March, 2014

Surviving Burns and Overcoming Burns

Dr Jonathan Reinarz

One of the most interesting aspects of burns work undertaken by Archibald McIndoe during the Second World War (see Wednesday’s post) was the establishment of the Guinea Pig Club. The Guinea Pigs were members of WWII Royal Air Force air crews who had undergone at least two operations for their burns injuries at East Grinstead Hospital, where McIndoe was based. Originally intended to be a drinking club for patients whose injuries could be dangerously dehydrating (see Monday’s post), it counted 39 members at its launch in June 1941, a year after the Battle of Britain. By the end of the war, there were 649 Guinea Pigs, most of whom were British (62%), but it also included Canadians (20%), Australians (6%) and New Zealanders (6%); 80% had served as bomber crew during the war. As war historian Emily Mayhew has suggested, the Club was ‘an attempt to institutionalise the unique spirit of the patient community at East Grinstead’ in order to aid the psychological recovery of burn victims. Patients collectively attended operations, assisted newcomers and otherwise offered support to each other when necessary.

‘Dealing with Disfigurement’

Rather than hide away these severely disfigured airmen, McIndoe considered both their physical and (as he termed it) psychical wellbeing. He recognised that patients relied on their surgeon ‘for mental support, for hope and encouragement.’ But he also encouraged his patients to resume ordinary lives, often commencing with a joint visit to a local pub. Most wanted to resume normal lives, but their wounds often made this more difficult than expected. McIndoe knew that his patients would inevitably attract much attention the moment they ventured into town to frequent pubs or restaurants, so he prepared the residents of East Grinstead for potential encounters with patients, some of whom were mid-operation, with tube pedicle grafts nearly in place to reconstruct missing chins or noses. He also invited key members of the town into the wards, encouraging them to become ambassadors in the community by regularly hosting concerts and balls, where patients mingled with locals. In this way, he made the residents of East Grinstead recognise and accept his patients and focus on their contributions to society, rather than their disfigurements. In the process, East Grinstead became known as ‘the town that didn’t stare’, while the hospital developed an international reputation for its Maxilla-Facial Unit. The staff was so successful at its work that 80% of aircrew patients eventually returned to flying duties. Such success continued into peacetime, but the details of McIndoe’s civilian work has been less documented. Despite the positive experiences of East Grinstead Guinea Pigs, many inevitably faced challenges when they re-entered their former communities. That said, many had learned how to deal with these difficult encounters from their membership of the Guinea Pig Club; a group of about 60 original members continue to meet.

Psychological support for burns patients has continued to grow since 1941. The emotional load on staff at burns units has also been recognised, with many practitioners expressing their own challenges coping with the onerous duties involved in caring for these unique patients. Unusually, when Guinea Pigs visited America following the war, their faces were kept out of the press for fear of alarming the public. Americans would inevitably learn about the psychological impact of burns in their own ways. The 1942 Coconut Grove nightclub fire in Boston was not the worst urban fire in twentieth-century America, but it had a huge impact on burns treatment. Besides directing attention to the consequences of inhalation injury, it provided valuable insights into the immediate and long-term psychological impact of severe burns and the importance of supporting patients after their physical wounds healed. As obvious as some of these lessons were, it seems they need to be relearned every decade or so. More often these days, the memories of disasters, collective and individual, are kept alive by patient groups. Many American victims of burns and scalds owe their emotional recovery to the Phoenix Society for Burn Survivors, a national organisation dedicated to burns patient support, public education and advocacy.  In Britain, patients with burns receive the support of similar organisations, including Changing Faces, BurnAid and the Katie Piper Foundation. So successful have burns units become at saving humans that their challenges have shifted. Many victims now expect medical teams to save lives and even restore former appearances. It is with such expectations that support groups also help a new generation of patients.

New portrait of Simon Weston recently unveiled at the National Portrait Gallery.

New portrait of Simon Weston recently unveiled at the National Portrait Gallery.

Jonathan Reinarz wishes to thank Emily Mayhew, Rebecca Wynter, Naiem Moiemen, Tony Metcalfe, Shah Mamta, Ken Dunn and James Partridge for their help with his research.

Dr Jonathan Reinarz is Director of The History of Medicine Unit and a Reader in the History of Medicine at the University of Birmingham.

March, 2014

Burns and Infections: The Birmingham Accident Hospital

Dr Jonathan Reinarz

Nearly 60% of burns patients die of infections contracted after their initial injuries. Historically, burns-related infections have proved particularly challenging. Burn wounds contain devitalised tissue and remain moist and warm during the healing process, thus an excellent breeding ground for bacteria. In the early twentieth century, burns did not appear to respond to existing antiseptic methods. Many doctors believed that burns themselves released toxins and attempted to neutralise these by treating burns with dyes and acids, which often hindered recovery. As a result, many practitioners continued to regard the infection of burns as inevitable.

In the 1940s, important research in this field began to be undertaken in the English midlands at Birmingham Accident Hospital. When an existing general hospital on Bath Row in the city centre was moved to facilities behind the newly constructed Birmingham Medical School in 1938, the old site was renovated and reopened in 1941 as the Birmingham Accident Hospital. (Incidentally, the site was also the last voluntary (or charity) hospital established in England and Wales before the introduction of the National Health Service). The new hospital’s Surgeon-in-Chief and Clinical Director William Gissane (1898-1981) regarded this as an experiment in the care of trauma in order to improve local accident services, which were inadequate across the country. At the outbreak of the Second World War and the associated production of military hardware, this had become obvious; the incidence of local industrial injuries, including burns, increased by 40%. During 1943, a small unit to treat burns and scalds was opened, and Gissane invited Leonard Colebrook (1883-1967) to be its first Director. Like Gillies (see yesterday’s post), Colebrook was a veteran of the Great War and contributed to a Government-appointed war wounds sub-committee run by Archibald McIndoe during the Second World War. Colebrook had investigated the bacteriology of wounds at the burns unit at Glasgow Royal Infirmary, where he had previously investigated puerperal sepsis in maternity cases. He therefore had experience of both burns and streptococcal infections when called on by Gissane to run the Medical Research Council-funded unit.

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‘The Topical and the Local’

On arrival, Colebrook quickly turned to the investigation of streptococcus infections in burns. With new topical anti-microbial agents, such as penicillin and propamide, he and his team managed to reduce the prevalence of these infections to 5%. Controlling infection, whether through topical creams, or ventilated wards and bandaging stations, allowed for new burns treatments, such as early excision, which is still described as an important measure to prevent infection as well as disfiguring contractures. When he retired in 1948, Colebrook turned to organising local and national burns prevention campaigns, focusing, for example, on safer electrical heaters and the introduction of less flammable clothing for children.

Colebrook’s successor was Edward Lowbury (1913-2007), who became bacteriologist at what was later renamed the MRC Industrial Injuries and Burns Research Unit in 1952. Among other things, Lowbury initiated the first properly controlled clinical trials in burns, and infection rates continued their downward trend, until the emergence of antibiotic-resistant bacteria in the late-1950s. The introduction of silver nitrate in 1966 halted this rise, but rates would continue to fluctuate, as safer alternatives were introduced. By 1963, the burns unit had already become a large regional centre comprising 36 beds, a ‘clean air’ dressing station and expanding research facilities, with Lowbury compiling a unique record of resistance changes until his retirement in 1979. Treating over 18,000 burned patients between 1941 and 1993, the burns unit developed a planned, systematic approach to the treatment of these injuries, which greatly reduced the frequency of associated infections.

Problems of infection in hospitals in the wider Birmingham region led to the establishment of the Hospital Infection Research Laboratory in the grounds of Dudley Road Hospital (later City Hospital) in 1964. Administered by the MRC Burns Unit and under the direction of Lowbury, the laboratory assessed the number of infections in regional hospitals, determining causes when possible. Although the Accident Hospital closed its doors in 1993, the Infection Control Research Laboratory continues to exist in a new location. Many of its earlier recommendations for controlling infection are still in place today. With the laboratory celebrating its 50th anniversary this year, staff have organised a commemorative conference, and the History of Medicine Unit at the University of Birmingham has organised an exhibition on ‘the history of hospital infection’, which will be on display in the foyer of the Medical School until the summer.

Dr Jonathan Reinarz is Director of The History of Medicine Unit and a Reader in the History of Medicine at the University of Birmingham.

 
March, 2014

War burns and the birth of plastic surgery

Dr Jonathan Reinarz

The majority of historical research into burns has concentrated on the remarkable reconstructive work undertaken on burns casualties during the First and Second World War. In fact, some argue that plastic surgery as a specialty first emerged during the First World War. Soldiers in both wars sustained horrific injuries and dreadful deformities from high velocity missiles, explosives and burns, many of which would previously have defied repair. A young ear, nose and throat (ENT) surgeon from New Zealand, Harold Delf Gillies, began the war in a surgical unit at the Cambridge Hospital, Aldershot. Alarmed by the number of face and jaw reconstructions he was having to perform, Gillies visited two plastic surgeons in France before setting up a larger surgical unit in 1917 at Sidcup, where he brought together a team of specialists, including ENT colleagues and dental surgeons. Gillies is best remembered for the tubed pedicle, a flap of skin which was harvested from the arm or chest, for example, stitched into a tube, so as to retain a blood supply and gradually migrated to the area where it was required. By the end of the war, Gillies had developed many other surgical techniques and performed over 11,500 operations. Many of these are included in his best known publication, Plastic Surgery of the Face (1920), which, along with Gillies’s archives, has recently been digitised and made available online as part of activities to mark the centenary of the First World War.

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From Airman’s Burns to Hiroshima

In one of those accidents of history that historians have become used to over the years, many severe burns in the Second World War were placed in the hands of another young surgeon, Archibald McIndoe, who happened to be the cousin of Harold Gillies. Unlike most of the casualties seen by cousin Harold, McIndoe treated primarily flame injuries that largely resulted from a decision to relocate the petrol tanks of fighter aircraft in front of the cockpit and pilot. The consequences of placing 48 gallons of fuel in the nose of a Spitfire rapidly became apparent during the Battle of Britain in 1940, when burn casualties mounted and the medical community defined a new injury, ‘Airman’s Burn’. Nearly 400 Royal Air Force (RAF) crew sustained serious burns to their face and hands in 1940 alone, Richard Hillary becoming perhaps the best known due to his memoir, The Last Enemy, in which he described his injuries.

‘I looked at my watch: it was not there. Then for the first time I noticed how burnt my hands were: down to the wrists, the skin was dead white and hung in shreads: I felt faintly sick from the smell of burnt flesh.’

While the smell of burn victims and high fatality associated with serious burns had led many to be isolated, removed or even excluded from nineteenth-century hospital wards, Hilary was lucky to be treated in a specialist burns unit by one of only four plastic surgeons operating in Britain at this time (including Gillies who would spend his second war at Park Prewitt Hospital in Basingstoke). Appointed civilian consultant surgeon to the RAF, McIndoe became responsible for Hillary and many other air-force casualties at a surgical unit which was established in a cottage hospital in East Grinstead, 40 miles outside of London. Here, he treated hundreds of burned airmen and developed surgical techniques in order to improve on existing plastic surgery techniques, which often left much to be desired. According to Mcindoe, in these early years of reconstructive surgery ‘the end result seemed to convert the pathetic into the ridiculous’. Rarely satisfied with his first attempts, McIndoe worked 12-hour days and frequently subjected his patients to more than a dozen operations. He rapidly became recognised as the authority in the field, influential in developing new operations and discarding older treatments, such as the use of tannic acid to coat burns injuries. He hosted many visiting surgeons at East Grinstead, which had trained 60 surgeons by 1943, and secured his reputation in 1944 when 50 North American plastic surgeons attended his unit for ten days to train in preparation for the D-Day landings. He also increased the levels and training of nurses on his wards and introduced saline baths into burns treatment.

After the 1945 atom bomb attacks on Japan, the attention of doctors turned to the impact of modern warfare on both military and civilian casualties. McIndoe himself argued that burns would likely outnumber all other injuries in future wars. McIndoe’s colleagues similarly promoted such ideas, suggesting that ‘atomic flash’ burns necessitated whole hospitals be transformed into burns units, arguments reinforced in the aftermath of Hiroshima and Nagasaki and during the Cold War. Many more units like that at East Grinstead were established in the 1950s, and McIndoe continued to work in his 50-bed Burns Centre at East Grinstead until his retirement in 1959. In a lecture to the Royal College of Surgeons in 1958, he comprehensively outlined his views on reconstructive surgery and paid homage to ‘the greatest plastic surgeon of all times’, Harold Gillies. McIndoe died in 1960, aged 59. A statue is being planned to recognise his work; if realised this will be one of only three existing British public monuments in England commemorating surgeons.

Dr Jonathan Reinarz is Director of The History of Medicine Unit and a Reader in the History of Medicine at the University of Birmingham.

March, 2014

The imagery of burns

Dr Jonathan Reinarz

Burns are visually distinct and emotionally overwhelming. They are horrific and iconic. Think only of Thich Quang Duc, the Buddhist monk whose self-immolation was filmed and photographed in a carefully orchestrated protest against Vietnamese President Ngo Dinh Diem in 1963. Sitting in the lotus position, the elderly monk was doused with petrol by fellow monks before he set himself alight. The act, not surprisingly, ended in his death, but the events of 11 June 1963 also sparked a dramatic escalation in the conflict between Vietnam’s dictatorship, which favoured the country’s Catholic minority, and its Buddhist community. A description of the event by American journalist David Halberstam manages to add drama to the haunting photograph taken by Associated Press photographer Malcolm Browne by emphasising more than just visual spectacle.

‘Flames were coming from a human being; his body was slowly withering and shrivelling up, his head blackening and charring. In the air was the smell of burning flesh…Behind me I could hear the sobbing of the Vietnamese who were now gathering. I was too shocked to cry, too confused to take notes or ask questions, too bewildered to even think.’ (D. Halberstam, The Making of a Quagmire, 1965, 211) 

Sociologist Michael Biggs has argued that the power of this extreme form of protest comes from the likelihood that self-immolation will end in death (70% of cases are fatal). Hunger strikes may be averted, but in cases of self-immolation, death is not conditional. Not surprisingly, responses to such images are dramatic.

‘The Napalm Girl’

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Napalm

My second example captures another moment in the history of Vietnam (8 June 1972), nearly a decade after Guang Duc’s self-immolation. It was taken minutes after inhabitants of Trang Bang, a village north of Saigon, experienced a napalm strike, and it shows children running towards a wire roadblock on Route 1, the main highway between Saigon and Cambodia. As described in the first pages of Robert Neer’s recent history of napalm, earlier these children had been huddled with their families in a temple under the protection of South Vietnamese soldiers, when the building was mistaken for a North Vietnamese target. A group of injured and frightened children subsequently escaped the site and fled to a nearby checkpoint, where a waiting journalist noticed a naked nine-year-old girl who had been stripped by napalm, which continued to burn. It was then that Associated Press photographer Huynh Cong ‘Nick’ Ut captured his Pulitzer-Prize-winning photo. To many, it dramatically depicts the impact of war on non-combatants, and the day after it was taken, the photo appeared in newspapers alongside the heading ‘The Terror of War’. ‘Napalm Girl’ has become the best known image of the Vietnam War and is credited with bringing about a shift in the American public’s attitude towards the conflict.

Although burns have the potential to erase a person’s identity, by literally scorching away their features, the ‘Napalm Girl’ now has a name, Kim Phuc, and her story has been told in a film and a well-known biography. After capturing this pivotal image, Nick Ut took Kim and her brother to a South Vietnamese hospital. She subsequently spent 14 months in the Barsky Unit in the American hospital in Saigon. Kim’s burns, which covered 50% of her body, were grafted by American surgeons and, after two years of treatment and rehabilitation, she was able to return to her village. Like many burns victims, her life was fundamentally transformed, only, in this case, it was further altered by the particular political context. Forced to leave school, she was regularly interviewed and became a ‘national symbol of war’. Eventually defecting from Vietnam while en route to Cuba, she now lives in Toronto, Canada with her family. In 1997, she established the Kim Foundation International, a charity that assists child victims of war.

‘Mohamed Bouazizi’

As unique as Kim’s story may appear, many burns casualties have resisted remaining individual tragedies. Like the fiery death of Guang Duc, some have inspired imitators, or galvanised collective action. More recent cases of self-immolation have demonstrated this yet again, with the suicide of Tunisian fruit-vendor Mohamed Bouazizi recognised as a catalyst of the Tunisian Revolution, if not the wider uprising in the Arab world; in Panara and Wilson’s The Arab Spring (2013), he is the butterfly of chaos theory whose fluttering wings continue to cause storms around the globe. While burns units in the West continue to treat cases of self-immolation (two were admitted to the Birmingham Burns Unit over the Christmas holidays), many more patients, past and present, share similarities with Kim Phuc. As in the past, approximately 50% of burns victims are children. Their stories, like that of Kim, are also more often heard, not just in the popular press, but at burns conferences, such as that mentioned in yesterday’s posting, in order to better understand the experiences of patients.

Dr Jonathan Reinarz is Director of The History of Medicine Unit and a Reader in the History of Medicine at the University of Birmingham.

March, 2014

Burns: A riot in the body

Dr Jonathan Reinarz

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You can imagine, as a medical historian, much of my research centres on ‘Saving Humans’. When I was asked to contribute to this blog, though, one particularly timely subject immediately leapt out: burns. I began researching burns last year in the British context for the years 1800 to 2000, and, in that time, the public has been reminded of the subject with regular reports of acid attacks, house fires, wars, suicides and revolutions. More than many other subjects I have researched, burns are both timeless and very timely. In June 2013, the Burns Collective was launched in Birmingham, creating a national centre for burns research linking hospitals in London, Bristol and the ‘Second City’. I attended the inaugural conference and instantly found myself fascinated by papers outlining current practices, research and priorities. Though the history of burns remains to be explored, they should also be familiar to all of us. Unlike many diseases and accidents which will thankfully remain a mystery to most of this blog’s readers, we have all experienced burns. However prevalent or timely, burns are also particularly suited to a blog managed by the University’s Institute of Advanced Studies. Like the IAS, which aims to bring together scholars from across the University of Birmingham’s various academic disciplines, burns are unique in the way they bring together people from across medicine’s many specialties. 

In a previous project, I had the opportunity broadly to explore the medical, social and cultural history of the skin. At its most basic, a burn is an injury of the skin, the body’s largest organ (though some now call it a ‘multi-organ’). Addressing burns and scalds only in passing, the project reminded us that burns are prominent in the cultural imagination, and have been so for hundreds of years. Neither are they confined to the realm of the dermatologist. Besides contributing significantly to the way in which we conceive of ourselves and others, the skin has many essential functions: it regulates the passage of fluids in and out of the body; it helps synthesis vitamin D, while shielding the body’s interior from ultraviolet radiation; it is a barrier that prevents disease-causing organisms from entering the body, while simultaneously receiving sensations which it passes on to the brain via the nervous system. As a result, when the skin is burned, whether by hot tea, a sunburn, or following more serious flame, electrical or chemical accidents, we experience pain, and much else that is more than just skin deep. The skin’s many features and functions are invariably compromised by burns, and people’s identities may be changed forever. The more serious the burn – anything larger than 10% total body surface area is considered a major burn – the more violent the body’s response. It is for this reason that burns have been described as ‘a riot in the body’. All bodily systems potentially respond to serious burns, especially if the victim also experiences smoke inhalation.

What is a burn?

The immediate aftermath of a severe burn is shock and suffocation, both related to a lack of oxygen. Plasma normally circulating in the blood surges to the tissues, leaving the blood thicker and prone to clotting. During the 24-hours following a burn, the affected area grows progressively more swollen; this is the period when blisters form. Fluid must be replaced to restore circulation and dilute the toxins being expelled in greater amounts by the kidneys (one formula used to help calculate fluid replacement was developed by Basil Pruitt, who attended the Birmingham congress). In the nineteenth century, the oozing appearance of burns might have led doctors to introduce treatments which only encouraged dehydration. As a result of these physiological changes, the body is less able to regulate temperature and shock ensues. One by one, the major organs are compromised by the loss of liquids. When the respiratory system is effected, breathing becomes difficult and the body deals with lower cardiac output by pumping more blood. The additional effort required to do so sends the body into a hypermetabolic, or catabolic, state, and it begins to break down tissues, burning protein as well as fat. As body mass decreases, the patient becomes more susceptible to infection and wounds also heal more slowly. The destructive increase in metabolism, on the other hand, is countered by feeding the patient amounts of food that might ordinarily be regarded as excessive. And, importantly, the whole process is not over in a day or two. Burns are an acute illness that lasts weeks or even months. Treatment of burns patients therefore becomes an intensive life-saving process, which these days extends beyond the immediate survival of the burned individual, and aims for full psychological recovery, involving psychiatrists, physiotherapists and social workers, among many other specialists and professionals. It is for this reason that victims of severe burns are treated in burns units. According to the British Burns Association, there are currently 27 specialised burn units in Britain. In the 1930s, more than half of major burns cases in this country might have died from their injuries. Today, 97% of approximately 16,000 people hospitalised for burns each year survive this ordeal.

Dr Jonathan Reinarz is Director of The History of Medicine Unit and a Reader in the History of Medicine at the University of Birmingham.

 
March, 2014

Drawing Lines: The Ethics of Abortion, Part V Jeremy Williams

My blog series this week has introduced readers to a few notable aspects of the philosophical debate over the ethics of abortion, and the ways in which some writers have hoped that we might be able to go beyond the bitter deadlock that characterises the public controversy. Abortion is more salient to the theme of ‘saving humans’ than one might initially suppose, I have suggested, insofar as the ethics of killing and saving are closely bound up with each other. But it is also pertinent to the idea of saving humans in another respect – namely, that it focuses our attention on the question of which humans it matters morally that we save, or not kill. Some political rhetoric is suggestive of the view that all members of the human species matter equally, from a moral point of view, but this is not, on further examination, what most of us in fact believe. Moreover, as we saw in the previous post, the view that all human lives, from the earliest embryo onwards, do indeed share equally in the high moral status and rights that you and I possess carries a number of strongly counter-intuitive implications, which it is questionable that even most committed opponents of abortion would accept.

Aside from its implications, the view that all human lives, from conception onward, have the same exalted moral status, falls foul of the fact that there is no morally relevant characteristic that one can point to that we can agree all members of the human species possess, and that could account for this being so. Simply being, on a genetic level, a member of the species homo sapiens cannot, as many philosophers have emphasised, be the sought-after characteristic, since it seems an arbitrary fact about us, like skin or eye colour. And the familiar claim that all human beings are endowed at conception with a soul is unintelligible to many, and not, from a secular liberal point of view, an appropriate grounds of public policy.

In any case, rather more commonly held than the view that humans acquire the moral status of a person at conception is the view that, at some point later in pregnancy, a line is to be drawn, separating abortions that are not an especially morally serious matter from those that are. That line, however, might be drawn in any number of points in the development of the fetus. The question, then, is which point in its development marks a truly morally significant change.

Within the confines of a blog post, I can do no more than scratch the surface of an enormously rich and complex philosophical debate. Suffice it to say that there are two principal candidate answers to the question of when prenatal human life acquires a sufficient degree of moral status to render abortion a morally problematic practice, and begin to constrain the range of circumstances under which it is justifiable. The first of these, and probably the one that is most regularly cited in real-world political debate, is viability – that is, the point at which it becomes possible for the fetus to survive outside the womb, either on its own, or with mechanical aid. The second, meanwhile, is sentience – that is, the point at which the fetus becomes capable of sensory experience. These changes in the fetus occur at roughly the same time – roughly around the end of the second trimester, with 20 weeks being the most conservative estimate. But that doesn’t mean that it does not matter which line we take to be the truly significant one from a moral point of view.

Now, consider viability. The point at which the fetus becomes viable depends on the state of medical technology. Thus, advances in neonatal medicine, which allow doctors to save younger and more premature infants, are generally accompanied by calls to restrict the abortion of fetuses of the same gestational age, who now count as viable. Yet, as philosophers sometimes point out, it is highly unclear why the viability line has any moral significance. For consider: scientists are currently in the process of developing artificial uteruses, which could incubate an embryo for the full nine months until birth.  Once that technology has been perfected, all embryos and fetuses will be viable, in that however undeveloped they are, they could survive outside of a woman’s body, by being transplanted into an artificial uterus, just as premature infants are currently transferred to an incubator. But this would then mean that, as a result of a merely technological change, all embryos and fetuses, from conception onwards, would now have a moral status that they previously lacked (and thus that many abortions that had previously been entirely morally unobjectionable would now be problematic, and perhaps impermissible). This is rather difficult to believe (though for a dissenting voice, see Boonin, 2003, p. 129ff).

This suggests, as many philosophers believe, that what matters for fetal moral status is not viability but sentience. The reasons to believe that sentience matters, moreover, are not confined to the negative one that the main competing account has strange implications. It is independently plausible to suppose that it matters morally how we treat beings that are capable of experience, because we can affect them in a way that we cannot affect beings that are entirely unfeeling. If a being is capable of experience, it has a life that can go better or worse for it, from the inside, and whose continuation would be good for it. But to end the life of a being that has never acquired that capacity for consciousness seems indistinguishable, in its effects on that being, from its never having been created at all – it has not yet begun a life, in any meaningful sense, of which it is now being deprived. For that reason, it seems plausible to suppose that abortion performed prior to the onset of fetal sentience is morally on a par with contraception.

Suppose we accept what is the most conservative plausible estimate as to when the fetus acquires a rudimentary degree of consciousness – namely 20 weeks. And suppose it was also thought that abortion would always be impermissible after that point. Nonetheless, we would have succeeded in justifying the overwhelming majority of terminations that are in fact performed. In the UK, for instance, in 2011, 91% of abortions were carried out before 13 weeks.

It is important to emphasise, however, that the view that sentience matters, and marks the point of onset of a degree of human moral status, does not yet commit us to the conclusion that all abortions performed after that point would be impermissible, or even especially difficult to justify. For it is consistent with this view to hold that, while the fact that a fetus is sentient, and would benefit to a degree from continued life, gives us a reason not to cause its death, that reason is at least initially quite weak, and often outweighed by other considerations – primarily those pertaining to the needs of the pregnant woman. One grounds for thinking this (for which see especially McMahan, 2002, or, e.g., DeGrazia, 2012), which I find attractive, appeals to the fact that a fetus that has just become conscious is unaware of, and only dimly psychologically related to, the life it will have in the future if not aborted. For this reason, that future life is, from the point of view of the fetus, rather like someone else’s life rather than its own. Thus, while a fetus that has just become sentient can be said to be harmed somewhat by death, it is not harmed greatly, and certainly not to the same significant degree as you or I, given how closely psychologically related to our future selves we are. The harm to the fetus of death may, however, increase over the remainder of pregnancy, as it becomes a more robust psychological presence, as it were, in its own life. If an explanation like this is correct, it would be consistent to think that, even if the fetus starts to become conscious at, say, 20 weeks (and it is questionable that it does), abortion is often justifiable at 24 weeks, or later, and therefore the law in the UK, for example, which includes a 24 week cut-off for most abortions, ought to stay as it is.

Sadly, given the constraints of this format, I lack the space to consider the view of fetal moral status that I have been canvasing here in any further detail, or its rivals. What I hope to have shown in this series is that those whose interest is in ethical questions of saving humans have abundant reasons to be interested in the philosophical dimensions of abortion. And, of course, abortion is not merely fascinating, at a philosophical level, but also an urgent need for the many women whom it saves.

References:

David Boonin, A Defense of Abortion (Cambridge: Cambridge University Press, 2003).

Jeff McMahan, The Ethics of Killing (Oxford: Oxford University Press, 2002).

David DeGrazia, Creation Ethics (Oxford: Oxford University Press, 2012).

March, 2014

Can Philosophy Resolve the Abortion Wars? The Ethics of Abortion, Part IV Jeremy Williams

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In many countries, much of the time, the public debate over abortion is both fractious and fruitless, revolving primarily around the unreflective exchange of slogans between two highly polarised rival campaigning groups, who display an almost tribal mutual aversion, and largely shout past rather than really speaking to each other. Understandably, this tends to make onlookers who are concerned with civility in democratic discourse despair – particularly in the United States, where tensions over abortion run particularly high. As the great legal philosopher Ronald Dworkin memorably described the situation there:

The war between anti-abortion groups and their opponents is America’s new version of the terrible seventeenth-century European wars of religion. Opposing armies march down streets or pack themselves into abortion clinics, courthouses, and the White House, screaming at and spitting on and loathing one another. Abortion is tearing America apart (Dworkin, 1993, p. 4).

That the abortion dispute is unusually highly charged may not seem surprising, given what the protagonists on both sides claim to be at stake (preventing the wrongful killing of innocent persons on the one hand, and preventing the wrongful imposition of pregnancy and parenthood on the other). Yet it might not be inevitable that the abortion controversy must be played out as a war, and philosophers have sometimes considered how they might be able to contribute to drawing the poison out of it. One key method by which some of them have hoped to do so involves interrogating and unpicking the rhetoric used by partisans in the public dispute. In some cases, it is suggested, the rhetoric on display does not accurately encapsulate what the protagonists really believe, or does not vindicate the conclusions that those who utter it assume that it does, or has further, unnoticed implications at which they would balk, were they made aware of them. Perhaps, if the belligerents could be shown that their slogans are defective in these ways, the familiar battle lines could in time be dismantled.

Judith Thomson’s defense of abortion, discussed earlier in this series, is an excellent example of this sort of argumentative strategy in action. According to Thomson, as we have seen, opponents of abortion are mistaken if they think that their hallmark claim – that fetuses are persons from conception onwards, with full rights to life – is on its own enough to show that terminating a pregnancy is impermissible. Another prime example of the same approach at work, meanwhile, comes from Dworkin. Like Thomson, Dworkin’s focus is (primarily, though not exclusively) on the avowed commitments of pro-life advocates. Those people claim to believe that fetuses are persons, with all the rights that that status entails. But Dworkin argues, strikingly, that it can be demonstrated that they don’t really believe this at all. For most of them do not think that abortion is without exception morally prohibited. Rather, they tend to believe that there ought to be some significant exceptions to a general ban on terminating pregnancies, at least in the earlier stages of pregnancy. In particular, they tend to hold that there should be such exceptions in cases where conception was a result of rape, or incest, as well as cases in which the fetus has been found to have some devastating illness or disability. Allowing abortion in such cases, however, seems incompatible with the view that fetuses are, at all stages of their gestation, persons. For if they were, they would presumably have rights not to be treated less favourably on grounds of arbitrary factors like the circumstances of their origins, or their health and native capabilities. Nobody, after all, thinks that the right to life of a person after birth is weaker and more easily overridden just because she is, say, a product of incest, or has a serious disability.

Thus, according to Dworkin, pro-lifers have powerful reasons of consistency to moderate their opposition to abortion. Indeed, he argues, provocatively, that when pro-lifers claim that even embryos and early fetuses are persons, what they actually mean is something rather less radical – namely that early prenatal life is intrinsically valuable, in a similar way to, say, a great work of art, or a rare plant. When a thing has intrinsic value, destroying it is a sort of cosmic waste, and difficult to justify. But it is not a wrongdoing on the scale of murder, and can be permissible in cases where killing a person would not be. If the real underlying view of pro-lifers is, as Dworkin claims, not that early fetuses are persons, but rather that they are intrinsically valuable, such that destroying them is a great waste, then they can, he says, consistently believe that there are exceptions to the general rule that abortion is wrong. However, Dworkin continues, once pro-lifers accept this explanation for their pattern of beliefs, they should also accept that women have a right to choose at least an early abortion. This is because the question of what things in the universe possess intrinsic value is deeply personal – an ‘essentially religious’ matter, as Dworkin puts it – and answers to it ought not to be imposed on those who conscientiously disagree. Thus, in Dworkin’s view, the right to choose an early abortion is of a piece with the rights to freedom of conscience and religious exercise, and should be endorsed by all who endorse the latter, core commitments of liberal democracy – however sincerely they might hold, as a matter of their own personal religious or philosophical doctrine, that the waste of prenatal human life is intrinsically bad.

Like Thomson, Dworkin seeks to radically remake the traditional abortion debate – in his case, by attempting to persuade pro-life advocates that the intuitive costs of the view they outwardly profess are too high, even for them. Can his strategy succeed? To be sure, when faced with Dworkin’s challenge, a committed opponent of abortion might be drawn to the conclusion that consistency on their part requires not abandoning her commitment to fetal personhood, but rather abandoning her commitment to allowing exceptions to the prohibition of abortion. That is a harsh view indeed, and deeply unappealing, even to many ardent pro-life advocates. It does, however, have its proponents.

Pro-choice philosophers have, though, adduced further powerful grounds for anti-abortionists to reconsider their belief that fetuses are persons, whose being killed is as tragic, harmful and wrongful as the killing of a normal adult human being like you or I. Significantly for the focus of this website, these return us to the theme of saving lives. In the first post in this series, I noted that philosophical defenders of abortion choice sometimes object that, to say that embryos and fetuses are, from conception, persons, is to imply, absurdly, that in a hypothetical choice between saving the life of one adult person on the one hand, and rescuing some larger number of embryos from destruction on the other, it would be permissible, if not mandatory, to do the latter. This challenge is not purely hypothetical, however, as Jeff McMahan notes (2002, pp. 165-6). A strikingly high proportion of pregnancies  – at least two thirds, in fact – end in spontaneous abortion. One would expect that those who believe that fetuses are persons would regard this phenomenon as an ongoing tragedy of epic proportions. And one would expect, as a result, that they would also be highly vocal in demanding that a much greater proportion of our social resources be devoted to researching and deploying various medical means to minimise these deaths – diverted, perhaps, from healthcare interventions that aim at preventing or curing medical conditions in adults and children, such as HIV, that claim fewer lives overall. Yet in fact they do not do so. This seems to suggest that they apprehend a difference between the loss of prenatal life and the lives of persons after all.

Thus, Dworkin and others have attempted to demonstrate to pro-lifers that they should soften their opposition to abortion, thereby taking at least some of the heat out of the ‘abortion wars’. Notice that, in doing so, they do not typically proceed by setting out to persuade people of some grand ethical theory. Rather, they proceed by attempting to show that there are glaring inconsistencies, and high intuitive costs, in the views that people already (profess to) hold.

Philosophers also adopt a similar strategy when engaging with and evaluating more moderate views, which contend that the moral status of a fetus varies according to its level of development. What aspects of the development of a fetus are relevant to its moral status? And what are the implications of fixing on one emerging characteristic of the fetus rather than another? The final post in this series turns to these questions.

References:

Ronald Dworkin, Life’s Dominion: An Argument About Abortion, Euthanasia, and Individual Freedom (New York: Vintage, 1994).

Jeff McMahan, The Ethics of Killing (Oxford: Oxford University Press, 2002).

March, 2014

Can the Thomson Argument be Saved? The Ethics of Abortion, Part III Jeremy Williams

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To resume our discussion of the ethics of abortion where we left it yesterday, we have seen that, according to Judith Thomson (1971), terminating a pregnancy is analogous to refusing to donate the use of one’s body for purposes of saving a needy stranger. On this argument, just as one can permissibly refuse to save a stranger when the bodily efforts and harms to oneself are high, so a woman can also permissibly refuse to continue to gestate a fetus at high cost to herself – even, crucially, if the fetus has the full moral status of a person. As we have also seen, however, critics object that saving a stranger and supporting a fetus are not, in fact, as closely analogous as Thomson claims, such that we cannot read off the conditions under which a woman may permissibly terminate a pregnancy by consulting the conditions for permissible refusal to be a Good Samaritan to a stranger. Although Thomson’s analogy between saving a stranger and gestating a fetus has been claimed to fail on multiple fronts (for an impressively thorough survey of which, see Boonin, 2003, chapter 4), the most significant failures of analogy appear to be, to repeat, that whilst a person who refuses to act as a Good Samaritan to someone in life-threatening need is merely allowing a stranger to die, for whose neediness she is not responsible, abortion involves a woman killing her own child, having voluntarily performed  the act that caused the child to exist and require her aid. How damaging to Thomson’s argument are these disanalogies?

Each of these disanalogies (that abortion involves refusal to aid one’s child, that it involves refusal to meet a need in someone for which the woman is responsible [outside of rape cases], and that it involves killing) might be thought sufficient on its own to fatally undermine Thomson’s defence of abortion. Alternatively, one might think that her argument cannot bear the combined weight of the disanalogies when they are all pressed at the same time. Philosopher Jeff McMahan (2003), for instance, has argued that it is intuitively just too difficult to believe that a person could be entitled to withdraw aid from someone who (a) is her own child, (b) is in need of assistance as a result of an act which that person performed (sexual intercourse) in the knowledge of that parenthood, and fetal dependency, can be a result of it, and (c) will be killed by the procedure that ends its dependency.

Against this conclusion, someone might argue that, if each of the three disanalogies can be shown individually not to make a moral difference, they could not add up to a decisive objection either. It is perfectly possible to argue that each of the three disanalogies, taken in isolation, is morally insignificant. For instance, one can argue that the parent-child relation in the case of a woman and fetus is purely genetic, and that this bare genetic connection, when unaccompanied by, e.g., emotional ties, shared experiences, or explicitly-made commitments, cannot be the ground of a special obligation to make large sacrifices on the fetus’s behalf. One can also argue that, while the woman is indeed responsible, in one sense, for the neediness of the fetus, this fact lacks its usual significance, because without the woman’s input, the fetus would not exist at all, and thus, if she does not provide the needed aid, she will not have made the fetus any worse off (McMahan, 2003, pp. 364-72). Finally, one can argue that, if letting the fetus die would be permissible, because of the burdens involved in supporting it, and if, further, being killed as opposed to being allowed to die would not be worse for the fetus, but would be less costly for the woman, it is difficult to see why killing the fetus instead of letting it die would not also be permissible (Boonin, 2003, pp. 188-212). If, on grounds such as these, we think that the three identified disanalogies do not have any moral weight individually, we might conclude that their combined weight must also be also zero. Yet because that conclusion remains, as McMahan points out, highly counter-intuitive, many will wonder whether it can possibly be right.

Suppose that we decide that Thomson’s argument can indeed survive in spite of the foregoing failures of analogy between pregnancy and Good Samaritanism. Nonetheless, the argument seems limited in other respects – it is highly unclear that it can justify the sort of abortion regime that pro-choice advocates typically press for. For instance, the justification for abortion under Thomson’s argument rests, as we have seen, on a woman’s right to refuse to accept a significantly burdensome bodily imposition, rather than on a right to resist the burdensomeness of parenthood. By implication, then, if, in the case of some woman, the burdens of pregnancy are acceptably light (as Thomson allows that they might be), but the burdens of parenthood later on would be heavy (e.g. because the fetus has a serious genetic disability) then there is no Thomsonite case here for abortion. Indeed, on Thomsonite grounds, to refuse to aid the fetus to avoid having to look after the child later (or to avoid having to undergo the psychological trauma attendant on having to give the child up for adoption), when the burdens of pregnancy themselves do not exceed those that a Minimally Decent Samaritan can be asked to accept, seems morally on a par with, say, refusing to save one’s infant child from drowning in a paddling pool, in order to avoid looking after it. But this is difficult to accept – on the standard pro-choice view, the postnatal burdens of parenthood as just as important, in making the case for abortion, as the burdens of pregnancy themselves.

A further counter-intuitive implication of the Thomson argument, noted by McMahan (2006), pertains to the moral contrast between killing the fetus in order to extract it, and non-lethally injuring it in the course of doing so. Causing the death of a person is more difficult to justify than causing a person an injury, because it represents a greater deprivation. On that basis, it seems that, according to the Thomson defence of abortion, if a woman for whom pregnancy is very costly is able to expel the fetus by either killing it or injuring it, she ought to choose to do the latter – even if the injury would have a serious impairing effect throughout the child’s later life. This conclusion, however, is seriously counter-intuitive – from a common sense point of view, causing a prenatal injury that will have serious lifelong consequences for a person seems a more serious matter than causing the death of a fetus. That we think this suggests that we implicitly accept that fetuses are not, as pro-life advocates claim, and Thomson grants for the sake of argument, morally on a par with persons in all respects. More specifically, it suggests that we implicitly think that fetuses are harmed by death to a lesser extent than persons (and thus that the harm of death for a fetus can be of less moral significance than the harm of lifelong injury to a person).

To conclude this discussion, it is worth emphasising that, while Thomson’s critics include opponents of abortion, they are not limited to them. Rather, they also include pro-choice philosophers who believe that, insofar as Thomson’s argument for the right to choose an abortion is limited, it would be unwise for defenders of abortion choice to rely on it – or at least to rely on it exclusively. It would be unwise, that is, for them to grant to their opponents that fetuses are persons, before arguing for the permissibility of abortion on grounds of a woman’s right to refuse to provide bodily aid at high cost to themselves. Of course, even if pro-choice advocates avoid making the Thomson defence central to their argumentative strategy, they might find that it has a useful subsidiary role to play in some discursive contexts. The crucial point, however, is that they will not be able to utilise it in order to escape taking a stand on the moral status of the fetus, or directly arguing against the pro-life claim that fetuses have the same rights and value as postnatal persons. This conclusion will come as something of a disappointment to supporters of abortion rights who had indeed hoped that Thomson’s argument might allow them to circumvent that thorny issue altogether (though this is not, note, a claim that Thomson makes on behalf of the argument herself). The remainder of this blog series turns the spotlight on precisely that thorny issue.

References:

David Boonin, A Defense of Abortion (Cambridge: Cambridge University Press, 2003).

Jeff McMahan, The Ethics of Killing (Oxford: Oxford University Press, 2002)

Jeff McMahan, ‘Paradoxes of Abortion and Prenatal Injury’, Ethics 116 (July 2006): 625–655.

Judith Thomson, ‘A Defense of Abortion’, Philosophy and Public Affairs 1 (1971): 47-66.

Useful links:

The charitable perspective

Abortion & Human Rights

The Ontology of Abortion

A Defense of ‘A Defense of Abortion’ On the Responsibility Objection to Thomson’s Argument

Humans and Persons: A Reply to Tristram Englelhardt

Too Long in gestating

Was I ever a Fetus

Image source : http://www.mercatornet.com/articles/view/canada_needs_a_national_debate_on_abortion

March, 2014

The Pregnant Woman as Good Samaritan: the Ethics of Abortion, Part II. Jeremy Williams

Bears_altru

The purpose of this blog series, which began yesterday, is to introduce some notable contributions made by moral philosophers to our understanding of the ethics of abortion, while pointing out some of the links between that topic and the website’s overarching theme of ‘saving humans’. In the first post, I began to discuss Judith Thomson’s seminal paper, ‘A Defense of Abortion’, with its memorable violinist example. In this post, I set out in more detail what Thomson takes this thought experiment to show, and point to some disanalogies between using your body to support a violinist and a woman’s being pregnant that have been taken by Thomson’s critics to fatally undermine her case. The discussion of Thomson concludes tomorrow.

As we saw last time, Thomson’s argument aims to show that pro-life opposition to abortion rests on a mistake. But whereas most supporters of abortion choice focus on attempting to unseat the pro-life claim that fetuses are persons with a right to life, Thomson’s strategy is the different, and innovative one of challenging the assumption that if the fetus is a person with a right to life, then terminating a pregnancy must be morally wrong. That assumption, according to Thomson, is unwarranted, since it ignores the fact that there are limits to the sacrifices that individuals can be expected to make through the use of their bodies for the sake of others, even when the latter are full persons and rights-holders.

At the core of Thomson’s case to that effect is the violinist example. The violinist is undoubtedly a person, with a right to life. And he needs the use of your body (more specifically, your kidneys) to continue to live. Yet, as the vast majority of people find, on consulting their intuitions about the violinist case, he lacks a right to be given what he needs, given the sacrifices that you would have to bear to support him. It would not be unjust, most of us think, either for you to unplug yourself to escape the burdens involved in continuing to aid the violinist, or for a third party, acting as your agent, to do the unplugging for you. By analogy, according to Thomson, even if a fetus is a person with a right to life, as opponents of abortion insist, it is not unjust for the pregnant woman to refuse to continue to support it, if the costs to her of doing so are sufficiently great, nor for her to enlist a third party to ‘disconnect’ her by performing an abortion. To claim otherwise, Thomson avers, is to insist on self-abnegation from the pregnant woman to a degree that morality cannot require.

Notice that Thomson’s argument does not rest on the claim that individuals are under no moral duty to use their bodies to assist others, or save their lives. On the contrary, she accepts that, under some circumstances, there is such a duty. What she denies is that we are under a duty to use our bodies in the service of others where doing so comes at high cost to ourselves. Helping others is mandatory, then, only insofar as the associated costs are acceptably low. Thomson calls the duty to help others at low cost the duty of Minimally Decent Samaritanism. This contrasts, in Thomson’s terminology, with Good Samaritanism, whereby a person helps another despite high costs. Unlike Minimally Decent Samaritanism, Good Samaritanism goes above and beyond the call of duty – it is, as philosophers put it, supererogatory. That, at any rate, is what commonsense morality tells us. Relatively few of us are either extremist libertarians, who believe that we are never obligated to come to the aid of others, even when doing so would be costless, or proponents of demanding moralities, who hold that we ought to sacrifice our fundamental interests for others’ sakes. Rather, most of us believe, as Thomson claims, that helping is morally required when the costs are reasonably low, but morally optional where the burdens and risks exceed some threshold of severity. Her argument is all the stronger precisely for not presupposing some controversial account of the limits of our duties to assist others.

Thomson’s commonsense understanding of the limits of the duty to help others implies (she herself suggests) a moderate or qualified right to terminate a pregnancy, whereby a woman is entitled to refuse to continue supporting her fetus if and only if the costs of carriage exceed the threshold of burdens that can be asked of a Minimally Decent Samaritan. Where that threshold lies, precisely, she does not say (it’s an extremely difficult question, after all, as many philosophers would attest). She does, however, point to two cases which she thinks it plausible to suppose lie on opposite sides of the line (see Thomson, 1971, pp. 65-6). To wit, she argues that, even if fetuses are persons, a fourteen year old who is pregnant as a result of rape would certainly be entitled to an abortion. But a woman in the seventh month of pregnancy, and who now wants an abortion merely so that she will not have to postpone a foreign holiday, would not. For the latter woman to complete her pregnancy is within the bounds, Thomson suggests, of what can be expected of someone, as a matter of Minimally Decent Samaritan.

So much, then, for the shape of Thomson’s landmark defence of abortion. If it works, it blows apart the conventional terms of the abortion debate, under which, to recapitulate, it is standardly assumed that abortion is permissible only if the fetus lacks the right to life of a person. Does the argument work, however? Critics of Thomson have argued that it does not, because it fails to give due weight to the ways in which woman’s gestating a fetus is unlike the assistance delivered by Good or Minimally Decent Samaritans. In particular, they have pointed out that

(a)    whereas a Good or Minimally Decent Samaritan is merely a bystander who, coincidentally, is in a position to render the needed assistance, a pregnant woman (at least if she has not been raped) is responsible for the fact that the fetus exists, and needs her help;

(b)   whereas a Good or Minimally Decent Samaritan is paradigmatically a stranger to the person needing aid, a pregnant woman stands in a special relationship to the fetus – namely that of parent to child.

(c)    whereas disconnecting oneself from the violinist, or refusing, in general, to assist a needy stranger whom one stumbles upon involves only allowing him to die, abortion typically involves killing the fetus.

These disanalogies are potentially highly damaging to Thomson’s argument. This is because it seems plausible to suppose that, while persons are in general only under a duty to provide life-saving assistance to others if the costs to them of doing so are reasonable, we can be expected to incur costs on a larger scale for the sake of saving someone for whose neediness we bear responsibility, or someone to whom we are specially related, or someone whom we would have to kill to avoid assisting. Whether Thomson’s argument can itself be saved from the objection that it ignores these disanalogies is a matter for tomorrow’s post.

References:

Judith Thomson, ‘A Defense of Abortion’, Philosophy and Public Affairs 1 (1971): 47-66.

Further useful links:

Is there a new ethics of abortion?

Contentious objection in medicine

Better Never to Have Been: The Harm of Coming Into Existence

Drawing the line

A Critique of Judith Jarvis Thomson’s A Defense of Abortion, Part I

Selected “study questions” regarding abortion, through the lens of Judith Thomson’s “A Defense of Abortion” 

Image Source Altruistic bears: http://commons.wikimedia.org/wiki/File%3ABears_altru.jpg

March, 2014

Saving, Killing, and the Moral Status of Human Life: the Ethics of Abortion, Part I

Dr Jeremy Williams

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In my blog posts this week, I will be discussing aspects of a topic that lies close to the heart of my own research interests in moral philosophy – namely, the ethics of abortion. This is a topic that never falls far from the political agenda, or the pages of newspapers. Indeed, simply summarising the legislative and judicial battles over abortion around the world that are either currently ongoing, or have taken place in the last year or so, would undoubtedly require more words than I have been given for this blog post. Abortion is also a topic of perennial controversy in philosophical circles (though here, given most philosophers’ liberal sympathies, the discussion perhaps takes place predominately between proponents of rival defences of abortion, rather than between defenders and opponents of abortion). As important and timely as the issue of abortion is, however, one might wonder what its relevance could be to a blog devoted to discussing questions pertaining to saving humans. After all, isn’t abortion most fundamentally a moral problem concerning the killing, rather than the saving, of humans?

To assume that abortion is about killing rather than saving would be too quick, however. In fact, abortion standardly involves both: it causes the death of the fetus, in the course of saving a woman from harms to her health, wellbeing, or prospects, many of which are very serious, and some of which are themselves life-threatening. In addition, and to make a more general philosophical point, the moral questions raised by killing and saving are intimately connected. In some cases, our beliefs about the ethics of killing may be undermined, and need to be revised or jettisoned, because they turn out to have unacceptable implications for the ethics of saving people from harm (or vice versa). Thus, to give a relevant example, it is sometimes argued that to claim, as opponents of abortion often do, that an embryo is a person who is harmed as much when killed as you or I, carries the implication that, in a choice between (a) saving the life of a single person, and (b) rescuing some larger number of embryos from destruction (when they could later be implanted into a woman and brought to term), it would be permissible, if not morally required, that we choose (b). That conclusion, however, would be unacceptable, and it is questionable that all but the most extremist pro-life supporter would contemplate endorsing it. This appears to put opponents of abortion under considerable pressure to revisit their view about the harm done in killing embryos.

My main aim in these blog posts is to introduce and examine some of the ways in which philosophers have sought to clarify, and to go beyond, the terms of the conventional debate on abortion, as played out between defenders of so-called ‘pro-life’ and ‘pro-choice’ perspectives. Given the overarching theme of this blog, in doing so I will also try to draw out some of the connections between my chosen topic and ‘saving humans’. I begin, in the first part of the series, with a discussion of what is arguably the most celebrated philosophical contribution to the abortion debate – Judith Thomson’s article of 1971, ‘A Defense of Abortion’. As it happens, at the core of Thomson’s thesis is the claim that continuing and completing a pregnancy as an instance of making a life-saving sacrifice, for the sake of someone else (the fetus) – a sacrifice which, in at least some cases, is too high for the woman to be morally required to undergo it, much less forced to do so. Indeed, crucially, on Thomson’s view, the costs attendant on being pregnant and giving birth can be too high for a woman to be under a moral duty to undergo them for her fetus’s sake, even if the latter is not merely human but has, as pro-life advocates typically maintain, the same high moral status as a person like you or I, with all the moral rights that that involves, including a right to life. Thus, Thomson aims to challenge the assumption (commonly made, incidentally, both by defenders and critics of abortion alike) that whether and how far termination of pregnancy is permissible, and protected by a woman’s ‘right to choose’, turns entirely on whether the fetus has, or lacks, the status and rights of a person. Even if it does, Thomson contends, that does not suffice to make the pro-life case that abortion would be impermissible.

More than forty years after its original publication, Thomson’s case in favour of abortion still ignites lively philosophical debate. But oddly enough, as influential as it has been in the ethical literature, it has never (on my observation, at least) gained much traction in the popular debate over abortion. These blog posts seemed an ideal excuse to give Thomson’s argument an airing outside its traditional habitat of the philosophy seminar room.

Thomson begins her argument by setting out the familiar pro-life reasoning against abortion. That reasoning begins, to repeat, with the premise that the fetus has, from conception, the full moral status, and rights of a person. If fetuses have that status, and those rights, the reasoning continues, abortion must be morally wrong. For although a woman has a right to control what happens in and to her body, that right is not as important as, and thus is morally outweighed by, the fetus’s right to life. That reasoning, Thomson initially suggests, seems ‘plausible’. In response to it, however, she then introduces one of the most iconic thought experiments in contemporary ethics – the so-called ‘violinist example’. Its purpose is to show that, even if a person has a full right to life, and needs access to our body for survival itself, it does not follow that we are under a duty to provide such access. Since paraphrasing Thomson’s example would only deprive readers of her characteristically wry and acerbic written style, I reproduce her presentation of it in full:

[L]et me ask you to imagine this. You wake up in the morning and find yourself back to back in bed with an unconscious violinist. A famous unconscious violinist. He has been found to have a fatal kidney ailment, and the Society of Music Lovers has canvassed all the available medical records and found that you alone have the right blood type to help. They have therefore kidnapped you, and last night the violinist’s circulatory system was plugged into yours, so that your kidneys can be used to extract poisons from his blood as well as your own. The director of the hospital now tells you, “Look, we’re sorry the Society of Music Lovers did this to you–we would never have permitted it if we had known. But still, they did it, and the violinist is now plugged into you. To unplug you would be to kill him. But never mind, it’s only for nine months. By then he will have recovered from his ailment, and can safely be unplugged from you.” Is it morally incumbent on you to accede to this situation? No doubt it would be very nice of you if you did, a great kindness. But do you have to accede to it? What if it were not nine months, but nine years? Or longer still? What if the director of the hospital says. “Tough luck, I agree, but now you’ve got to stay in bed, with the violinist plugged into you, for the rest of your life. Because remember this. All persons have a right to life, and violinists are persons. Granted you have a right to decide what happens in and to your body, but a person’s right to life outweighs your right to decide what happens in and to your body. So you cannot ever be unplugged from him.” I imagine you would regard this as outrageous, which suggests that something really is wrong with that plausible-sounding [pro-life] argument I mentioned a moment ago (Thomson, 1971, pp. 48-9).

The violinist example is both arresting and deeply thought-provoking. The question, however, is whether it is sufficiently analogous to pregnancy that we are entitled to draw conclusions about the moral permissibility of abortion on the basis of it. I pick up that question in the next post in this series.

References: Judith Thomson, ‘A Defense of Abortion’, Philosophy and Public Affairs 1 (1971): 47-66

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