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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=rept20 Educational Philosophy and Theory Incorporating ACCESS ISSN: 0013-1857 (Print) 1469-5812 (Online) Journal homepage: http://www.tandfonline.com/loi/rept20 How to do things with words: Speech acts in education Renia Gasparatou To cite this article: Renia Gasparatou (2018) How to do things with words: Speech acts in education, Educational Philosophy and Theory, 50:5, 510-518, DOI: 10.1080/00131857.2017.1382353 To link to this article: https://doi.org/10.1080/00131857.2017.1382353 Published online: 05 Oct 2017. Submit your article to this journal Article views: 59 View related articles View Crossmark data How to do things with words: Speech acts in education* Renia Gasparatou Department of Educational Sciences and Early Childhood Education, University of Patras, Patras, Greece ABSTRACT Originating from philosophy and science, many different ideas have made their way into educational policies. Educational policies often take such ideas completely out of context, and enforce them as general norms to every aspect of education; even opposing ideals make their way into school's curricula, teaching techniques, assignments, and procedures. Meanwhile, inside the actual classrooms, teachers and students are left in limbo, trying to comply with, techniques, evaluation forms and a growing technical educational vocabulary. Here I would like to propose an antidote to this absurdity by reminding us what teachers and students already know. Such an antidote can be found in J. L. Austin's speech act theory. In this paper, I propose we revisit speech act theory and treat it as an educational theory. That might help us dismantle false dichotomies troubling education for decades. The point is not that the discussion over educational policies and priorities should stop, but that it should be kept in appropriate perspective. A modified speech act theory can help us facilitate such a perspective. Introduction Originating from philosophy and science, many different ideas have made their way into educational policies. For example, the cognitive agenda prioritizes disciplinary knowledge, promoting subject-based curricula designs; on the other end of the spectrum, the enhancement agenda aims at personal happiness and emotional flourishing; such a view rather promotes learner-based curricula designs and may even invite positive psychologists to inform educational policy. This is not the end of the story. A naturalistic model suggests we view ourselves as natural beings with brains, hormones, neurons and genes interfering with our personal growth; thus, we need some neurobiology to inform educational practice. The situated cognition or situated agency discussions highlight how our familiar social, political, cultural environment shapes us into what we are. An autonomy ideal argues that education should nurture autonomous individuals, while the political ideal insists in cultivating a more humane society. The list is ongoing. Philosophers of education have long reflected on the frivolous aspects of these agendas (Ecclestone & Hayes, 2008; Edwards, 2012; Goldman, 1999; Griffiths & Tann, 1992; Haynes, 2006; Kristjansson, 2007; Schrag, 2011; Smeyers, Smith, & Standish, 2007; Smith, 2002; Standish, 2012a, 2012b; Suissa, 2008; Zevin, 2010). But even from the perspective of common sense, it is not hard to see that each of the ideas above has some merit; nor that they are all rather vague. Also, that none really qualifies as a general theory that you can apply to everything all the time. Or that, if you do take them as general theories, most would contradict the others. KEYWORDS Speech acts; emotions; performativity; J. L. Austin © 2017 Philosophy of Education Society of Australasia CONTACT Renia Gasparatou email@example.com An earlier version of this paper was presented in the 2016 PESGB annual conference. EDUCAtionAL PhiLoSoPhy AnD thEoRy, 2018 VoL. 50, no. 5, 510–518 https://doi.org/10.1080/00131857.2017.1382353 EDUCATIONAL PHILOSOPHY AND THEORY 511 What might be evident to common sense, however, can be perplexing to educational policy. Educational policies often take such ideas completely out of context, and enforce them as general norms to every aspect of education; even opposing ideals make their way into school's curricula, teaching techniques, assignments, and procedures. Meanwhile, inside the actual classrooms, teachers and students are left in limbo, trying to comply with evaluation forms, tests and a growing technical educational vocabulary that defy common sense (Ball, Maguire, & Braun, 2012). Here I would like to propose one more antidote to this absurdity by reminding us what teachers and students already know. Such an antidote can be found in J. L. Austin's speech act theory. In this paper, I propose we revisit speech act theory and treat it as an educational theory. In the next sections I will (i) summarize Austin's original speech act theory, (ii) highlight its relevance to education, and (iii) propose some revisions, so that it can better serve educational discussions. In the final section, (iv) I will just give some examples of how speech act theory might help us dismantle false dichotomies that have been troubling education for decades. The point is not that the discussion over educational policies and priorities should stop, but that it should be kept in appropriate perspective. A modified speech act theory can help us facilitate such a perspective. Educational acts Many have commented on the different roles of an educator (Britzman, 2009; Carr, 2003; Heck & Williams, 1984; Mulcahy, 2011; Smeyers et al., 2007; Standish, 2012a; Vick & Martinez, 2011; Watkins, 2011; Zevin, 2010). Educators are transmitters of information, facilitators for developing knowledge and skills, performers, researchers, professionals, morality coaches, authority figures, role-models etc. Each of these roles is vague and complex. Yet, any educator complies with all such roles easily, with their every speech act. Speech acts denote, according to J. L. Austin, the various things we do with words. Austin (1962) begins his How to Do Things with Words (HDTW) lectures trying to distinguish between two kinds of utterances: (1) constatives provide information, and (2) performatives perform certain acts. He soon undermines this distinction and claims that whenever we say something about the world, we also do something in the world. In fact, we do three different acts: (a) A locutionary act or locution: the act of pronouncing sounds 'with sense and reference' (Austin, 1962, pp. 92–98, 101, 102). I utter, 'Do this and you'll never see me again'. It is the act of communicating some kind of information, using the proper syntax and the right vocabulary. The information may be true or false. Note that the giving of information is also an act. (b) An illocutionary act or illocution: the act that I do in uttering this sentence under the specific circumstances. In uttering this sentence, I made a promise; or a warning; or a threat. The context mostly signifies which illocution was performed. (c) A perlocutionary act or perlocution: the act(s) that I do by uttering this sentence. I persuade you to do this or I get you not to do this; and as a further result you may or may not see me again. The perlocution involves the consequences of my utterance to the audience and may happen in the future. The context again allows you to interpret my utterance and mostly signifies which perlocution will be performed. Austin's distinctions between the three acts are again pretty blurry. So after a while, he insists that the three are indistinguishable. We need to grasp 'the total speech act in the total speech situation' in order to understand what's been said (Austin, 1962, p. 147). Reading How to Do Things with Words starts off with a feeling of frustration: Austin suggests a distinction and takes it back; then, he makes a new triple distinction; which he immediately, takes back again; and right after that, he implies it yet again, but this time he just focuses on the illocutionary act for the most part of the rest of his lectures. The performative force gives an utterance its meaning. Austin now outlines three main factors for the happy functioning of the performative: (a') speaker's intentions when uttering the sentence (b') the following of certain conventions depending on the context, and (c') speaker's authority. For example, if I say 'I do', I will manage to get married only if I am in an actual wedding ceremony and I am the groom or the bride. 512 R. GASPARATOU Speech act theory is supposedly applicable to all human communication. I believe, however, that the way it is set out makes it more appropriate for certain kinds of contexts. And education is probably its very best arena. First of all, the three major factors for the happy performance of the speech act, as Austin puts it, intentions, conventions and authorities, are clear most of the time. In formal educational contexts some basic intentions are clear, prescribed from the very start; the teacher has the intention to teach and the student has the intention to learn. Many other intentions may arise in the context of a classroom, but these two are the major ones. Formal education is by definition a conventional process; schools and universities have rules, procedures, deadlines, exams; and lots of role-playing within chains of command. Within this chain of command, certain people get to be authorized speakers at certain times; teachers, instructors, students have certain authority to speak at certain cues. With conventions, intentions, and authorities all set in place, education already meets the basic requirements for the application of speech act theory. Secondly, education provides a context in which all three dimensions of the speech act can be useful. (a) There is a huge amount of information to pass on. All kinds of information about art, physics, philosophy, math and literature are the locutions of such speech acts. (b) Education also invites students into form of life, to use a Wittgensteinian term; all kind of practices, like giving promises or warnings are conveyed; illocutions carry out this familiarization process. (c) Ideally, education also helps the young become better: autonomous, moral and happy, create a better society for all, etc.; education hopes to produce certain perlocutionary effects. Not all contexts can equally support a three-dimensional speech act. If I see you out on the street and say 'hi', I hardly pass on any information. If I do, it is getting through by the illocution (that is, by my tone and gesture), and not by the very sounds with sense and reference that I uttered, as Austin suggests. In ordinary conversations, not only the distinction between locutions and illocutions can be problematic, but also the distinction between illocutions and perlocutions. Butler (1997) is right to say that in cases of an insult, for example, it is not clear how the perlocution is distinguished from the illocutions that produced it. In educational contexts, however, such a distinction is both applicable and useful. Illocutions pertain to the speaker. Perlocutions pertain to the audience; they refer to the future and more permanent results of speech acts in the lives of the students: the things they know, the jobs they get, the buildings they may buld, their future selves, cities, and societies. The moment a student walks in a classroom then, they are open to new locutions; become vulnerable to all kinds of illocutions; as to perlocutionary effects, in a sense, these effects are what education is all about. Such a phenomenon may not be unique in the classroom; other contexts have the same effect too. For example, therapy or church can have the same effect for its believers. And yet, you don't have to believe in education for the same effect to happen. In the classroom, all the three dimensions of the speech act are pumped up; and all can be useful tools in order to look closely and analyze the different aspects of educational practice. Locutions point to all kinds of information we pass on; illocutions on all the many ways we use to do it; perlocutions on all kinds of results we get. Yet, education happens as the result of the total speech act in the total speech situation. That brings me to the third and most important reason that speech act theory is relevant to education: its dismantling power. Speech act theory may help us isolate and analyze different aspects of educational practice but it can equally show how closely these parts are interconnected. We can hardly speak for one dimension without pulling the others ones in as well. In order to fully explore speech act theory's dismantling power however, a small modification is needed. The original speech act theory is totally blind to the emotive force that is present in all our utterances (Gasparatou, 2016). In fact, emotions are intertwined with intentions and conventions, hence influencing the whole speech act spectrum. And in order to allow education to happen, we need to acknowledge the emotional element of speech acts. EDUCATIONAL PHILOSOPHY AND THEORY 513 Strengthening speech acts' dismantling power It is rather surprising that Austin talks about all the things we do with words without even mentioning emotions. Today, there is some literature implying a relation between speech acts and emotions. Robert Solomon notes a parallel between the two; emotions, he says, are the 'preverbal analogs of what Austin called 'performatives'- [they] do something in the world rather than simply describe [...] a state of affairs' (Solomon, 1993, pp. 135, 136). Butler (1997) talks about excitable speech, commenting on the power of language to hurt. More recently Stanley Cavell draws a distinction between performatives on the one hand and passionate utterances on the other; an utterance gets to be one of those two kinds (Cavell, 2006, pp. 19, 155–192; Munday, 2009). My suggestion, however, is different: every utterance has an emotive force that adds to its meaning (Gasparatou, 2016). The total speech act in the total speech situation relies on and brings on emotional forces all around. Attending the emotional force within our utterances can allow us to further undercut the distinction between locutions, illocutions, and perlocutions, that Austin already undermines. It moreover allows us to dismantle the distinction between intention, convention, and authority; Austin demands all three for a happy performance of the speech act, and he never questions their limits. The context of a classroom is an ideal setting to see how emotions influence all three and blur even this final distinction. Just think of your elementary school teacher. Since then, you have probably met people with far stronger authority and yet, very few can encourage you, advise you, or disappoint you as that teacher could. Authority is not just about the power structure of the relationship, but also because of the emotions that are in play. Emotions authorize or de-authorize. Especially in educational contexts, you need a certain set of intentions and emotions in order to perform educational acts. Being a teacher comes with a recommended emotional repertoire. For example, I have to care about my students; it is OK to love them; it is forbidden to fall in love with them. Step out of this prescription and you are hardly recognized as a teacher. Now, in a classroom, a student is typically encouraged to do lots of math, permitted to learn some philosophy and totally discouraged from going fishing. Speech acts like the above are intentional, even though a teacher might perform them without being fully aware of it. I might say 'aren't you happy now' and perform any of the above; which one I perform depends partly on my emotions. Speech acts are parts of our educational strategy and such strategies come out through the emotional shades that our utterances reveal. Such strategies moreover are tied up with all community's conventions and activities; to grasp them implies you have grasped the community's habits, its emotional repertoire, and its rules (Harré, 1986; Solomon, 1993). Real life conversation, with all its implicatures, gives rise to the social world, its practices and its rules (Harré, Moghaddam, Cairnie, Rothbart, & Sabat, 2009; Schatzki, 1996); and education is part of this conversation. Education moreover, provides the young with paradigm cases for the application of social rules and strategies. We can hear a teacher say 'this is not acceptable behavior'. If this is a reaction to bullying, the speech act will typically be very different than if they react to someone eating while they teach. They might get angry in both cases, but it will be a very different kind of anger. Emotions underline very subtle distinctions of appraisal that typically reveal communal values. Moods, personal values, intentions, but also customs, communal practices, even stereotypes, and biases are expressed by our emotional speech acts. If the happy performance of a speech act then, relies on intentions, conventions, and authority, emotions underlie all three. In fact, adding emotions to the speech act theory might enable it to better account for all human communication. Again, however, it serves better as an educational theory. For education prescribes the norm. Norms run with emotions anyway, but again the effect is maximized in educational contexts. If for example, we are in at a dinner party and I drop some wine on your trousers, I ought to apologize. If I am the teacher in a classroom, however, and I spill ink on a student's trouser, I must apologize. My reaction implies the norm; what I should feel, what I should say, how I am to say it; and also how you are to take it. 514 R. GASPARATOU Under the magnifying lens of an educational setting, emotions influence the whole speech act spectrum. They influence illocutions and perlocutions, for both the speaker's and the audience's evaluations, interpretations and reactions are crucial here. And interpretations are open; you might feel insulted and angry, even when I didn't mean to insult you at all. And the more important the encounter is to you, the more you struggle with interpretations. Hence, interpretations change; what you found insulting at first, might, on second thought, seem like a warning. Whatever my illocutionary intentions were then, the perlocutionary effects of my speech acts are not entirely under my control. Part of this control lies with you. That is why the same speech act can have many different effects on different students. Moreover, failing to produce the intended act does not mean that you fail to produce any act. You may intend to inspire, yet manage to intimidate, putting in motion a whole set of other perlocutionary effects. Or you may produce the same effects either way. There is a certain amount of indeterminacy in teaching that is partly explicable by the elusiveness and the complexity of the emotive forces within our speech acts. Illocutions and perlocutions are related to emotions and can subscribe to the performative aspects of education, but the same also holds for the cognitive aspect that relates to locutions. Giving information is, according to many, the primary aspect of education. Austin implies that the delivery of information is also an act. And, may I add, this is not unrelated to emotions, values, and intentions either. We typically teach math and not fishing mostly because there is a stronger value attached to math. Certain pieces of information and reasoning skills are important because we expect that our students' choices may depend on them (Goldman, 1999). Here I am not going to discuss whether we are always right in the value we attach to each subject, or whether education should include more. I just want to point out that the locutions of teaching are performative at two levels at least. First, a teacher's locutions imply what he or she acknowledges as worth learning. And second, while passing on this information they expect to influence students. We only teach what we value, and we value it because of the desired effects it hypothetically brings. Locutions are indeed significant then because they are performative. The effect of our teaching depends on the information conveyed. A math teacher is supposed to teach students some math; a philosopher teacher is supposed to teach students some philosophy. We cannot enhance our students (emotionally or otherwise) if we deprive them of correct and useful information. However, the way the information comes out is crucial for its being grasped. Some manager or minister of education might try to present a new curriculum, and publish a new set of obligatory textbooks for school: they want to change the information to be delivered. For there is definitely a lot of performative implicature within information; a lot of performative implicature regarding which history book you read, on how many hours of literature or technology you allow schools to have, or on which novel you use in classroom. However, no matter how many curricula or books you change, one cannot change perlocutionary effects without changing teachers' emotive performance as well. Whatever you may impose on a teacher to teach, they are going to influence the information with their teaching, and their actual physical performance in the classroom (Watkins, 2011; Zembylas, 2016). So, if the point is to have less or more patriotic history lessons, for example, you don't just need to change the book, but also the attitudes of the teacher. The very delivery of information influences what is taught. In fact, intentions, emotions, and attitudes influence information so much and in so many ways that sometimes one may not relate to certain pieces of information at all. After all, this is one of the reasons why we have political correctness language rules in schools. Stereotypes, however, can always find their way into the classroom. Imagine a literature teacher who never asks boys a question, whereas she dialogs about literature with girls all the time. There is surely some performative force there, even if neither the teacher nor their students realize that. The solution yet is not to ban the performative force of teaching (Mulcahy, 2011; Standish, 2002; Vick & Martinez, 2011; Watkins, 2011; Zembylas, 2016). For, if I do not relate to the information in some performative way, I might not even listen to it. Take online learning platforms for example. E-learning is very hip and one of the arguments in favor of it is that it excludes some of the downsides of faceto-face teaching, such as sexist or racist biases (Khan, 2016; Meier, 2007). MOOCS and e-classes were explicitly designed to exclude illocutions for all the bias that they carry. Together we may have missed all the performative force that allows for student-teacher relation; or even a simulation of a relation, EDUCATIONAL PHILOSOPHY AND THEORY 515 an illusion or a fantasy of looking up-or down-to that person in front of you. Banning the illocutions and the emotions that drive them, we also ban the possibility for an actual involvement of both parties in the educational practice. It is not surprising then, that more and more, there is a tendency to simulate a face-to-face teaching experience. We no longer just have explanatory power points or animated lifeless models; now we also include video lectures, sometimes recorded in real classrooms so that the student can accompany the information with some performative force. And we have even made-up other ways to perform illocutions; chat rooms that came together with the invention of emoticons and acronyms, such as LOL, from the very start. Education relies on some kind of relation between the speakers. And a relation, even a bad or weak or illusionary one, depends on the emotions and the attitudes of both parties. This is an extra burden one cannot get rid of. We have to embrace it and work through it. We can change our attitudes, but we cannot extract them from our educational acts. All this implicature of attitudes, intentions, conventions and emotions itself transmits information; it is full of content about what is acceptable, enjoyable, insulting or about how one is supposed to behave or react to this or that practice. Even mere performance without verbal locutions carries information, very crucial information indeed. Not only the informative is performative then, but also the performative is informative. Moving beyond dichotomies Speech act theory can help us analyze the main different aspects of education, without losing sight of their interconnections. It puts focus on the informative and the performative aims of education; it emphasizes education's standing on the intentional, conventional and authoritative ordinances of our communities; and at the same time, it weakens such distinctions: the informative is and relies on the performative and vice versa. Intentions, conventions, and authority all are intertwined together, bringing personal and communal values, norms, emotions, repertoires, moods and aspirations into play. Not only the content of the theory is important for education then, but also its dismantling power. Austin messes up dichotomies; he creates distinctions, only to withdraw them a bit later. His method may seem messy at first. But it could be a good approach when talking about the complex phenomenon of education: it illuminates the different aspects of education while at the same time undermining their differences. In a way then, speech act theory can bring us back to the realm of common sense. Good education depends on literacy. We want to teach and learn all kinds of worthy information. Art, biology, philosophy, math and literature, are among the disciplines we find worthy or pleasant or useful for all kinds of different purposes we hold dear. Valuing and mastering the proper information is a big part of a familiarization process into one's community. And it depends on us doing stuff with this information, like being able to intimidate or encourage, bore or excite, order or promise. Participating in a community relies on both the locutionary and the illocutionary aspects of our speech acts. Only then, education produces the ideal perlocutionary effects: it helps the young discover their potential, be responsible and somewhat autonomous, flourish, find jobs, create communities and lead their own lives. Intellectual habits, character traits, ideals and ambitions are nurtured. Within every speech act, all the above are put in motion. The information is being passed on. The invitation to a variety of practices is being delivered. Individuals and societies change. All the aims of education, for which policymakers argue, are produced speech act by speech act. Hopefully, this theory then can mess up a variety of dualisms that haunt education for decades and show it for what it is: a series of informative and performative, mental and physical, communal and personal, cognitive and emotive intentional speech acts. It may then, be worthwhile to reread, and even a bit rewrite, speech act theory as an educational acts theory. Speech acts, for example, can facilitate today's discussions aiming at bridging the cognition-emotion dualism, thus helping us dismantle the debate between the enhancement agenda versus the cognitive agenda (Gasparatou, 2016; Dunlap, 2012; Jones, 2012; Zembylas, 2016). In the context of the updated speech-act theory, the cognitive and the emotive run together within our every utterance; and this is why they produce the (perlocutionary) effects we expect from education (Gasparatou, 2016). Emotions 516 R. GASPARATOU cannot be well distinguished from all other attitudes, intentions and conventions that make up illocutions. They are neither well distinguished from cognition, the processing or delivering of information. Speech acts can also include some versions of naturalism. We have social, but also biological restraints and potentials. Education indeed relies on our mental life, our social habits and our physical bodies (Barad, 2003; Mulcahy, 2015; Patten, 2011; Zembylas, 2007). Even Austin allows for a small participation of one's body when talking about the physical act of pronouncing noise (Austin, 1964, pp. 92,101,11–114; Gasparatou, 2013). We ought to extend this theory and allow for the whole body to contribute to the production of a speech act; brains and minds, hormones, gestures, facial expressions, glances, and blushes are part of the act. Speech act theory can bridge the gap between the mental and the physical; add to the discussions about how the body influences educational processes (Barad, 2003; Mulcahy, 2015), while reminding us that educational acts are always intentional (Schatzki, 1996; Solomon, 1993). Perhaps they are not always conscious. Even emotional and bodily expressions are intentional though, and always open to interpretation. Speech acts are cuts of a conversation of us with the others on all three levels: we exchange locutions, illocutions and perlocutions all the time; we are shaped by other people's acts and we shape others and ourselves by our own. Which brings me to the last and most important dichotomy we suffer when we talk about education: the one between the teacher and the student. There are indeed many chains of command in education. Even today, after the rise of democratic or progressive education, in many parts of the world and even in subtle ways, the traditional model of a didactic teacher rises every time we insist on the teacher-student distinction. The teacher is often perceived as the speaker in a classroom and the students as the audience. However, in real contexts and real classrooms, there are no single speech acts. To speak of a single speech act is to take a snapshot in a conversation. Speech acts-in education also-come in series of interactions between people. Acting as a teacher sure comes with a certain set of prescribed speech acts. Such a realization runs, however, in different directions. First, educational acts bring the podium seat with them. Each of us is a teacher and a student (Zevin, 2010). Perhaps not always, not at the same time, or not as much. Yet, even in a classroom in which I teach, I also get taught. My very ability to teach or facilitate discussions relies on whether I engage with my students' speech acts. Their speech acts constantly provide me with input, propositional and otherwise. An angry student carries their anger's authority; a cinephile student carries his hobby's authority; a religious student carries his religion authority, and so forth. Being able to engage in an exchange of speech acts you are able to change seats all the time; already you are educated enough to do it; and you can act both as an educator and a student. Moreover, certain speech acts may also disarm me as a teacher. An insult may cost me any authority; insisting on some incorrect information may also have the same effect. What both have in common is lack of responsibility. Educational acts are intentional and normative and thus, carry a demand for responsibility on all parties involved in education. Speech act theory then can provide us insights that may help us analyze the dynamic between teachers and students and further the discussions on non-authoritative teaching practices (Biesta, 2010; Cornelissen, 2010; Mercieca, 2012; Watkins, 2011). After all, education happens all the time and to all directions as long as any conversation takes place. The topics mentioned above are just some ideas about how speech act theory, modified and treated as an educational theory, can help us analyze issues and weaken dichotomies that have been troubling education for decades. Let me add one final comment that may add up to the value of re-examining speech act theory as an educational theory. Whenever discussions about educational policies turn on a dispute, policy-makers have decided what kind of argument should decide on the issues: data. On this, there is no much dispute. Verificationism is dominant today; whatever we do in education needs to be described, documented, measured and assessed by concrete data (Gasparatou, 2017; Standish, 2012a). Since the method of assessment of each ideal is almost unanimous, it is rather surprising that the debates like the above are ongoing. Now, I don't have anything against data. So far as we realize they are a small part of the educational speech act game, relevant to our other intentions, emotions, attitudes, biases and stereotypes, open to interpretations and capable of producing all kinds of effects. Austin, when he presented his speech EDUCATIONAL PHILOSOPHY AND THEORY 517 act theory had a similar reaction to verificationism. He did not deny that there are certain levels of our utterances, of which verification is desirable, namely the locution. Yet, he shows that the locution is blind if you do not know what to do with it. Moreover, he suggests that a locution is also an act: what words you actually use, just like what kind of data you choose to employ, is very much performative. It is not surprising then, that with all these data we have been collecting, all the different kind of tests, evaluation forms and metrics, we are still undecided on most important issues that educational practices put forth. Perhaps we should be looking at a different direction. Educational speech acts are normative. They include values, emotions, judgments, rules. Logical positivists, the strongest defenders of verificationism, knew that in the realm of normativity there can be no verification. They would call it the realm of non-sense; Austin and others would rather call it the realm of performativity. Whatever you may call it, education is definitely within this realm. So, if nothing else, seeing education in the light of speech act theory can make us realize what would not count as the ultimate criterion; what would not be the final word in educational debates; and what would not be an improvement. We cannot pretend that educational acts will ever be assessed blindly and solely by metrics. Education is messy, just like all human communication and relations. But if we try to ban the messiness of our educational speech acts, we ban education. Disclosure statement No potential conflict of interest was reported by the author. Notes on contributor Renia Gasparatou is Assistant Professor in DESECE, University of Patras. She teaches epistemology and philosophy of education. Her research interests include epistemology, philosophy of education, science education and philosophy for children. References Austin, J. L. (1962). 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The somatic appraisal model of affect: Paradigm for educational neuroscience and neuropedagogy. Educational Philosophy and Theory, 43, 87–97. Schatzki, T.R. (1996). Social practices: A Wittgensteinian approach to human activity and the social. Cambridge, MA: Cambridge University Press. Schrag, F. (2011). Does neuroscience matter for education? Educational Theory, 61, 221–237. Smeyers, P., Smith, R., & Standish, P. (2007). The therapy of education. London: Palgrave Macmillan. Smith, R. (2002). Self-esteem: The kindly apocalypse. Journal of Philosophy of Education, 36, 87–100. Solomon, R. C. (1993). The passions. Indianapolis, IN: Hackett Publishing Company. Standish, P. (2002). Disciplining the profession: Subjects subject to procedure. Educational Philosophy and Theory, 34, 5–23. Standish, P. (2012a). Transparency, accountability, and the public role of Higher Education. Educational Futures, 5, 3–14. Standish, P. (2012b). 'THIS is Produced by a Brain-Process!' 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Philosophy

A commentary on: The Alleged Coupling-Constitution Fallacy and the Mature Sciences
          by Ross, D., and Ladyman, J. (2010). The Extended Mind, ed R. Menary (Cambridge, MA: MIT Press), 155â166.

GENERAL COMMENTARY published: 27 December 2016 doi: 10.3389/fpsyg.2016.02033 Frontiers in Psychology | www.frontiersin.org 1 December 2016 | Volume 7 | Article 2033 Edited by: Guy Dove, University of Louisville, USA Reviewed by: Louise Barrett, University of Lethbridge, Canada *Correspondence: Luke Kersten email@example.com Specialty section: This article was submitted to Cognitive Science, a section of the journal Frontiers in Psychology Received: 22 September 2016 Accepted: 15 December 2016 Published: 27 December 2016 Citation: Kersten L (2016) Commentary: The Alleged Coupling-Constitution Fallacy and the Mature Sciences. Front. Psychol. 7:2033. doi: 10.3389/fpsyg.2016.02033 Commentary: The Alleged Coupling-Constitution Fallacy and the Mature Sciences Luke Kersten* Department of Philosophy, University of Edinburgh, Edinburgh, UK Keywords: terminological issues, cognitive systems, problem solving, the extended mind, underdetermination A commentary on The Alleged Coupling-Constitution Fallacy and the Mature Sciences by Ross, D., and Ladyman, J. (2010). The ExtendedMind, ed R.Menary (Cambridge,MA:MIT Press), 155–166. ISBN: 9780262014038. The extended mind thesis holds that the mind can leak out into the world (Clark and Chalmers, 1998; Wilson, 2004; Clark, 2008). Ross and Ladyman (2010) have offered a novel critique of this view by arguing that the question of cognitive extension is largely terminological or semantic, that it is a product of an immature science employing unhelpful metaphors about containment. They write, for instance: "We do not believe there is any basis for a general fact of the mater about what is and what isn't a cognitive system. Modelers will and should draw system boundaries in whichever ways maximize efficient capture of local phenomena" (Ross and Ladyman, 2010, p. 156). There is no matter of fact as to whether cognitive systems are extended or not, as such descriptions are drawn from too early a stage of scientific investigation. In this commentary, I offer one response to Ross and Laydman's terminological or semantic objection to the extended mind. Ross and Laydman's challenge can be framed as follows. If it turns out that calling cognitive systems extended or not is a matter of choice, then cognitive science can continue business-asusual. However, if the extended mind thesis turns out to offer principled grounds for talking about cognitive systems, then some of the most basic assumptions of cognitive science might require revision-for example, that the brain is the seat of cognition (Wilson and Clark, 2009). Thus, in order to evaluate the merits of the extended mind thesis, it first needs to be shown that there is a substantive issue at stake. To gain traction on the challenge, consider how an issue is normally identified as semantic rather than substantive. Consider, for example, the simple case of how to pronounce the word for the red fruit-berry of the nightshade plant Solanum lycopersicum, commonly referred to as a tomato. Those in North America might say "toma/to" [t e"meI " to  ], while those in the United Kingdommight say "to/ma/to" [t e"mα:t e  ]. Under normal circumstances, it seems wrongheaded to ask whether one or the other pronunciation is correct, even though the intension and extension are the same. Contrast this with whether the basic subatomic elements in physics are particles or waves. Here, the choice of terms seems more principled. There seems to be something about the world that determines which term is more suitable, even though the current state of the science is undecided. What accounts for the difference arguably is that in the latter's case the choice among terms has something to do with how the terms track matters of fact. One philosophical manifestation of this idea is "underdetermination," the idea that there might be two or more equally good theories or explanations for some phenomena (Laudan, 1990; Laudan and Leplin, 1991). The classic example is that a high correlation of cartoon viewing and violent playground behavior equally supports the explanations that watching cartoons causes violent Kersten Commentary: The Alleged Coupling-Constitution Fallacy children and that children prone to violence tend to enjoy watching cartoons. Because there are multiply sufficient methods of description, the evidence alone fails to determine the correct view. The choice among explanations is underdetermined. The question is whether such a state of affairs holds in the case of cognition. Are cognitive systems underdetermined such that the choice among labels is relative? Or, is there is a matter of fact determining whether the extended or internalist description is more appropriate? Consider a particular cognitive task: problem solving-to be more specific, consider how cognizers might solve a particular board configuration of the board game Rush Hour (the purpose of which is to move small toy vehicles across a board). One method is that agents might form internal representations and then manipulate those representations to solve the problem. Another is that agents might repeatedly use visual inspection, neural processing and actual movements of cars on the board to solve the problem. The first of these methods corresponds to the traditional explanation offered in cognitive science, where vision provides the initial input to an internal cognitive system which then executes bodily actions in service of solving some particular task (Newell et al., 1960; Newell and Simon, 1972). Emerging research, however, suggests that people often solve problems more in line with the second method. Cognizers often rely on repeated action-perception cycles during problem solving (Kirsch, 2009). Repeated interactions and transformations of the physical environment-for example, configurations of the board-are used to literally see different pathways through the problem space. Notice the difference in the underlying cognitive systems. In the first method the cognitive system is internally bounded and trades in internal representations, while in the second method the cognitive system is, in part, constituted by the perceptual and motor interactions integratively coupled to the internal processes. The second method employs a cognitive system that spreads out across brain, body, and world. One might respond by arguing that something has been smuggled into the foregoing analysis to bias an extended conclusion. Notice, however, that the method for identifying the cognitive system was task neutral. First, the function of interest was specified. Then, the supporting system was individuated, which revealed causally integrated units spread across the brain, body, and world. The relevant system turned out to be extended only after the cognitive task and function were specified, even though it could have turned out to be entirely internal. Return, then, to the initial worry about terminological relativeness from Ross and Ladyman (2010). It was said that an issue was semantic when it could not be shown that there was a matter of fact for deciding between competing accounts. What has been shown is that, in some cases, such a requirement fails to obtain. There is a fact of the matter as to whether cognitive systems are extended in at least some cases. The extended mind debate, then, is more than a mere terminological or semantic issue. This is not to say that the extended mind thesis is true, but it is to say that contrary to Ross and Ladyman (2010) the question of the extended mind is a substantive one. AUTHOR CONTRIBUTIONS The author confirms being the sole contributor of this work and approved it for publication. REFERENCES Clark, A. (2008). Supersizing the Mind: Embodiment, Action, and Cognitive Extension. Oxford: Oxford University Press. Clark, A., and Chalmers, D. (1998). The extended mind. Analysis 58, 7–19. Kirsch, D. (2009). "Problem solving and situated cognition," in The Cambridge Handbook of Situated Cognition, eds P. Robbins and M. Aydede (New York, NY: Cambridge University Press), 264–306. Laudan, L. (1990). "Demystifying underdetermination," in Scientific Theories, Vol. 14. Minnesota Studies in the Philosophy of Science, ed C. Wade Savage (Minneapolis, MN: University of Minnesota Press), 267–297. Laudan, L., and Leplin, J. (1991). Empirical equivalence and underdetermination. J. Philos. 88, 449–472. Newell, A., Shaw, J. C., and Simon, H. (1960). "Report on a general problem solving program," in Information Processing: Proceedings of the International Conference on Information Processing, ed S. de Picciotto (Paris: UNESCO), 256–264. Newell, A., and Simon, H. (1972). Human Problem Solving. Englewood Cliffs, NJ: Prentice-Hall. Ross, D., and Ladyman, L. (2010). "The alleged coupling-constitution fallacy and the mature sciences," in The Extended Mind, ed R. Menary (Cambridge, MA: MIT Press), 155–166. Wilson, R. A. (2004). Boundaries of the Mind: The Individual in the Fragile Sciences: Cognition. New York, NY: Cambridge University Press. Wilson, R., and Clark, A. (2009). "How to situate cognition: letting nature take its course," in The Cambridge Handbook of Situated Cognition, eds M. Aydede and P. Robbins (New York, NY: Cambridge University Press), 55–77. Conflict of Interest Statement: The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Copyright © 2016 Kersten. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. Frontiers in Psychology | www.frontiersin.org 2 December 2016 | Volume 7 | Article


Philosophy

This article considers some different views of fairness and whether they conflict with the use of a version of Cost Effectiveness Analysis (CEA) that calls for maximizing health benefits per dollar spent. Among the concerns addressed are whether this version of CEA ignores the concerns of the worst off and inappropriately aggregates small benefits to many people. I critically examine the views of Daniel Hausman and Peter Singer who defend this version of CEA and Eric Nord among others who criticize it. I come to focus in particular on the use of CEA in allocating scarce resources to the disabled.

Volume 3, Issue 1 Cost Effectiveness Analysis And Fairness 1 Cost Effectiveness Analysis and Fairness 1 F.M. KAMM Harvard University AbstrACt this article considers some different views of fairness and whether they conflict with the use of a version of Cost Effectiveness Analysis (CEA) that calls for maximizing health benefits per dollar spent. Among the concerns addressed are whether this version of CEA ignores the concerns of the worst off and inappropriately aggregates small benefits to many people. I critically examine the views of Daniel Hausman and Peter singer who defend this version of CEA and Eric Nord among others who criticize it. I come to focus in particular on the use of CEA in allocating scarce resources to the disabled. Cost Effectiveness Analysis (CEA) in medical care tries to maximize health benefits produced per dollar spent. Its use is recommended when society cannot afford every form of health care and must chose what to provide. Yet it is often taken as a truism that there can be deep conflicts between maximizing benefits and distributing fairly, in general. For example, the philosopher robert Nozick imagined a "Utility Monster" [where utility is (roughly) experiential well being] such that for any resource up for distribution, one always produces more additional benefit at less cost if one gives the resource to the Monster rather than to others even though he is already 1. 1.this paper is a response to Daniel Hausman's "How Can We ration Health Care Fairly and Humanely" as originally presented at "bioethical reflections: A Conference in Honor of Dan brock," at Harvard Medical school Nov 22. 2014. All references to Hausman are to that paper. Hausman focused on brock's discussions of the problems of fair chances, priority to the worse off, aggregation, and discrimination raised in several of his articles, including "Ethical Issues in the Use of Cost-Effectiveness Analysis for the Prioritization of Health Care." Hence, the order in which I discuss some issues in this paper follows the order in which Hausman chose to discuss brock's work. Journal of Practical Ethics F.M. KAMM2 much better off than they. this would result in one person getting all the additional benefits while all others get none. this seems unfair. CEA cannot result in this most extreme form of unfairness because of limits that result from how it calculates benefits. Each additional year of very healthy life is given a value of 1; no one can get more than 1 per year. still, it is possible that only those who are already very healthy can achieve many additional years at a value of 1 at low cost if they are saved from an otherwise fatal bacteria. Maximizing health benefits per cost would imply helping them rather than people who are not as healthy and can achieve only fewer additional years at a value of less than 1 and at higher cost if they are saved from the same threat. this too seems unfair. Why does it seem unfair to help only the Utility Monster and the healthy people? Fairness is about how one person is treated relative to another. this is by contrast with a notion such as justice which need not be comparative; that is, we could decide what justice requires that we give a person in virtue of his conduct independently of considering what anyone else is owed. Hence, we could treat someone justly in giving him what he is owed and thereby increase unfairness because we treat him justly while not treating anyone else justly. [For example, we might punish some who deserve this even if we cannot punish all who do. this case also shows that fairness is only one moral dimension on which we can evaluate how we treat people or states of affairs we produce; it is possible that we should sometimes override fairness to be just (or to achieve some other moral value).] According to what measure shall we compare people to see if each is being treated fairly relative to others? suppose we think that all that fairness requires in allocating benefits is that a certain amount of benefit be given the same value regardless of the person who will be benefited; no extra value should be assigned to a certain amount of benefit in person A rather than in person b. We could call this the simple standard. According to this standard, Nozick's Utility Monster and our CEA bacteria case need not involve unfairness, for we could give the same value to a certain amount of benefit in the lives of everyone but it happens that more benefits can be produced in the Utility Monster and in the already healthy. these examples suggest that there may be more to fairness than the simple standard. Indeed, there are different views about what fairness requires and deciding which is right is no easy matter. In this article, I will call attention to some different views of what fairness requires and consider whether, according to these views, fairness problems arise in the medical context as a result of using a version of CEA that Volume 3, Issue 1 Cost Effectiveness Analysis And Fairness 3 always emphasizes maximizing health benefits per dollar spent. Without pretending to settle the matter, I will raise some issues to consider. However, it is important to realize that even if there are problems with this version of CEA, this does not imply that it is never consistent with fairness to use some form of cost effectiveness evaluation. For example, it seems fair and right to treat one hundred people equally well with a cheap drug rather than an expensive one, other things equal. It would also be fair and right to use a drug with which we can save two hundred people rather than an equally costly one with which we can save only one hundred of these people. 1. some think that when we cannot help everyone, fairness requires that people get a chance for medical care in proportion to their need for it, regardless of outcome in terms of CEA. For example, imagine that we can produce more cures per dollar if we treat six people with one fatal disease rather than only five people with another fatal disease. In this case the route to maximizing health benefits involves giving a life saving benefit to more rather than fewer equally needy people, by contrast with Nozick's Utility Monster. Hence, this case raises the question of whether it is unfair to save a greater number of people rather than give each group a chance to be saved in proportion to the need of each multiplied by the number of people in the group. some think that fairness does not demand giving chances in proportion to need in the group but itself requires counting numbers of people, balancing one person of similar need (and, perhaps, expected outcome) against another and allowing the greater number to get the resource. On this view fairness does not require giving some chance to be helped to fewer people, when all suffer from equally serious problems. Nevertheless, even on this view of fairness it may be right to give equal chances to be saved to two groups if they each contain the same number of people of equally sick people when we only have enough resources to treat one type of fatal disease. but proponents of CEA should see no reason to give equal chances if outcome per dollar would be the same. It is only if we take seriously the personal perspectives of each person, and so recognize that each person is not indifferent to whether he or someone else survives, that we see why fairness could sometimes require giving equal chances to different people even when their need and outcome are the same. (If we take seriously the perspectives of different people, we might even think it is wrong to deprive one person of his 50% chance to be treated merely because we would get a slightly better outcome if another person were treated.) We have been focusing on cases in which each person needs a cure for a fatal Journal of Practical Ethics F.M. KAMM4 disease. However, if the original view of fairness that we considered (requiring chances in proportion to the strength of people's need) were true, someone who has a weak need for a scarce resource should get a small chance to get it. but does fairness really require giving a small chance to someone who needs the resource to cure his sore throat so that if against great odds he wins, someone else who needs the resource to save his life dies? Would we be overriding fairness in order to achieve a better outcome if we did not give the person with a sore throat a chance? I suspect not for in other cases achieving a better outcome would not lead us to override what fairness really requires. For example, suppose a doctor and a janitor both equally need a scarce life-saving medicine. If the doctor survives, he can save someone else's life from another illness, the janitor cannot. Although we could achieve a better outcome if we save the doctor (two people saved rather than one), this need not be sufficient reason to deny equal chances to the doctor and janitor in need of the scarce medicine. If we would not override fairness in this case to achieve the better outcome, this suggests that if we deny the person with the sore throat a proportional chance, we are doing so because we do not think fairness requires his having a chance, not because we are overriding fairness for the sake of a better outcome. Hence, I have argued that while CEA does not necessarily contravene fairness in not giving chances to individuals in proportion to their need, it may fail to recognize an appropriate role for giving equal chances when need and outcome would be the same. 2. a. Another possible fairness concern about CEA is that it is indifferent to whether an equally cost effective benefit, such as relief from a certain amount of pain, goes to someone moderately ill or to someone severely ill. some think fairness requires that the severely ill should be preferred. Indeed, it might be thought that fairness requires providing even a somewhat smaller benefit to those who are severely ill rather than a larger benefit to those who are moderately ill, holding cost constant. A "prioritarian" view of what fairness requires implies, roughly, that it is reasonable that the claim to benefits of those who are worse off should be weighed more heavily than those who are better off because it is right to give priority to improving the condition of a worse off person before improving someone who is already better off than Volume 3, Issue 1 Cost Effectiveness Analysis And Fairness 5 he is.2 this view of fairness implies, contrary to the simple standard, that a given benefit in one person should sometimes have greater value than the same benefit in another person. (However, giving priority to the worse off is not the same as always caring for the worse off regardless of benefit that can be achieved.) b. A third fairness concern about CEA is that providing minor, inexpensive health improvements (such as teeth fillings) in many people may be more cost effective than providing bigger, more expensive improvements (such as treating appendicitis) in a few, but fairness may require giving greater weight to the latter. this issue arises because CEA permits summing small benefits to each of many people to produce a large aggregate benefit that is then weighed against a smaller aggregate benefit composed of summing bigger benefits to a few people. the question is when it is fair to aggregate and weigh smaller benefits to some people against bigger benefits to others to decide how to allocate scarce resources.3 this question about aggregation is sometimes related to the issue of not giving priority to the worse off, when the small benefits would go to many people already better off and the bigger benefits would to go to a few people more severely ill. c. Let us consider these second and third concerns about the fairness of CEA in greater detail. With regard to the second, some think that willingness to help the severely ill even when this produces fewer benefits per dollar need not depend on a prioritarian conception of fairness. rather it can reflect compassion for those in dire straits. Dan Hausman argues for this. On his view CEA is the reasonable, rational, and not unfair way to decide how to allocate medical resources but we sometimes override it because of compassion for the severely ill. On this view, compassion can conflict with reason (even if it does not always), and it is this compassion (rather than a reasonable view of fairness), that can lead us to help the severely ill when doing so conflicts with CEA. One problem with this view is that it can seem fair and reasonable to give priority to treating those who are only moderately ill rather than those slightly ill even though compassion is not triggered for the former in the way it is for those in dire 2. there is a noncomparative view about giving priority to the worse off according to which the moral value of giving a benefit to someone varies with how well off in absolute terms that person is- the worse off, the greater the value. this view does not require comparing how well off someone is relative to others. I am focusing on the comparative prioritarian view in taking it to be an interpretation of fairness which is a comparitive value. 3. It is not unfair to aggregate and weigh small benefits to a few against the same small benefits to many others, other things equal. but I am concerned with aggregating and weighing smaller benefits against bigger ones. Journal of Practical Ethics F.M. KAMM6 straits. similarly, we do not now feel greater compassion for twenty year olds who we know will die in thirty years at age 50 than for twenty year olds who we know will die at age 65. Yet we might still think it is morally right to invest in research that will buy five more good years for those who would die at 50 rather than in research that will buy 7 more good years for those who will die at 65, even if this conflicts with CEA. Presumably, this is because it seems reasonable to help people who would be worse off when they die, in having had shorter lives, than to help people who would be better off, in having had longer lives, even if they are not helped. this reflects a prioritarian conception of fairness. Here is another problem with the view that it is compassion rather than a conception of fairness based on reason that sometimes conflicts with CEA. We often override compassion to do what is morally reasonable. For example, we may feel greater compassion for an incurably blind person who will also have to deal with a second problem if his arthritis is not treated than for a sighted person who will become (only) nearly blind if he is not treated. In this case, holding other factors constant, the blind arthritic will be the worst off person if he is not treated. Yet it seems morally acceptable and reasonable to cure the more severe condition of near blindness rather than the less disabling condition of arthritis, when we cannot do both. suppose it is morally right to resist the call of compassion in this case. then perhaps in other cases when we do not give up on helping the worst off person though helping him conflicts with CEA, it is because giving up would be contrary to reason and fairness rather than to compassion. this would imply that sometimes CEA is not the reasonable and fair approach. Further support for the view that CEA does not necessarily coincide with what is reasonable and fair comes from considering the third concern mentioned above, whether it is always fair to aggregate small health benefits to many people and weigh the aggregate against the smaller aggregate of bigger benefits to fewer people, when the benefits to each group cost the same. suppose that each of many people has a mild headache and is otherwise already much better off health wise than someone whom we can save from appendicitis. suppose that none of the many people is a compassionate person and each would give up no more than the money for an aspirin that could cure his headache in order to help a dying person. but there are so many of these people with mild headaches that the aggregated harm of many headaches that would occur if each sacrificed the money for an aspirin is greater than the harm prevented in using the money to save the person with appendicitis. though none of Volume 3, Issue 1 Cost Effectiveness Analysis And Fairness 7 the people is rescuing the one person because of compassion for him, presumably they would not change their individual aiding behavior on the grounds that the aggregated loss to all of them is so enormous by comparison to one person's loss of life. No one has to be compassionate in order to realize that it would be a bizarre mistake of reason to treat the very large aggregate of small losses to each of the many people as if it had the same moral significance as a very large loss to a single person that was suffered to prevent a smaller loss to another person. some suggest that the fair way to decide what to do in such cases, when the small harm (such as a headache) is occurring to each of many separate persons, is to compare, in a pair wise fashion, how much harm would be suffered and avoided by a severely ill person depending on whether he is helped with how much harm would be suffered and avoided by each of the the many depending on whether they are helped. Fairness is comparative but it requires comparing how we treat individual persons, one person at a time. suppose that no one of the many will suffer anywhere near as great a loss as the single person would. then if our view of fairness combines pairwise comparison with priority to the worse off, curing a headache in each of many people would never take precedence over curing even one much worse off person. A conception of fairness that involves these two components-pairwise comparison and prioritarianism-would justify the third concern with CEA. by contrast, Peter singer, a philosopher who supports CEA, believes it is morally correct to aggregate smaller individual benefits to better off people and weigh the aggregate against a bigger individual benefit to a worse off person. For example, in a New York Times Magazine article on rationing (singer 2009), he considered how to compare the health benefit achieved in saving one person's life with curing a serious condition such as quadriplegia that does not threaten another person's life. He tells us to consider the trade-off each person would reasonably make in his own life between length of life and quality of life. suppose every person (already disabled or not) would be indifferent between living ten years as a quadriplegic and living five years nondisabled. this seems to indicate that people take living as a quadriplegic to be half as good as living nondisabled.4 singer thinks that such data would show that using our resources to cure two quadriplegics is just as good as saving someone else's life when all three people would have the same life expectancy if helped (for example, ten 4. I say "seems" because it is possible that as the absolute number of years unparalyzed decreases (even if the ratio of unparalyzed to paralyzed years in the choice does not fall below 1⁄2), people would no longer be indifferent. Journal of Practical Ethics F.M. KAMM8 years). His reasoning seems to be that if someone would give up five out of ten years of his own life rather than be quadriplegic, that would justify curing one person's quadriplegia rather than saving someone else's life for five years, and the combined benefit of curing two people with quadriplegia would justify not saving the life of another person who would live for ten years. several things seem problematic about this reasoning. First, in the tradeoff between quality and quantity that a person might make in his own life, it is that person who benefits from the tradeoff. When we make tradeoffs between different people, the people who get the improved quality of life are not the same people who suffer the loss of more years of life. trade offs between people may raise different moral issues than the trade off within one life. this is related to the point made earlier that fairness considerations arise when we take seriously that different people are not indifferent to whether benefits and losses fall in someone else's life or their own. second, the conclusion that curing two quadriplegics who would live for 10 years anyway is equal to saving for ten years of life someone else who would otherwise die depends on aggregating the benefit to two people to weigh against the loss to the single person. We can see how problematic this is by considering the following example: suppose that the trade-off test within one person's life showed that a small disability (e.g. a permanently damaged ankle) made life only 95% as good as a nondisabled life. this implies that a person would rather live 9 1⁄2 years without the small disability than ten years with it. On singer's view, this implies that we should cure one person's small disability rather than save someone else so that he can live for an additional 1⁄2 year. It also implies that we should cure the small disability in twenty-one people rather than save someone so that he can live for an additional ten years. this sort of problematic reasoning may have led to the rationing plan in Oregon many years ago in which resources were to be allocated to cap many people's teeth rather than save a few people's lives (for further discussion see Kamm 2007, chapter 2). the concern with always aggregating small benefits can also be independent of concern to give priority to treating those more severely ill. For suppose all patients have the same disability. We have a choice of making very small improvements to the disability in each of a great many patients or providing a complete cure to one patient. It would not be morally unreasonable (and might not be unfair) to do the latter, for we then make a significant difference in this person's life rather than a barely perceptible Volume 3, Issue 1 Cost Effectiveness Analysis And Fairness 9 difference to each of many others. this is so even though aggregating the many barely perceptible differences creates an enormous total difference.5 3. Notice that in many of the cases we have considered, if a particular person is not helped, he will certainly suffer a great loss and be worse off than others who would certainly avoid only small losses and already be better off than he. but we may also consider the role of risk in deciding what is fair. We know that it can be reasonable for each individual to take a small risk of a great loss such as losing many years of life by dying if this is the price of achieving a high probability of lesser benefits. For example, someone might run a small risk of dying from an aspirin in order to get a high probability of relief from a nonlethal headache. If everyone in a community does this, in a large enough population it is certain that someone will die from an aspirin though each person had only a very small chance of dying. It seems morally permissible to allow individuals to expose themselves to such a small risk of the large loss of life for the sake of a small benefit. this is so even if we know that someone will die because he took the risk and because when he is dying there will be nothing we can do to save him. However, this need not mean that when it is still possible to save this person whose risk of dying has gone from small to certain, or when there are certain people who were always known to be at great risk of dying, fairness does not require aiding them if we can rather than protecting many people from each having a headache (One place in which I discuss this issue is Kamm 2008). suppose there are a few people who will certainly die unless we treat them. should we treat them or rather use our scarce resources to stop a small risk of death to many others when it is certain that more than a few of these many will face certain death as well? this is the situation we may face when deciding whether to allocate scarce funds to combat AIDs by either treating those already ill or preventing future cases. suppose fewer people overall will die from AIDs if the money is put into prevention than if it is put into treatment, and so prevention is most cost effective. but prevention deals with a small risk that each of many people has of dying while treatment deals with some people who will otherwise certainly die. (Notice that to make sure it is only the known probability of any given person dying whose relevance to an allocation decision we are judging, we should hold constant the time at which those already ill and those who will become ill would die. Otherwise, we may be judging the relevance to an allocation decision of sooner rather than later deaths, not greater or smaller probabilities each person has of dying.) It is true that without 5. Larry temkin has emphasized this point. Journal of Practical Ethics F.M. KAMM10 prevention more people who once had only a small risk of getting AIDs will eventually face certain death. but at the time we must decide how to spend funds there are certain people who already have a known prognosis of certain death if they are not treated now whereas it is not the case that there are already some people in the larger group who have a known prognosis of certain death if prevention measures are not taken now. rather there are many people each of whom has a small chance of being a person who will face certain death. so we must choose between helping those who will certainly die and those who each have a small chance of facing death.6 On at least one view, fairness seems to require helping those with a higher individual risk of dying as ascertained by a pair wise comparison of the risks each person faces at the time we must allocate resources. this is because if we engage in pairwise comparison, we could justify to each person with the low risk of death not helping him and helping the person who will certainly die instead. by contrast, it seems we could not justify to the person who will certainly die leaving him to help each of those who have a small chance of death. On this view, it is individuals' comparative risk at the time we must allocate, not the ultimate outcome in which more rather than fewer people will die, which should lead us to allocate the money to the less cost effective treatment policy. this is so even if fairness requires saving the greater number of people when these are all people who face certain death if not helped. 4. Another possible fairness concern with CEA is that it might involve discrimination against those who are poor or disabled as it may cost more to treat these people by contrast to the rich or nondisabled, and the health benefits achieved may also be less. Peter singer relies on CEA when he argues that if we accept that disability can make a person's life less good health wise, and we want to maximize the health benefits we get with our resources, we should save the life of a nondisabled person rather than someone whose disability cannot be cured, other things equal. the only alternative to this, he says, is to deny that disability per se makes someone's life not as good health-wise, and then there would be no reason to allocate resources to cure or prevent disabilities which seems wrong. However, there are other alternatives, I think. I agree that understanding the issue of disability and allocation of scarce resource should not depend on accepting the view that disabilities make little difference to the quality of life. For if we hold this view, we may see little reason to invest 6. this analysis of the case is argued for by Norman Daniels (2012) and Johann Frick (2013 and unpublished) though they may not hold time of death constant. Volume 3, Issue 1 Cost Effectiveness Analysis And Fairness 11 in curing disabilities. We should also recognize that a satisfied "mood" is not the sole measure of the goodness of one's life, independent of objective capacities. Consistent with all this one proposed response to a view like singer's is offered by Eric Nord, Norman Daniels and Mark Kamlet in their article (2009).7 they think it is important to distinguish two different questions. the first is: "Is a health state one we would prefer to cure?" suppose we answer yes. A second question arises if we have this health state and it cannot be cured but life is still worth living, and we also have a lifethreatening treatable condition but the medicine is scarce. the second question as stated by the authors is: "should we defer to those who can be restored to more complete health than we can because they lack the untreatable condition?" the authors say we can reasonably answer 'yes' to the first question-we would prefer a cure to the health state-and 'no' to the second question. they do not say what explains the reasonableness of these responses. Given the way their second question is phrased, it might be thought that one simple explanation is that the person with one untreatable condition does not have a duty to defer because he does not have a moral duty to sacrifice what is very important to him (his life) to produce the outcome that would be considered best from an impartial point of view. the fact that this view, which is standardly held by those who reject consequentialism, might explain the consistency of the first and second answers suggests to me that the second question as phrased by Nord, Daniels and Kamlet is the wrong one to pose if we want to get to the heart of the issue in allocating scarce resources. this is because it should be an impartial distributor who is allocating the resources, not a candidate for the resource and the mere fact that a candidate need not defer to another candidate does not mean that the impartial distributor must give these people the same chance of treatment. Analogously, someone need not give up his medicine that will save his leg so that someone else may use it to save his own two legs. but if the drug is publicly owned and to be distributed by an impartial agent, he should prefer to help the person who would otherwise lose two legs. so a crucial issue in dealing with singer's CEA-inspired view is whether, if an impartial distributor says yes to the first question, this distributor should also decide to treat the person who can be restored to more complete health. In my own past work (first in Kamm 2004), I have been interested in the answer to this question (which I shall refer to as the impartial question). 7. Nornan Daniels brought my attention to what was said in this article in his commentary at a panel in February 2013. Journal of Practical Ethics F.M. KAMM12 suppose I am the impartial distributor. When I imagine a case in which someone has a paralyzed finger, I can see that this can make life not as good in a small way, other things equal, and give us a reason to fix the disability. Hence, my answer to the first question is yes. but when I consider whether to save someone's life from pneumonia when I can only save one person, the fact that one of the people I would save has a missing finger and the other has all his fingers should, I think, make no difference to whom I choose, given the important benefit that is at stake for each person and that each person desires to be the one to live. Hence, I should answer "no" to the impartial question. One explanation I have suggested for this is that a factor (such as a missing finger) could give us a reason to act in one context (curing it) while it is an irrelevant consideration in another context where the action in question (saving a life) is different. so it was an instance of what I call "contextual interaction."8 However, suppose a nondisabled candidate for a scarce life saving surgery will live for twenty years after it and a disabled candidate will live for only two years because his disability interferes with doing exercise after surgery. A large difference in length of life in the outcome might be a morally relevant difference between the candidates, and that might make it not be unfair to do the surgery on the nondisabled candidate, given that each will die if not helped. this is so even if we would be using an effect of the undeserved or unjustified disadvantage in the disabled as grounds for choosing to impose further disadvantage on him. Furthermore, consider another case about which we ask the first question and the impartial question. suppose we agree paraplegia is a deficit that we should prefer to cure. Now imagine two people with paraplegia who each need to be saved from fatal heart disease. the only difference between them is that in one of the people the scarce heart disease medicine will also cure his paraplegia. this is also a case in which one candidate has an untreatable condition (paraplegia) and a treatable one (heart disease) and another candidate lacks the untreatable condition (because his paraplegia can be cured). I suggest that it might be right for the impartial distributor of a scarce resource to choose to save the candidate whose paraplegia will also be cured rather than the other candidate. However, I think that this is not simply 8. One counterargument to this that singer also gives is meant to show that it is reasonable to connect the answer to the first question to an answer to the impartial question. this is because, he thinks, the morally right way for an impartial allocator to decide is determined by what any person would decide reasoning about his possible future state when he is ignorant of which person he will be. I do not think this is correct and argue against it in Kamm (2013). but it is useful to see an argument, aside from maximizing good outcomes, that has been thought to connect a yes answer to the first question to a yes answer to the impartial question. Volume 3, Issue 1 Cost Effectiveness Analysis And Fairness 13 because being alive with paraplegia is worse than being alive with full mobility (other things equal) and CEA rates a treatment as more effective if a person is saved to a life of higher rather than lower quality. rather, it has something to do with how bad paraplegia is and with our medical procedure causing the paraplegia cure. For my sense is that it's not being unfair to treat the second person whose paraplegia we can cure does not imply that in a different case it would be fair to treat the heart condition of someone who is not paralyzed independently of what we do rather than treat a permanently paralyzed person who also has the treatable heart condition.9 these two heart cure cases suggest that a possible problem with CEA is that it does not distinguish the first case, in which our treatment is more cost effective in one candidate because it saves a life and also causes the change in disability status, from the second case in which our treatment is more cost effective in one candidate only because it saves someone who is already nondisabled independent of our doing anything to cure him of disability. However, the two heart cases do not suggest that if each of two people has a paralyzed finger and a scarce life-saving drug that each needs to save his life will unparalyze the finger in only one of the people, that we should give that person the medicine. that a condition is one that we would prefer to cure does not mean that it is serious enough in itself that our being able to cure it in one person but not another should make a difference to whom we give a drug needed by each for a much more serious condition. 5. Conclusion: In this article, I have considered several views about what fairness requires and allows, in conditions of certainty and risk, and how CEA understood in its strongest form may conflict with fairness. It has not been my aim to decide which conception of fairness is correct or to decide how important fairness is relative to other moral considerations. Nor has it been my aim to deny that cost effectiveness should sometimes play a role in allocating scarce resources. However, if the value of maximizing good outcomes relative to cost is neither a preeminent value nor necessarily fair, there are bound to be moral questions about limits on the use of CEA that will need to be resolved. Acknowledgements: I am grateful to Julian Savulescu and a reader for the Journal of Practical Ethics for comments. 9. I consider this issue in more detail in (Kamm 2013), a revised version of (Kamm 2009) Journal of Practical Ethics F.M. KAMM14 rEFErENCEs Daniels, Norman. "reasonable Disagreement about Identified vs.statistical Victims " Hastings Center Report, 42, no.1 (2012), 3545 Frick, Johann. "Uncertainty and Justifiability to Each Person: response to Fleurbaey and Voorhoeve " in Inequalities in Health ed. N. Eyal et al (New York: Oxford University Press, 2013) ---. "treatment and Prevention of HIV/AIDs and the Question of Identified vs.statistical Lives" (unpublished) Kamm, Frances M. "Deciding Whom to Help, Health Adjusted Life-Years, and Disabilities," in Public Health, Ethics and Equality, eds. s. Anand, F. Peter, and A. sen (NewYork: Oxford University Press, 2004) ---. Intricate Ethics (New York: Oxford University Press, 2007) ---. "should You save this Child? Gibbard on Intuitions, Contractualism, and strains of Commitment." in Reconciling Our Aims , ed. A. Gibbard (New York: Oxford University Press, 2008) ---."Aggregation, Allocating scarce resources, and the Disabled," Social Philosophy and Policy 26 (Winter 2009), 148-97 ---. "Aggregation, Allocating scarce resources, and the Disabled," Bioethical Prescriptions: To Create, End, Choose, and Improve Lives (New York: Oxford University Press, 2013) Nord E, Daniels N, and Kamlet M. "QALYs: some challenges." Value in Health. (Mar 2009) 12 suppl 1;s10-5 singer, Peter. "Why We Must ration Care," New York Times, July 19,