Bioethics, healthcare policy, and related issues.
Just saw the film Hard Candy, directed by David Slade (who has done almost nothing but music videos previously), and starring Patrick Wilson and a remarkable Ellen Page, who comprise almost the entire cast. Rated R for no good reason. The story revolves around the relationship between a precociously intelligent 14-year-old girl and a somewhat creepy early-30s photographer who pursues her online and then in person. When they meet, she suspects he is a pedophile responsible for the disappearance of another teenage girl – and then turns the tables on him in an act of revenge or vigilante justice.
The movie is somewhat unevenly paced – the first half hour is a tour-de-force of acting from both main characters, as they alternately engage in an exploratory flirtation and then each retreat to more age-appropriate demeanors; the moment when the plot takes its definitive twist and goes off in a new direction is also the moment when the director seemingly forgot what the movie was about, however. The second half is less a psychological intrigue than a straightforward vengeance tale. The result is a weird mashup of Lolita and Death and the Maiden, as directed by David Cronenberg. However, leaving aside the inconsistency, there are some provocative things in it, and some questions raised about how we are to understand young sexuality, our revulsion by pedophilia (and our protective impulses toward young girls especially), and our common impulses toward destructive retribution in response.
The castration scene was notable, too.
In order to discuss the moral/philosophical issues raised by the film, it is necessary to discuss the plot content. The material below the jump contains plot spoilers. Please come back after you’ve seen the film, if you prefer not to have the plot revealed.
A theme running through many of my posts is the patient-centered ethic of care: patient autonomy as the pre-eminent ethical principle, and patients’ values as definitive of the ends and goals of medical practice. This conflicts with a paternalistic notion of care, of course (and in doing so is hardly unique in today’s ethical climate). But it also conflicts with any “exceptionalist” medical ethic, that is, any claim that the ethics of medicine somehow take precedence over individuals’ rights or values because medicine, as a unique and traditional profession, has an “internal ethic” that trumps the ethical claims of mere patients, or of society. I am not the only person to hold such positions, though my views on them are probably further out on a limb than most people’s. However, I also believe these views impinge on a proper understanding of the factual ground of medical practice as well.
Obviously, medical science just is what it is – moral principles do not change the facts of the case (even if they influence which facts are sought by researchers, or acted on by clinicians). But medical practice, even more than most technological practices, operates on a highly value-laden vision of scientific fact, and nowhere more so than in the concept of the “definition of disease”. To traditionalists, nothing could be simpler: disease is whatever conflicts with “health”, and “health” can be identified in some sort of “I-know-it-when-I-see-it” natural law fashion. (More recently, the notion of “normal species functioning” has emerged as a “scientific” definition of health.) To critics, the “obvious” conception of health and disease is fraught with imposed meanings: not merely what kind and range of conditions or functions we take to be “normal”, but even what conditions are recognized at all. (The history of women’s depression, ADHD, and homosexuality are cases in point. “Drapetomania” – the pathological inclination of American slaves to run away – is a tragically hilarious example of socially-constructed disease, and likewise Tris Engelhardt’s celebrated paper on “the disease of masturbation” is a classic on the subject.)
For the most part, this debate has been a conceptually important, but in practice marginal, bywater of bioethics. It matters a great deal what diseases are recognized as candidates for treatment, but, with the exception of certain controversial psychiatric conditions (notably homosexuality), those determinations have been imposed by insurance companies, not derived by philosophers of medicine. The issue is coming to the fore today, however, in high-profile ethical controversies with distinct practical impact.
