- Genetic Tests
- Philip Kitcher
- Quality of Life
In The Lives to Come: The Genetic Revolution and Human Possibilities (1996), Philip Kitcher explores a number of social and ethical issues surrounding genetic knowledge and genetic technologies. My interest here is in his discussion of just one of these issues: the use of genetic tests in decisions about whether a foetus should be aborted or brought to term.1 Kitcher regards such test-based decisions, whatever their outcome, as belonging to the realm of eugenics, and I agree; however, I shall not defend that view here. Rather, taking for granted the eugenic status of test-based decisions, I shall examine some of Kitcher’s views on the proper procedure for reasoning to these decisions. In brief, Kitcher argues that test-based decisions should turn not on whether individuals-to-be would suffer from disease, but whether they would likely fail to attain a high quality of life. What I want to bring into focus is the reasoning behind this conclusion about eugenic reasoning. I aim to show that one of Kitcher’s main complaints about the disease/non-disease criterion—that it inappropriately privileges the goals of the body over the goals of the person—applies far more damagingly to the quality-of-life criterion he favours.2
1. Right and Wrong in the Eugenic Utopia
I begin with a brief description of the wider philosophical context of Kitcher’s proposals about eugenic reasoning.3 For Kitcher, eugenics of some kind has become inescapable, since eugenics is ‘a mixture of a study of heredity and some doctrines about the value of human lives’,4 and we are stuck with some such mixture no matter what course of action we choose. At present, in Kitcher’s view, the affluent democracies are engaged in what he calls ‘laissez-faire eugenics’,5 with citizens free to roam within a burgeoning test and gamete supermarket, helping themselves to whatever they can afford. That is one possible mixture, and surely benign compared to some. But what mixture is the best one? What kind of eugenics should we aspire to, and what kinds should we avoid?
Kitcher suggests that there are four dimensions along which a eugenic programme can go wrong. Put another way, there are four questions to be asked of a possible eugenic programme. First, whose reproductive activities matter? Second, are people free to make their own reproductive decisions? Third, which traits are to be eliminated and which promoted? Fourth, how accurate is the scientific information? Ask these questions of the Nazi eugenic programme, and the answers mark out the extremes of moral failure. Defined negatively as whatever the Nazi programme was not, the best possible eugenic programme will thus be inclusive and non-coercive, targeting traits for elimination or promotion according to prejudice-free criteria and impeccable data.6
The Nazis showed how not to design a eugenic programme. But the eugenic past as Kitcher reads it contains positive as well as negative guidance. In the eugenic beliefs of George Bernard Shaw, Sidney and Beatrice Webb and other social reformers in Britain in the early twentieth century, Kitcher finds pointers toward a version of laissez-faire eugenics that balances respect for reproductive autonomy with concern for the common good. The vision is of what Kitcher calls a ‘utopian eugenics’.7 In his eugenic utopia, all people will have full access to all reproductive options, and full freedom to choose among them. But they will also be educated to think through their reproductive decisions within a certain framework. That framework will ensure understanding of what genetic tests reveal, and what their limits are; it will instil a sense of obligation to consider the consequences of reproductive decisions upon the wider community; it will promote tolerance of unpopular decisions; and it will show what morally legitimate eugenic reasoning looks like.
With a backward glance at Nazi eugenics, Kitcher argues that test-based decisions should not turn on the presence of alleles for traits judged simply undesirable. A judgement of undesirability might derive from nothing more than social prejudice. (Think of parents-to-be in Germany in the 1930s, desiring children who would grow to be tall, with fair hair and blue eyes.)8 What is needed is a criterion that will guarantee a prejudice-free decision. To find this criterion, Kitcher turns his attention to a widespread intuition: that it is legitimate to abort (if it is ever legitimate) when the child-to-be would suffer from, say, Tay-Sachs disease, or some other painful, inevitably lethal condition; but illegitimate to do so if, say, the predicted height of the child-to-be was slightly below average. Discover what drives this intuition, Kitcher argues, and we shall discover the basis for moral reasoning about genetic tests.
Kitcher makes two attempts at plumbing this core intuition about legitimate and illegitimate decisions. First he explores the possibility that, at bottom, we are concerned to prevent diseases. Suppose we could discover certain facts about bodies that reveal where disease ends and health begins. We would then have an objective, prejudice-free criterion for deciding whether to abort a tested foetus. Not a perfect criterion, of course: few alleles cause disease against all possible genetic backgrounds and in all possible environments. The promise of the disease/non-disease criterion is not that it would make decisions easy—though geneticists in the eugenic utopia would provide a much fuller statistical and biochemical context for tests than provided at present, and parents-to-be would be much better equipped to make use of this contextual information in their decisions. The promise of the criterion is rather that it would immunize decisions made on its basis from social prejudice. But Kitcher in the end rejects disease considerations as a basis for morally legitimate eugenic reasoning, on grounds I shall explore below.
He moves on to examine a second possibility: that, at bottom, we are concerned to prevent not disease but low quality of life. To return to the core intuition, we seem to feel that, in the case of the foetus with the Tay-Sachs alleles, it is merciful to abort because the individual-to-be would inevitably live a brief, cramped life, causing enormous distress to the family; whereas in the case of the foetus with alleles for below-average height we can well imagine the individual-to-be as a person who enjoys a rich and fulfilling life. For Kitcher, this diagnosis of the core intuition is the correct one. As he envisions the civics classroom of the eugenic utopia, discussion will dwell not on whether shortness, say, is a disease, but on whether individuals with alleles predisposing them to shortness have a sufficiently low quality of life, and sufficiently often, for parents-to-be to consider aborting foetuses with those alleles. Such discussions will lead to a more general examination of the determinants of quality of life, and the need to keep vigilant against prejudices that reduce quality of life for certain kinds of people below what it would otherwise be.
Reckoning capacities for quality of life, and the consequences on others of a potential life, can never be exact. Nevertheless, Kitcher argues, so far as these decisions are made in light of facts about bodies and societies, and are motivated by a concern for freedom that is universal, these decisions will be, not value-free, but free of all but the least contested values. According to Kitcher, there are three main issues to consider when judging the potential quality of life of an individual: first, the potential for self-determination; second, the potential for central wishes to be fulfilled; third, the potential scope for pleasurable experience. I shall have more to say below about the second of these elements in particular. For now, let me return to Kitcher’s rejection of the disease/non-disease criterion, and his grounds for that rejection.
2. The Disease/Non-Disease Criterion
What is wrong with the disease/non-disease criterion? Kitcher concedes that much of what we call ‘disease’ falls on the Tay-Sachs side of that felt divide between conditions that should be prevented and those that should not. It is the borderline conditions that raise difficulties; and, in Kitcher’s view, to decide these cases without prejudice, we need a clear view of the natural properties distinguishing disease from non-disease. Following the influential work of Christopher Boorse,9 Kitcher uses the language of ‘function’ and ‘dysfunction’ as a first step towards characterizing these properties. In functional terms, diseases are deviations from normal bodily functioning. To tell whether or not a condition is a disease or disability, we just need to discover whether it involves bodily dysfunction. But this nostrum does not so much solve the problem of understanding disease as postpone it. Unless we can spell out what it is for bodies or parts of bodies to function or fail to function, test-based eugenic decisions will ultimately derive from the same rubbishy mix of intuitions and prejudices we are looking to replace. Furthermore, even if we manage to assemble a workable account of biological function, grounded in features of present physiology and evolutionary history, there remains the possibility that the class of diseases and the class of functional disturbances will not, on inspection, coincide.
Some philosophers doubt whether talk of normal and abnormal functioning has any purchase at all in modern, Darwinian biology.10 Kitcher is the author of an influential account defending and explaining such talk.11 What he is sceptical about is whether a workable account of abnormal functioning amounts to a workable account of disease. In summary, he argues that normal functioning can be disturbed without there being disease; that diseases therefore are not disturbances of normal functioning after all; that the disease/non-disease criterion is therefore not demonstrably value-free, and is no guarantor against prejudice in eugenic reasoning; and that eugenic reasoning therefore cannot derive moral legitimacy from the disease/non-disease criterion.12
Kitcher adduces two examples of disturbed functioning without disease: delayed motherhood in women, and homosexuality in men. According to Kitcher, women who put off having children disturb the normal functioning of their bodies in two related ways: by not producing all the offspring they might have; and by increasing their risk of breast cancer (for natural selection has designed breasts such that, used early in adulthood for feeding infants, breasts become resistant to cancer). Kitcher suggests that women who delay childbirth, though functionally abnormal, cannot be suffering from disease, because people suffering from disease naturally desire (or at least require) treatment that will return them to the normal state, and women who delay childbirth desire no such return. As Kitcher puts it, ‘many Western women do not want to restore “normal” functioning, hoping instead that medicine will find ways to avoid the increased risks of death without employing the tactics with which human evolutionary history has equipped them’—that is, without forcing women to start having children earlier.13 For Kitcher, homosexual men likewise show dysfunction without disease. Perhaps because their brains contain small hypothalamic nuclei, their bodies do not fulfil their goal of reproduction, either at all, or as completely as they might have. But, Kitcher suggests, since homosexual men neither desire nor require normalizing treatment, they are not suffering from disease. Granting dysfunction, he asks, facetiously, ‘would it be legitimate to intervene medically, to try to restore “normal functioning”? Are untreated men with the small nuclei “diseased”?’14
In sum, childless women and homosexual men do not count as diseased because their personal goals are being fulfilled, even if their bodies, and/or their selfish genes, suffer in consequence. On the basis of these two examples of apparent dysfunction without disease, Kitcher concludes that there is more to being a disease than being dysfunctional.15 But he also draws a larger lesson. For Kitcher, the failure of disease-as-dysfunction shows the folly of elevating the goals of the body above the goals of the person:
Even though we have been shaped by natural selection, we have non-Darwinian values, so that longevity and fecundity do not assume overriding significance for us . . . laborious attempts to develop an objective—value-free—notion of disease are ultimately of no help, because they ground our understanding of health and disease in facts about our evolutionary history that, although they may sometimes be congruent with our goals for ourselves, are quite external to those goals.16
Let me turn now to assess the examples of childless women and homosexual men in turn. Neither presents a simple instance of dysfunction without disease. Taking childlessness first, it is helpful to recall a distinction Boorse insisted upon in arguing the case for disease-as-dysfunction some twenty-five years ago: between disease and illness.17 For Boorse, a disease is an internal state that depresses functional ability below the level typical for organisms of the relevant age, sex and species, while an illness is a disease grown serious enough to be incapacitating. In Boorse’s view, it is not judgements of disease but judgements of illness that prompt decisions about treatment. So there is no contradiction in stating that childless women with functionally disturbed breast tissue are diseased, even though they do not regard themselves, and are not regarded, as needing treatment. On the contrary, the distinction between disease and illness seems especially valuable in this context. Presumably women thinking about having children later in life would like to make that decision in light of all the relevant facts. The loss of functioning that their breasts will undergo in virtue of a decision to delay childbirth is one of those facts. Having a concept of disease-as-dysfunction, distinct from illness, enables a clearer view of the potential conflict between the functional goals of the body (to bear children, and produce milk to feed them) and the personal goals of the individual (perhaps to delay having children whilst becoming professionally established, and without falling ill). From Boorse’s perspective, at least, the concept of disease-as-dysfunction, with the related concept of illness firmly in tow, does not so much privilege the goals of the body as ensure against the confusion of the goals of the body with the goals of the person.
So it is at least arguable that female childlessness is an example of dysfunction with disease after all. What about male homosexuality? Boorse has argued that homosexuality is an example of dysfunction with disease, on grounds similar to those I outlined above.18 I find resources in Boorse’s work that point the other way, however, to the view that homosexuality does not involve dysfunction at all. Here I have in mind a second of Boorse’s distinctions, between normal functioning and functional readiness.19 According to Boorse, what matters in judgements of disease is not whether a sub-system of the body is functioning, but whether it is ready and able to function with typical efficiency on typical occasions. To see how this distinction bears on homosexuality, contrast a sterile heterosexual man with a fertile homosexual one. In terms of functional readiness, it is the heterosexual man who has disease, since a disturbance to his reproductive system has left him unable to father children. Even if this man never tried to father children, so that his reproductive system strictly speaking never failed to function, it still makes sense to regard that system as dysfunctional, and the man himself as therefore diseased. Likewise, the homosexual man is not diseased, because he would be able to father children if the occasion arose. As with the judgement of disease in the sterile heterosexual, the judgement of health in the fertile homosexual is made irrespective of whether occasions to perform functionally in fact arise.
In sum, of the two examples Kitcher adduces, neither offers an unambiguous example of dysfunction without disease. When we recover distinctions that Boorse made in arguing for disease as dysfunction in the first place, but which Kitcher ignores, we find perspectives from which childlessness shows dysfunction with disease, and homosexuality shows disease-free normal functioning. So far as these perspectives are indeed the correct ones from which to view these conditions, Kitcher has failed to undermine the disease/non-disease criterion, and one of his chief complaints about the criterion—that it privileges the goals of the body over the goals of the person—is misdirected. Indeed, Kitcher’s complaint strikes home not as a criticism of the maligned disease/non-disease criterion, but of the lauded quality-of-life criterion.
3. The Quality-of-Life Criterion
Recall that Kitcher analyzes potential quality of life along three dimensions. The first dimension is the scope for self-determination. The wider the range of goals from which a person can choose, the wider the scope for self-determination, and the higher the quality of life. The second dimension is the scope for fulfilling chosen goals. The more mobile and independent a person can be, the wider the scope for fulfilling chosen goals, and the higher the quality of life. The third dimension is the scope for experiencing pleasure. The larger the amount of pleasure experienced, the higher the quality of life.20
Kitcher does not much use the language of ‘function’ in describing what it is for lives to go well or badly, and we do not expect him to use that language. After all, as we have seen, Kitcher regards the attempt to tie eugenic reasoning to a functional account of health and disease as wrongheaded. In his view, a concern with normal functioning inevitably leads us to attend to the functional goals of bodies, while intuition counsels that we attend to the personal goals of individuals. Kitcher proposes quality-of-life considerations as the means of escape from the counterintuitive judgements that lie in wait beneath disease-as-dysfunction considerations. At first glance, quality-of-life considerations do seem to concentrate attention on the goals of persons rather than bodies. We are led to ask about the range of contemplated goals, and the extent to which selected goals are fulfilled, including the goal of being happy. But notice that each of these has its physical correlates, or preconditions. To contemplate the widest possible range of goals, for example, one needs to develop a certain amount of cognitive equipment; and to develop that amount of cognitive equipment, one needs to have—let me put it plainly—a normally functioning brain.
Notwithstanding Kitcher’s reticence about using functional language in spelling out its demands, the quality-of-life criterion deals as much with function and dysfunction as does the criterion it is meant to replace. Consider the second dimension of quality of life, the fulfilment of central wishes. When Kitcher illustrates how immobility and dependence can make for frustrated wish-fulfilment, and thus for low quality of life, his examples are all examples of abnormal bodily functioning. We learn that people ‘born with severe forms of muscular dystrophy cannot direct themselves toward goals that demand great exertion’; that ‘some genetic conditions make it impossible for women to bear children’; that ‘others, involving extreme malformations of the genitalia, preclude normal sexual relations’.21 Apart from that ‘normal’, the references to functionality in all of this are implicit. To find them made explicit, we need to turn to one of the major sources for Kitcher’s views on assessing quality of life, an influential article by Dan Brock. For Brock,
[s]erious illness or injury resulting in serious functional impairment often requires a major revaluation of one’s plan of life and its major aims and expectations. Over time, such revaluations can result in undiminished or even increased levels of happiness, despite decreased function, because the person’s aspirations and expectations have likewise been revised and reduced. The common cases in medicine in which, following serious illness, people come to be satisfied with much less in the way of hopes and accomplishments illustrate clearly the incompleteness of happiness as a full account of the quality of life. To be satisfied or happy with getting much less from life, because one has come to expect much less, is still to get less from life or to have a less good life.22
This passage is revealing not just because it makes the relationship between quality of life and normal functioning explicit. It also shows something of the surprising nature of that relationship within the Kitcher-Brock calculus. Abnormal functioning turns out to reduce quality of life two times over. There is a more straightforward reduction, and a less straightforward one. The more straightforward reduction is that arising from the reduced scope for satisfying central wishes. Ignoring for the moment the less straightforward reduction, we can imagine people with degenerate musculature, misshapen genitals and so on as contemplating lots of different personal goals, deciding which ones will be their goals, and then attempting to throw their bodies into pursuit of the selected goals—only to find that their bodies render certain goals unobtainable, and that their lives diminish in quality accordingly. But that is not the whole story. Right at the start—or so the Kitcher–Brock calculus assumes—people with abnormally functioning bodies whittle down the set of contemplated personal goals according to the limitations of their bodies. This whittling down of goals is the source of the second reduction in quality of life. It seems the lives lived within narrowed horizons are lives of lower quality—perhaps because a remembrance of goals renounced shadows those lives thereafter, darkening even the achievements, and reducing quality of life accordingly. ‘[M]any of those who grow up knowing that certain kinds of lives are out of their reach’, writes Kitcher, ‘may nonetheless chafe at the restriction, feeling that they have been blocked from the direction they would have chosen for themselves’.23 As for parents-to-be, Kitcher advises them to go with inclinations to choose against the disabled, bearing in mind the still lower quality of life that can result if narrowed horizons contain no attractive goals at all:
To learn that a fetus carries a genetic condition that will lead to irreversible muscular degeneration in early childhood, that the person born would be able to move and to communicate only with the aid of equipment and considerable human support, would incline many prospective parents to conclude that the life would not be worth living. Yet is this not to impose values from without? People born with such disabilities develop self-conceptions whose corresponding central goals can be attained without independent mobility—they draw their horizons around their distinctive talents . . . But while being rightly impressed with what they have achieved, we should beware of concluding from prominent examples that there will always be distinctive talents to be developed, that excluding the entire array of personal goals for which independent mobility is required will leave something toward which a life can be successfully directed.24
I have argued that, with the appropriate distinctions in view, disease judgements that privilege the goals of the body are indeed consistent with prior intuitions. Quality-of-life judgements that privilege the goals of the body are another matter entirely. But that is precisely what quality-of-life judgements along the lines sketched above do, by making high quality of life effectively co-extensive (albeit covertly) with normal functioning. Consider that, according to the Kitcher-Brock calculus, two people who have fulfilled the same personal goals to the same degree have nevertheless achieved lives of different quality if one of those people has a functionally normal body (higher quality) and the other a functionally abnormal body (lower quality). It does not matter that both people report the same level of happiness with how their lives have gone. There are two ways to interpret such a surprising result. Either the result is correct, and people really do, objectively, achieve lives of different quality depending on their physiologies, even when those people regard themselves as have achieved lives of equal quality. Or the result is incorrect, and the presumptive and counterintuitive coupling of high quality to normal functioning is revealed as false.
For Ron Amundsen, the coupling of high quality and normal functioning is worse than false. He detects within it a familiar social prejudice against the disabled. (He notes that physicians generally give lower quality-of-life marks to their disabled patients than those patients give themselves.)25 If Amundsen is right, then the proposed quality-of-life criterion does not just privilege the goals of the body inappropriately, but, in a eugenic context, perniciously. The eugenic decisions it leads to and legitimates would turn not on value-free facts, nor on evaluative judgements of the least contestable sort, but on evaluative judgements of the most highly contested sort.
All concerned with genetics, persons and responsibility should be grateful to Kitcher for his groundbreaking arguments. Whatever their merits or defects, they have permanently raised the level of discussion about genetic tests and their use. By his own example, Kitcher has shown what it is to think through the problem of eugenic reasoning with clarity and sensitivity. I have tried to respond appropriately; and, to that extent, this brief paper is as much homage as critique. Needless to say, I have not shown that, contra Kitcher, eugenic reasoning should be based on disease considerations. Doing so would require the marshalling of a number of positive arguments, most likely defending disease as dysfunction and the concept of normal functioning. Rather, I have tried to show that Kitcher’s arguments against disease considerations and for quality-of-life considerations fail in important respects. Reviving some lapsed distinctions concerning disease, I have argued that Kitcher’s examples of counterintuitive disease judgements fail to undermine the case for understanding disease as dysfunction, and that his complaint about such judgements privileging the functional goals of the body is misdirected. Furthermore, as I understand them, the quality-of-life considerations he favours privilege functional goals just as much as disease considerations, and with much more disturbing consequences. If these difficulties are genuine, then we are still some way off from knowing which principles ought to guide eugenic reasoning. At least this side of the eugenic utopia there is still, for all Kitcher’s considerable advances, much work to be done.
An earlier version of this paper was presented to staff and students in the Leeds HPS Division, February 2001. I am grateful to them for their comments, and to Rachel Cooper, Lindsay Gledhill, Hallvard Lillehammer and Chris Megone for much-needed criticism, guidance and encouragement.
- 1 Throughout I discuss genetic testing in relation to decisions about aborting foetuses. But it is not difficult to imagine a future in which test-based decisions are made about zygotes created in vitro. It is even possible that individual sperm and eggs will be inspected for the presence of certain alleles, and the most genetically promising individual sperm allowed to fertilize in vitro the most genetically promising egg, thus eliminating the need even to discard superfluous zygotes. The point is that problems associated with genetic tests on the unborn are independent of the problems associated with abortion, and will persist long after abortion has dropped out of the equation (if it does).
- 2 I shall not address Kitcher’s other main complaint, that the disease/non-disease criterion provides no basis for grading urgency of intervention (Kitcher, 1996, p. 214).
- 3 See esp. Kitcher (1996), chs 8, 9 and 13.
- 4 Kitcher (1996), p. 191.
- 5 Kitcher (1996), p. 196.
- 6 For an alternative view of the lessons of the eugenic past, see Buchanan et al. (2000), ch. 2. For an excellent concise history of eugenics, see Paul (1995).
- 7 Kitcher (1996), p. 202.
- 8 It is hard to better the historian E. J. Hobsbawm’s characterization of social prejudice at work in the eugenics of the early twentieth century, when extreme eugenicists tried ‘encouraging valuable human strains (usually identified with the bourgeoisie or with suitably tinted races such as the “Nordic”), and eliminating undesirable strains (usually identified with the poor, the colonized or unpopular strangers)’ (Hobsbawm, 1987, p. 253).
- 9 See esp. Boorse (1977). For Boorse’s responses to voluminous criticism of what is now known as his ‘biostatistical theory (BST)’ of health and disease, see Boorse (1997). For a broad perspective on the concepts of health and disease, see the papers collected in Caplan et al. (1981).
- 10 See, for example, Amundsen (2000) and Lloyd (1998).
- 11 Kitcher (1998).
- 12 See esp. Kitcher (1996), pp. 207–14. Kitcher does not argue that the analysis of disease as dysfunction is the onlyanalysis that could show the concept of disease to be prejudice-free. Hence, revealing that analysis as flawed is not tantamount to showing the concept of disease to be prejudice-ridden.
- 13 Kitcher (1996), p. 212.
- 14 Kitcher (1996), p. 213.
- 15 In discussing these two examples, Kitcher also mentions organisms, such as salmon and insects, that die in the course of reproducing (Kitcher, 1996, pp. 212–3). These too reveal, at a remove, how the goals of individuals and the goals of their bodies and/or genes can come apart. But these examples do not bear as such on whether diseases are disturbances of function.
- 16 Kitcher (1996), p. 213.
- 17 Boorse (1977), pp. 551–2, and, more generally, Boorse (1975).
- 18 Boorse (1975), p. 63. For criticism of Boorse’s position on homosexuality, see Cooper (2001).
- 19 Boorse (1977), pp. 561–2.
- 20 See esp. Kitcher (1996), pp. 285–97. Kitcher has dealt at length with a criticism of quality-of-life considerations that I shall not address here: that a concern for quality of life should direct us away from genetic interventions that help the few and toward social interventions that help the many. For one critique along these lines, see Gannett (1997). For Kitcher’s defence against this criticism, see Kitcher, 1996, Kitcher, 2000.
- 21 Kitcher (1996), p. 289.
- 22 Brock (1993), p. 309.
- 23 Kitcher (1996), p. 289.
- 24 Kitcher (1996), pp. 292–3.
- 25 Amundsen (2000), esp. pp. 46–8.
Amundsen, R. (2000) ‘Against Normal Function’, Studies in History and Philosophy of Biological and Biomedical Sciences 31, 33–53.
Boorse, C. (1975) ‘On the Distinction between Disease and Illness’, Philosophy and Public Affairs 5, 49–68.
Boorse, C. (1977) ‘Health as a Theoretical Concept’, Philosophy of Science 44, 542–573.
Boorse, C. (1997) ‘A Rebuttal on Health’, in J. M. Humber and R. F. Almeder (eds), What is Disease? (Totowa, NJ: Humana Press), pp. 1–134.
Brock, D. (1993) ‘Quality of Life Measures in Health Care and Medical Ethics’, in Life and Death: Philosophical Essays in Biomedical Ethics (Cambridge: Cambridge University Press), pp. 268–324.
Buchanan, A., Brock, D. W., Daniels, N. and Wikler, D. (2000) From Chance to Choice: Genetics and Justice (Cambridge: Cambridge University Press).
Caplan, A. L., Engelhardt, H. T. and McCartney, J. J. (eds) (1981) Concepts of Health and Disease: Interdisciplinary Perspectives (Reading, MA: Addison-Wesley).
Cooper, R. (2001) ‘Disease’ (unpublished ms.).
Gannett, L. (1997) ‘Tractable Genes, Entrenched Social Structures’, Biology and Philosophy 12,403–419.
Hobsbawm, E. J. (1987) The Age of Empire, 1875–1914 (London: Abacus).
Kitcher, P. (1996) The Lives to Come: The Genetic Revolution and Human Possibilities (London: Allen Lane/Penguin Press).
Kitcher, P. (1998) ‘Function and Design’, in D. Hull and M. Ruse (eds), The Philosophy of Biology (Oxford: Oxford University Press), pp. 258–279.
Kitcher, P. (2000) ‘Utopian Eugenics and Social Inequality’, in P. Sloan (ed.), Controlling Our Destinies: Historical, Philosophical, Ethical and Theological Perspectives on the Human Genome Project (Notre Dame, IN: University of Notre Dame Press), pp. 229–262.
Lloyd, E. A. (1998) ‘Normality and Variation: The Human Genome Project and the Ideal Human Type’, in D. Hull and M. Ruse (eds), The Philosophy of Biology (Oxford: OxfordUniversity Press), pp. 553–566.
Paul, D. (1995) Controlling Human Heredity: 1865 to the Present (Amherst, NY:Humanity Books).