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Whilst autonomy has received a great deal of attention through the years, vulnerability has become a concept of increased interest in applied ethics and philosophy only in recent decades. This volume discusses the various ways in which the concept of vulnerability plays out in different fields of ethics, and it does so with grace. It seems to support the agenda of authors who promote notions of 'relational autonomy' and contextualized agency. The contributors represent various fields of philosophy and ethics in combination with relevant fields such as political science, medicine, history, and law. The volume consists of 13 chapters and an introduction, and in what follows I shall briefly discuss each of the contributions in turn.
The book comprises two parts, the first of which is entitled 'Vulnerability, Individual Agency and Social Justice' and the second 'Vulnerability in Applied Ethics'. However, these titles in combination with the title of the volume and the content of the book leave the reader wondering: why does applied ethics deserves a place in the title of the book (and metaethics, social philosophy, feminist philosophy and political philosophy, for instance, do not)? The editor, Christine Straehle, points out in the introduction that one of the volume's aims is "to introduce readers in applied ethics to this revised and more plausible understanding of the bases of autonomy and to correct the still widespread understanding of autonomy as independence in bioethics and medical ethics" (p. 6). Whilst the chapter titles accurately reflect the contents of the chapters, the title and the stated aim of the volume raise an expectation of a thorough metadiscussion that, for instance, Henk ten Have includes in his book Vulnerability – Challenging bioethics (2016). This kind of discussion is largely absent here though it is occasionally touched upon in several chapters.
Christina Straehle's introduction paves the way in which the reader will approach the chapters not only in a descriptive but in an argumentative manner. She is explicit in displaying the agenda of the book and it is easy to follow – at least for a reader who is sympathetic to the strategy of teasing out nuances of concepts of autonomy and vulnerability. The reader's expectations build on the insightful introductions to each chapter. Moreover, Straehle succeeds in illustrating dialogues on common themes between various chapters.
The first part begins with the chapter 'Vulnerability and the Incompleteness of Practical Reason' by Carla Bagnoli. She distinguishes two kinds of vulnerability, ethical and ontological, and argues that the ontological notion should be understood in a constructive way. Interestingly, her contribution suggests that constraints that are typically considered to pose a threat to the individual's autonomy and agency should be understood as constraints that give shape to human practical reasoning instead of constraining it in a problematic way. Vulnerability is something that enables autonomy, as vulnerability is constitutive of human rational agency.
The second chapter, 'Vulnerability, Autonomy and Self-Respect', by Straehle herself, continues exploring the positive aspects of 'vulnerability'. With the help of 'self-respect', she scrutinizes different notions of vulnerability as well as connecting the discussion to social justice. She follows Rawls in arguing that self-respect is a background condition for a just society and different kinds of vulnerability can either be self-constituting or self-negating. Similarly to the first chapter, she rejects the narrow reading of vulnerability as directly in tension with agency and autonomy by discussing the ways in which the concept of 'vulnerability' is constitutive of the self in the context of love. At the same time, however, she identifies the problematic vulnerabilities and argues for duties that tackle these issues.
Joel Anderson argues in 'Vulnerability, Autonomy Gaps and Social Exclusion' that ontological vulnerability may result in injustice in the public sphere. He identifies and discusses a particular problem when institutionalized expectations and the individual's capacity for autonomous action do not meet. He calls instances of this mismatch 'autonomy gaps' and points out that they are dynamic states not directly derivable from either the (too) demanding policies or the (inadequate) autonomy skills. Instead, he calls for a nuanced reading of the gap and vulnerability in question. He fleshes out his point through several cases, e.g. a discussion on the requirements of voting in the US and the expectations of access in the public sphere. Whilst the multiple examples deliver the idea that these autonomy gaps are not restricted to merely one or two phenomena, their number unfortunately seems to eat away a little from detailed discussion.
Naïma Hamrouni continues with issues of social justice in 'Ordinary Vulnerability, Institutional Androgyny, and Gender Justice'. She questions formal and substantive accounts of equality by arguing that they maintain the problematic feature in the ways in which the society is organized. Both accounts leave "the standard of independence" intact and result in socially constructed vulnerability that is seen to be reducible to biological differences between men and women. She suggests that institutional androgyny is a way forward in acknowledging "ordinary vulnerability" and achieving gender justice in society and she utilizes the issue of motherhood to make her case.
On a more theoretical note, Catriona Mackenzie identifies in 'Vulnerability, Needs and Moral Obligation' the tension between different kinds of vulnerability, and argues against a view that sees the normativity of vulnerability stemming from the potential harm (by someone) to one's interest. In turn, she proposes an account which attempts to reconcile the universal human finitude and relational vulnerabilities: in her view, political and moral obligations track from failures to fulfill individuals' needs. She sees needs as being more fundamental than interests; needs are relational and this allows for nuanced considerations of the degree and nature of normativity that is called for in particular instances. By seeing that some of our needs stem from our ontological vulnerability, obligations to react to the needs can be justified accordingly.
Vida Panitch and L. Chad Horne continue the general discussion of the grounds of vulnerability in 'Vulnerability, Health Care and Need' in a critical manner. They argue that most accounts of vulnerability rely on harm or unmet needs, thus leaving the concept of vulnerability as 'a middle man', i.e. redundant. Furthermore, grounding vulnerability in risk of harm or unmet needs may be problematic as the relativity of these views poses challenges in terms of universality and the comprehensiveness of principles stemming from vulnerability and safeguarding social justice. They flesh out the problems by discussing the challenges of institutional vulnerability theories in the context of health care and, conveniently, this brings the reader to the second part of the volume.
The second part begins with Samia Hurst's contribution 'The Most Vulnerable Patients in Health Care', in which she characterizes a framework in which normative vulnerability is identified in health care. She goes through the 'fragile claims' that are more or less relevant for health care. Fragile claims identify people's morally protected interests. Her focus is on identifying vulnerable individuals and her contribution taps into the tension between general health care structures and individuals with particular vulnerabilities. What kind of general framework in health care is required in order to identify specific individuals with varying clusters of vulnerability? Unlike Panitch and Horne, she sees that vulnerability accounts may be constitutive of universality and comprehensiveness.
Michael J. Deem discusses the challenges of genetic counseling in 'Vulnerability in Genetic Counseling and the Ground of Nondirectiveness'. He criticizes the principle of nondirectiveness as it has been formulated in previous discussion about genetic counseling for the problematic requirement of value-neutrality. His chapter illustrates the traditional potential tension between autonomy and vulnerability. His focus on genetic counseling displays nicely the problematic power relations as the health care setting, genetics in particular, is not equal in terms of epistemic knowledge, but at the same time, the chapter seems to have shades of a conception of 'client autonomy' as independence that is precisely the sort of notion some of the other contributions argue against. Deem brings up the issue of trust that Claudia Wiesemann discusses from another perspective in detail in the following chapter.
Wiesemann sheds light on the complex relation between trust and vulnerability in 'On the Interrelationship of Vulnerability and Trust'. She highlights the active role of vulnerable individuals by discussing the act of trusting, and elaborates what is morally required when vulnerability is understood also as related to issues of trust. Instead of seeing trust as a potential threat to autonomy, her reading is more nuanced regarding the truster, trustee, and trusting. She also questions the common view that becoming vulnerable is always undesirable and highlights the fact that people do seem to have reason to trust others. The reader is left wondering about the latter point. It is of course true that people have reason to trust each other in varying circumstances, but at the same time it does not take away the problematic instances of violations of that trust, even when the trust seems well justified.
Wiesemann having discussed the (im)plausibility of attributing moral agency to autonomous individuals, Colin Macleod continues this discussion with a special emphasis on children and religious doctrines. He brings up the issue of parental influence and children's decision making in 'Doctrinal Vulnerability and the Authority of Children's Voices', exploring the field from "mature minors" to very young children who have not committed themselves to any religious doctrine and their varying roles in medical decision-making regarding their well-being. This insightful chapter also suggests means to identify children capable of authoritative medical decision-making and considers the challenges of the suggested view.
The last chapter offers a different take on the same issue that Macleod elegantly analyses. Bobbie Farsides highlights an aspect of the policies and practice of clinical research in 'Children, Clinical Research and Vulnerability', the argument that children should be protected in medical research. This protection has sometimes been understood as a claim that they should be more or less excluded from clinical research because the standard for being a research participant has been an adult participant, from which the children fall short by their very nature. The reader is left wondering how prevalent this kind of view actually has been, as it is clear that the lack of clinical research on certain children's conditions and medical treatment is likely to result in lack of evidence-based medicine and treatment for children. It may consequently have severe or even lethal consequences for children who are in need of medical assistance. In line with a report from the Nuffield Council on Bioethics, this chapter suggests that more effort should be placed on the elaboration and practice of ethically acceptable clinical research in children. Instead of viewing exclusion of children from clinical research as protection, the chapter argues for ways in which children can be regarded as active participants in research whilst having protective measures for them in place. Nevertheless, Farsides also acknowledges that even with the best guidelines and effort, conducting clinical research in children may sometimes be ethically problematic.
The volume provides a nuanced understanding of vulnerability, against the simplistic reading in which vulnerable agents are likely to be victimized and which may give rise to injustice. Even though the chapters vary greatly from each other, they possess common themes and features that connect them in a way that makes them more than a random collection of writings on the concept of vulnerability. Furthermore, if the most substantial criticism that this review offers lies in its title, the readers can infer that this is a book I recommend for anyone who is interested in rethinking the notion of vulnerability and applying it in the real world.
ten Have, Henk. (2016) Vulnerability – Challenging bioethics. Routledge: New York.
© 2017 Susanne Uusitalo
Susanne Uusitalo, Ph.D. University of Helsinki, Finland