Libertarians and Health as a Human Right

Negative and Positive Rights

Negative rights are essentially the right to non-interference in one’s endeavours to secure one’s needs and wants while positive rights are the right to have at least some of one’s needs and wants provided by a social group, government, or other agency. Negative rights are rights to liberty, and libertarians claim that only negative rights can be defended or protected, and entitlements are gained only through the just acquisition of goods. In this framework, a clean environment and humane means for earning a living are goods

that must be acquired through an individual’s free exercise of will or initiative. Libertarians claim that no one has an obligation to provide these goods, although it might be nice if some sympathetic and well-meaning individuals desire to do so of their own initiative (i.e., they claim it is supererogatory, morally good but not morally required). 

It is difficult to establish the ontological status of human rights, especially without an appeal to some right-granting divinity who has endowed humans with special rights or else simply by claiming that humans are entitled to natural rights derived from nature. Ronald Dworkin, for example, proposes the following: “Individuals have rights when, for some reason, a collective goal is not a sufficient justification for denying them what they wish, as individuals, to have or to do, or not a sufficient justification for imposing some loss or injury upon them.” While his definition offers no specific rights, he notes an advantage of his formulation is that “it does not suppose that rights have some metaphysical character, and the theory defended . . . departs from older theories that do rely on that supposition.” Rights are, then, a matter of agreement of what people should be granted or permitted the freedom to do. These rights, subsequently, create obligations on others. Arguments for negative rights are secular but also difficult to defend ontologically. It would be nice if rights, like planets or viruses could be empirically verified, but it is hard to imagine someone “discovering” a human right.  

In the absence of empirical discovery, we may rely on consensus. If we achieve a level of agreement on a moral law, we may then work together to establish legal codes to enforce such moral laws. In giving examples of moral laws, many find it hard to imagine that any rational person would object to a normative code prohibiting wanton murder. While there may be bizarre outliers, we assume that everyone would want some protection from being murdered. This shared impulse motivates a disgust with and opposition to socially sanctioned murder. In the same vein, we may proffer a theory of rights that claims all individuals in full possession of their faculties will desire the ability to make choices for themselves while recognizing that their choices may be limited by preventing them from limiting the choices of others.  As a result, murder is prohibited by law with severe penalties, and virtually no one objects to legal prohibitions against murder. 

Even without empirical verification, though, most people in the West recognize the existence of negative rights. While popularity of a moral theory is certainly not a way to determine the legitimacy of any moral claim, negative rights have achieved a level of respect in my culture that positive rights do not enjoy. Because rights imply attendant obligations, individuals are less likely to agree to the existence of positive rights, especially if they feel they will be called upon to grant entitlements to others. If I can defend a right to a healthful environment and health care in the language of libertarians as negative rights, I increase my chance of achieving greater consensus in the United States. I do not claim, however, that the right to autonomy or even to be left alone is held universally across all cultures. Some cultures may feel that individual rights should be set aside for the collective good. Western political theory, economics, policy, and law is built on the assumption that liberty should be maximized, and any productive examination of rights in the United States should proceed with this assumption in mind. In fact, even John Rawls, a frequent target of libertarians, insisted that a just society would promote the greatest liberty compatible with equal liberty for all. Therefore, I will proceed by examining the implications of assuming that negative rights exist and must be honored and defended. It is possible that many positive rights, or entitlements, rejected by libertarians may be justified on grounds accepted by libertarians, especially if they flow from violations of liberty. 

Libertarian Defense of Negative Rights and Rejection of Positive Rights

Libertarians claim that negative rights entail only negative obligations, requiring nothing of individuals but to leave others to their own devices; however, they claim that negative rights often entail positive duties such as the duties to provide security and legal remedies. It is useful to identify such instances where libertarians would likely agree that even negative rights require positive duties. Given that some positive duties such as providing a police force and national defense are entailed in libertarian claims, it seems reasonable to suggest that further positive obligations should be considered. To put it more strongly, if the libertarian conception of human rights is applied consistently, victims of human rights abuses have acquired a staggering list of entitlements required merely to redress the harm they have endured (see chapter 3 for examples).

In arguing against the claim that one would be doing something bad by not saving a child drowning in a shallow pond by simply getting on one’s knees and pulling the child out of the water, Joshua Katz responds by saying, “If the force of the argument rests entirely on intuition, my competing intuition that I am entitled to do as I wish with my property, including my body, is just as valid.” Most non-libertarians will find the statement that one is not obligated to save a drowning child at no real cost to oneself rather shocking, but the libertarian claim really is this extreme. 

Robert Nozick, who offers a more nuanced argument than that of Joshua Katz, is one of the most often cited philosophers defending the libertarian view. Nozick describes the required level of ethical obligations to include “rules and principles mandating respecting another (adult) person’s life and autonomy, forbidding murder and enslavement, restricting interference with a person’s domain of choice, and issuing in a more general set of (what have been termed negative) rights.” As discussed in Chapter One, Nozick goes on to describe three higher levels of ethics: ethics of responsibility, ethics of caring, and the ethics of light. Nozick believes the higher levels of ethics must never be enforced by a state or even by social disapproval of individuals. Within Nozick’s framework, any well-off individual is free to provide any benefit whatsoever to anyone at any time so long as its provision is based on a free choice. He sees most instances of unequal distribution of income as the result of free choice. 

One problem with this conception of liberty is that some people lack basic resources as a result of factors unrelated to their own free choices. Some are hampered in their pursuit of essential goods by bad luck such as natural disasters or impaired health while others are hampered by acts of injustice such as theft, assault, and so on. For a libertarian such as Nozick, someone’s bad luck may be tragic, but it imposes no obligation on others to change the situation. If someone (Nozick suggests a famous basketball player) has more assets as a result of superior talent, physical fitness, and drive, there can be no defensible reason to require this person to give away assets gained as a result of superior talent or hard work. In this example, gaps in income result from free choices made by some people paying their income for the privilege of seeing another individual perform, placing no obligation on the performer to correct or mitigate the resulting income gap. Of course, in reality, people who pay to see basketball games tend to have the resources to meet their basic needs for survival. Others lack resources because their property was stolen from them. In such cases, Nozick would claim the property should be returned as the victim’s liberty has been violated. Ensuring that people are protected from assault or theft imposes a duty on us to provide law enforcement, courts, and jails or other means of deterring or limiting criminal behavior. Nozick acknowledges that it is the role of government to ensure basic security. Libertarians focus on security in terms of police forces and national defense to protect against theft and invasion while remaining obstinately indifferent to security from loss of resources due to environmental destruction and abusive trade practices. 

Even with his limited conception of security, Nozick appears to run into trouble, when considering the case of historical injustice. If someone is descended from a well-off family whose fortunes were plundered by thieves in a previous generation, it seems clear that this person deserves repayment of the family fortune (e.g., descendants of Jews trying to recover from European museums artwork stolen by Nazis). Even when there is no theft of property, an injustice occurs when poverty is the result of the denial of basic liberties as in the case of slavery. Slaves are denied the ability to participate in trade for mutual benefit, and their resulting poverty is passed from generation to generation. In his earlier work, Anarchy, State, and Utopia, Nozick asks, “If past injustice has shaped present holdings in various ways, some identifiable and some not, what now, if anything, ought to be done to rectify these injustices?” He does not answer the question, says there is no theory to address this problem, and declines to provide one. In a footnote, he says, “If the principle of rectification of violations of the first two principles yields more than one description of holdings, then some sort of choice must be made as to which of these is to be realised. Perhaps the sort of considerations about distributive justice and equality that I argue against play a legitimate role in this subsidiary choice.” Although this would appear to be a substantial problem for his theory, Nozick declines to provide a theoretical response to the question he has raised, at least in Anarchy, State, and Utopia. 

In Invariances, he gives a slightly more robust description of historical distributions of wealth, although nagging problems remain. In this book, Nozick conceives of cooperation to mutual benefit as the core of ethical demands for society, saying his view “makes mandatory the widest voluntary cooperation to mutual benefit; it makes only that mandatory; and it (in general) prohibits interactions that are not to mutual benefit, unless these are entered into voluntarily by all parties.” The preceding quotation makes the use of “voluntary” and “mandatory” seem nearly incoherent, but, being charitable, we can assume that each person is obligated to expand the circle of cooperation without dictating specific choices one must make. In Nozick’s conception, it is possible to imagine two groups who have not interacted in the past; one group may be newly arrived immigrants with fewer resources than members of a socially prominent native group. Nozick notes that initial exchanges will leave wide disparities between the incomes of the two groups as a result of the unequal starting positions for the people in each group. Over time, though, each group has the possibility of gaining more resources and engaging in more equal exchanges. Each exchange is just so long as no group is involuntarily left worse off. He says, “The new distribution need only surpass what each got under the old distributions for cooperation to be mutually beneficial.” In this description, Nozick adds a troubling note parenthetically. He notes, “Because African Americans were brought to the United States in slavery and subject to strong caste restrictions afterward, their subsequent history, unfortunately, has been different.” His comments in both books seem to leave open the possibility that reparation payments for slavery or some other form of compensation is demanded by his theory. If he believes such reparation is demanded, he does not explicitly state it. 

Besides the problem of rectifying the injustice of slavery, Nozick’s view raises other problems. If one group of people has no resources at all and faces starvation, any goods given to them would make them better off. Such people are ripe for extreme forms of exploitation. For example, one might promise to provide a small supply of food for a person in exchange for 16 hours per day of labor in dangerous conditions. While this condition is arguably an improvement over starving to death (some may even disagree with this), I argue that such exploitation is unethical and deserving of social disapproval and prohibition. Before an individual can enter into voluntary cooperation for mutual benefit, that individual must have his or her basic needs met for true negotiation to be possible. 

Nozick’s discussions of historical injustice are of particular importance. In his earlier work, he fails to provide an account of how historical injustices should be addressed, and his later accounts provide such a gradual resolution that many victims will never see any benefit from their new participation in an economic system that has benefitted others for generations.  Nozick rejects any state-imposed redistribution of wealth, but implies that past injustices must be redressed. If much of the poverty we see in contemporary society is the result of past discrimination, then it would seem that Nozick is obligated to support exactly the kind of redistribution of wealth that he is arguing against in the example of the basketball player. If it is no longer possible to identify each past injustice with certainty, this should motivate us to make general allowances for all of the worst off in society, and this would, indeed, require a patterned distribution such as that favored by John Rawls. At a minimum, the least advantaged members of society must be lifted to a position where it is possible for them to reject offers that are harmful to their health or well-being (this would prevent, for example, people selling their own organs under dangerous conditions because they see it as their only hope for survival). 

Theft as a Negative Right of the Poor 

A number of theorists have attempted to take libertarian assumptions and use them to show that economic inequality is unjust even based on libertarian principles. Some attempt to view the existence of inequality itself as a violation of the negative rights of the poor, but this approach fails to address libertarians on the assumptions they accept. Libertarians will not accept responsibility to address any inequality or suffering they did not themselves cause. For this reason, the best approach is to show that inequality stems from basic violations of rights that are the responsibility of both producers and consumers operating in an unjust system. In the next section, I will work through a few of the most common arguments for rectification, ending with the strongest argument, which is put forth by Thomas Pogge. 

For some, the existence of economic inequality in itself is evidence of injustice that legitimately gives the poor the right to extract wealth from the affluent. For example, James Sterba challenges libertarian notions of rights in his book, Justice for Here and Now by claiming the poor have a right to steal from the rich. Sterba begins this discussion by recognising that libertarians feel it is the privilege of the rich to do with their resources as they please, without interference from the poor or anyone else. However, he notes that we could claim that the poor have a negative right to take the basic resources they need from the rich without interference. In so doing, he blurs the distinction between negative and positive rights, but he acknowledges that libertarians would reject the claim that these statements of negative rights are equal. His claim, then, is that there must be some way to distinguish between competing liberties (in this case the liberty of the rich to keep what they have acquired and the liberty of the poor to take what they need). He first notes that it is not reasonable to require someone to do something the person is incapable of doing (for example, he says that being in a coma prevents one from having any other obligations, as those obligations are impossible to fulfill.) In addition to actions that are impossible, he makes a more controversial claim that it is unreasonable to make certain demands of certain people. 

With this in mind, he notes that the rich are capable of sacrificing some of their wealth to ensure the survival of the poor, but it is impossible for the poor to live without the basic necessities for survival. As a result, the poor have a legitimate claim against the rich, but the rich have no legitimate reason for refusing to aid the poor. Rather than simply giving away money, the rich may provide assistance to the poor, by offering them employment, and he claims the poor are obligated to take advantage of any opportunity to work. Thus, the obligation of the rich to sacrifice their wealth is reduced as the opportunities for fruitful work are increased. Sterba attempts to confound the common arguments of libertarians, who often claim that altruism is good but not obligatory. He claims that when the poor are prevented from taking surplus wealth from the rich, they are being forced to be altruistic in the sense that they are sacrificing their well being for the benefit of the rich. Since any social arrangement requires either the rich or the poor to be altruistic and to sacrifice a degree of liberty, the libertarian ideal cannot be achieved. As such, Sterba claims society should be arranged so that the poor either have opportunities to work to provide for themselves or the rich should sacrifice some of their liberty to hoard excess wealth in order to provide for the basic needs of the poor. Of course, libertarians do not view it as an act of altruism when the poor do not take wealth from them as the poor have only a right to keep what they have earned for themselves. 

If the poor do indeed have a right to the wealth of the rich and can be empowered to claim it, it is unlikely they will feel altruistic to the privileged classes.  In his conclusion, he puts quotation marks around the words “negative” and “positive,” and suggests that the rich and poor can work out what is morally right in a libertarian framework. He concludes:

In such societies where basic human rights have been denied, certain criminally disobedient acts thereby become morally permissible, and existing legal authorities have no right to punish them. Rather than punishment, the appropriate corrective in such cases is to make the changes required to guarantee just those basic human rights, which have been denied. 

Here Sterba’s argument changes from a demand for altruism to a response to violations of basic rights. The claim that human rights have been denied in the past and demands rectification is empirical (see chapter 3) and needs no argument from altruism. The simpler argument is simply that poverty results from human rights violations and demands rectification. The poor have no negative right to take resources from the rich that resulted from hard work and free choices, but the poor do have the right to demand redistributions when inequality in wealth is the result of unequal treatment under laws of the past or from simple abuses of their own liberty in the past. In contrast to Sterba, my claim is that economic inequality grows out of human rights violations, giving the poor the right to demand resources from the affluent. 

For the millions in the world who are starving to death, the liberty to take what they need from the affluent for basic survival can never be more than a thought experiment. Only more powerful citizens of the world have the ability to guarantee their basic needs are met. Meeting their needs, then, requires recognition of a past injustice that must be redressed, creating a positive obligation to help them. Of course, for those who cannot fight for their own survival, those of us who can are obligated to do what we can to ensure their basic needs are met. Further, those who cause harm that results in starvation and disease are specifically obligated to provide remedies; simply ceasing to do further harm will hardly achieve a just state of affairs. The poor have the right to reclaim the resources they require for survival when their condition arises from unjust circumstances, which arise from violations of autonomy. Those who are robbed of their ability to participate in beneficial cooperation by disease, disability, or bad luck have no option to cooperate and make particular demands on those who are well off. For those robbed of any autonomy, negative liberty is of no value. Restoring a minimum level of autonomy in the form of positive liberty is a basic requirement for even a minimally just society. 

Positive Duties of Negative Rights

In his essay titled “Enforcing Economic and Social Rights,” Osvaldo Guariglia points out that although negative and positive rights and duties are assumed to have corresponding negative and positive obligations, all rights, whether negative or positive, entail positive duties. He quotes Henry Shue to argue that negative and positive rights are grounded in parallel arguments and that without guarantees of subsistence, no other rights at all can be exercised. Those who are unable to subsist are unable to exercise any sort of autonomy and are reduced to the status of things or resources for the well off. Any interest in liberty requires lifting to a level of subsistence at the least. Therefore, guaranteeing positive rights is essential to providing protection for negative rights. In addition, rights and duties are not neatly corresponding by kind (negative and positive). Often, negative rights entail positive duties. While citizens have a negative right to be left alone and secure in their freedom from assault, he says, “public agents and judges have a special positive duty to protect and ensure people’s security and integrity.” Similarly, state actors and individual citizens have a negative duty to refrain from any actions that will harm the worst off. He notes that everyone must share the duty to ensure the security of the state and refrain from actions that harm the worst off, such as degrading water or soil or engaging in corruption. Of course, participation in a social system that privileges some individuals over others would harm the worst off. Rather than arguing that social and economic rights are negative rights, Guariglia claims there is an interdependence between positive and negative rights that prevents one from being privileged over the other. This claim is problematic as not everyone living below a level of subsistence is a victim of a rights violation, or at least it is possible to imagine someone who has chosen to reduce himself or herself to the status of object. Having the ability to exercise autonomy is not a requirement to do so. Of course, individuals who truly reduce themselves to the status of objects are either extremely rare or nonexistent. People in such a position generally do not participate in economic cooperation because they are denied the opportunity. Guaranteeing this opportunity is demanded by a respect only for their negative rights to exercise their own autonomy to live according to their own choices. Rather than interdependence between positive and negative rights, negative rights themselves carry positive obligations. 

While the poorest members of society share in an obligation to protect overall security by refraining from actions that harm others and taking positive actions to ensure that others are free to exercise their liberty to the greatest extent possible, the poorest must also be protected from harm and limits on their exercise of freedom. Economic and social rights are essential to the overall security of society. Even if we accept a libertarian framework, the full exercise of negative rights demands positive duties we must all share. 

Similarly, Onora O’Neill’s essay, “Lifeboat,” examines the distinction between killing someone (violating their negative right to be left alone) and letting someone die (not fulfilling a positive duty, if one exists, to provide assistance). She begins by assuming that persons have a right not to be killed and a corresponding duty not to kill, and she make no assumptions beyond this. She also notes that there are exceptions to the prohibition of killing and the right to be left alive. Killing is justified in cases of self-defense and unavoidable killing. An unavoidable killing might occur when someone steps in front of a train after it is too late for the operator to stop the train. Given these assumptions, she argues that if several people are on a lifeboat that has sufficient supplies to enable everyone onboard to survive until rescued, anyone who denies supplies to any passenger of the lifeboat is killing that person. In other words, failure to provide the basic needs for survival is tantamount to murder. In this way, a negative right to not be harmed entails a positive duty to provide essential supplies. She recognizes various situations where it might be justified to kill one passenger. If the lifeboat is well equipped, it is justified to kill someone who is threatening to jettison supplies and cause the deaths of other passengers. On an underequipped lifeboat, decisions must be made about which passengers might be allowed to die, but her primary concerns are with a lifeboat with just enough supplies to sustain the lives of all the passengers on board. 

The lifeboat may not be a perfect metaphor for the earth, as O’Neill acknowledges, but her metaphor raises questions for the situation we now face on earth. Writing in the 1990s, libertarian Jan Narveson rejected the comparison of the earth to a lifeboat by declaring that the earth has plenty of resources to support many more people than live on it. He did not feel the situation would change in the foreseeable future, and he claimed that the writers of the 1970s and 1980s were filled with unjustified visions of gloom and doom. Indeed, it has been proven that the earth had greater resources than anticipated and food yields have exceeded some predictions. However, with one-fifth of the world’s population living in extreme poverty, the world is indeed living in a crisis that Narveson did not predict. O’Neill’s prescient vision, on the other hand, speaks to us in the 21st century as extraction of resources and production of food require increasingly dangerous and extreme measures (extreme subsea drilling and factory farming, for example). O’Neill imagines that each individual on the lifeboat has an equal right to the supplies, but people on earth claim property rights that they feel entitle them to consume resources even when others are denied. Further, some people on earth are enabled to consume more only by denying resources to others. The wealthy consume, but the burden of their consumption rests on the backs of the poor. Denying individuals the resources necessary for basic survival is killing, and this claim echoes Locke’s proviso that acquisition of property is only acceptable when one leaves enough and as good of any given resource. Claims on property by some over others would have to be justified, and this is sometimes difficult, especially when people use the resources of distant countries without sharing the benefits with those who live in those countries. Unequal distribution can result, as previously noted, from bad luck or from injustice. If people are unable to access health care because their resources have been stolen, they are victims of injustice even according to the most ardent libertarian arguments. However, even if they are victims of bad luck, O’Neill provides a way of conceptualising their suffering as harm done to them by those who have the resources to save them. She avoids distinguishing between negative and positive acts, saying, “Such attempts seem unpromising since any act has multiple descriptions of which some will be negative and others positive.” Nonetheless, withholding resources is a familiar example of a “negative” act in the literature on rights and duties. By labelling denial of resources as a positive act of killing, O’Neill reframes one of the central tenets of the libertarian argument. She shows that it is not only possible to view entitlements as the products of negative rights, but she also shows that refusal to aid the poor can be seen as a positive act of violence. Rather than completely rejecting a theory based in liberty, however, she could recall Locke’s claim that it is unjust to take resources without leaving plenty for others. While her example is designed to compete with libertarian descriptions, it is not necessary to demonstrate the injustice of taking so many resources that others are harmed. 

Thomas Pogge has attempted to provide a robust and thorough defence of social and economic rights while not denying the minimalist claims of libertarians. In fact, he says he agrees with libertarians that the distinction between causing poverty and failing to prevent it is morally significant. He says, “Thus, I invoke and explicate both human rights and justice for the limited purpose of supporting negative duties, that is, duties not to harm that impose specific minimal constraints . . . on conduct that worsens the situation of others.” He argues that poverty and inequality in the world have not resulted from benign neglect but from harmful actions of the world’s affluent populations. In order to fulfil our negative duty not to harm, then, we must actively work to change social institutions that unjustly harm the poor.  Similar to arguments discussed above, he claims that negative rights entail positive duties to prevent harm.

Pogge claims that it is essential to separate human rights from claims to legal rights. His arguments are pragmatic, in the common sense of the term. He points out that sometimes a right is fulfilled even in the absence of legal codification. As an example, he says that if everyone in a given society has access to enough food, a legal guarantee of access to food is not needed. On the other hand, legal guarantee of methods to redress abuses of employers is of little value to those who lack the means to hire lawyers or otherwise pursue redress for abusive treatment. 

Pogge sees human rights as a progression from natural law to natural rights to human rights. Each progression entails a narrowing of content, but it is the content of human rights and their attendant obligations that are of interest here. First, human rights are secular and, therefore, can be shared by humans of different faiths. Second, human rights are political rather than metaphysical. Third, human rights apply to humans and only humans. Finally, human rights are claims only against certain actors. The final point is the least clear. In his view, to promote human rights is to create an institutional order that protects human rights. He says his conception of human rights derives from the fact that humans have basic human needs that give rise to “weighty moral demands” and that each need is the “object of a human right.” Given the staggering number of people who die as a result of extreme poverty, “weighty” seems an understatement.  

Given his stated agreement with libertarian arguments for negative duties, Pogge is obliged to respond to libertarian critiques of social and economic rights. He begins his response with a claim that a right to some good means that society should be organized so that each person has access to that good. For most libertarians, it would be enough for each individual to refrain from doing anything to block access to any available good; it would not require that individuals make an active effort to guarantee access. For Pogge, this does not mean that any particular individual is responsible for providing the good as in the form of an entitlement, but that all individuals, collectively, are responsible for creating social arrangements that ensure secure access to the good for everyone. 

Pogge claims that his conception of human rights does not violate libertarianism’s tenet that human rights entail only negative duties. Rather, he claims that the human rights of others require us to refrain from helping to sustain any social order that denies rights to others; for example, we are prohibited from supporting institutions in which “blacks are enslaved, women disenfranchised, or servants mistreated.” Those who participate in the current arrangement by benefiting from injustice as traders, workers, or even consumers without actively working to eliminate injustice are sustaining the social order. Those whose rights are denied have a claim not against everyone but only against those who actively participate in an unjust social order. If individuals cooperate in such a social order, they are obligated to compensate by protecting victims or working for reform. 

Responding to the claim that social and economic rights are mere “manifesto rights,” Pogge says they are rights that are not realised, leave unclear who should guarantee them, and cannot reasonably be met. He gives the example of the “right” to a happy love life. As no one can guarantee a happy love life, this is a manifesto right, but he thinks it can be reformulated as a legitimate rights claim. If we see that cultural biases and taboos prevent people from securing a happy love life that would otherwise be possible, then we have an obligation to remove those barriers, and the right to a happy love life is reconceived as a right to live in a society with no obvious obstacles to achieving a happy love life. 

Pogge argues that his conception of rights can help to give a common language to western countries that emphasize political liberties over economic and social rights and socialist and developing countries that view human rights primarily as economic and social rights. Arguments will persist, of course, over what goods we are obligated to provide based on this idea of human rights, but an argument over what goods must be provided is a step forward from arguments between two competing conceptions of rights. 

Health as a Negative Right

Under any theoretical framework, everyone has a human right to living conditions that are not harmful to health. A Rawlsian conception of justice demands care for the worst off; Utilitarians such as Peter Singer posit that we must all sacrifice to save the poorest people in the world; and the capabilities approach of Martha Nussbaum and Amartya Sen also demand that we do what we can to promote human flourishing. It is libertarians and ethical egoists who are most likely to insist that the affluent have no obligations to the poorest members of society. The attempt to formulate a right to health in libertarian terms is an attempt to respond to libertarians on their own terms. 

In addition, though, the argument from negative rights stresses that for many of the least advantaged people in the world, ill health is the result of injustice. Even Robert Nozick does not deny the obligation to redress harms caused by past injustice. While some of the world’s poor have surely made choices that led to their poverty, many have become poor as the result of victimisation by colonisation, corrupt governments, or greedy corporations. These harms must be redressed. Just as libertarians readily insist that individuals have a right to protection from petty thieves and bullies, a just social order, rooted in libertarian theory, requires protection from institutional abuses of human rights. 

Others have become poor because of bad luck. They may be limited by disability or illness, or they may have had their fortunes destroyed by natural disaster. Libertarians argue that everyone has a right to do with their own body as they please, but disease and disability rob many of the choice to do with their bodies as they please, and their right to act on their will requires a greater commitment from those who are well off. Libertarians are unlikely to agree that they are obligated to restore autonomy to those who have lost it through bad luck, but I would claim that protecting autonomy for victims of bad luck is similar to guaranteeing physical security from crime or assault. We are all at risk of being robbed of our autonomy by disease or bad luck, so we should cooperate to ensure the security of all (in the same way we work together to protect ourselves from invasion). Or course, much of the inequality in the world is the result of simple violations of negative rights as typically conceived by libertarians. At a minimum, we are required to guarantee conditions in which all individuals have the ability to act on their own autonomy, even if their choice is to neglect to exercise their will. In cases of clear violations of rights, libertarians may be forced to give up “their” property to help others as the victims of violations have a rightful claim on the property. In cases of bad luck, libertarians should agree to give up some of their property to ensure security in the same way they give up property to ensure national and personal security.  


In 1976, Lawrence Davis published an analysis of Nozick’s entitlement theory focusing on Nozick’s rectification principle. Nozick’s rectification principle states, “The principle of rectification presumably will make use of its best estimate of subjunctive information about what would have occurred . . . if the injustice had not taken place. If the actual description of holdings turns out not to be one of the descriptions yielded by the principle, then one of the descriptions yielded must be realized.” Nozick suggests that we try to determine what would have happened to a victim of a rights violation if the violation had not occurred. In the same way that we might write alternate endings of a movie, we must predict what state someone should be in in the absence of any violations. If they are not so well off, we must restore them to the state they would have otherwise achieved on their own. For example, if someone steals money, they must pay back the money with the interest it would have earned rather than the actual amount stolen. The difficulty of determining how slaves would have fared in the absence of slavery or how indigenous people would have fared in the absence of invasion and conquest prohibits this theory from being realized. This is why other theorists, such as John Rawls, advocate a patterned distribution to compensate for prior harms. The Human Development Approach, of course, rejects a simple distribution of resources and attempts to restore a full range of capabilities for all citizens. 

Even if I benefit from harm to someone, I may not be responsible for rectifying the harm. If I own one of ten rare antique automobiles and some malicious person decides to destroy one of the ten, the value of my automobile may rise dramatically, increasing my net worth significantly. Assuming that I do not participate in an auto-trading syndicate that takes out the competition through destruction or theft and I have no dealings with the responsible person, I am not obligated to redress the wrong done to the owner. In a sense of unity, my fellow car owners and I may decide to provide increased security from auto destruction. We may set up a system of insurance to protect ourselves from any future events, and we may even decide to help this unfortunate victim of this crime recoup some of the loss. Providing relief to the victim, in this case, is supererogatory. If the same situation holds with corporations that do damage to people in other countries, then perhaps we are not responsible for rectifying the injustice.

But this is rarely the case. War in an oil-producing country may cause a spike in the price of oil, which benefits companies in other countries who depend on high oil prices to generate healthy profits. Through no action of their own, these companies benefit from great harm caused to citizens of a war-torn country. It would seem bad form for them to exploit the situation by gouging consumers with burdensome prices, but no one would expect them to intervene to stop the war. 

The more common scenario, however, deals with the externalities of doing business from day to day. Externalities are the costs of business that are not borne by the business itself; rather, they are borne by outside citizens, non-human animals, and the environment. Mining ore from a mountain does damage to the mountain, the runoff may pollute surrounding streams and lakes, and the land may become hazardous even for walkers in the area. If a mining corporation is forced to maintain the mountain in a safe and sustainable manner, the corporation may not be able to compete with other companies who are not forced to do the same. In order to maximize profits and remain competitive, then, companies must try to shift the burden of externalities to others. Frequently, local residents are left to clean up the mess for themselves, which is often impossible. Thus, residents suffer from the loss of land, the loss of clean air and water, and the loss of a safe living environment. 

Any principle of rectification demands that these citizens, who have not chosen their condition, receive reparation to restore their living environment to healthful conditions. While it is impossible to “stop the film” as Nozick suggests, we at least know that if their land had not been damaged, these citizens would live in an area that is not in and of itself a cause of disease and injury. A clean and safe environment becomes a right, then, when citizens suffer from unsafe conditions caused by the actions of others rather than the free choices of the citizens themselves. 

Most corporations will argue, of course, that they had prior agreements to conduct their work of extraction or other harmful activities. They will insist that they acquired the right to conduct their business in such a manner through a just acquisition, according to the principles put forward by libertarians. In such cases, the corporation will argue that they have a legitimate agreement with the property owners, typically the government of a country, to do the harmful work. In such a case, the question is not whether an injustice has occurred, but only who is responsible for rectification. Unfortunately, collusion between governments and corporations happens in most countries, including wealthy countries such as the United States. In such cases, it is against the interests of the corporation, and often of government officials, to protect the rights of individuals who will be affected by externalities.

Rectification requires a collective will and a collective effort. Nozick says victims of injustice should be restored to where they would be if the injustice had not occurred. It is impossible to know where people might be, for example, if slavery had never existed. However, it is possible to look at individuals suffering from disease caused by environmental pollution and know that clean environment would have a better outcome. These individuals have a right to a clean environment and adequate healthcare to treat their illnesses. Rather than looking from the point of injustice forward as Nozick suggests, we can look from current conditions to the past to evaluate whether people have caused their own burdens through free choices. If they have not, Nozick’s libertarian principle of justice demands that all who made free choices to harm others be responsible for reparations and rectification. This would include all businesses and governmental entities that colluded to cause these harms. Further, policies must be put in place to prevent further harms from occurring. In chapter 4, I discuss specific policy proposals aimed at protection of human rights. These include reparation payments; guarantees of free, prior, and informed consent; protection of farmer autonomy; and rules against exploitation in pharmaceutical research. 


Ultimately, the libertarian conceptions for justice based on the inviolability of negative rights or negative liberty do not eliminate positive obligations to create just conditions on the ground. Only if all current conditions resulted from free choices of everyone affected could libertarian arguments free anyone from obligations to help those suffering from disease, poverty, and brutal living conditions. If the world’s least advantaged either chose to live in squalor and disease or had absolutely no contact with the most advantaged, they would make no demands on us (for example, we would not feel obligated to fix problems of poverty and starvation on a newly discovered planet with human-like creatures on it). However, no such planet and no society of self-destructive individuals has been found. The empirical claim that those who suffer are responsible for their own conditions is not supported by historical facts. Rectification will require modifications to the legal system to both repair damage done and prevent further injustice from occurring. These modifications are likely to look similar to suggestions from John Rawls or the Human Development Approach. It is not that all theories of justice say the same things; it is simply that some conditions are so inhumane that no serious theory could hold them to be just.

One argument against intervention is that a free market imposes more restrictive conditions on businesses than government regulation because consumers will not participate in a system that harms them. This rosy view ignores the fact that many who are affected by externalities or even direct harm are not participants in the trading scheme in the first place. Many people in the world are not involved in the race to consume the products transnational corporations are producing. While some may be dispossessed and desiring to enter into trading and economic advancement, others would prefer to simply be left alone on the land that has supported them and their ancestors for centuries. This situation frequently arises when corporations and governments collaborate to exploit the land inhabited by indigenous people. According to the principles of John Locke, of course, those who mix their labor with the land to support themselves thereby own the land. Indigenous people do take the view that they own the land they and their ancestors have lived on and worked to support themselves. The libertarian call for unregulated markets ignores the property rights already held by many indigenous people of the world as defined by libertarians. Their acquisition of the land is based on libertarian principles of just acquisition; denying them their liberty and property rights requires a contradiction of libertarian principles.  Addressing this problem would require all parties to receive “free, prior, and informed consent” from all people affected by business agreements. This would help to ensure that all agreements did actually flow from free choices. Agreements and practices that do not arise from conditions where all parties affected have given such consent violate libertarian principles of liberty and autonomy. 

While many of the victims of injustice do not participate in the legal agreements that affect them, many others do participate in the global trading scheme as consumers and voters without knowledge or awareness of the impact their actions have. Everyone who participates in and benefits from a global economic structure is responsible for ensuring that trading policies and practices are just. The ethical demands do not fall simply on transnational corporations but also on consumers, voters, producers, economists, media, and elected officials. Only coordinated effort can bring about just and humane conditions for all citizens. This does not require great altruism or self-sacrifice; it only requires a recognition that all humans are born with equal moral standing. For libertarians to ignore the moral standing of anyone is to enter into a contradiction. 

Everybody’s Talking About Bioethics Now #COVID19

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Since this pandemic got rolling, it seems everyone wants to talk about bioethics “trolley problem” quandaries like how to decide which of three dying patients gets the one ventilator on hand or whether it is okay to lock up healthy people to prevent the spread of a deadly virus. All the boring stuff suddenly got real and real fast, but maybe it’s not that interesting.

You should give the ventilators to the people with the best chance of surviving, right? I think that is how triage works. And, oh, was it all right to tell people to turn off their lights when bombers were flying overhead in the middle of the night? Sometimes even the rugged individualists have to work as a group. The problem is that some of our rugged individualists have never really been put in a position to make tough decisions, so they aren’t prepared.

And that gets us to the real ethical issues here. It is really unethical to be unprepared for emergencies. Experts in many fields have been warning of coming pandemics for at least 15 years. Even George. W. Bush, bless his tiny heart, knew he had to prepare for pandemics, and he at least took at stab at it. And the ever financially minded Barack Obama prepared for pandemics and even dealt with one on his watch. His didn’t get quite so out of hand, of course, and no one should have to tell you why.

So, the important ethical decisions were made years ago, and many of them had to do with the most attention-starved principle of bioethics, justice. The failure to prepare for a public health emergency affects everyone, as we now see, but too many people have always seen efforts to protect public health as efforts to protect “people not like me.” This isn’t always a sign of racism; sometimes it is just pure classism. Some people just don’t hate based on skin color, religion, sexuality, or any of that stuff. They hate poor people of all types.

This is also not a matter of choosing between the “economy” and the needs of working people. Preparing for a pandemic would have meant having mechanisms in place for extensive testing, tracing, and isolation that would have prevented the need to shut down almost all business activities. With proper preparation, the world would have suffered but could continue functioning.

And I guess a lot of Americans really were satisfied with their employer-provided health insurance that they are now losing, because it turns out their employers really never valued them as much as they assumed. It would seem that intelligent and hard working people should always be able to get healthcare, and that’s what we’ve been trying to tell you. You can be hardworking and intelligent and also poor, and maybe it is good that more people are learning this rather difficult lesson right now. Maybe it will help in the future.

But public health isn’t all about health insurance, though turning infected people away from a hospital because they can’t pay is certainly not a good way to protect the public from a pandemic. No, protecting the public health, which is really protecting national security (and global security) is about being able to deal with emergencies, which would require not selling off all the equipment you might need. Most homeowners have never used a fire extinguisher, but the ones who used them successfully were pretty happy they had invested in buying one and taken the time to learn how to use it.

So, yes, more than a decade ago, epidemiologists, virologists, climate scientists, public health experts, public health ethicists, and environmentalists were warning that the world was becoming much more hostile. How do we prepare to ensure our own long-term survival isn’t really as much fun as debating who gets the last ventilator, maybe, but it can save many more lives.

And maybe you’re saying there’s no point in going on about this now as it’s too late. What’s done is done, you’re saying, but this ain’t over, folks. One way or the other, COVID19 will be resolved, but other pandemics will follow along with drought, flooding, mass migrations, and a host of other public health crises that aren’t that hard to imagine if you only try. You may think I’m crazy, but I’m not the only one. Plenty of experts in relevant fields are already imagining the worst and best case scenarios. Maybe it’s time to listen to them.

Pandemics, Climate Change and the Threat of Innumeracy

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Among other things, this pandemic has shown the danger of innumeracy. Over the past few weeks, many have tried to minimise the effects of the pandemic by posting blogs and memes listing absolutely accurate statistics that are also terrifying to the specialists tracking the number of infections. Just for example, many people said a fatality rate of 2.0 (or even 1.0) was about the same as that for influenza. Of course, a fatality rate of 2.0, would be 20 times as bad as the seasonal flu, and even 1.0 would be tens times as bad.

Among those posting information to minimise the effect of the pandemic were healthcare providers, including doctors who work with infectious diseases. Doctors trained in medicine and not risk assessment are not better at assessing risk and probabilities than the general population. The 1982 book, Judgment Under Uncertainty: Heuristics and Biases, edited by Daniel Kahneman, Amos Tversky, and Paul Slovic, examined the ability of people, with several chapters devoted to medical professionals including doctors, to assess risk based on probabilities. People in general, including doctors, just aren’t that good at it.

Subsequent research in medicine has shown similar results. Without specific training in assessing risk based on statistics and probabilities, doctors are no better than the general public at making decisions. We all need a more robust understanding of statistics, probabilities, and risk assessment.

It would help us better understand the risk of pandemics, and it may help us better understand the risk posed by climate change. Many people still think it isn’t a big deal to have the average global temperature increase by 1 degree.

Pandemic, Panic, and Complacency

Crudely, generally, and absolutely not universally, deadlier viruses are easier to contain geographically than milder viruses. Ebola, MERS, and SARS all have much higher mortality rates than Covid-19 and were limited to smaller regions. The obvious reason for this is that sicker people are too sick to spread a virus to the community and the world at large. Covid-19 spreads easily because it appears to be spread in the absence of symptoms and for an extended period of time. People who are infected travel, go to work, go shopping, visit hospitals, and so on.

Quite a few people point out that the mortality rate for Covid-19 may be overstated because an unknown number of people probably contract the virus without ever showing symptoms, so these survivors are not a part of official counts. That’s true, but it is also true that people who have died of pneumonia and other infections may also have had undiagnosed Covid-19. No one knows which group of people is larger, so estimating the mortality rate is still just a guess.

Given that the mortality rate is only a guess, experts have made their best guesses at somewhere between 1.0 and 2.7 percent. The mortality rate for seasonal flu is 0.1 percent. Based on this, Covid-19 will cause from 10 to 27 times more deaths than the flu. 646,000 people die from influenza annually. If Covid-19 reaches a similar saturation, that will mean deaths from 6.5 million to 17.5 million people.

Each year, hospitals and surgeries strain under the burden of treating complications related to seasonal flu. Add a few million cases of pneumonia to the mix, and you have the potential for a fairly daunting problem. Panic doesn’t help anyone, but this is a serious global health event.

On an Emergent Awareness of Impending Death (#fiction #prose #essay)


Sometimes life just smacks you in the face. You’re just minding your own business and out of nowhere comes a big punch to the gut, or, yeah, a slap to the face or whatever. This mostly happens when you’re young. By the time you reach a certain age, if you are so lucky to live that long, you’ll be punch drunk enough, trust me.

Anyway, that’s why she couldn’t believe her rabbit was dying. No, she wasn’t pregnant or anything—her pet rabbit was riddled with tumors and needed to be put down. She’d never lost anyone that close before, and the tears came in waves. She was inconsolable, as you are when you lose something precious.

So she called her mother for comfort, which is a pretty reasonable thing to do, even for someone who is technically grown up and fully adult. Relying on mothers for comfort is a habit many of us never break until fate forces our hand on the matter. She called her mother and told her the devastating news, but her mother wasn’t really as sympathetic as she had expected, so she was a little crestfallen for a minute.

Her mother listened for a minute or two to the tears and lamentations before saying, “You go on like this for your rabbit when you know I have cancer, too?”

It was true that her mother had cancer and she definitely knew about it, but she was still naïve enough to believe doctors could save lives. She had heard of people surviving cancer, so she assumed her mother would be one of those, not one of the unlucky people you hear about in other families. We’re always pretty sure the worst things won’t happen to us, aren’t we?

She would be sadder and wiser soon enough, and maybe the rabbit served as a kind of omen or preparation for what was to come. Maybe it would help her get through the days, months, and years ahead. When you look back on things, it’s hard to say what helped or didn’t as you can’t imagine how bad things might have been otherwise. Trauma and grief can be pretty all consuming, you know, and your imagination for other possible worlds disappears.

You’re just sort of stuck, boxed in, and frozen.

Anyway, that’s how it all started. Tests, promising results, surgeries, promising outcomes, more tests, different doctors, different hospitals, different promises, and different prognoses were all to follow. Sure, the best of us indulge in magical thinking or just wishful thinking, anything to not indulge in despair, even when despair is rationally the correct choice. You pretend that rabbit cancer is categorically different from human cancer. You pretend doctors are magicians. You just get on with it.

Or sometimes you don’t. You decompensate. You look for comfort in anonymous sex, “mood altering” substances, or purely defiant denial. And you’re done for. Death keeps coming, and you find out you’re strong enough to face it down. I know, some people aren’t strong enough to face it down, but anyone reading this has been strong enough so far, so you’ve been strong for a long time.

Keep it up.

Quaker Eugenics: Antinomies and Paradoxes

Some of history’s most famous and infamous hereditarians were Quakers: Samuel Morton, Francis Galton, Karl Pearson, Daniel Garrison Brinton, and Henry Herbert Goddard. In varying degrees, they exhibited a passion for knowledge and scientific research, concern for the improvement of society, and social action. How their association with the Religious Society of Friends (Quakers) influenced their scientific and social undertakings is a matter of some speculation, but an examination of Quaker values and historical trends may shed some light on their endeavours.

The history of the Quaker religions is relatively short, only appearing in England in the 1650s and in America shortly after that. Early Quakers in England, most notably George Fox, opposed the authority of the Church of England and embraced the idea of personal religious authority. In fact, the early Quakers challenged all authority, refusing to doff their hats for anyone and insisting on using the informal pronouns ‘thee’ and ‘thou’. Quakers asserted that God is within every person and that honesty and simplicity were required of a religious life. Quakers were seekers of knowledge and truth and were suspicious of wisdom received by others.

Whilst their views may not seem surprisingly radical in the twenty-first century, it caused a multitude of problems in the seventeenth century. Quakers frequently encountered conflict with authorities and endured lengthy confinement in prison and even executions. Partly as a result of this history, it would seem, Quakers often took up the cause of prison reform and were (and are) adamantly opposed to the death penalty. They opposed violent conflict of any kind. Their belief that God is within every person led them to accept women as spiritual and political leaders. For the same reason, Quakers opposed slavery early in their history. It is surprising, then, that so many famous hereditarians and even outright eugenicists were Quakers. A brief overview of some prominent individuals and institutions in Quaker history may help unravel the paradoxes of Quaker history.

One of the earliest Quakers, Mary Dyer, was herself accused of producing undesirable offspring. First an Antinomian and later a Quaker, she first appears in the public record in 1637 after becoming the mother to a ‘monstrous birth’. Antinomians preceded Quakers slightly in history, arising in the early seventeenth century. Antinomians were also slightly more radical, rejecting all authority to the point that by today’s standards they might be considered anarchists. Massachusetts Governor John Winthrop wrote tracts connecting Antinomian women and monstrous births, especially Mary Dyer and Anne Hutchinson. After attention came to the birth, the baby was exhumed and Anne Hutchinson was identified as one of the midwives. Winthrop wrote, ‘Then [Hutchinson] confessed all, yet for further assurance, the childe was taken up, and though it was much corrupted, yet the horns, and claws, and holes in the back, and some scales, &c. were found and seen of above a hundred persons’.[i] For Winthrop and others, ‘monstrous’ births were evidence of God’s intent to expose Antinomian heresy. Giving birth to a monster was equated with actually being a monster. Dyer would not become a Quaker until the 1650s, and the idea that sins are passed from parent to child is as old as Christian theology, of course, but Dyer’s experiences set an interesting precedent for the future of Quakers and inherited defects.

Dyer became a Quaker whilst in England. She had gone to England with her husband, who was on an embassy to Parliament. Quaker men and women often took a missionary role and endured long prison sentences as a result. Dyer returned to America in 1657 only to be arrested with two other Quaker missionaries, William Robinson and Marmaduke Stephenson. She was released briefly to Rhode Island but was again arrested when she returned to visit Robinson and Stephenson. They were banished but chose to challenge the law and were eventually sentenced to death. Dyer was forced to witness the hanging of her friends and prepared for execution, but she was given a reprieve at the last moment. She refused to step down from the scaffold and was forcibly removed and banished once again. After being again sentenced to death, she wrote to the Massachusetts General Court, ‘In Love and Spirit of Meekness I again beseech you, for I have no Enmity to the Persons of any; but you shall know, That God shall not be mocked’.[ii] On June 1, 1660, Mary Dyer became the only woman ever executed as a Quaker.[iii] Mary Dyer is now being recognised in the history of feminism. Anne G. Myles says, ‘Mary Dyer and other early Quaker women are at once the great inheritors and progenitors of women’s resistance—resistance to unjust laws and the manifest institutions of power, to that power as it is mediated through the policing of gender norms, and to both of these factors’ capacity to silence women who step out of bounds’.[iv]

In England, both Quakers and Puritans opposed the authority of the Church of England, but in America they opposed each other. The Quaker belief that God was in everyone combined with extreme pacifism and righteous indignation with those who disagreed caused them many problems. Early Quakers opposed war and defended the rights of slaves, women, and the mentally ill. Partly as a consequence of their own oppression and imprisonment, Quakers resisted harsh, dehumanizing, and demeaning punishments.

The Religious Society of Friends arose in the years of 1652–1656 in England, but Quakers began meeting in America at about the same time. These new Friends would sometimes tremble with fervor and became known as Quakers. In early Quaker gatherings, men and women would sit in silence to wait upon the Lord for spiritual guidance and revelation from the light within. The light is sometimes referred to as the Light of Christ or the Light of God. Quakers rejected the idea that a religious authority was necessary to interpret the Bible or spiritual leadings of God. At these meetings, George Fox emerged as a leader of the Quaker movement. Becoming a Quaker required at first to become ‘convinced’ of the truth of Quaker beliefs followed by a slower conversion to a life of inward discipline. Quaker values included pacifism, simplicity, and integrity.[v]

Given the quality of the Quaker values, it is not surprising that the first opposition to slavery in America came from Quakers. In 1688, Quakers in Germantown, Pennsylvania spoke out against the evils of slavery.[vi] David Lovejoy notes that Quaker opposition to slavery increased during the eighteenth century based on Quaker values of equality. He says, ‘For each and every man, regardless of race, was capable of receiving the light if he would but give himself over to it. Religiously, then, Quakers had an inbred sense of equality which, by the middle of the eighteenth century, they brought to bear upon several social problems about them’.[vii] Given the egalitarian nature of Quaker values, the strong opposition to slavery seems unavoidable. The surprise is that later Quakers would become known as the first ‘racial’ scientists.

Among the most influential Quakers in America was William Penn, who had friendships with both George Fox and John Locke. Penn attempted a bold experiment and set out to create a society that embodied the Quaker values and followed the blueprint of a Lockean democracy. When Penn encountered Native Americans in Pennsylvania, he wrote, ‘The worst is that they are the worse for the Christians, who have propagated their vices and yielded them tradition for ill and not for good things’.[viii] Describing Penn’s field report on Native Americans, Frederick Tolles and Gordon Alderfer write:

What is impressive about Penn’s field report on American Indians is the same thing that was exceptional about his practical relations with them—his freedom from the prejudice against ‘savagism’ that colored most 17th century accounts of Native Americans. Because he took them for what they were—no less human, no less endowed with Inward Light than white men—he was able to appreciate and understand their culture in something of the spirit of the modern anthropologist.[ix]

Penn was aware of the negative effects Christian settlers had on natives of America. He attempted to establish a social system that would ameliorate these effects and establish an order of respect for the worth and necessary freedom of all. His Quaker ideals may not have been fully realised, and we will see that Quaker efforts often have unintended consequences and apparent contradictions.

John Howard, for example, was a Quaker prison reformer in England who died in 1790. He testified before the House of Commons in 1774, and many of his recommended reforms had been instituted in England’s jails. Howard was a supporter of providing separate cells for prisoners and providing them with ‘silence, solitude, and meditation’. In other words, he brought solitary confinement to England’s prisons.[x] On his use of solitary confinement, Janet Whitney says,

He practiced them with disastrous effects on his only son. He left them as a terrible legacy to the boys of Christ’s Hospital whose solitary punishment dungeons, instigated by him, were responsible for more than one case of hysteria and insanity. And we see Howard’s system of solitary confinement as one of the most dreaded and dehumanizing agencies in the run of British prisons today.[xi]

That Howard practiced such confinement on his only son indicates that it was not a lack of compassion that guided him, but a lack of foresight of the consequences of his theory. This phenomenon is not unique to Quakers, of course, but the history of Quakers and the treatment of prisoners and the mentally ill shows many well intentioned errors of judgment.

In 1796, English Quakers began a more successful experiment in the treatment of mental illness that continues today. After visiting a Friend who was in the York Asylum, concerned Friends enlisted the help of William Tuke, a Quaker tea merchant, to raise funds for an alternative asylum. The result was The Retreat, a mental hospital that emphasised humane treatment of patients, providing useful occupation, resocialization, and a harmonious environment. The hospital remains a Quaker ministry and now has 160 beds.[xii]

In 1813, Quakers in the United States followed the lead of their English counterparts and opened the Friends Asylum for the Relief of Persons Deprived of the Use of Their Reason. Before Friends Hospital, as it is now called, opened, Philadelphians could pay a shilling to see men and women chained in the dank basement of Pennsylvania Hospital. The Quakers were outraged and wanted to provide ‘moral treatment’ for the mentally ill. The Quakers insisted that patients be given private rooms with windows, compassion, conversation, and the opportunity to walk about the grounds. The Quaker model was adopted by the State Lunatic Asylum at Harrisburg when it opened in 1851. The Friends hospital itself was based on The Retreat in England after Thomas Scattergood, a Philadelphia tanner, visited the hospital at York. The Friends hospital still operates on the model of ‘moral treatment’. Dr. James M. Delaplane, director of the hospital, said, ‘The Quakers did not believe that you should hurt people to make them behave in certain ways and neither do we today’.[xiii]

Although Quaker Elizabeth Fry does not appear to have known John Howard, she was his immediate successor in prison reform in England, though with less disastrous effects. One major difference between Fry and her predecessor is that she was concerned only with female prisoners. She felt female prisoners needed a separate prison staffed by female wards. She managed to gain approval for an experimental prison at Newgate. Of her success, she said:

Our rules have certainly been broken, but very seldom. . . . I think I may say we have full power amongst them [the women] for one of the said it was more terrible to be brought up before me than before the judge, though we use nothing but kindness. I have never punished a woman during the whole time, or even proposed a punishment to them; and yet I think it is impossible, in a well-regulated house, to have rules more strictly attended to.[xiv]

Fry’s success at Newgate expanded her views on the role of women both as prison reformers and as social activists. She encouraged better treatment in prisons, hospitals, lunatic asylums, and workhouses. She encouraged women to move beyond the domestic sphere to help bring about much needed reform. She also exhorted women to visit women incarcerated in all the above institutions, saying, ‘Were ladies to make a practice of regularly visiting them, a most important check would be obtained on a variety of abuses’.[xv] Elizabeth Fry is remembered for her strong advocacy for women and Quaker values. Concern for prisoners and the mentally ill is consistent in Quaker history, sometimes bringing improved conditions and sometimes having less desirable effects.

Abby Hopper Gibbons was an American prison reformer and social activist in the late nineteenth century. She worked with Josephine Shaw Lowell to improve condition of inmates at asylums and prison with particular attention to the women. One of Gibbons’ goals was to have women supervise female inmates.[xvi] In a letter to New York Governor Samuel Tildon in 1882, she appealed to her experience as a Quaker in confronting social problems, saying:

A Friend by birth and education, my path in life has been of a character so practical as to leave no doubt as to the feasibility of selecting women of known capacity and sound common sense. In the sect or out of it we claim no superiority on any ground nor do we confine our experience to a limited class. Largely associated with both men and women in charitable work, I have seen the advantage of cooperation and have noted progress in the internal management of the affairs and institutions. This is conceded by our best men who are glad to have women share the responsibilities and active service for which they are especially fitted. And after all, why should it be more difficult to find women than men?[xvii]

In addition to her work in the prisons and mental institutions, she was also concerned with other women’s issues, including prostitution. She was appalled by the moral double standard imposed on women when it came to vice. As a leader of the moral purity movement, she opposed legislation intended to regulate prostitution and reduce disease. Abby Gibbons argued forcefully for the protection of prostitutes, but her solution may have been to provide more harsh punishment than what already existed. She advocated reformatories to help educate prostitutes in better means of employment (better as defined by the moral purity movement leaders). Margaret Hope Bacon makes this comment on Gibbons’ plan:

These reformatories had been advances over the jails of the period, but the staff treated the inmates as tractable children to be trained and urged indefinite sentences in which this training could take place. Thus, prostitutes arrested and sent to reformatories would actually be deprived of their liberty more harshly than men picked up on any comparable charge.[xviii]

Once again, the effort to care for others and give solutions to their problems can easily become an effort to control others. The liberator sometimes becomes an oppressor. The belief that God is in every woman might mean that every woman’s life must be respected, but Quakers often believe the light of God must be nurtured even when such nurturance takes some amount of involuntary loss of liberty.

Josephine Shaw Lowell worked with many Quakers and was a philanthropist and reformer as well. According to Nicole Hahn Rafter, Lowell is not referred to as a eugenicist in most biographies. Rafter suggests this may be because Lowell died in 1905 before the term ‘eugenics’ became popular. Nonetheless, Rafter credits Lowell and her collaborators with starting eugenic criminology at the Newark Custodial Asylum for Feeble-minded Women. Lowell wanted both to improve conditions for those in asylums and to prevent the need for asylums in the future. She advocated a strong program of eugenics to prevent degeneracy.[xix]

Samuel Morton spent a good deal of time in the nineteenth century measuring skulls for cranial capacity. He believed that brain size was a good predictor of intelligence. He did not appear, however, to have an active political agenda. As a Quaker, he was opposed to slavery, but he did not believe all humans to be of equal intelligence. Despite his apolitical approach, his contemporaries used his research to political ends. One such contemporary was the openly racist phrenologist Charles Cauldwell, and another was Morton’s colleague Josiah Nott, a physician in the state of Alabama.[xx]

Francis Galton is often considered to be the father of British eugenics. Galton was born in a Quaker family, though this fact is often obscured in descriptions of his life. One might think his Quaker heritage was not important to either Galton or his collaborators, but Karl Pearson, another British hereditarian following in Galton’s footsteps, placed much importance on Galton’s heritage. Pearson, also a Quaker, credited Galton’s Quaker heritage for his brilliance. He said, ‘Not only did the Society of Friends unite men religiously but it produced special temperaments genetically . . . Almost a biological type’.[xxi] One must wonder whether Pearson was being intentionally ironic by labelling members of a particular religion as a biological type. Although Galton is considered the father of eugenics and given some measure of blame for the eventual racist and fascist aims of many eugenicists by many, Daniel Kevles claims that Galton was no more racist than most Victorians in England. Kevles claims that British eugenics had more to do with class than race.[xxii]

Galton sought to regulate marriage according to the quality of potential parents. Galton, like Morton, felt that intelligence could be measured by measuring the size of one’s head. He also felt that other traits, such as a strong work ethic, were heritable. When his cousin, Charles Darwin, told him that he had previously thought that men were roughly equal in intellect but differed only in ‘zeal and hard work,’ Galton replied that ‘character, including the aptitude for hard work, is heritable like every other faculty’.[xxiii]       One might think that Galton’s work has now been relegated to the historical record, but he is still seen as a creditable scientist by many, just as he was in his own time. The August/September 2008 issue of Scientific American Minds says of Galton,

In 1883 English anthropologist and polymath Sir Francis Galton dubbed intelligence an inherited feature of an efficiently functioning central nervous system. Since then, neuroscientists have garnered support for this hypothesis using modern neuroimaging techniques.[xxiv]

It is hard to see how neuroimaging could verify the results Galton discovered by measuring the circumference of skulls, but this passage serves to highlight the place of distinction Galton held and still holds. Galton’s advocacy for restricting marriage and family size again seems to be counter to his Quaker heritage. Contrary to Pearson’s comments on Galton’s Quaker heritage, it does not appear that his theories or the practices he advocated were based on Quaker teachings. Pearson’s comments seem to claim that Quaker families are ‘good’ in the sense of being respectable rather than of being moral. By the nineteenth century Quakers had gone from being outsiders always in conflict with the law to being respectable and affluent members of society. It was Galton’s affluence that enabled him to pursue his research, after all, more than his dedication.[xxv]

Galton’s immediate successor was Karl Pearson, a British socialist and Quaker. Pearson, though, had doubts whilst still at King’s College and later whilst studying in Germany. By the time he returned to England, he had become more of an agnostic and an adherent of Spinoza’s philosophy, which proved the existence of God but equated God more with the universe than the spiritual power most Christians worship. Whilst in Germany, Pearson was contemptuous of students studying Darwin’s evolution looking for solutions to social ills. He was instead attracted to German idealism and historicism. Following the ideas of Hegel and Fichte, he believed that moral and social progress was best expressed through the state. In the late 1880s, Pearson changed his mind on Darwin when he came in to contact with social Darwinism that replaced competition among individuals with competition among groups.[xxvi] Pearson did not advocate radical direct action to bring about a socialist state. Rather, he felt a socialist state should emerge slowly following the work of intellectuals. He felt it was up to the ‘power intellectual’ to guide society.[xxvii]

Pearson headed the Galton Eugenics Laboratory in Britain, but he ‘refused to join the Eugenics Education Society, to participate in political activity, or to make available his institutional resources and expertise for the support of legislative measures’.[xxviii] Pearson was intent on establishing eugenics as an academic discipline, and he felt that the social activists associated with the eugenics movement were doing it harm in that area. Pearson did not like to be involved in political activity and preferred to promulgate his research through academic journals and learned talks and activities. He was a racist who disparaged both Jews and Blacks, but he took pleasure in shocking a Newcastle cleric by saying that Adam, the source of all humans, must certainly have been ‘Negroid’.[xxix] It is tempting to say that Pearson’s temperament may have resulted from his Quaker upbringing, which was stern, especially from his father, but that his theories had little to do with Quakerism. His comments on Galton’s Quakerism show that he admired Quakers generally, though, so he was not completely divorced from its ideas. Many Quakers of his time had moved toward socialism of varying sorts. Nonetheless, Pearson did not seem to be following Quaker faith. Instead, he appeared to be following intellectual trends of his time rather than the much older teachings of his religion.

Born of Quaker descent, Daniel Garrison Brinton was a leading American ethnologist who produced prolific publications on race and, more specifically, race inferiority. He divided races into categories ranging from savage to half-cultured to enlightened. He argued that Africans, Native Americans, and Chinese had failed to produce ‘empires’ for want of developed minds. Brinton was adamant that there must be no mixing of the Caucasian race with other races. He said that miscegenation would bring ‘indelible degradation’ to the descendents of the white partner. He put the burden of keeping society stable on the shoulders of white women. He said that only the woman could preserve the ‘purity of the type’. His pronouncement simultaneously established the superiority of the white man whilst relieving him of any responsibility for preserving social order.[xxx] The original tenets of the Quaker heritage appear to have been lost in the mind of Brinton. Lee Baker says of him:

Although his Quaker background and these obituaries raise some intriguing questions, they demonstrate how deeply ingrained notions of white supremacy were even among putative radical scholars and activists, how accepted notions of racial evolutionism were among the intelligentsia regardless of political orientation, and how integral notions of racial hierarchies were to anarchist ideology during the last decade of the nineteenth century.[xxxi]

In short, views on racial inferiority seemed to override egalitarian concerns that are a part of Quaker faith.

Henry Herbert Goddard was reared as a Quaker, and he never abandoned his faith, even if he seemed to have gone far afield of the idea of equal human worth. He was taught Darwinian evolution in school at Providence as a matter of fact. A classmate of Goddard’s said that the instruction enabled Quakers to follow scientific debate without any ‘wreckage of faith’.[xxxii] Though they seem contradictory, Goddard never lost his faith as Pearson had done. Indeed, Goddard seemed to feel his efforts in eugenics would help society by creating more individuals of moral worth such as Quakers. In his study of the ‘Kallikak’ family, he overtly equates ‘Quaker family’ with ‘good family’. Goddard’s steadfast faith, indeed, may have helped him be less steadfast with his intellectual theories.

Goddard conducted a study of the ‘Kallikak’ family in a classic study of hereditary feeble-mindedness. In his study, he asserted that Martin Sr. had two lines of descendents, one beginning with a feeble-minded woman named Deborah and another with a good Quaker woman. He describes the two lines of descent from Martin as follows:

The Kallikak family presents a natural experiment in heredity. A young man of good [Quaker] family becomes through two different women the ancestor of two lines of descendents: the one characterised by thoroughly good, respectable, normal citizenship, with almost no exceptions; the other being equally characterised by mental defect in every generation.[xxxiii]

To solve the problem of inherited degeneracy, Goddard proposes a system of segregation and colonization for the feeble-minded. He sees this as the best way to improve conditions for society. His plan of action is bold, direct, and full of latent prejudice. Goddard’s conclusions would seem to go against the belief that all have God within them, but Goddard’s continued faith in Quakerism, at least nominally, is reflected in how he describes Martin’s courtship of his wife. He says:

During the summer of enforced idleness he wooed and won the heart of a young woman of good Quaker family. Her shrewd old father, however, refused to give his consent. To his objections, based on the ground that Martin did not own enough of the world’s goods, the young man is recorded as saying, “Never mind, I will own more land than ever thou did, before I die,” which promise he made true.[xxxiv]

Goddard seems to view Quakerism as a sign of moral goodness, but he does not, at this time of his life, seem to equate Quakerism with any particular social obligation. He was perhaps too caught up with his research or too impressed by the exciting developments in science to recognise his own prejudice and the negative consequences of prevailing attitudes and practices.

In later life, Henry Herbert Goddard, who had advocated strict eugenic laws, always felt obligated to social commitment. He attempted to follow Quaker values throughout his life, but his later life seems to have had greater humility and sincere devotion. Of his later life, Leila Zenderland says, ‘He committed himself to various causes, sending not only money but also letters containing advice or expressing ‘a concern’ – as we Quakers say’.[xxxv] He supported Einstein’s Emergency Committee of Atomic Scientists, which opposed the use of nuclear weapons. He would not support the Committee on United Europe because it took a hard line with Stalin, and he said, ‘A soft answer turneth away wrath’.[xxxvi] In these later years, Goddard championed gentle parenting and a peaceful demeanor. On intelligence, he decided that there was not enough information about genes to say that intelligence was inherited. He said only that ‘we know enough to safely conclude that the possibilities of variation are great’.[xxxvii] When he was nearly eighty, he sent a Christmas letter, and Deborah Kallikak was among the recipients. Helen Reeves, one of Deborah’s teachers, said that Deborah’s reaction was to say, ‘The nicest thing about it . . . is that he thought I had the brains to understand it which of course I do’.[xxxviii]

Another prominent Quaker of the twentieth century, Jean Toomer, stands in contrast to judgmental theorist such as Goddard. Toomer was a prominent author during the Harlem Renaissance. He was born in 1894 and did not become a Quaker until 1940 after attending meetings for about five years. During his years as a Quaker, he became a sought after speaker and leader with special interest in teaching young people. Rather than social activism, he advocated inward change. He wrote, ‘If we are to consider politics, then surely it should be our aim to come nearer to the Politics of Eternity rather than express views about the politics of our time’.[xxxix] But in 1947 he expressed himself a little differently on the need for inward development and social change: ‘The truth is that both approaches are needed. I have stressed the necessity of inward change because it is relatively neglected in our day’.[xl] Toomer judged himself to be somewhere between one-eighth and one-sixteenth black. He lived among Blacks, whites, and Jews. Perhaps as a result of his own mixed heritage, he opposed attempts at racial categorization. He saw racial purity as a myth and felt that rejection of the idea of race could help to unite individuals as part of the human race.[xli] He said, ‘Human blood is human blood. Human beings are human beings. . . . No racial or social factors can adequately account for the uniqueness of each—or for the individual differences which people display concurrently with basic commonality’.[xlii] Toomer returned to the original Quaker ideal that God is within each person.

Lancelot Hogben lived from 1895–1975 and was a biologist who held, among other positions, a chair in social biology at the London School of Economics. He was a humanist and social radical. He sought the development of a rationally ordered society but opposed the efforts of eugenicists. Although he later described himself as an atheist, he practiced Quaker ethics for his entire life.[xliii] This is not inconsistent with Quaker practice. Many Quakers, especially liberal Quakers of the twentieth century and later, define God in abstract terms, even embracing atheism and defining God as the universe. But even in 1648, Quaker Gerrard Winstanley declared that Christ ‘is not a single man at a distance from you but the indwelling power of reason’.[xliv] This may help to reconcile Hogben’s Quakerism with his exclamation, quoted by Daniel Kevles, ‘I’m an atheist, thank God’.[xlv] Kevles also credits Hogben with convincing Julian Huxley that his views on the unemployed would only help foster Nazism.[xlvi] Hobgen rejected eugenics and favored instead humanistic socialism, hoping always to help bring about an ordered world free from war and poverty.

Whilst Quaker history is filled with people in all periods who resolutely defended the worth of each individual with an egalitarian zeal, a number of changes took place in the nineteenth century. Between 1860 and 1880, the Society of Friends in the United States experienced a revival. After a decline in the numbers of Quakers in the United States in the early part of the nineteenth century, large tent meetings spread to both coasts in the latter part.[xlvii] This is somewhat misleading, however, as it obscures the growing schisms within the Quaker community, which was no longer a single community. Indeed, Quakers in the later nineteenth century divided into factions so different that an outsider would probably not recognise that they were of the same faith tradition. Quaker historian Howard Brinton says,

There were then in the second half of the nineteenth century in America three kinds of Quakers designated by the names of three persons. The Hicksites represented the more mystical, liberal, noncreedal branch; the Gurneyites, the more evangelical, authoritarian and theologically conservative branch; and the Wilburites, a branch whose position was between the other two.[xlviii]

The Hicksites were the most liberal of the three groups both socially and politically. The Hicksites would continue to fight racism, oppose war, and insist on each individuals right and responsibility to seek meaning and follow his or her conscience. The other branches were more conservative socially and maintained the severity of their Quaker forbears, continuing to stress a devotion to religious life and Christ. The conservative branches also established creeds, whilst the liberal branch remained without creed or doctrine. The creeds stressed justification and sanctification and resembled mainline protestant religions more than early Quaker religions. Both Herbert Hoover and Richard Nixon were Quakers, and it seems impossible they could be of the same faith as Jean Toomer and Lancelot Hogben, but the branches are so different that it is consistent with modern Quakerism to produce such diverse individuals.

The apparent paradoxes in the actions of Quakers stemmed partly from changes in the religion, partly in changes in society, and, occasionally, simply from changes in individuals. The early Quaker religion was a religion of radical outsiders who were treated as an underclass both in England and America. These radicals had to fight for the right to even exist, and they were forced at every turn to demand humane treatment. For these Quakers, it was impossible to imagine a loving God that would tolerate inhumane treatment of anyone. They recognised God in every individual and felt that the abuse of anyone was an abuse of God. For this reason, they opposed harsh treatment of criminals, especially the death penalty, and fiercely resisted war in all its forms. These Quakers recognised the equality of races and the rights of women and children. It is no surprise, then, that early Quakers would oppose slavery and the harsh treatment of the mentally ill and prisoners.

By the later nineteenth century, though, Quakers had become more established. Many were now affluent, and Quakers such as William Tuke and Johns Hopkins could afford to donate large sums of moneys to fund institutions. Other Quakers, such as Francis Galton and Karl Pearson could afford to travel the world and attend the best schools. Rather than being outsiders, Quakers could now affect social policy and legislation. Of course, some Quakers would want to enforce their religious severity on others. For many, what might now be called ‘clean living’ was an obvious solution to social problems. Abby Hopper Gibbons would support the moral purity movements. Quakers of this period were likely to believe they had achieved their status in society through purity and religious rigor. The compassion that drove early Quakers to seek freedom for slaves and prisoners now translated into a desire to care for others by exerting some control over their choices.

The nineteenth century also showed shifts in scientific thinking, especially after Darwin’s work became widely known. As mentioned above, many Quakers of this period could afford to attend leading universities in the United States and Europe. The basic tenets of genetic determinism and social Darwinism were presented to many students as facts just as they are today. Quakers concerned with improving society would of course turn to the latest theories from leading scientist of the time. Indeed, it is not surprising that Quakers joined progressive movements and sometimes embraced socialism of varying sorts. The later nineteenth century was a turning point for Quakers as it was for society writ large. Quakers divided into many factions depending on which Quaker values seemed of greatest importance to them. In the ensuing decades, the liberal branch of Quakerism is the only one to remain without a creed in the United States. Hicksites are now members of the Friends General Conference (FGC), which still opposes discrimination, harsh punishments, and war. The modern FGC is also tolerant of universalism (the belief in universal salvation or universal worth) and even atheism or agnosticism. The past involvement of Quakers in eugenics and racial purity movements should serve as a reminder to contemporary Quakers that moral hazards are always present.


            [i] Anne G. Myles. ‘From Monster to Martyr: Re-Presenting Mary Dyer’. Early American Literature. 36:1, 2001, 3.

            [ii] Myles, 3-7.

            [iii] Myles, 3-7.

            [iv] Myles, 18.

            [v] Brinton, 1-15.

            [vi] David S. Lovejoy, ‘Samuel Hopkins: Religion Slavery, and the Revolution,’ The New England Quarterly, 40:2, 1967, 228.

            [vii] Lovejoy, 229.

            [viii] Frederick B. Tolles and E. Gordon Alderfer, The Witness of William Penn (New York: Octagon Books, 1980), 125.

            [ix] Tolles and Alderfer, 124.

            [x] Janet Whitney, Elizabeth Fry: Quaker Heroine (Boston, Little Brown, 1940), 227-228.

            [xi] Whitney, 228.

            [xii] Quaker Tour of England, The Retreat Mental Hospital., accessed July 31, 2008.

            [xiii] Debbie M. Price, ‘For 175 Years: Treating Mentally Ill With Dignity,’ The New York Times. April 7, 1988.

            [xiv] Price, 229.

            [xv] Price, 255.

            [xvi] Margaret Hope Bacon, Abby Hopper Gibbons: Prison Reformer and Social Activist (New York: State University of New York Press, 2000), 145 – 160.

            [xvii] Bacon, 156.

            [xviii] Bacon, 155.

            [xix] Nicole Hahn Rafter, Creating Born Criminals, (Chicago: University of Illinois Press, 1997), 35-50.

            [xx] Milford Wolpoff and Rachel Caspari, Race and Human Evolution (New York: Simon and Schuster, 1997), 89.

            [xxi] Gerald Sweeny, ‘Fighting for the Good Cause: Reflections on Francis Galton’s Legacy to American Heriditarian Psychology,’ Transactions of the American Philosophical Society, 91:2, 2001, 29.

            [xxii] Kevles, 76.

            [xxiii] Stephen J. Gould, Mismeasure of Man, (New York: W. Norton & Co., 1996), 108-109.

            [xxiv] Christian Hoppe and Jelena Stojanovic, ‘High-Aptitude Minds,’ Scientific American Minds, August/September 2008, 61.

            [xxv] Gould, 107.

            [xxvi] Kevles, 23.

            [xxvii] Kevles, 24.

            [xxviii] Kevles, 104.

            [xxix] Kevles, 76.

            [xxx] John S. Haller, ‘Race and the Concept of Progress in Nineteenth Century American Ethnology,’ American Anthropolgist, New Series, 73:3, 719 – 721.

            [xxxi] Lee D. Baker, ‘Daniel G. Brinton’s Success on the Road to Obscurity, 1890 – 99,’ Cultural Anthropology, 15:3, 412.

            [xxxii] Zenderland, 31.

            [xxxiii] Henry Herbert Goddard, The Kallikak Family (New York: Arno Press, 1973), 116.

            [xxxiv] Goddard, 99-100.

            [xxxv] Zenderland, 337.

            [xxxvi] Zenderland, 337-338.

            [xxxvii] Zenderland, 338.

            [xxxviii] Zenderland, 338-339.

            [xxxix] Kerman and Eldridge, 267.

            [xl] Kerman and Eldridge, 267.

            [xli] Kerman and Eldridge, 341-342.

            [xlii] Kerman and Eldridge, 342.

            [xliii] Max Perutz, ‘Friendly Way to Science,’ Times Higher Education., accessed August 4, 2008.

            [xliv] Godless for God’s Sake: Nontheism in Contemporary Quakerism, ed. David Boulton (Dent, Cumbria: Dales Historical Monographs, n.d.), 88.

            [xlv] Daniel J. Kevles, In the Name of Eugenics: Genetics and the Uses of Human Heredity, (Berkeley: University of California Press, 1985), 124.

            [xlvi] Kevles, 127.

            [xlvii] Zenderland, 18.

            [xlviii] Brinton, 234.

When the hospital refuses to provide treatment

Few things are as horrifying as the idea that a hospital might refuse to treat you or a loved one at a time of crisis. This is so frightening, that many used the specter of “death panels” to terrify Americans from supporting the Affordable Care Act, which had no provision for such panels. All the same, we don’t get to go into hospitals demanding whatever treatments we think are appropriate. Doctors, other medical caregivers, and insurance companies all have a say over what treatments are acceptable for various conditions.

One of the most common issues before Hospital Ethics Committees is futility. In all the cases I experienced personally, a family member demanded treatment for loved ones that threedoctorsdoctors deemed inappropriate as they felt it offered no benefit to the patient. In most of these cases, the patient was either dying or already pronounced brain dead when the conflict arose, but other types of conflict over futility arise from time to time.

For a less grave example, consider people who get a cold or cough and go into the doctor demanding antibiotics to treat what is generally a viral infection. Some doctors might prescribe antibiotics just to appease their patients, but others will refuse on the grounds that the treatment offers no benefit to the patient while carrying both costs and some risks. (If you prefer an even more absurd example just to illustrate the point, imagine someone demanding cholesterol medicine to treat a broken arm.) This type treatment is futile because it will have no effect on the condition being treated.

Another kind of futility is both more common and more serious in its consequences. These cases often, though not always, involve infants on ventilators or elderly patients receiving artificial nutrition (feeding tubes) and hydration. In these cases, doctors and the family or other surrogates agree that the feeding tubes or ventilators are keeping the patient alive, but disagree on the value of doing so. In some cases, the patient may be suffering and medical providers feel the patient’s suffering makes it unconscionable to continue treatment. In other cases, the patient may be in a permanent state of unconsciousness or even be brain dead, and the healthcare providers feel the patient no longer exists as a person in any real sense. All the qualities associated with life (consciousness, will, pleasure) are already gone, so treatment has no use.

Few forces in the world are as powerful as the duty we feel to protect our children or to care for our parents or other loved ones. The one comfort we take in the face of such a devastating loss is that we “did everything we could.” When doctors tell us that doing “everything” is costly, painful, and of no value, it can be more than painful to accept. Complicating matters is that most of us have heard of miracle cases where people recovered despite dire prognoses. When told that no more than one in a million patients survive such a condition, family members often only hear that there is some chance of survival. It is a point of honor that they will “never give up” on their child or parent.

I’ve seen doctors handle futility with great skill and also with awkwardness. In one case, a man was convinced the hospital was abandoning his wife at the time she most needed care. The man felt the doctor was expressing the needs of the hospital rather than the needs of his wife. Once he was reassured that she would be cared for even in the absence of treatment, he felt much better about discontinuing treatment. In another case, the doctor made every effort to assure the parents of an infant that she and the entire staff would stay with them throughout the ordeal and do everything possible to reduce both the suffering of the child and the pain of the parents.

It is impossible, of course, to eliminate all disagreements and conflict, but I think doctors who are able to effectively communicate empathy and concern for the patient and the people who love the patient have greater success at avoiding battles with patients. We all want to know our experiences are recognized and validated. We all want to be heard. We also want the dignity of our loved ones to be promoted and protected, especially as they face death, which strips them of autonomy and self-respect. We want healthcare providers to recognize that we hold our dying loved ones in the highest regard even if they can no longer speak for themselves and show why they are worthy of such respect. When we fight for their lives, I think we are really fighting for their dignity and worth as a person. Doctors will do well to keep that in mind.

The Proper Way to Grieve for a Child: Cicero’s Example

Epictetus stated he would embrace death before...
Epictetus stated he would embrace death before shaving. (Photo credit: Wikipedia)

In advising us on how to respond when we encounter someone who has lost a child or suffered an equally calamitous loss, the stoic philosopher, Epictetus said, “Don’t reduce yourself to his level, and certainly do not moan with him. Do not moan inwardly either.”  These negative emotions are dangerous to us and to others, so we must be sure to keep them in check.

This sounds harsh, but Epictetus also advises us not to beat ourselves up when we do give over to grief. He says, “Some who is perfectly instructed will place blame neither on others nor on himself.” Epictetus assures us that death is not to be feared, and our terror of it comes from within, but blaming ourselves for our feelings is also pointless.

Scottish philosopher David Hume, reflecting on the nature of tragedy in art, makes a comment about the best way to comfort a parent who has lost a child. Hume says, “Who could ever think of it as a good expedient for comforting an afflicted parent, to exaggerate, with all the force of elocution, the irreparable loss which was met with by the death of a favorite child?” I’m sure Hume is right that we shouldn’t exaggerate the loss, but I would also advise against minimizing the loss in any way, which is what Cicero’s friend, Servius Sulpicius Rufus,  did after the death of Cicero’s daughter, Tullia.

David Hume
David Hume (Photo credit: Wikipedia)

Sulpicius said, “If you have become the poorer by the frail spirit of one poor girl, are you agitated thus violently? If she had not died now, she would yet have had to die a few years hence, for she was mortal born.” Sulpicius sounds harsh in this instance, but this is actually offered only after he introduced the topic, saying, “If I had been at home, I should not have failed to be at your side, and should have made my sorrow plain to you face to face. That kind of consolation involves much distress and pain, because the relations and friends, whose part it is to offer it, are themselves overcome by an equal sorrow.” If he had been available, he would have comforted Cicero and perhaps avoided the need for such harsh and critical words later, apparently.

Cicero, Kopiezeichnung einer Büste aus London ...
Cicero, Kopiezeichnung einer Büste aus London (Herzog Wellington) (Photo credit: Wikipedia)

Cicero expressed his gratitude for the comforting words laced with recrimination, but also acknowledged their ineffectiveness, saying, “For I think it a disgrace that I should not bear my loss as you – a man of such wisdom – think it should be borne. But at times I am taken by surprise and scarcely offer any resistance to my grief, because those consolations fail me.”

Cicero had also been writing consolations for himself, and he felt himself the inventor of this type of self-help. He said, “Why, I have done what no one has done before, tried to console myself by writing a book.” (This is quoted by Han Baltussen in the Nov. 2009 issue of Mortality in an essay titled, “A grief observed: Cicero on remembering Tullia.”) Unfortunately, Cicero’s Consolations have not survived the passage of time, so we can only infer what they may have said. In a letter to Titus Pomponius Atticus, Cicero remarked that he wrote in order to heal, but his writing also kept him out of public view, preserving the privacy of his grief and avoiding a vulgar display of emotion.

Cicero also took his turn in consoling others, Baltussen notes, “In the examples where Cicero aims at consoling others, we find a subtle approach, developing, as it were, a ‘philosophy of empathy,’ in which he consciously or unconsciously takes personal and political aspects into account. He shows great sensibility in narrowing or widening the emotional gap between him and the consolee.” Cicero noted that one task as consoler was to establish that he needed consolation himself, as he was grieving for his friend’s loss. I think this goes a little beyond mere empathy. Cicero actually feels his own sorrow upon hearing of the sorrow of a dear friend. He understands the friend’s pain because it is a magnified form of his own pain.

I personally feel that Cicero’s struggle with his grief highlights a social failure to deal with grief constructively. Can we not manage to express and process grief openly without fear of censure from friends and counselors? Since the time of Cicero, we have developed grief therapy, expressions of support for the bereaved, and paid lip service to the process of healing. Yet, we still criticize those who can’t “get it together” within a short time. Sadness is seen as weakness, especially for men, and we do not tolerate prolonged grieving. Cicero was lucky to have friends and the ability to spend time grieving and writing his consolations. Men with less power would have had no option but to keep working without respite.

Grief (Photo credit: tombellart)

As for me, I don’t know the best way to console others, but I’ve thought a little about what kinds of consolations have helped me in the past, and these are the things that I appreciate. First, recognize that my pain is of such a magnitude that it obscures the horizon, and I can’t see beyond it. Second, do acknowledge the enormous value of the life I have lost. Third, do remind me that the person I lost had life filled with wonder, love, accomplishments, and happiness. Fourth, remind me also that this person is in a state of peace with no more struggle, pain, or discontentment. Finally, and perhaps most importantly, assure me that I am not alone in the world, my grief is justified, and that a future is possible.

The proper way to grieve for a child

I hate Galveston.

When I look out over the seawall, I find no peace in the sounds of wind and wave or comfort in the roiling swirls of water gently crashing into the jetties. I see only the bodies of children being dragged and slammed with senseless violence against the sand just beneath the waves. As I look out over the Gulf of Mexico, I see only a sadistic child-eating monster mocking the hole in my chest.

And May is the cruelest month, because it was Mother’s Day in 1992 that I lost my niece and nephew to the powerful spring rip tides along the coast of Galveston. My niece, Cindy, who was seven, was pronounced dead on the beach, but my nine-year-old nephew, Doug, was flown to John Sealy hospital and placed on life support. Although the doctors offered us no hope of his recovery, he was kept on life support for 72 hours to monitor his brain activity.

The only photo I have of Doug and Cindy, from 1990.

During that agonizing 72 hours, we did what most families do. We held his hands, stroked his hair, talked to him, read to him, took him his favorite stuffed bear, massaged his legs, and loved him with every ounce of strength we had. At the moment they stopped life support, the Galveston radio station played his favorite song, “Born in the USA.” Yes, we were on the radio. We were on the news. Our family’s grief was broadcast on the nightly news. I avoided the cameras, but the children’s father was there, tears cascading down his face, explaining how he felt about the death of his children. Who needed this explanation?

Perhaps it is surprising, and perhaps it is not, that I decided to enter the medical humanities program at the University of Texas Medical Branch in Galveston. I spent years driving to Galveston and going into the hospital where my nephew died. Sometimes I avoided the building, but other times I went there and sat in the garden specifically to think of what had happened before. When I completed my required ethics practicum, I went on rounds with the doctors in the pediatric ICU—of all places.

As part of this experience, I was able to witness conversations with doctors and the parents of children who would never recover. The doctors were kind, caring, and professional, and every word destroyed me a little. I imagined the conversations the doctors and nurses must have had regarding my family in 1992. I imagined how they debated the proper course to take: how long to keep him on life support, how to break bad news to the family, and how to prepare for the death of a nine year old. I had thought this experience might help me come to grips with my past trauma, but I honestly cannot say it did.

As medical humanists, we study the ways people make meaning of suffering, but I want to tell you with great heartfelt certainty—there is no meaning in the death of a child. And when you try to make meaning of it, you rob me of my grief. I am entitled to my grief. My pain is my own. When you tell me the children were on loan from God, and he has called them home, I am only amazed that you worship a monster and call it God. When you tell me they are in a better place, I want you to know that the world they left behind is immeasurably worse for their absence. When you tell me anything, you amplify my pain and submerge me in the depths of despair with no comfort and no meaning.

What does someone grieving the death of a child need? Solitude. And comfort. Silence. And conversation. A distraction. A project. Time to do nothing. Time to think. Time to cry. Time to scream. Time to fall apart. Time to get it together. There is nothing you can do. But, really, you should try. And you should know when to back off.

I can remember talking to priests, ministers, social workers, counselors, and well-meaning friends. No one can really offer any comfort, but a few people managed to refrain from intensifying the pain. In particular, Robert Schaibly, who was the minister at First Unitarian Universalist Church in Houston at the time, offered sincere condolences with no advice, no explanation, and no demands. He was empathetic and shared my pain without taking it as his pain. No other clerical person I met was able to achieve something that seems so simple. Perhaps the simplest acts require the greatest art.