.That means simplifying the complex (as far as pos-sible without oversimplification) and clarifying theobscure (as far as possible without distortion). Irealize that there are objections to this conception ofphilosophy, and limits to its application. Even so,Kottow’s article doesn’t strike me as philosophy inthat sense of the word.

In opposition to Boorse (1975), Kottow asserts thatboth health and disease are ‘value-laden’ concepts.This much has been argued, extensively, by a numberof philosophers, including Seedhouse (1986), Fulford(1989) and Nordenfelt (1987) – none of whomKottow discusses. (He refers to two short articles bySeedhouse on bioethics, but ignores his work on thedefinition of health, making no reference to the veryinfluential Health – the Foundations of Achievement.)It’s not clear to me what Kottow’s piece adds to theirarguments, nor am I clear as to what is the relation-ship between the analysis of health and disease as‘value-laden’ and the paper’s main conclusions aboutthe proper limitations of medical practice. Since thetitle of the paper refers to ‘value-laden medicine’, arelation is strongly implied, but insofar as there arearguments in the paper for Kottow’s conclusion, theyseem to be independent of his analysis of health anddisease.

If anything, this analysis creates problems forKottow’s conclusion. For Kottow concludes thatmedical practice should be limited to the treatmentof ‘disease’ and should not expand any further in the

area of so-called ‘health enhancement’. He states‘medicine is concerned with disease but not withhealth, except to reach out into the health realm inorder to prevent disease’ (Kottow 2002, pp. 78–79).But if the concepts of both health and disease arevalue-laden, this distinction is, conceptually, highlyproblematic. If people value living longer, or lookingmore attractive, or having more intelligent children,then there are no a priori grounds for refusing to classify stupidity, ugliness or the deterioration associated with old age as forms of ‘disease’ or ‘dysfunction’.

Kottow states (with an obscure allusion to Kant)that ‘health is not an objective condition’ (p. 79). Butif that is so, it is presumably because it is ‘value-laden’, and on Kottow’s analysis the same can be saidfor disease. So even if we accept that medicine shouldbe concerned with ‘disease’ rather than ‘health’, thisdoes not help to establish any specific conclusionabout the proper bounds of medical intervention.Kottow cites approvingly (p. 80) Callahan’s sugges-tion that medicine should not cater to the desire tobe better than ‘merely normal’ (Callahan 2000), butonce we have parted company with Boorse, it is not clear why the statistical norm for one’s kindshould delimit the proper scope of medical concern.Kottow might appeal to Fulford’s analysis of ‘illness’in terms of ‘ordinary doings’ to support his use of theconcept of ‘normality’ (Fulford 1989). Alternatively,he could perhaps consider Nordenfelt’s (1987) ideaof ‘vital goals’ as a basis for delimiting propermedical concern. However, he does neither of thesethings and instead appeals to the distinction between‘disease prevention’ and ‘health enhancement’.

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92 © 2003 Blackwell Publishing Ltd

C O M M E N TA R Y

Critical thinking vs. moral expertise: a commentary on ‘The rationaleof value-laden medicine’ (Kottow 2002; Journal of Evaluation inClinical Practice 8, 77–84)

Michael Loughlin PhDSenior Lecturer in Philosophy, Department of Humanities and Applied Social Studies, Manchester MetropolitanUniversity, UK

Commentary on ‘The rationale of value-laden medicine’ (Kottow 2002)

© 2003 Blackwell Publishing Ltd, Journal of Evaluation in Clinical Practice, 9, 1, 92–94 93

Clearly, some people do value extending their livesas long as possible – just as some value physicalattractiveness or having brighter children. If Kottowwishes to rule out ‘technoscientific’ (p. 79) medicalinterventions in pursuit of such goals, then he cannotrest his case on some assumed consensus about whatconditions represent bona fide ‘diseases’. His ownespoused position on the meaning of ‘disease’ leadsus (if we accept it) to be sceptical about the intellec-tual foundations for any such consensus.

Kottow might instead claim that there is somethingwrong with the ‘values’ that such medical interven-tions serve or (more modestly) that other values aremore important. In other words (and rather unsur-prisingly), if Kottow wants to defend ethical claimsabout how medical practice ought to be conducted,he needs to explain and defend the ethical premisesthat supposedly support his specific conclusions.This,presumably, is the role of the sections of the paperthat concern bioethics.An additional feature of thesesections is an attempt to explain the nature ofbioethics and to defend this ‘discipline’ againstcertain critics.

According to Kottow, a ‘fundamental idea’ of‘bioethical discourse’ is that ‘values in the clinicalencounter ensue from three sources: the patient, thehealth care provider and society’ (p. 82). These‘sources’ of value generate ‘criteria’ and a ‘sound’clinical encounter can only be obtained when ‘thethree criteria meet’. The ‘criteria’ derive from the‘values’ of the parties. So, the physician must be‘really convinced’ that ‘the values of accurate andnecessary diagnosis are being honoured’. The patientmust ‘feel ill’ and agree that the costs and risks of themedical intervention will ‘lead to better managementof his/her condition’. Similarly, ‘social institutions’must ‘agree that this medical act constitutes a rea-sonable and fair allocation of resources’. The ‘task of bioethics’ is to ‘look into’ this ‘three-tiered valuesystem’, and ‘to suggest how each should receive itsproper due’. He claims (p. 81) that bioethics is the‘specific area of expertise’, which ‘consists in explor-ing the values involved in biomedical activities andassisting in their proper assignment’.

Unfortunately, Kottow says little to explain thenature of the specialist knowledge or expertise that‘best qualifies’ bioethics to pronounce on suchmatters as ‘fairness of public funding of medical ser-

vices’ (p. 81). Over and above ‘looking into’ or‘exploring’ the values of the three parties Kottow hasidentified, what precisely does the bioethicist do todetermine their ‘proper due’ or ‘assignment’? Is therea methodology that enables the bioethicist to deter-mine the ‘correct’ answer to such questions? If so, theproper application of this methodology should reli-ably lead to outcomes that are ‘ethically sound’, justas the proper application of the methodology of civilengineering should reliably lead to buildings that arestructurally sound.

At points, Kottow writes as if this were so, sug-gesting bioethics can ‘cultivate . . . moral excellence’in medical practice, and that when bioethicists have‘identified and scrutinized’ values they can ‘handlethem with ethical excellence’ (p. 81). (What does itmean to ‘handle’ a ‘value’ with ‘ethical excellence’?Could Kottow provide a demonstration?) ButKottow surely knows that bioethicists are not ‘moralauthorities’ and that there is no consensus amongthem that goes beyond the platitudinous. As a rule,bioethicists are in favour of justice, benevolence,autonomy and respecting patients’ rights – as aremanagement theorists, politicians of all parties and,one imagines, most cat owners. Obviously, the inter-esting ethical questions concern how to interpretthese terms in specific cases, and on such questionsthere is no greater consensus among bioethicists thanamong any other section of the population. Even ifthere were such a consensus, that is not, in itself,adequate demonstration that the consensus view iscorrect. There may well be a consensus amongstastrologers about the personality traits of Geminians.In the absence of a demonstration of the basis for a claim to expertise, consensus among the self-proclaimed ‘experts’ proves nothing.

I have argued in my Ethics, Management andMythology (Loughlin 2002a) that too much work inbioethics contributes to the mystification, rather thanclarification, of moral thinking. Kottow’s talk of cul-tivating moral excellence strikes me as a goodinstance of this. He provides no argument for his viewthat ‘increasing the regulatory influence’ of ‘ethicalcommittees’ (p. 83) will necessarily make practicesmore ‘ethical’ or their outcomes ‘excellent’. Since dif-ferent ethicists hold (sometimes radically) differentviews on what is ‘ethical’, it is hard to see whatdefence could possibly be made of such a claim. The

M. Loughlin

94 © 2003 Blackwell Publishing Ltd, Journal of Evaluation in Clinical Practice, 9, 1, 92–94

very fact that people label themselves ‘ethicists’ doesnot show they are better qualified to determine the‘proper’ values in a given practice than ‘ordinary’practitioners. To write as if this follows is effectivelyto argue by word association. One may as well con-clude that a vote for the Austrian Freedom Party (afar-right organization founded by former Fascists)will obviously lead to greater freedom in Austria,since members of the Freedom Party must be ‘bestqualified’ to specify what ‘freedom’ means.

Similar criticisms of bioethics have been made by Seedhouse (1995, 1998), and Kottow attempts aresponse (p. 81). Unfortunately, he presents a garbledversion of Seedhouse’s position, implying the choice is between ‘the quest for principles’, which can be ‘right and true’, and developing ‘problem-solving algorithms’. In fact, Seedhouse’s position on this issue seems rather close to my own. He viewsethics as a branch of philosophy, where philo-sophy is seen as a method of reasoning rather than a body of knowledge. (I defend this interpretation of Seedhouse – and raise questions concerningKottow’s assumptions about moral epistemology – in Loughlin 2002b.)

The purpose of philosophy is to promote criticalthinking, to enable people to ask fundamental ques-tions, and so to provide a defence against dogma,mystification and bogus claims to expertise.The issuebetween philosophers like myself and bioethicistslike Kottow is not about whether there is a rightanswer in any given situation. Rather it is about thebest way to go about finding out the right answer. Iargue that it is a mistake to attempt to develop a setof ‘norms or principles’ and insinuate that the rightanswer can somehow be read off these general prin-ciples in any given context. Insofar as the disciplineof ethics can contribute to practical thinking, it is byenabling practitioners to develop critical skills so thatthey can find the right answers for themselves. This iswhy I characterize philosophy as a form of ‘training

in intellectual and moral self-defence’ (Loughlin2002a). It is not a route to ‘ethical expertise’ and itsmethods are likely to be of use to practitioners whowant to think critically and for themselves – not to those looking for someone else to ‘guide’ theirdecisions.

So while I sympathize with some of Kottow’s statements (in particular his concern that medicalprogress should benefit the world’s poor rather thanimproving further the lot of the rich), I do not seehow his main arguments – about the distinctionbetween health and disease, and about the nature ofbioethics – actually substantiate his key conclusions.Therefore, I cannot see his article as an excellentillustration of the application of philosophicalmethods to issues of proper medical practice.

References

Boorse C. (1975) On the distinction between disease andillness. Philosophy and Public Affairs 5, 49–68.

Callahan (2000) Judging the future: whose fault will it be?Journal of Medicine and Philosophy 25, 677–678.

Fulford K.W.M. (1989) Moral Theory and Medical Practice.Cambridge University Press, Cambridge.

Kottow M.H. (2002) The rationale of value-laden medicine.Journal of Evaluation in Clinical Practice 8, 77–84.

Loughlin (2002a) Ethics, Management and Mythology:Rational Decision Making for Health Service Profes-sionals. Radcliffe Medical Press, Oxon.

Loughlin (2002b) Arguments at cross-purposes: moralepistemology and medical ethics. Journal of MedicalEthics 28, 28–32.

Nordenfelt L. (1987) On the Nature of Health. D. Reidel,Dordrecht.

Seedhouse D.F. (1986) Health – the Foundations ofAchievement. Wiley, Chichester.

Seedhouse D.F. (1995) Why bioethicists have nothinguseful to say about health care rationing. Journal ofMedical Ethics 21, 288–291.

Seedhouse D.F. (1998) Against medical ethics: a responseto Cassell. Journal of Medical Ethics 24, 13–17.