Sahana: Hello everyone! Welcome to In Limbo Conversations! Today, we have with us Meredith Schwartz. She's an Assistant Professor of Philosophy at Ryerson University. Her research focuses on the moral concepts of respect, responsibility, trust, and risk, as they are deployed in clinical ethics and health policy. For more information about her work, please check here. Thank you for joining me, Meredith.
Meredith: Thank you for having me.
Sahana: In today's conversation, I'd like to focus on some of the points you have raised in your book "Moral Respect, Objectification and Health Care". In the book, you presented an egalitarian account of moral respect which applies to both non-autonomous and autonomous patients; and more importantly, given the current pandemic situation, you also talked about why moral respect is central in in medical context. So I thought we could start by talking about the current pandemic situation and the objectification that usually occurs within medical situations. You have discussed how modern medicine is inherently objectifying and you have also mentioned ten forms of objectification. I was wondering if you could tell us why you find modern medicine to be inherently objectifying and maybe you can give us some pandemic specific instances, or where you have seen these forms of objectification occur.
Meredith: Sure. So, in the book, my goal is to put forward an egalitarian account of respect, because the more traditional account of respect and bioethics is respect for autonomy - where autonomy is understood as medical decision-making. It leaves out a whole lot of people because many people aren't autonomous - maybe because they're too young, they're children. Or maybe because the very illness that they are seeking treatment for might lower their autonomy skills, or perhaps even get rid of most of their autonomy skills. So, I thought it was really important to have an account of respect that applies to everyone because, as I understand it, respect is the moral concept in western philosophy that recognizes equal moral value and I think that when we respect someone, we treat them as a being that has inherent value. And although it does make sense to have a certain amount of capacity to have someone respect your decisions - because if you lack that capacity, then the decisions that you make might not be wise, you might not understand entirely what you're doing - but it doesn't seem like you need to have autonomous capacities to deserve respect as a person.
In the book, I talk about the Kantian idea that respect is the way that we engage with someone, when we engage with them as more than a mere object. And so, I take his account of dignity, which he describes as a certain kind of value and I say that respect is founded on dignity. It is founded on that kind of value, and I see the value of dignity as being a kind of intrinsic, absolute, and inalienable value that differs from price. Price is what you can gain on the marketplace and when we think about treating someone as more than a mere object, we'll find that denying their autonomy or violating their autonomy - that is recognizing that they have autonomy and ignoring it anyway - both of those are hugely important ways of objectifying someone. So I'm not at all criticizing the idea that we ought to respect autonomy, but I'm saying that there are other ways of objectifying people too. For example, you can treat their subjectivity as though it doesn't exist or is unimportant. I understand subjectivity to be more of one's emotional reactions, one's experience of the situation - not necessarily one's decision making capacities.
Price is what you can gain on the marketplace and when we think about treating someone as more than a mere object, we'll find that denying their autonomy or violating their autonomy - that is recognizing that they have autonomy and ignoring it anyway - both of those are hugely important ways of objectifying someone.
Or you can treat people as fungible - something is fungible when you can exchange two things of the same kind for one another without loss of value. So, for example, if we traded one dollar for another dollar, you don't care that you have this particular bill - because it has the same value, so it's fungible. Or if you have one cord of wood, you can change it for another cord of wood of the same grade without loss of value. But people aren't like that! So, I can't just take your mother and kill her and then give you another mother and say, "Oh that's fine!" because that would entail a loss of value. So, another way of objectifying people is to treat them as fungible.
You can also treat them as inert, that is, as lacking agency. You can reduce them to nothing but their body. There are a whole variety of ways that I describe in the book. There are ten and they're inspired by Martha Nussbaum, Rae Langton, and Kay Toombs' work on objectification. Now, their work is mainly done in a sexual context; they are thinking about sexual objectification of women. But what I wanted to point out in the book, is that medicine is also very objectifying, because medicine treats the object - body. So it's looking at physiological processes and it's trying to fix those physiological processes. The medical method has to treat patients as fungible to a certain extent. So if this patient couldn't be compared, or sort of made equivalent to previous patients, then we'd have no idea how to treat them - it would be new every time. So, we do have to think about one person in terms of their ability with another sometimes in medicine. It is appropriate to treat people as a node; for example, if the patient is in a coma or if the patient is undergoing surgery, then you have to treat them as a node and in fact, treating them as a node might actually be a way of respecting them since, you know, that's what you have to do to keep them alive under those situations. Medicine also has a focus on the body so it's not necessarily going to reduce the patient to the body. It might try to treat the whole patient, but in terms of curing the illness or treating the illness, it's going to be focused on the object body rather than other things. And so, for all these reasons, I think, that people can experience the medical encounter as incredibly objectifying. This isn't always going to be the case - if you just go in to get a flu shot, you're just in and out and it's perhaps not that important in that kind of a context. But, particularly, if people are dealing with chronic issues or issues that are serious and going to affect their life plans, or if people are in an institutionalized setting, then I think a focus on trying to counter the objectification with a respectful engagement becomes more important - particularly in institutionalized settings because the setting itself removes a lot of those things that make up a self, right? So in an institutionalized setting, the room that you're in might have a few of your objects, but not to the same extent as your apartment or your house, and so a lot of those things that would hold your memory and yourself aren't present. So in those settings it is particularly acute.
...if people are dealing with chronic issues or issues that are serious and going to affect their life plans, or if people are in an institutionalized setting, then I think a focus on trying to counter the objectification with a respectful engagement becomes more important - particularly in institutionalized settings because the setting itself removes a lot of those things that make up a self, right?...
Sahana: So, in contrast to this objective attitude, you mentioned an interactive attitude - it attends to the patient's uniqueness, their non-fungibility, and their inherent moral value or technique. This attitude is also related to the communicative view of respect which you have explored in your dissertation titled "Respect and Healthcare Ethics: Respect, Social Power and Health Policy"- could you tell me a bit more about the interactive or communicative attitude and about second person respect in the medical context?
Meredith: So the idea of respect as involving a second-person relation comes from c- and he's drawing on Strawson's work. The idea is that we can interact with people from different perspectives. These perspectives follow the grammatical persons. We can take a first [person] perspective on a moral issue. For example, when we're asking about our own self, reflecting on our own self - How should I live? What should I want? What should I do now, in light of my other values? What kind of person should I be? The sort of virtue-ethics questions; that's one way we can reflect. Probably the most common way that philosophers have thought about moral issues is from the third person. So, the third person is when we take the perspective of an outside judge who is impartial and is reflecting on the situation with a "view from nowhere", perhaps, to use Nagel's term. This has been attractive to philosophers because it's seen as a way of being unbiased, of investigating a moral situation in an impartial, unbiased and disinterested way. But as Carla Bagnoli points out, you can engage with another person without necessarily taking up a bias, and so the second person's standpoint is where we recognize the moral equality of the other.
Darwall's work really focuses on reactive attitudes; so he's looking at attitudes like praise and blame, where we see each other as having equal moral authority and we see each other as the source of reasons. For example, if you tell me to "get off your foot", it's because you're telling me to get off my foot that I have that obligation - it's not just an impartial obligation. So I took that idea from Darwall, but I think that his account is too limited. In his account, he really focuses on reactive attitudes and equal moral authority, and so that means that his account, like other accounts that focus on autonomy, is going to exclude those who lack autonomy - perhaps because of an illness that they're experiencing or perhaps because they're too young. When he talks about children in his book, he says you can't really respect them - you can only show them quasi-respect. So, what I wanted to do is have a fuller accounting of the moral domain where we might treat each other as an equally morally valuable person. I think there are other activities, besides reactive attitudes, where we show a person's value - for example, caregiving; when we give care to another, then we do so as an expression of our recognition of their value. When we "hold each other in personhood"- to use Hilde Lindemann Nelson's words - then we're showing that that person has value to us. You might have a parent who has Alzheimer's Disease, but you still have those relationships and those relational connections, and you still tell stories and engage with them emotionally, although this can also be difficult, as their capacities change. It's part of the way that we show that the person still has equal moral value despite limited capabilities.
..what I wanted to do is have a fuller accounting of the moral domain where we might treat each other as an equally morally valuable person...You might have a parent who has Alzheimer's Disease, but you still have those relationships and those relational connections, and you still tell stories and engage with them emotionally, although this can also be difficult, as their capacities change. It's part of the way that we show that the person still has equal moral value despite limited capabilities...
Sahana: I was wondering- are there any instances you have seen during the pandemic which has sort of stood out for you as objectifying or interactive? Like is there anything that you see as objectifying during this context?
Meredith: Sure. In the book"Moral Respect, Objectification and Health Care", I had a section where I talked about long-term care homes and some of the problems that I see there and I think that we saw that play out very much in the context of the pandemic, at least in Canada. We had some horrible atrocities arise, for example, there is a long-term care home where many of the workers just abandoned their work - they just didn't come in, they didn't have adequate personal protective equipment or PPE and so, they just left the residence. And when people came back, they found people lying in their own excrement, they found people who had died and not been properly... And so, in Canada, we had to bring in the army to help with that situation. And I think that that situation actually reflects a lot what I was talking about in Chapter Four - where, in Ontario, different care homes use different models of care, but many care homes are using a sort of task-oriented model of care. So, that's where the personal support worker is charged with doing certain things, like feeding, bathing and clothing, and they have to report on this to their managers. They're not given very much time. They're only given the bare minimum of time to do it and that encourages a sort of objectification of the person. This can be particularly true if the person has a non-normative way of being in the world; that is, if, you know, they have Alzheimer's and, perhaps it's hard to interpret what they're saying or what they're doing as meaningful; this takes time. And so what happens, I think, in those kinds of situations, is that without the meaning-making, without the time to develop these second-personal, respectful relationships, there's going to be less time to the person. And in this situation, I want to say that it's not just objectification of the the patient, who's receiving the care, it's also a form of objectification of the health care worker. So the health care worker, the personal support worker, rather than being valued as a human being, is being treated like a cog in a machine - something that is just there to do a task. So, without the respect for the health care worker, it's hard for them to engage in making meaning. So, Kantianism is often contrasted with Utilitarianism and I see something similar in this kind of a situation where the long-term care homes are trying to maximize the bottom line. They want to maximize efficiency - which is a Utilitarian type of idea - and respect is saying "No, no, you can't do that.. you have to also account for someone's humanity.. for their humanness and for our need to engage with each other as moral equals.."
Sahana: Right. Okay.. In this context, in the book, you had also mentioned a limitation. You had said that it was not a form of respect that can easily be adopted by a health care professional in the absence of institutional support. So what do you think are the concrete measures or practices which can be taken in the medical situation today, especially in the health crisis situation, to have an interactive and respectful attitude to the patient?
Meredith: Okay, so let's just stick with the long-term care home example, and then I'll provide some more positive examples. So, in the long-term care home example, I think, one of the things that would help, is to change decision-making structures. So, Joan Tronto talks about care ethics and in her discussion of care ethics, one of the things that she describes are these four phases of care. So first, we need to decide what needs exist - that we have to care about something. Then we have to decide how to care for it - so, how are we going to meet those needs? Then we have to have someone who gives care and someone who receives the care. Tronto points out that in hierarchical bureaucratic structures, the first two phases are often separated from the second two. So, it's often managers or board members who are deciding what the needs are and how to meet those needs - and that's often happening from the sort of objective stance, right? So, "what is a need" and "how best should we meet that need" from a depersonalized perspective. So thinking about "well-being" from an objective perspective. And then they say, "Okay you need to go do these things" to someone else - who is the care provider. In Toronto's theory, she talks about how it's really important to understand how the care is received; so you don't actually know if you've met the need until you've seen how that the person responds to that meeting of the need. I think the caregiver and care receiver interaction is where the possibility for second-personal caring comes in. If you are not even going to meet the patient, then the only thing you have - to rely on - is some kind of third-personal idea of objective well-being. If you're actually giving the care and seeing how that's responded to, then that's where we have the capacity to have a second-personal engagement. So, I think that what needs to happen is there needs to be more shared decision making so that the people who are receiving the care and the people who are providing the care have some input into the way the care is organized and structured. And this has to be good for the caregiver as well, it's not just about the care receiver; it has to be a liveable kind of work for the care caregiver.
..we need to decide what needs exist - that we have to care about something. Then we have to decide how to care for it - so, how are we going to meet those needs? Then we have to have someone who gives care and someone who receives the care...If you're actually giving the care and seeing how that's responded to, then that's where we have the capacity to have a second-personal engagement. So, I think that what needs to happen is there needs to be more shared decision making so that the people who are receiving the care and the people who are providing the care have some input into the way the care is organized and structured..
I also wanted to say that throughout the pandemic there have also been, I think, really excellent and almost heart-wrenching examples of healthcare professionals respecting patients in this sort of second-personal way that goes beyond just respecting their decisions. One of the images that really struck me in this kind of way was doctors and nurses working in the hospital wearing full PPE and they put a picture on their chest, right? And so, that's a recognition of the patient's subjective experience - you know, that the patient is going to feel fear, that everyone around them is gonna look unfamiliar and frightening. That was a very small step that they took that, I thought, was a recognition of humanity and personhood. So, it might not always require changing big, huge institutional structures - but I do think that changing institutional structures would help.
Sahana: Okay, okay. So, in the end, could you tell me a little bit about your latest book - the volume that recently came out, titled "The Ethics of Pandemics"? What was your hope for the volume? It was especially exciting to see the case studies and the questions for reflection. How do you figure the text, sort of, featuring in the philosophical literature on the pandemic?
Meredith: Yes, thank you very much! So the edited collection I put out - called "The Ethics of Pandemics" with Broadview Press - is intended to be a textbook and that's why there are the discussion questions and the case studies, and so forth. We thought it would be probably interesting for people to teach about pandemics while we're in the midst of one, while people are interested in the kinds of ethical issues that arose. We tried to make it fairly accessible in price and fairly short, because we were thinking that some professors might not want to do a whole class on the ethics of pandemics, they might want to just do a unit and so, by trying to keep the price down - it's 20 Canadian, I think..
Sahana: I think that's great! Coming from a Global South country, I think that's great..
Meredith: Right! Yeah, so one of the limitations of the book actually is that it does focus a little bit on North America and this is because we weren't sure whether we would get International Rights when we first started the book, but I believe they did secure international rights so.. One of the things that I've done to try to remedy that, is that we have a companion website and so, I'm adding additional articles on the companion website and that's where you find more non-western perspectives on the pandemic. I wish I could have put it in the book but, like I said, there's a lot of limitations.
Sahana: Okay, that sounds great! Could you could you share the link with me later for the companion website? Maybe I could share it with my students and they could see..
Meredith: Sure, yeah!
Sahana: That's great! That's all the questions I had Meredith, and thank you so much for being so patient, for joining me today, for taking out the time.
Meredith: Well, thank you for having me, and thank you for reading my work! I really appreciate it and it's nice to get to share these ideas. Thank you!
Ethics of Pandemic: https://broadviewpress.com/product/the-ethics-of-pandemics/#tab-description
Companion Website: https://sites.broadviewpress.com/pandemics/
Moral Respect, Objectification and Health Care: https://www.palgrave.com/gp/book/9783030029661
Dissertation “Respect and Healthcare Ethics: Respect, Social Power and Health Policy”: https://dalspace.library.dal.ca/bitstream/handle/10222/14366/Schwartz,Meredith,PhD,PHIL,November2011.pdf?sequence=3