Wittgenstein And Therapy

This is the first section of an essay published in the Spring 2011 Journal Of Leeds University Philosophy Society.


This essay will examine therapy as a theme uniting all of Wittgenstein’s arguments in the Philosophical Investigations (Wittgenstein, 2001). It will begin by observing some translation errors and omissions which bear directly on how that idea should be considered, and will then continue by considering how therapy permeates Wittgenstein’s approach in several of the arguments presented in that work. In particular, it will be shown that the `popular’ conception of Wittgenstein’s meaning in several quotations that are widely known in philosophical circles is incorrect. Also an intriguing insight into Wittgenstein’s intentions is gained by consideration of the frontispiece quotation and its context.

The therapeutic background to Wittgenstein’s position is considered in relation to Freud, and this brings out common elements with the work of Ryle. This leads to characterization of Wittgenstein as being primarily a negative philosopher concerned to eliminate false conceptions to which we are prone. This is the primary therapeutic aim; going beyond mere elimination of error, which would be an aim of all argument. Wittgenstein aims to show how deep-seated are the errors to which we are naturally prone and to permit us to heal ourselves rather than persuade us of the truth.

Further, Wittgenstein may be seen as using multiple voices in his work. This echoes psycho-therapeutic practice but also is a method to require our engagement in disentangling his own voice — should that figure — and those of ourselves as objectors. Wittgenstein is also very prone to use of similes. All three of these characterizations are viewed through the therapeutic prism.

Several of the major arguments in the Investigations will be reviewed from the perspective gained. Finally other works by Wittgenstein, primarily On Certainty, will be considered in the same light.

Should Nozick Call Darwin As A Witness?


Nozick claims on several occasions that his picture of knowledge as truth tracking would be favored by natural selection. The two following citations are indicative of this element of Nozick’s position; they are taken from widely separate sections of his major work: `evolution, which doth make trackers of us all, would select for global tracking rather than especially favoring the local version’ (R Nozick, Philosophical Explanations, Belknap Press of Harvard University Press, 1981, p. 194) or `there would be evolutionary selection for better capabilities to detect facts and to have true beliefs’ (ibid., p. 284). The importance of this claim for Nozick rests on more than these remarks however. It would be a defect of his claims about knowledge if the picture thereof meant that we as evolved creatures could not reach it or approach it on any view incorporating the claim that possession of knowledge enhances evolutionary fitness.

At some level, this claim must be true. Any creature in possession of knowledge about benefits available in the environment such as food sources will outperform one not in possession of such knowledge. And any creature making dramatically inaccurate over-estimations of its own capacities will suffer the consequences. However, this essay will argue primarily from Dennett that the picture of complete knowledge being indisputably good for fitness is too simplistic.

This leads to the potential challenge to Nozick’s position. Evolution will only make us trackers if tracking provides knowledge and knowledge is optimally fit. If the second claim fails, then even if tracking provides knowledge, we may not do it. If we do not do it, then either a different account of knowledge is needed, or we accept that Nozick has described something we will struggle to reach and may not need to.

Nozick does have a defense however. It will be shown that avoiding false positives and false negatives are differentially important as a practical matter in different cases. Yet Nozick can concede this but ask what is the link from practical importance to relevance for epistemic assessment. Since this link cannot be provided, Nozick’s account is in fact safe from attack from evolutionary perspectives. A further variant challenge based on the interaction between evolution and distances in possible world space is considered, and again it seems that Nozick has an adequate response.

One final charge to press against Nozick might be to observe that if in some cases false belief is better for us, then the best way to obtain that might be via avoiding tracking thus: tracking itself could be unfit.

Nozick’s Account Of Knowledge

Nozick has a four-factor account of knowledge that can be seen as an extension of the traditional tripartite model of justified true belief. Nozick’s account relies heavily on the subjunctive conditional. This refers to the connective in sentences like `if A were to be the case, then B would be the case’.

The following standard terminology may be used.

  • p: the belief or proposition in question
  • s: the subject
  • B: two place operator preceded by a subscript indicating the subject and succeeded by a subscript indicating the belief
  • ☐→: subjunctive conditional connective
  • ¬: negation
  • On this basis, Nozick’s four conditions for knowledge are as follows.

    1. p
    2. sBp
    3. ¬ (1) ☐→ ¬ (2)
    4. (1) ☐→ (2)

    Condition (3) is known as Sensitivity because if s satisfies it, his beliefs are sensitive to p becoming false: he will no longer believe p in those possible worlds where p is false. Condition (4) is known as Adherence because if s satisfies it, his beliefs adhere to p remaining true: he will continue to believe p in possible worlds where p is true.

    The possible worlds analysis is primarily due to Lewis (D Lewis, Counterfactuals, Blackwell Publishing, 2001) and may be summarized as follows. Possible worlds are sets of propositions. The actual world is given by the set of propositions that are true in the actual world. Different possible worlds have a number of propositions that are true in them, and the closeness of two possible worlds may be considered as related to how many propositions share the same truth values in both worlds; and how dramatic the effects of the changes are.

    Nozick believes that Sensitivity and Adherence are of equal importance. Zalabardo (J Zalabardo, UCL Dept. of Philosophy), forthcoming disagrees and claims that Sensitivity is more important that Adherence in that the former does more work and the latter introduces more problems than it solves. For Zalabardo, Nozick’s account would be improved by dropping the Adherence condition altogether. If an evolutionary account can be produced to show that Sensitivity is more likely to be selected for than Adherence, that would bear on this argument.

    Nozick introduces Adherence to allow for a type of counterexample which might be termed `fortunate avoidance of misinformation’. The first example relies on the familiar skeptical problem of the brain in a vat being fed data indistinguishable from sensory input. If the experimenters doing this fed the brain the information that it was in fact a brain in a vat, we would not be tempted, according to Nozick, to allow it knowledge on the point. This is because the brain would not have formed such a belief in the close possible world where the experimenters do not feed in such knowledge.

    A further counterexample due to Harman is handled similarly. A man reads a newspaper recording that the dictator is dead. This is true, but the regime suppresses the information issuing denials in subsequent editions; the man in question fails to see these denials and so continues to believe the truth. Intuitively though, we are more likely to allow that this is a case of knowledge, after all the man has formed a belief which is true by a method which was in fact reliable, whether he knows it was or not.

    It should be noted that Nozick’s reference to `local […] global’ in the quotation given in the first paragraph of the Introduction is irrelevant to our purposes here. He is using the terms temporally to restrict (via the term `local’) the range of times relevant to our assessment of whether s knows p. If p includes `now’ then it could change its truth value later but we might still be prepared to accept that s knows p = `it is raining now’ even if s ceases to know that later on because the rain stops. Nozick acknowledges that further conditionality may be required to account for this but believes it can sit atop his system rather than replace it.

    So in the quotation, Nozick is in fact claiming that natural selection would prefer durable or robust knowledge rather than some evanescent version; this seems clear and does not change the position in relation to whether evolution will require tracking. Importantly, he believes that evolution would favor tracking of both types even though it would preferentially select the global version.

    The Evolution Of False Belief

    While prima facie it would seem to be evolutionarily beneficial always to have true beliefs (i.e. knowledge) there are in fact many situations wherein false belief provides a higher level of fitness. Several examples are discussed by McKay and Dennett (R McKay and D Dennett, The Evolution of Misbelief, Behavioral and Brain Sciences (2009) 32, 493–561) including item recognition in an outdoors setting, which will be the major example considered here, in the next subsection.

    Other examples discussed include expectations of AIDS patients, false beliefs about the self and the placebo effect. These will be outlined briefly. The citation given in the case of AIDS patients relates to the initial period of prevalence of the disease in the US, at a time prior to the development of treatments. Life expectancy in such patients was measured in months. Contrary to received wisdom emphasizing acceptance, patients who ignored their HIV status and remained in denial experienced slower onset of symptoms and significantly lengthened survival.

    Remarkably, it appears that optimal mental health may be associated with delusionally false and positive beliefs about the self in relation particularly to one’s own capacities. It is well known that this is a frequent occurrence, and so on the type of argument made throughout the paper, it should have a benefit. Everyone thinks they are a better driver than average and they make strong claims about the prowess of their children. All of these delusions may have elements of becoming self-fulfilling prophecies. Students who believe they will perform well in exams are less likely to succumb to performance anxiety and to remain focused on work which will of course improve such performance. Most ironically, people generally claim that they are less susceptible to self-delusion than others.

    The placebo effect is well-known and need not be considered in detail here. The belief that crystals will heal one can make that partially true, and the mere presence of doctors and a medical setting can begin healing before any treatment is commenced. Explanations of this have included the idea that the immune system of the body may be compared to an army with antibody cells being the soldiers. The body may throw the reserves into action when in a medical setting because this is less risky when reinforcements in the form of external treatments are expected to become available. If this account is true, it would be one example of a situation in which a mechanism could evolve to translate false belief into beneficial action, though naturally in an evolutionary setting we would need to replace `hospital’ by `safe environment’.

    Some explanations for the prevalence of religious beliefs focus on the psychological benefits.

    In addition, this type of idea is also present in many other philosophers. Nietzsche: `throughout immense stretches of time the intellect produced nothing but errors; some of them proved to be useful and preservative of the species: he who fell in with them, or inherited them, waged the battle for himself and his offspring with better success’. (F Nietzsche, The Gay Science, Cambridge University Press, 2001, III S.10) By this, Nietzsche means for example the facts that there would have been no astronomy without astrology and no chemistry without alchemy. Ryle (G Ryle, The Concept of Mind, University of Chicago Press, 1949, p. 13) also writes of new more useful myths replacing older myths in physical science, giving the example of the concept of force replacing that of Final Causes — the improvement not deriving from veracity. Unger (P Unger, A Defense of Skepticism, The Philosophical Review, Vol. 80, No. 2 (Apr., 1971), pp. 198-219) considers a circumstance that `allows a false belief to be helpful’, viz. when the alternative is to have no belief at all and some action is called for.

    Error Asymmetry In Object Recognition

    Absolute knowledge under all circumstances would indeed be optimally evolutionarily fit, but this is not obtainable. Given an irreducible amount of error, it becomes clear in some situations which would have applied evolutionary pressure to the perception systems of early humans, that this error is best accepted in one direction rather than the other. Nozick acknowledges this: `some sacrifice in the total ratio of true beliefs would occur to achieve a higher ratio of important true beliefs’. (ibid., p. 284)

    Imagine a situation in which an individual glimpses an item through the trees. It might be a bear or a rock. The terms `bear’ and `rock’ are placeholders for two categories of items: dangerous and harmless. The following table illustrates the possible outcomes in a matrix across what the item actually is and what the observer believes it to be.

    Case True Situation Belief T/F Value
    A) rock rock T good
    B) rock bear F bad
    C) bear rock F very bad
    D) bear bear T very good

    The column headed `Value’ indicates the quality of the outcome for the observer. Note at once the strong asymmetry in the cost of error, where it exists. If A). the observer sees a rock and believes it to be a rock, this is a good outcome: no action need be taken. If B) the observer sees a rock but falsely believes it to be a bear this is a bad outcome but not a disastrous one. Perhaps the observer will needlessly take avoiding action and dissipate some energy.

    The worst possible outcome C) is where the observer sees a bear but falsely believes it to be a rock. This is dangerous and is the situation one would expect to be minimized in successfully reproducing individuals. The best outcome is D) where a bear is seen and correctly identified as such: avoiding action can be taken. Note that we are merely classifying the perceptual outcome: so D) is a good perceptual scenario despite the fact that the individual might in fact be better off overall if there were no bears around at all.

    Case A) is fine for the subject but relatively uninteresting. Note that natural selection will act only weakly against belief formation mechanisms that are only somewhat positive or negative and will not act at all if they are not harmful or beneficial. Thus a subject persistently misidentifying items within a category will not be selected out to the first approximation, though this may still occur if it produces a second order effect producing a higher error rate in the dangerous category: an example of this would be a subject performing sub-optimally on bear recognition via misidentifying trees as rocks in a scenario where bears frequently live in trees.

    A similar table is shown below to explain the emergence of dominance hierarchies in animals. (S H Vessey, Dominance among Rhesus Monkeys, Political Psychology, Vol. 5, No. 4 (Dec., 1984), pp. 623-628) These do not develop solely through combat; some combat avoidance is more optimal than for groups to lose members through constant deadly competition. This indicates that the previously given bear/rock example is not the only exemplar of this type of argument. The test proposition is p = `I will win this combat’; and C is true if the animal opts for combat.

    Case True Situation Belief T/F Option Value
    A) p p T C good — won
    B) p ¬p F ¬C bad — missed win
    C) ¬p p F C very bad — lost
    D) ¬p ¬p T ¬C good — avoided loss

    It is known that animals will avoid combats they believe they would lose, and also err on the side of caution. This means they will accept some B) cases in order to avoid any C) cases. This is the worst and potentially fatal outcome wherein the animal falsely believes it will win: i.e. a Sensitivity failure. The argument is unaffected if animals do not in fact have beliefs but merely act as if they do, presumably by some heuristics which also will track the truth if they are optimal. The asymmetry results from the fact that the animal needs to win some combats, though not all, but must avoid all serious defeats. Animals relying more on Sensitivity are more likely to survive.

    It may be noted that there is a minor asymmetry between the two tables in that the two success cases are described as `good’ and `very good’ in the first table, while both are simply `good’ in the second table. This disparity hides nothing major about the account, which is not committed to the strengths of the asymmetry as opposed to the existence thereof. It simply reflects that fact that avoidance of combat carries significance for the establishment of dominance hierarchies in animals. Winning is certainly the best outcome, but avoiding a loss may not be too far distant a second best. However, in the case of the first table, it seems very clearly less valuable to identify a rock correctly than to identify a bear correctly because there is little purposeful interaction with rocks.

    Error Asymmetry In Self Beliefs

    Delusionally positive beliefs about the self can be beneficial if they relate to mental capacities; false beliefs about some physical capacities would be harmful. The table below shows the payoffs. The test proposition is p = `I am smarter than the rest’. In p, the term `smart’ may be replaced by any beneficial mental quality.

    Case True Situation Belief T/F Value
    A) p p T good — accurate view of smartness
    B) p ¬p F bad — underestimation of smartness
    C) ¬p p F very good — `bluffer’s bonus’
    D) ¬p ¬p T bad — missed bluffer’s bonus

    The term bluffer’s bonus is used to indicate situations of the type where poor students have an unrealistically high belief in their own prowess and thus in fact do better in an exam because they are not discouraged from working by an accurate perception of their likelihood of failure. Since exams did not take place in evolutionarily relevant times, we would need to consider positive mental qualities such as problem-solving ability. Persons with an unrealistically high assessment of their own skills might obtain the bluffer’s bonus by persisting longer with a difficult task.

    Alternatively, some types of physical capacity could be used, such as `I can cross this difficult terrain without food or significant discomfort’ while avoiding any risks in the area of unrealistic views of combat prowess. The bluffer’s bonus may additionally be adaptive because it aids deception of others in relation to ones own capacities.

    Challenges To Nozick


    The ideas of Sensitivity and Adherence may be paraphrased as below.

  • Sensitivity: avoid too many positives i.e. minimize false positives
  • Adherence: obtain all the positives i.e. maximize true positives
  • If we take the scenarios in which a bear is present, then Adherence is more important than Sensitivity. We want to detect all the bears and can handle some false alarms. The situation is reversed for the scenarios in which a rock is present however: Sensitivity is more important than Adherence. A failure of Sensitivity means that were a rock not to be present (and so a bear is present), the observer would fail to recognize the danger presented by the bear. A failure of Adherence means that the observer is needlessly scared by a rock. This may be slightly deleterious in that it could distract from more useful pursuits or lead to a propensity to react less when faced with an actual bear, but is certainly much less dangerous than failing to recognize the actual bear.

    So far the bear/rock scenarios are neutral for Nozick. Sensitivity and Adherence both play important roles in the two possibilities. However, the question then becomes one of the prevalence of bears and rocks in the evolutionary environment, or the relative proportion of dangerous to harmless items. Since we are here, and also this is the case now, there is a strong presumption that in fact there were far fewer bears than rocks. Therefore in the situation as it obtains, and presumably has done throughout the evolutionary period, Sensitivity is more important than Adherence.

    Nozick’s response here will be the one outlined in the Introduction. Sensitivity may indeed be more important than Adherence to the extent that it is more likely to produce knowledge, but this is not sufficient to delineate the transition from practical importance to relevance for epistemic assessment. We might have an argument that shows that one or other of Sensitivity or Adherence is more beneficial evolutionarily. This could perhaps show that we are more likely as evolved creatures to rely on Sensitivity or Adherence.

    But it would still be possible that there is a different sense of `importance’ to be considered in deciding whether s knows p. Even if in the actual world, one of the conditions was operative far more frequently, this could only show that knowledge was approached in the actual world more frequently via one condition. However, the importance for Nozick would be outlining the shape of knowledge as it extends out into near and far possible worlds, or more precisely what shape our counterfactual beliefs would have to take in reasonably close possible worlds in order to qualify as knowledge in the actual world.

    Omniscient beings would have beliefs that tracked the truth in all possible worlds. Fortunate mortals who happened merely to have true belief do not qualify as having knowledge because they would cease to hold the belief in very close possible worlds. We have not evolved omniscience, but on Nozick’s picture we have evolved to have beliefs that are somewhat robust out to some distance in the space of possible worlds.

    Another possibility for Nozick would be to observe that positive items have not been considered, and to claim that inclusion of these would alter the picture. We may term these `apples’: the category can stand for any useful or nourishing object. It seems here that neither Sensitivity nor Adherence will play a major role. Failing to spot an actual apple will not be greatly harmful providing plenty of apples are still detected. Misclassifying something else as an apple will similarly be unlikely to be grossly harmful as the error will be detected fairly shortly. In any case, the same argument can be made that positive and negative items alike will be much less prevalent than neutral ones and so the inclusion of positive items likely does not alter Nozick’s position in either direction.

    Bluffer’s Bonus

    The most significant case is C) in which the Bluffer’s Bonus is obtained. This can result in substantial out-performance. In this case, Adherence has not been operative. The other case of false belief, B), involves a failure of Sensitivity. This outcome is unhelpful to the participants who are unrealistically pessimistic about their performance prospects, but since they are in fact highly capable, they will do well providing the pessimism remains within bounds.

    Nozick can admit that in this set of cases, Adherence has played the more important role. He can then note analogously with the previous set of bear/rock cases that inverting p to `I am dumber than the rest’ will invert all of the value entries and Sensitivity will become more important. We would then need a way of assessing whether euphoria or depression have been more common in order to decide the relative practical importance and this seems a difficult task.


    In addition, Nozick may be able to rely on potential ethical implications of his account. This becomes relevant from an evolutionary perspective because there is some evidence that altruistic behavior is adaptive. This appears counterintuitive because altruism means giving up resources for no apparent gain. And yet altruism could evolve in groups — even non-interrelated ones — because of the benefits to be gained from mutual assistance.

    After having developed his tracking account of knowledge, Nozick extends the tracking analysis into ethics (ibid., p.291 by noting that ethical behavior should track rightness. In this new context, Sensitivity may be approximated by `we should not do those things which are not right’ and Adherence by `we should do those things that are right’. No clear answer can be given as to the correct picture of ethics, but it is clear that any version which only uses one of these principles would be very different to the duplex account. Sensitive but non-Adherent ethics would prohibit murder but permit negligent slaughter while Adherent but non-Sensitive ethics would mandate saving drowning babies but remain silent on murder. To the extent that those characterizations are correct and to the further extent that we have any evolved ethical behavior, Nozick has a further line tending to show that evolution favors retention of both conditions.


    A different line of argument can also appear to produce differential levels of importance for Sensitivity and Adherence, though this time leading in the opposite direction of giving priority to Adherence. This relies on Nozick’s observation that close possible non-actual worlds can influence the evolution of our belief-formation mechanisms. Without moving too far in the direction of Lewis’ modal realism, this can be understood as allowing for some flexibility to adapt to changing environments. Clearly creatures with excellent belief-formation mechanisms in the actual world will not be as fit as those which in addition, would retain such mechanisms in close possible worlds. Such creatures would be robust in changing environments.

    If Nozick’s account of knowledge is correct, then this should mean that we have beliefs which are Sensitive and Adherent over some range of close possible worlds. There is some expenditure of evolutionary capital as it were to provide additional capacities and these do not produce compensatory payoffs in the actual world until it changes. This means that there will be a limit to the remoteness of possible worlds which can influence the development of belief-forming mechanisms. Intuitively, this just means that creatures with abilities to form correct beliefs about extremely implausible developments from their current environment will not be favored.

    The asymmetry between Sensitivity and Adherence can now be seen. Adherence is tested in closer worlds than Sensitivity because p is true in the actual word. Intuitively, the two conditions combined require that beliefs (Sensitivity) switch off in worlds where $\neg$ p but (Adherence) not before then. Nozick’s response here will be to rely on the flexibility inherent in the possible worlds approach. He can insist that the objector provide an account of why the range of evolutionarily relevant worlds is smaller than the distance to the nearest $\neg$ p worlds.


    It seems that Nozick is able to head off any evolutionarily-based challenges to his account of knowledge: we could have evolved to be Sensitive and Adherent.

    Buchanan On The Content Of A Human Right To Health Care


    Buchanan examines potential methods of specifying the content of the human right to health care. There is throughout his work a recognition of the importance of the claim that restricting any right to health care solely to medical care is misguided. It is very plausible that health care needs are best served by an approach including additionally extra-medical effort in public health such as sanitation and vaccination programs.

    Buchanan has throughout his papers been very clear that a `right to health’ and a `right to health care’ are very different. The former suffers from manifold difficulties including issues around preventing an explosion of resource use but in addition, that of how one would define the target standard to be reached. If this is set at the highest possible level, then it will be fantastically expensive. If on the other hand it is set below that level, then some people will be able to use private resources to improve their position, which could be seen as unfair. It is notable that in the chapter currently under discussion, Buchanan weakens his opposition to a right to health significantly whereas in his other work, he has been clear that only a right to health care can reasonably be considered.

    Buchanan argues that attempts to define the precise scope of a right to health care have been misguided, and in any case unsuccessful. This putative right is necessarily vague and only appropriate political procedures should be used to specify the content.

    There are also prior questions as to whether human rights exist at all, and why, and there is of course a major set of difficulties around conflicts of rights both within rights to health care and between that right and other rights. Buchanan notes two features he assesses as being essential to all human rights claims, as below.

  • `Rights’ claims are stronger than desirability/goodness claims (i.e. `A has a right to X’ means `A is morally entitled to X’)
  • Human rights are universal in the sense that they `are held by people simply as people’.
  • This paper will fall into two major sections. Firstly, Buchanan’s arguments will be summarized with some brief expositional commentary. In the final section, more detailed comment and criticism will be provided.

    Buchanan’s Arguments

    Right To Health Care, Right To Health

    A right to health care is too narrow. Health is a complex issue which includes a myriad of other influencing factors such as poverty. Since it is well-known (Malat, 2005) that poverty brings with it a host of adverse health effects, simply giving the same amount of care to everyone would have widely disparate results. A further complication arises because of the bidirectional causality likely involved: some have suggested that health is best fostered by addressing the issue of poverty (Kevany, 1996) while others wish to reduce poverty by promoting health (Weil, 2007).

    Consideration of the fairness of those disparate results would involve consideration of the yet more intractable and even potentially taboo political issue of the extent to which the poor can be said to be deserving or undeserving. Attempts to justify restriction of resource use on the poor often founder on `genetic lottery’ type objections: I may deserve my lack of resources because of the unintelligent way I have administered my life choices, but to what extent can I be said to deserve my intelligence level?

    On the other hand, a right to health is too demanding — it is an impossible standard to meet even in wealthy countries. For example, as technology develops, babies born at ever more extreme levels of prematurity become more viable (Holmstrom, 1993) at some expense. The viability at various degrees of prematurity could be increased considerably but this would have substantial resource implications.

    There are two reasons to attempt to find an acceptable interpretation of a `right to health’. There may exist a practical basis: major human rights treaties assert a right to health. In addition, it is undeniable that health is complex, and includes factors other than medical care.

    Further, there are two ways to understand a `right to health’ as including a `right to health care’. We could understand a right to health as shorthand for some specific requirements (including a subset of health care). This accepts the following definition to a limited extent: a `right to health’ is the same as `rights to services rendered by health care professionals to individuals or populations’. If so, this includes preventative or curative treatment.

    Alternatively, `basic human interest is so important as to justify asserting a social obligation to satisfy that interest’. This would include rights to health care and rights to a healthy environment as parts of a right to health.

    Arguments Against A Human Right To Health

    Cranston (Cranston, 1973) argues that civil and political rights are universal but social and economic rights are not. This is for two reasons. Firstly, social and economic rights cannot be implemented easily (i.e. via simple legislation) and providing them would be expensive. Against this, it may be said that the issue of limited resources arises for civil and political rights as well, and requires enforcement (e.g. rights to a fair hearing and prohibition of torture).

    But secondly, according to Cranston, social and economic rights are not of `paramount importance’, but are merely goals (such as rights to holiday pay). Cranston argues that the divide between civil/political rights and social/economic ones is analogous to the division between duty and charity. Such giving may be desirable, but there is no absolute moral obligation.

    Buchanan’s complaint is that Cranston simply labels social/economic rights as best supported by charity without providing an argument for this. Also, Cranston cannot avoid the fact that government expenditure is required even for civil/political rights.

    A further problem noted by Cranston is that there is no readily identifiable duty holder. Cranston assumes there can be no rights that cannot be readily provided by identifiable parties. Buchanan again wonders whether this not also true of civil/political rights. And in any case, rights respecting institutions could and in Buchanan’s view should be developed to uphold them.

    Justifying A Human Right To Health Care

    Buchanan describes three attempts to perform this task in the literature and dismisses them all.

    Basic Needs Argument

    This section focuses on health care as a basic need. Human rights are `generated by a basic set of needs shared by all people’. Basic needs are defined as those essential for survival. However, this is both too narrow and too broad. We need quality and quantity of health as well, and it is impossible to provide all care needed for everyone to survive.

    An alternative definition of basic needs as being those required for minimum security is examined; Buchanan credits David Ozar with this approach. The argument relies on the fact that without the freedom to attend to needs other than survival, a person cannot live a life that fulfills human capacities.

    However, this is not well defined enough to specify content for a number of reasons. New technology is constantly becoming available; threats to health vary geographically; and the approach does not tell us whether people have a right to life-maintaining care (e.g dialysis).

    To assure survival over time may require much health care, but surely no rights exist for everyone to receive transplants as needed. Liver transplants are frequently refused to persons who would doubtless benefit from them, because others would benefit more and there is a scarcity of organs available for transplant. It seems that under all foreseeable circumstances, such a right would always be impracticable. Buchanan concludes therefore that the right to health care is not survival-related.

    Human Dignity Argument

    In the section entitled `Health Care and Human Dignity’, Buchanan notes that the view implied in public documents such as the UDHR (General Assembly, 1948) is that `human rights are those moral entitlements that respect human dignity’.

    But this still does not solve the problem of needing to come up with a plausible list of basic human needs. And what is `human dignity’? If it is something like `suitable conditions for humans’, then it equates human dignity to possession of human rights. This obvious circularity means this approach is not valuable in defining rights.

    Health Care as a Basic Right

    Buchanan cites an argument due to Shue that basic rights underpin other rights. One cannot enjoy freedom of assembly without also enjoying the right to physical security. Many countries around the world enshrine the right to free assembly in theory, but employ state or semi-state personnel to inflict violence on persons exercising that right.

    Shue has a tripartite definition of relevant rights in the areas of security, liberty and subsistence. The latter includes health care and public health measures. The problem is that the approach allows an uncontrolled expansion of basic rights such that effectively all rights are basic. For example, the right to effective political participation implies education, a free press, free speech and other rights and so the term basic comes to apply to all human rights

    And moreover, even if health care can be shown to be basic in Shue’s sense, this does not give us a specification of the content.

    Justifying The Human Right To Health Care

    Finally, Buchanan essays his own attempt at producing a justification because none of basic needs, human dignity or basic rights arguments have successfully specified the content of a right to health care. Buchanan attempts instead to argue that human rights are moral claims based on basic human interests. Equal consideration for all persons is `fundamental to morality’. Everyone has an interest in being healthy.

    The Content Of The Right To Health Care In International Law

    The attempt of Toebes (Toebes, 1999) to specify content begins with the phrase `irrespective of available resources’. Buchanan describes this as `inexcusable’ on the grounds that it does not supply a rationale for the specification of content and in addition leads to obvious resource issues.

    Toebes then supplies a lengthy list of desirable outcomes in the areas of family planning, immunization, drug availability, water, sanitation and environmental quality. There is no question that these are all beneficial; but making them rights does not seem helpful when they simply cannot be provided in many parts of the world.

    The international law approach also fails to be country and situation specific: malaria is an issue in sub-Saharan Africa but not Arizona. And Buchanan observes that international law fails to allow for cultural differences. He also cites religious objections to population control, in the form of a boycott by Islamic countries of an international agreement to that end. The claim was that family planning interferes with matters more properly controlled by a deity.

    Buchanan’s final fall-back position is that appropriate democratic procedures should be used to specify the content of health care rights.


    Buchanan closes the chapter with an acknowledgment of limitations in the analysis and the call to apply democratic machinery to the problem. If we define global rights in the context of resources available to poor countries, those rights will be minimal. If we do not do that, the rights will be unaffordable.

    This may in fact mean that unequal resource distribution globally is the root problem. Buchanan concludes that the international context is the right one in which to examine the right to health care.


    Basic Needs Argument

    Do we accept Buchanan’s reasoning for rejecting health care as a basic need in the survival version as sufficient? We do after all provide major surgery and other treatments to prolong life on the NHS. Many people would intuitively respond to this type of safety net argument. Even in the US before the recent reforms, the uninsured are treated in emergencies at the expense of others. Apparently each insured person pays $1,000 extra to cover the uninsured (White House, 2009).

    Buchanan might also observe that examining questions of survival scarcely seems relevant in wealthy countries where people do not as a rule face starvation.

    Alternative Derivation

    Could Buchanan derive a `right to health care’ from a `right to life’ and abandon a `right to health’? A `right to life’ appears in the UDHR along with `liberty and security of person’ so one might think that the framers intended it more as a prohibition on states employing (arbitrary) execution. If that is the case, it would be probably too strained to move it in the direction of health care, especially when that issue is separately treated in article 25.

    Taking Rights Seriously

    Should the word `rights’ be interpreted in a very restricted way such that if people have them, strenuous efforts should be made to permit their exercise including allowing for such ends impingement on others’ freedoms? The more rights there are, then the more frequent conflicts of rights will be, and thus the more rights will be infringed, since any conflict resolution will not allow full expression of all rights in conflict. This weakens the view that rights as a term should be reserved for strict entitlements — the provision of these should be of the highest importance. Systems in which conflicts of rights proliferate promiscuously weaken the very term `rights’ beyond meaning.

    Expense Distinction Between Civil/Political and Social/Economic Rights

    Cranston argues that there is a distinction between civil/political rights and social/economic rights based on the differential expense of providing the two. Buchanan counters by noting that provision of the former also costs money because of the need to provide impartial courts, prisons and police services among other public goods.

    But this is surely too quick. Public expenditure in the UK under the social/economic heading dwarfs spending in the area of justice. The following departmental spending levels relate to the UK in 2010/2011 (Chancellor, 2010a)

    Government Department Planned Spending
    Justice £8.9bn
    Home Office £10.1bn
    Home Office – Police £9.7bn
    Department for Work and Pensions £158.6bn

    It should be noted that there is in addition substantial welfare spending in regional departments amounting to approximately a quarter of the central Department for Work and Pensions figure, such that total welfare spending was £192bn at the time of the June 2010 budget (Chancellor, 2010b} To favor Buchanan, one might assume that the entirety of the Home Office non-police budget is spent on providing civil/political rights for citizens, which is not the case because significant Home Office expenditure relates to such matters as processing claims of asylum seekers and accommodating them. Even then, it is clear that social/economic rights spending is much larger than civil/political rights spending.

    Since the quantum of resource required for providing civil and political rights is much less than that required to provide social and economic rights, and even if it transpires that provision of the former is still unaffordable, that scarcely provides an argument to attempt to provide both.

    It might be countered here that failure to provide a right in practice does not remove that right. For example, if someone is burgled, we do not therefore conclude that they do not enjoy a right a personal security. We say on the other hand that they have a right which has been violated. The state attempts to ensure that such violations do not occur but cannot eliminate all such violations.

    The distinction seems to be the particular level of utopia which must be enjoyed wherein the right can be realized. If such a utopia is in fact extremely remote, then it seems meaningless to insist that a right which can only be made available in nirvana exists in the real world. Some societies, for example Japan, do manage to reduce burglary to very low levels — whether by enforcement or culture is besides the point. Whereas no earthly society could provide a wide array of social/economic rights because the resource commitment involved would detract from the social/economic position of others, and thus impinge on their own social/economic rights. No one has the right to be a burglar.

    Agenda Change

    Can we justify bringing `rights to health’ as opposed to `rights to health care’ back on the agenda? Buchanan has rightly attacked Toebes for her use of the phrase `irrespective of available resources’. Any defenses of such lines fail, if they proceed by noting that some rights may be respected and the statement that they must be can be placed after that phrase. For example, an objective may be specified as follows: `irrespective of available resources, anti-discriminatory policies must be implemented’.

    This argument fails because while strictly speaking nothing false has been said, there is a strong implicature that anything occurring after the phrase will in fact involve expenditure. And then resource constraints become operative. If anti-discrimination policies can be implemented successfully without cost, then the phrase is irrelevant. Otherwise, it suffers from the usual problem and permits no expenditure on other priorities.

    `Effective’ Participation

    What does `effective’ mean in Shue’s argument that there is a basic human right to `effective political participation’? Does anyone ever satisfy it, given the microscopic impact of any single voter on any given national question? (It must be noted that this objection is more in the character of challenging Shue and thus supports Buchanan’s position.)

    Foundations Of Morality

    Can we hold that equal consideration for all persons is `fundamental to morality’ from the perspective of a wealthy country without eliminating morality?

    It is likely that many readers will be located in relatively prosperous nations. Even in those nations, equal consideration is not much in evidence. If we consider the wider world, it seems hard to argue that rich countries are acting with equal consideration for persons who are not their citizens. Any argument attempting to justify this would run the risk of claiming basic human rights which exist for all people but only if they are in possession of the right type of passport.

    If then there is no equal consideration, and that is foundational to morality, then morality rests on unstable ground.

    Buchanan’s Basic Interests Argument

    This argument seems to be susceptible to all of the criticisms Buchanan has made of the other three attempts he identifies in the literature; it is thus difficult to allow that he has been any more successful. This failure is perhaps tacitly acknowledged in the fact that Buchanan’s final position is to leave the problem to democratic institutions.

    Buchanan’s approach again does not provide a specification; also everyone has other interests we do nothing about.

    International Law

    Is looking to international law to specify rights following the right direction of causation? It might be more appropriate and certainly would be when working from a philosophical viewpoint to have some more well-founded justification of human rights or to allow that there are none if no argument can be provided.

    In defense of Toebes, it might be said against Buchanan that she is simply taking a legal approach. If one accepted the UDHR as binding, then article 25 is compendious:

    “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”

    This would suffice for a lawyer to say that the rights exist, because in legal terms it is indeed sufficient for a right to exist that an appropriate document thus specifying has come into force. But law and reality are distinct, and it is clear from the discussion that in fact the aims of article 25 are some distance from realization.

    Deciding whether the UDHR is binding is itself a major question. The initial document itself is not binding; it has no signatories. It was however ratified in the General Assembly by 48 votes with 8 abstentions and no votes against; further, elements of it have been incorporated into national law.

    Public Documents

    Buchanan may be able to respond that he does not actually run the argument himself that rights exist because they are listed in documents such as the UDHR, as opposed to merely discuss it. Anyone who does take that line runs the risk of arguing A therefore A, no matter how august and venerated a particular document is. At most, this could establish that current practice allows the existence of a particular right — even for such rights if any that are widely observed — and would say nothing as to the correctness or otherwise of the existence of that right.

    Historical Failure

    Buchanan appeals finally to democratic institutions to specify content, but this leaves him open to the question as to why, if democracies can solve the problem, they so far have not. The alternative would be to accept that the status quo, at least in democratic nations and perhaps in reasonably wealthy ones, is optimal. Were that the case, we would be justified in wondering why we have been reading this book and why it was written.

    In addition, existing situations do strike a balance between common provision and shared expense burdens, but may not do so optimally. Prior to the Obama health care plan, more than 30m Americans were uninsured, one in three Americans were without coverage at some point in any two year period, and one and a half times more was spent per capita on health care than any other country without there being any health benefits of the extra spending (White House, 2009). It remains to be seen what level of improvement will be provided by the reforms but it seems unlikely that they will solve all imaginable problems and even then, efforts at reform had been stalled in Congress since 1943. Indeed, at the time of writing, significant legal and constitutional obstacles were being created that could bar progress on implementation of the reforms.


    Should we take any account of religious objections? This is likely to be rather a sterile debate. The rationalist may argue that any irrational considerations should be ignored. Anyone opposing that viewpoint will likely fall into one of three camps. The first will be those holding religious viewpoints, who are not susceptible to rational argument. Otherwise the claim that family planning would interfere with divine prerogatives would fall foul of the objection that any omnipotent being would not find such measures (or indeed anything at all) a hindrance.

    The second camp will be those who do not hold relevant religious views themselves, but would like those of others respected. The final camp will be those who do not hold religious views and are less concerned about respecting those of others, but are merely pragmatic about the prospects of generating international agreement without taking note of non-rational considerations.

    It seems likely that argument will not serve to move people from one camp to another, and will not shift people from their religious views, despite the likely health benefits thereof. In the UK, there would be more organs available for transplant were the current `opt-in’ transplant consent system replaced by an `opt-out’; but it is unclear what reasons other than religious ones can be advanced against the more radical proposal that even the opt-out is futile and counterproductive for living people in need of organs.

    International Enforcement

    Should we invade non-democratic states to enforce the rights of their citizens? At what cost? Presumably if the `rights’ are taken very seriously, no cost considerations could be taken into account where an invasion could reduce rights violations. But even under more pragmatic analyses, it would seem that many invasions could be successfully mounted to depose unappealing regimes. This would then be the reserve justification for the invasion of Iraq, once it transpired that no weapons of mass destruction existed in that country. We may suspect that the type of political view that favors a wide definition of human rights and also strenuous efforts at fostering them would balk at such a conclusion.


    A Buchanan, Justice & Health Care, Oxford University Press, 2009, Ch. 9

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    M Cranston, What are human rights?, London: Bodley Head, 1973

    General Assembly of the United Nations, The Universal Declaration of Human Rights, 1948

    B Toebes, The Right to Health as a Human Right in International Law, PhD thesis, Intersentia/Hart, 1999

    Office of the White House Press Secretary, REMARKS BY THE PRESIDENT, September 9, 2009

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