Meanings as Species

Philosophy

Penultimate version – published in Notre Dame Philosophical Reviews, 2021 "Review of Mark Richard's Meanings as Species" Indrek Reiland This book explores the idea that the meanings of words are like biological species. On Richard's view, the meaning of a word in a group's language is what he calls its interpretive common ground or ICG. The ICG of 'cousin' in the English of the residents of Boston is the set of presuppositions about the term they normally make and are expected to make: "that cousins are relatives, that cousins are the children of your folks' sisters and brothers, that people have cousins but dogs and bumblebees do not etc." (49) Meanings qua ICG-s are like species in being historical, process-like entities that can gradually change over time. The book is divided into six chapters. In chapter 1 Richard frames the overall project as growing out of a desire to reconcile Quine's view that any meaning-related, supposedly analytic claim like 'cats are animals' can be given up without changing the meaning 'cat' with the common-sense view that the notion of meaning is perfectly acceptable. Chapter 2 dismantles internalist attempts to resuscitate an epistemologically interesting notion of analyticity. These two chapters form more something like the background to the view to be offered, rather than being part of the view itself. In chapters 3-4 Richard starts developing the view of meanings qua ICG-s. In the first, he sets out the basics while simultaneously defending the traditional view of philosophy as conceptual analysis. In the second, he starts discussing meaning change and how it relates to questions of sameness of reference and extension over time. In chapter 5 Richard discusses how meanings qua ICG-s are related to propositional attitude ascriptions. As he himself puts it, this chapter is again somewhat of a digression from the main thread. Finally, chapter 6 continues the discussion of meaning change, looking at concrete cases and how they could be explained, starting with the simpler examples of 'skyline' and 'gay' and ending with the staple contested cases of 'rape' and 'marry'. Many of the chapters contain further brief, relatively self-sufficient discussions of specific philosophers' recent arguments that are more or less loosely related to the central 2 thread: Russell on analyticity (Ch. 1), Chalmers on conceptual continuity (Ch. 2), Cappelen on intuitions (Ch. 3), Field on deflationism (Ch. 4), Dorr & Hawthorne on speech reports (Ch. 5), and Haslanger on conceptual engineering (Ch. 6). As should be evident from the above overview, the discussion is wide-ranging, moves criss-cross in different directions, and contains many digressions. The downside of the breadth is that the view of meanings qua ICG-s and of meaning-change is left at a somewhat impressionistic level and is hard to pin down precisely. Partly because the exposition of its tenets is spread out between the chapters and partly because of the conversational style, the reader has to do quite a bit of work themselves to piece together something that can be compared to alternatives and critically assessed. Below is my best attempt, together with some questions that arose. Meanings and concepts. Words have meanings in languages. But what is meant by 'meaning'? Richard is commendably explicit in making clear that he's interested in meaning in the sense of what competent speakers grasp, "the anchor of linguistic competence" (3, 49). On the other hand, the relevant notion of competence is left entirely intuitive in a way that is potentially problematic. In any case, as we saw above, a word's meaning qua the anchor of competence is supposed to be its ICG. Richard takes a word's meaning to be equivalent to the concept it expresses (50, 5354). In saying this, he must primarily be thinking of concept-words like 'cousin' and 'pasta'. But aren't there important differences between the notions of linguistic meaning qua the anchor of competence and the notion of concept, however construed? There are some words such as 'hello' and 'ouch' which clearly have meanings, but which nobody takes to express concepts. And there are some words like 'I' which have a single meaning in English, but which plausibly express a different concept in each of our mouths. This is not to mention further problems raised by context-sensitive and polysemous words and their complex relations to concepts. Is the view of meaning qua ICG on offer supposed to cover words like 'hello' and 'I' as well or is Richard actually primarily interested in concept-words or even concepts themselves? It is not totally clear. On the one hand, he says that in cases like 'hello' the ICG is exhausted by information about how the word is used (is, in fact used? Or how it is correct or permissible to use it like Kaplan, to whom Richard refers to, would have it?). On 3 the other hand, he grants that a lot of what he has to say, especially about meaning change, sounds much more plausible when put in terms of concepts (128). Richard also thinks that we need to add "pragmatic" information to the ICG of words along the lines of: "in uttering 'snow' the speaker is referring to snow, in uttering 'is white' the speaker is ascribing the property of whiteness to what she referred to with 'snow'; to do this sort of thing – refer to x and go on to ascribe y to it is to assert that x is y." (71) But already this seems to drive a wedge between the notions of meaning and concept. Presumably no such information is included in characterization of the relevant concepts. Furthermore, one might wonder whether such information might not be sufficient for an account of the specifically *linguistic* meanings qua anchors of competence with the relevant words. If I tell you that in Estonian, 'lumi' is for referring to snow, 'on valge' is for predicating whiteness and to do that is to say that snow is white, what more do you need to know to be able to use 'Lumi on valge' in Estonian? Thus, one might wonder whether the sort of rich descriptive information Richard takes to be part of the ICG of 'cousin' might be better thought to have something to do with the concept COUSIN or even something further like a conception of cousins, a set of beliefs or presuppositions about them. From Idiolects to Shared Languages. Words have meanings in languages. But what is meant by 'a language'? Richard's explanatory starting point seems squarely individualist. He starts from idiolects, but unlike Davidson in his anti-language papers, he, like Lewis, works up to the notion of a shared language (Davidson 1986, Lewis 1975). Take individual speakers and their idiolects which partly consist of a lexicon, a set of words. The speakers make certain assumptions about the use of these words which take the form of descriptive claims a la 'cousins are parents siblings progeny'. Such a set of assumptions he calls the word's use (133). Speakers form groups that share a language in the sense that their uses are coordinated in forming the word's ICG. This explains why they can converse with each other without problems. One might wonder what difference, if any, there is between the idiolectal uses construed as a set of assumptions and shared language meanings construed as ICG-s? Aren't both just sets of presupposed information? What does the fact that the assumptions are a matter of common ground consist in (an explicit comparison with Lewis would've helped perhaps...), and what does it really add? 4 Contrast the much more common, social order of explanation shared by philosophers from Dummett to Burge to Kaplan. That view starts with the notion of public language as a historically embedded social practice. Public language meanings are thought to be importantly different from anything an individual's words could possess on their own, usually having to do with their normativity. On a socialized version of a Richard-style view, the ICG could be understood in terms not of assumptions that speakers in fact make, are disposed to make or that it is conventionally regular to make, but that one is required to make, to speak correctly. How does Richard's view of ICG compare to this normative alternative? Consider the other side of the coin, competence in the shared language. Richard says that to be a competent speaker of a shared language one must have the "right sort of cognitive contact" (68) with the ICG. What is it to possess that? The simplest view is that it is to make the right assumptions. But Richard acknowledges that this is not necessary. If Ruben is fanatical about cousins and thinks that only men can be cousins then he is not assuming "C: cousins are parents' siblings' progeny" (69). But that doesn't bar him from being competent with 'cousin'. As Richard puts it: "To understand a word, it suffices to know how it's supposed to be used; knowing that doesn't require that one use that word in that way." (69). On a social view you would cash out 'supposed' in terms of knowing the rule you have to follow to speak correctly. However, despite some off-hand references to rules of use (17, 87), Richard tells us in a footnote that he doesn't think there are any such rules but just regularities in use (157). The force of 'supposed' is instead to be understood in terms of Ruben making a yet-another assumption, a higher-order one: "D: Speakers who use 'cousin' expect their audience to recognize that in using the word they presuppose C" (69). Since individuals presumably wouldn't make such higher-order assumptions without being embedded in the group, this is where Richard's view goes beyond mere overlap of uses and becomes genuinely social, while stopping short of normativity. It's an interesting proposal, but as you can see, piecing it together takes some interpretive work and one would have wished for a more detailed explicit discussion of the details vis-à-vis established alternatives in terms of Lewisian conventions and social rules. Species-Analogy. Meanings are like species in how they change. Species are population lineages, collections of individuals diachronically related by descent and synchronically related by "some species-making relation" (98). What sorts of linguistic entities are 5 supposed to be analogous collections or individuals? Again, Richard starts from individuals' lexicons and the words they contain. The lexical entries are individuals with a history. My 'cousin' is mine and yours is yours, but each was acquired in some way, usually from other people. The word 'cousin' in the shared language is a collection of these entries and thus it also has a history. The same goes for its meaning. I have my use and you have yours. The meaning qua ICG of 'cousin' in the shared language of some group is a collection of these uses and has a history as well. Thus, both the words themselves and their meanings are constituted by collections of individuals and have a history. They are species-like in two respects. First, there can be some acceptable variation in the individual lexical entries (e. g. pronunciation, ICG) while these still constitute the same word (100). Second, they can gradually change some of their properties over time while not ceasing to exist. This brings us to our final topic. Meaning Change and Referentialism. Meanings are like species in how they change. One sort of meaning change is a matter of a word losing its old meaning and acquiring a new one. For example, 'meat' used to mean 'solid food', but now means something like 'animal flesh eaten as food'. This is the type that comes with change of topic or subject. In the past we used the word to talk about one thing, now it has changed its meaning and we use it to talk about something different. Richard calls this change of meaning. However, he also wants to make room for the possibility of meaning change that allows retention of topic – change in meaning (106). I hinted above at a view that would separate the properly linguistic or meaningrelated (e. g. 'lumi' is used to refer to snow) and the conceptual (the concept SNOW) (compare Glanzberg 2018). On such a view it would be natural to think that the only sort of meaning change is change of meaning and any putative change in meaning is really change in concepts or something further. This is not how Richard thinks of things since he equates meanings and concepts qua ICG-s. On his view, there can be change in meaning since some of the rich descriptive claims that are part of ICG can be shed and new ones added, without the topic changing. What does it take for there to be no change of meaning despite changes in meaning? In other words, when does meaning stay the same? Richard considers a view he dubs Referentialism, which holds that sameness of meaning/concept over time can be understood in terms of sameness of reference and argues against it. Take 'pasta' in the mouth of 6 English-speakers in the mid-19th century when it was thought that pasta is necessarily made of wheat compared to 'pasta' in the mouth of English-speakers today who think that pasta can also be made out of rice, seaweed etc. Richard wants to say that there has been no change of meaning in 'pasta', but there has been change in meaning/concept qua ICG. However, he also claims that there has been a change of reference. To my ear, this sounds bizarre. If there's been just change in meaning which is supposed to come with retention of topic, how could reference have changed? Doesn't topic = reference = the kind of foodstuff, pasta? But what Richard has in mind instead is that 'pasta' has changed its extension, it now applies to a lot more than it did before. But this makes the argument against Referentialism feel a bit straw-manish. Referentialists, among whom Richard seems to include Soames, think that sameness of meaning over time = sameness of topic over time, but presumably they wouldn't think that this is a matter of mere sameness of extension. Extension obviously changes over time for all sorts of reasons that have nothing to do with meaning. One might go further and doubt most of Richard's claims about changes in meaning or concept. Richard seems to think that it's obvious that 'marry' has recently undergone a change in meaning because more and more people now think that people of the same sex can marry. To me, this seems false. I don't think the requirements for specifically linguistic competence with the English word 'marry' have changed one bit between 1900 and now. But let's get to more neutral ground and ask whether even "the" concept MARRIAGE has changed. Why think this, rather than thinking that the only things that have changed over time and that can differ wildly between different people are the associated conceptions, sets of beliefs or presuppositions about the topic? Richard doesn't tell us, but I think many people will find this the most crucial question facing the meaning/concept=ICG-picture. I hope that the above has left you with the impression that this book contains a fresh and exciting, if a bit raw and underdeveloped, perspective on a number of topics related to meaning, concepts, and how they change. It can be profitably read and reflected on for a long time. It is Richard's first step in a new, more foundational direction, and we can only eagerly await his next words on the subject. 7 Acknowledgments Thanks to Alex Grzankowski, Eliot Michaelson, and Elmar Geir Unnsteinsson for comments and discussion. References Davidson, D. 1986. "A Nice Derangement of Epitaphs". Truth and Interpretation: Perspectives on the Philosophy of Donald Davidson. Ed. E. Lepore. Cambridge: Blackwell, pp. 433-446 Glanzberg, M. 2018. "Lexical Meaning, Concepts, and the Metasemantics of Predicates". The Science of Meaning. Ed. B. Ball, B. Rabern. Oxford: Oxford University Press, pp. 197-225 Kaplan, D. MS. "The Meaning of 'Ouch' and 'Oops'" Lewis, D. 1975. "Languages and Language". Minnesota Studies in the Philosophy of Science. Ed. K. Gunderson. Minnesota: University of Minnesota Press, pp. 3-


Review of Linda Trinkaus Zagzebski, _Exemplarist Moral Theory_

Philosophy

College of Arts and Letters Notre Dame Philosophical Reviews 2017.10.27 Everything Linda Trinkaus Zagzebski Exemplarist Moral Theory Published: October 26, 2017 Linda Trinkaus Zagzebski, Exemplarist Moral Theory, Oxford University Press, 2017, 274pp., $69.00 (hbk), ISBN 9780190655846. Reviewed by Noell Birondo, Wichita State University Linda Trinkaus Zagzebski believes that a comprehensive moral theory can be constructed by identifying moral exemplars and by investigating (to put it very roughly) what it is that makes them tick. We identify moral exemplars by direct reference to persons we admire "upon reflection." Moral exemplars are persons like that. Two emotions will play a central role in this type of moral theory: admiration, and its opposite, contempt. Zagzebski's theory proceeds by rough analogy with a physical theory that identifies instances of water and then goes on to investigate the physical make-up of the natural kind, water. But an even better comparison, as she says, is to a community of linguistic users which identifies various instances of tigers, say, and then goes on to investigate the (possibly evolving) referent of the species-term "tiger." Zagzebski provides an engaging, illuminating, and deeply human discussion of how the details of this exemplarist approach, with its investigation into the psychological make up of moral exemplars, might be developed. The book is in eight chapters and the argument builds by degrees. The three earliest chapters set the stage for the theory proper, deployed in chapters 4-7. The final chapter, by far the most arid, is "Exemplarist Semantics and Meta-Ethics," which includes a discussion of, e.g., moral terms and the necessary a priori. The initial chapter provides an overview of the project and will be familiar to some readers, since it earlier appeared in a well-regarded collection on moral and epistemic virtue. [1] Chapter two draws on empirical and other sources, including Kierkegaard and Nietzsche, to discuss the nature of admiration and its trustworthiness. The chapter includes some brilliant observations on the development of resentment for what is admirable: "a general cynicism about the admirable that leads to a reluctance to admire anybody" (45). In a generally optimistic book, this discussion of moral psychology gone sour is refreshingly biting. The third chapter introduces Zagzebski's portraits of three historical moral exemplars; it also displays her helpfully balanced, multi-layered methodology for learning about them. This includes first-personal testimony, second-personal familiarity, including biographies and other narrative accounts, and third-personal observation, especially psychological studies of exemplars. The substantive ethical theory comes, as I said, in the four central chapters. The topics of these four chapters are: virtue and other aretaic notions, emulation of exemplars and moral reasons, the good life (on the relation of the admirable life to the desirable life), and deontic notions and their importance. Here is a tiny sampling of how the theory works. In the realm of the aretaic, Zagzebski provides the following account of virtue: A virtue is a deep and enduring acquired trait that we admire upon reflection, consisting of a disposition to have a certain emotion that initiates and directs action towards an end, and reliable success in reaching that end. (113) She immediately adds, though, that this account can be "revised after investigation." By that she means that it can be revised after empirical investigation -investigation into what we admire "upon reflection." (More on that notion below.) In the realm of the deontic, Zagzebski makes direct appeal to moral exemplars, giving this definition of duty: A duty in some set of circumstances C is an act that persons with phronesis (persons like that) would judge to be the only option in C. It is an act such that if they did not do it, they would feel guilty, and they would blame others if others did not do it. (196) Among other qualifications and clarifications of such deontic definitions, Zagzebski says explicitly that she is not offering any kind of non-cognitivist analysis. "The existence of wrong acts and moral duties," she says, "does not depend on the existence of exemplars of Exemplarist Moral Theory // Reviews // Notre Dame Philosophical ... http://ndpr.nd.edu/news/exemplarist-moral-theory/ 1 of 4 11/4/17, 8:41 PM practical wisdom" (196 -97). Given that snapshot of the current project, readers who are familiar with Zagzebski's earlier book, Divine Motivation Theory (Cambridge University Press, 2004), will naturally wonder how her discussion in this book (EMT) differs from, or what it adds to, the defense of moral exemplarism provided in the earlier book. It seems to me that there are two major differences. The first is that the version of moral exemplarism defended in EMT aims to be consistent with a thoroughgoing philosophical naturalism (167) -after all, she says, we live in naturalistic times -whereas the earlier book defends a version of exemplarism that, in its unrestricted form, emphatically does not share that aim. In the unrestricted form in the earlier book, the Incarnation of Jesus Christ serves as the bridge that allows human beings to emulate God, the supreme moral exemplar. The discussion in EMT is much more ecumenical, since it leaves out any transcendental backing, and the book may therefore appeal to a wider audience. Indeed, in apparent contrast to her earlier discussion of exemplarism, Zagzebski says that: "An exemplar with a radically different psychic structure would be unrecognizable" (138). [2] The second major difference is that EMT draws extensively on contemporary empirical psychology in order to investigate the various motivations, emotions, reasons, beliefs, etc., of those persons we admire upon reflection, the moral exemplars. Indeed, the book strains to testify to its own empirical adequacy. There is a fair amount of empirical evidence along with Zagzebski's repeated insistence (for whose benefit is far from clear) that the various claims defended in the book are empirically testable. This quest for empirical respectability, familiar by now in certain areas of moral philosophy, is at times illuminating and at other times distracting. Having said that, I would like to emphasize that Zagzebski's overall discussion here strikes me as one of the best I have seen in balancing philosophical theory, experimental evidence, and various forms of literary and biographical narratives of moral exemplars. Moral exemplars provide the foundation of the theory. That is, individuals, not concepts, provide the foundation of the theory. Zagzebski takes this non-conceptual foundation to be "the greatest advantage" of her theory over its rivals, especially when it comes to providing an account of virtue (128). [3] She provides three extended discussions of historical exemplars. The selection of these three exemplars might at first seem like an odd mix: The first two are twentieth-century Roman Catholic Europeans and the third one is Confucius. But the selection is not meant to be representative of the class of world-historical moral exemplars. The three men represent three types of exemplars: the hero, the saint, and the sage. Each exemplifies a virtue that for him is dominant, although they, of course, have other virtues as well. The hero exemplifies courage, the saint exemplifies Christian charity (caritas, agapê), and the sage exemplifies wisdom. I will focus here on Zagzebski's example of the hero, as a way of saying something below about what admiration "upon reflection" amounts to. Leopold Socha was a sewer inspector and former thief who helped some of his fellow Poles escape the early deaths that were threatened by the Nazi occupation. Socha helped them hide in the city's sewers for months, providing them with food and other necessities, and risking his own life. Many of them survived. In this episode in his life, Socha seems to have shown great courage. But there are also a few mitigating factors. First, Socha helped at the beginning only because they paid him to do so, otherwise he would not have done so. Second, he apparently thought his helping behavior would redeem his past sins, an ulterior motive. And third, he is reported to have proclaimed proudly to bystanders, once the survivors emerged from the sewers, "These are my Jews." Zagzebski says that Leopold Socha is a moral exemplar. She thinks that we will find him admirable "upon reflection," at least along the dimension regarding courage. But even that admiration will be tempered, for some of us, by moral concern. One might also wonder about seemingly courageous people with considerably less admirable ends -about the 9/11 attackers, for instance, or Japanese kamikaze pilots, or Harry Truman. Were they also heroes? To whom? Zagzebski advances a nuanced position in response to one of the issues involved here, pointing out that, according to recent studies, a person's admiration will differ depending on whether that person assesses the end of action from his or her own point of view, or from the point of view of the person whose action it is (115). But there is also a harder question here, about cross-cultural disagreements over admirability. In those cases, Zagzebski's position had better not entail, as it can sometimes certainly seem, that what settles the question is some kind of cosmic Gallup poll. On her official view, as I have indicated, what settles such questions will be what 'we' admire "upon reflection." But what does she mean by "reflection" or "self-reflection"? Zagzebski answers this question by helpfully observing that: The best we can do to be confident an emotion is fitting is the same as the best we can do to be confident that a belief is true: we find that it survives reflection over time on our total set of psychic states when we are using them the best we can to make them Exemplarist Moral Theory // Reviews // Notre Dame Philosophical ... http://ndpr.nd.edu/news/exemplarist-moral-theory/ 2 of 4 11/4/17, 8:41 PM fit their objects. That is what I mean by conscientious self-reflection. (45) That response strikes me as, in general, exactly right. But I wonder whether Zagzebski also has something stronger in mind. In a number of places she appeals (apparently approvingly) to the developing "moral sense" of a child (129 n., 154) and to the idea "that humans have an innate moral sense" (135 n., 129). Zagzebski insists that her project remains quite distinct from any version of Aristotelian eudaimonism, although certain aspects of her view may be consistent with it, or even overlap with it. But it depends on how eudaimonism is understood. Unfortunately, Zagzebski considers only one of two possibilities for Aristotelian eudaimonism, even though contemporary Aristotelians go in two fairly opposed directions on this point. This is what she says about the relationship of her general approach to Aristotle's: In constructing a theory in which the admirable is more basic than the desirable, I am reversing the priority Aristotle gives in the Nicomachean Ethics. There he defines the good as the desirable -what everyone desires for its own sake (NE 1094a18 -20), and he identifies that with eudaimonia, a life of well-being or flourishing. (31 -32) Since Aristotle clearly thinks that virtue is admirable or praiseworthy, Zagzebski is able to say that for Aristotle "the good in the sense of the desirable is basic, and the good in the sense of the admirable is derivative" (32). But this is only because, on Zagzebski's view, eudaimonia is constituted by "the things we naturally desire in life" (165). Hence on her view eudaimonia will be recognizable as such independently of the virtuous person's outlook (despite Aristotle's indications to the contrary) and virtue will be "derivative" from it, for instance by providing the means to it or by being constituents of it. On Zagzebski's understanding, Aristotle's project amounts to what I have elsewhere characterized as an 'external' validation of the virtues, and I agree with the many contemporary Aristotelian commentators who think that no such project can be correct, neither as a philosophical project in its own right, nor as an interpretation of Aristotle. [4] In fact an 'internal' approach to Aristotelian eudaimonism will look a lot like Zagzebski's own proposal on this issue: When I say that it is good for a person to be virtuous, I do not mean that virtue benefits a person in the sense that virtue is a means to other elements of a good life, although that may be true also. Virtue is an element of a desirable life because virtue is admirable, and it is desirable to be admirable. (182) There is nothing in this summary of Zagzebski's view on the relationship between the admirable and the desirable with which Aristotelian eudaimonism, understood in its most plausible form, needs to disagree. [5] It is bewildering that Zagzebski explicitly debars herself from any sustained discussion of contemptible persons. She says that as a general matter, "I am not comfortable naming names of contemptible persons" (47). She makes that remark just before making a special exception in the case of Hitler, whom she considers to be a "safe bet" when it comes to the category of the contemptible. But why wouldn't there be many safe bets? Given Zagzebski's theory, and its appeal to our reflective abilities, it seems to me that identifying contemptible persons (she calls them 'anti-exemplars') should be as uncontroversial as "naming names" of admirable persons. Such 'anti-exemplars' are persons we find contemptible upon reflection. Anti-exemplars are persons like that. If Zagzebski's theory is correct, such claims should be as uncontroversial as they are in the case of exemplars: Such persons are, after all, those whom we find contemptible upon reflection. My suspicion is that Zagzebski's discomfort here traces back to worries (perhaps latent, and certainly deep) about her response to cross-cultural disagreements over admirability. This question concerns the very first step in Zagzebski's theory, about identifying moral exemplars. The question deserves much more attention than I can give it here -but it is also quite sure to receive it, given the highly original moral theory that Zagzebski delivers in this engaging and insightful book. But it is also true that Zagzebski can be almost excessively uncritical of the evaluative views of others. At one point, for instance, she describes what the "good life" can often mean to well-traveled and well-fed university professors like ourselves, and she claims that, "We pity those people who have not read Plato or listened to Beethoven, and whose lives mostly involve manual labor" (171). But, in that case, aren't we wrong to pity the many hard working people who fit that description, the many generations of fishers, farmers, and so on? "I would not say we are wrong," Zagzebski says, "but surely the kind of 'good life' I have described is optional" (171). [6] That response, coming fairly late in the book, caught me by surprise. Because if that is what we university professors think about the hard-working people who fit Zagzebski's description, then I would say, not only that our conception of the good life is optional, but that we, and especially our pity, are fairly well contemptible. Perhaps it is just difficult for me to see how an exemplarist moral theory can Exemplarist Moral Theory // Reviews // Notre Dame Philosophical ... http://ndpr.nd.edu/news/exemplarist-moral-theory/ 3 of 4 11/4/17, 8:41 PM benefit from declining to highlight the many ways in which we fall short in our ethical lives, by continuing to emulate those who are, in fact, contemptible. Moral exemplars no doubt command a lively appreciation of the contemptible, and that appreciation, as depressing as it can no doubt be, is something that can sustain us against the dangers of false heroes, and false prophets, and lesser, but equally false moral beacons of all kinds. ACKNOWLEDGEMENTS Thanks are due to Thomas L. Carson for his extremely helpful written comments on an earlier draft of this review, and also to David E. Soles for his valuable feedback. [1] Virtue and Vice, Moral and Epistemic, ed. Heather Battaly (Wiley-Blackwell, 2010). [2] Some reviewers of Divine Motivation Theory pointed out that it is not clear that God can serve as an exemplar for human beings, and that it is anyway controversial whether God has any emotions, which are the psychic elements that we would need to emulate in order to motivate virtuous actions. See Thomas L. Carson's review in Mind 116 (2007) 254-57; and Christopher Toner's in the Review of Metaphysics 64:1 (2010) 171-74. [3] That comment gives a sense of how Zagzebski can sometimes overstate the putative advantages of her approach over competing theories, since (e.g.) Martha Nussbaum interprets the Aristotelian approach to ethical investigation precisely by appeal to an externalist theory of language of the type deployed by Zagzebski. See section III of Martha C. Nussbaum, "Non-Relative Virtues: An Aristotelian Approach," Midwest Studies In Philosophy 13 (1988) 32-53. Moral philosophers sympathetic to John Stuart Mill will also be surprised to see the assessment (apparently Zagzebski's own) that Mill "ignores virtue" (21). [4] For further discussion of these points about Aristotelian eudaimonism, see my "Virtue and Prejudice: Giving and Taking Reasons," The Monist 99 (2016) 212-23; the article also appears in a mildly revised and expanded version in Virtue's Reasons: New Essays on Virtue, Character, and Reasons (Routledge, 2017), ed. Noell Birondo and S. Stewart Braun, 189-202. See also T. H. Irwin, "Nil Admirari? Uses and Abuses of Admiration," Proceedings of the Aristotelian Society, Supplementary Volume 89:1 (2015) 223-48, on admiration in Aristotle and other moral philosophers, and in response to an earlier version of Zagzebski's EMT ch. 2. [5] I disagree for similar reasons with Patrick M. Clark's view that exemplarism fares better than Aristotelian eudaimonism when considering the motivations of a virtuous agent facing death. See Clark's discussion of Zagzebski's earlier work on exemplarism in his Perfection in Death: The Christological Dimensions of Courage in Aquinas (The Catholic University of American Press, 2015), ch. 6. On the eudaimonist side, see John McDowell's remarks on courage in his insufficiently discussed paper, "Eudaimonism and Realism in Aristotle's Ethics," in The Engaged Intellect: Philosophical Essays (Harvard University Press, 2009), 23 -40; originally published in Aristotle and Moral Realism, ed. Robert Heinaman (Westview Press, 1995), 201-18. [6] Zagzebski makes it quite clear that she does not herself think that such traditional lifestyles are pitiful; but the question in play here is about the appropriate ethical response to the familiar type of elitism that she describes. Copyright © 2017 ISSN: 1538 1617 College of Arts and Letters Accessibility Information Notre Dame, IN 46556 Exemplarist Moral Theory // Reviews // Notre Dame Philosophical ... http://ndpr.nd.edu/news/exemplarist-moral-theory/ 4 of 4 11/4/17, 8:41 PM


Philosophy

Animal-derived constituents are frequently used in anaesthesia and surgery, and patients are seldom informed of this. This is problematic for a growing minority of patients who may have religious or secular concerns about their use in their care. It is not currently common practice to inform patients about the use of animal-derived constituents, yet what little empirical data does exist indicates that many patients want the opportunity to give their informed consent. First, we review the nature and scale of the problem by looking at the groups who may have concerns about the use of animal-derived constituents in their care. We then summarise some of the products used in anaesthesia and surgery that can contain such constituents, such as anaesthetic drugs, surgical implants and dressings. Finally, we explore the problem of animal-derived constituents and consent using Beauchamp and Childressâ four principles approach, examining issues of autonomy, beneficence, nonmaleficence and justice. Disclosing the use of animal-derived constituents in anaesthesia and surgery is warranted under Beauchamp and Childressâ four principles approach to the problem. Although there exist systemic and practical challenges to implementing this in practice, the ethical case for doing so is strong. The Montgomery ruling presents additional legal reason for disclosure because it entails that patients must be made aware of risks associated with their treatment that they attach significance to.

DEBATE Open Access Using animal-derived constituents in anaesthesia and surgery: the case for disclosing to patients Daniel Rodger1* and Bruce P. Blackshaw2 Abstract Background: Animal-derived constituents are frequently used in anaesthesia and surgery, and patients are seldom informed of this. This is problematic for a growing minority of patients who may have religious or secular concerns about their use in their care. It is not currently common practice to inform patients about the use of animal-derived constituents, yet what little empirical data does exist indicates that many patients want the opportunity to give their informed consent. Discussion: First we review the nature and scale of the problem by looking at the groups who may have concerns about the use of animal-derived constituents in their care. We then summarise some of the products used in anaesthesia and surgery that can contain such constituents, such as anaesthetic drugs, surgical implants and dressings. Finally, we explore the problem of animal-derived constituents and consent using Beauchamp and Childress' four principles approach, examining issues of autonomy, beneficence, nonmaleficence and justice. Summary: Disclosing the use of animal-derived constituents in anaesthesia and surgery is warranted under Beauchamp and Childress' four principles approach to the problem. Although there exist systemic and practical challenges to implementing this in practice, the ethical case for doing so is strong. The Montgomery ruling presents additional legal reason for disclosure because it entails that patients must be made aware of risks associated with their treatment that they attach significance to. Keywords: Animal-derived products, Informed consent, Vegetarianism, Veganism, Principlism, Montgomery, Paternalism, Anaesthesia, Surgery, Dressings Background Providing healthcare in a culturally diverse society can involve a number of unique challenges and compromises. The problem of animal-derived products in healthcare has received some attention in the literature [1–3]. However, very few clinicians remain aware of the scale of the problem, and even fewer have considered how it could be navigated in a way that respects the rights and interests of patients. When so many individuals and groups differ on fundamental concepts, what constitutes care for one patient could be interpreted as harm by another. Some of these fundamental disagreements surround the ethical permissibility of products utilised in healthcare that contain an animal-derived constituent. Patients with certain religious and secular beliefs may express concerns about the use of animal-derived constituents in their care, and in some cases, this can result in a patient refusing certain kinds of treatment [1, 4–6]. The area of perioperative care is notably problematic because of the broad range of products employed that may contain animal-derived constituents, such as anaesthetic drugs, surgical implants and dressings. An increasing number of individuals would like to and may even expect to be informed of any animal-derived constituents that could be used in their care. The United Kingdom (UK) represents a diverse and multicultural population who hold a variety of religious and secular beliefs about the permissibility of using animals for food, clothing, research or medical products, * Correspondence: email@example.com 1Department of Allied Health Sciences, School of Health and Social Care, London South Bank University, 103 Borough Road, London SE1 0AA, England Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Rodger and Blackshaw BMC Medical Ethics (2019) 20:14 https://doi.org/10.1186/s12910-019-0351-4 and this population is increasing. Between the 2001 and 2011 censuses, the Muslim population in England and Wales increased by 1.2 million, and from 3% to 5% of the total population [7]. For Muslims, products containing animal-derived constituents are unlikely to be halal-compatible with Islamic dietary laws. Furthermore, research commissioned by The Vegan Society found that about 1% or over 500,000 of the over-15 UK population now follow a vegan diet which amounts to more than a 300% increase since 2006-a significant proportion of who avoid non-dietary animal products [8]. This steep increase in both the Muslim and vegan populations implies that the number of individuals who might object to the use of animal-derived products used in healthcare is growing rapidly. This raises some significant ethical and practical issues for clinicians, the most pertinent being deciding what information should or should not be disclosed to patients about the products being used to treat them. The importance of disclosure has been recently highlighted by the Montgomery v Lanarkshire Health Board [2015] case, which has transformed UK law on informed consent [9]. With regard to informing the patient of any material risks involved in their treatment, the Montgomery ruling shifts the emphasis from what clinicians would agree is reasonable, to what a reasonable patient would expect to know. The ruling means that clinicians must communicate relevant information to a patient, even if its disclosure could lead the patient to make a choice that may not be in their best interest [10]. Patients are entitled to make decisions that a clinician disagrees with, unless they lack capacity to make an informed choice [11]-even if a clinician is concerned that disclosing certain information could cause psychological harm or lead a patient to refuse life-saving treatment [12]. In this article, we explore which patients may wish to be informed about the use of animal-derived constituents in their anaesthetic and surgical care, and then describe some of the products that may contain them. We then consider some of the ethical issues associated with using these products in anaesthesia and surgery. Employing Beauchamp and Childress' influential four principles of bioethics-autonomy, beneficence, nonmaleficence and justice-we examine the case for disclosing this information to patients and the potential challenges of doing so [13]. Who has concerns about the use of animal-derived constituents? In 2017, the Vegan Society sent a letter to the UK's Secretary of State for Health, detailing their concerns about the use of animal-derived constituents in healthcare, and the current lack of transparency on the labelling of medicines [14]. Understandably, the growing number of vegetarians and vegans want to know if the drugs they might be prescribed contain animal-derived constituents. Individuals are increasingly restricting their consumption and use of animal-derived products for a number of reasons: perceived health benefits, environmental concerns, ethical reasons such as promoting animal welfare, and objections to the intentional killing of non-human animals [15]. It has been estimated that between 3 and 7% of the UK population are vegetarian [16]. Importantly, not all vegetarians would necessarily object to the use of drugs, dressings or implants that have animal-derived constituents. Merely being vegetarian does not necessarily entail objecting to the use of animal-derived products, since some reasons for being vegetarian may not extend beyond dietary preferences [2]. This is in contrast with vegans who typically will not eat or use dairy products, eggs or other animal-derived products. Vegans are much more likely to have concerns about any animal-derived products that may be used in their care, and will want to be fully informed. Many will wish to avoid animal-derived products as far as possible and opt for an alternative, should one exist. Charlotte Houltram, a vegan anaesthetist, has stated that achieving an animal-derived product free anaesthetic can be practicable and offers helpful guidance on how to do so [17]. Houltram notes that because all drugs currently in use in the UK have been tested on animals during their development, none of them can be considered to be fully vegan. Consequently, their use will always involve a degree of compromise. There is also a more sizeable population who potentially may object to the use of animal-derived products in anaesthesia and surgery for religious reasons. In one survey of 13 representative religious leaders, 10 (77%) expressed concerns about the use of biological products-including those with animal-derived constituents-in healthcare and thought that informed consent should be obtained from patients [18]. A subsequent study by Eriksson et al. explored which religious groups object to the use of drugs, implants and dressings containing animal-derived constituents [19]. It was discovered that a number of the world's largest religions objected to the use of some animal-derived products. For example, Muslims-Sunni and Shiite-in the study objected to the use of any porcine-containing products. In Islam, pork and its by-products are considered 'haram' which means forbidden and so for some Muslims the use of porcine-containing products is impermissible, even if the alternative non-porcine containing product-should one exist-meant that healing and recovery was delayed or it was more expensive [18, 20]. For some Muslims, what would be unlawful to consume can also be considered unlawful in the context of Rodger and Blackshaw BMC Medical Ethics (2019) 20:14 Page 2 of 9 healthcare [21]. Nevertheless, Islam is not homogenous and there remains no definitive consensus regarding the use of products that contain an animal-derived constituent [20, 22]. Individual Muslims may therefore have differing beliefs and ways to navigate such conflicts should be considered [21]. Hindus from one of the major traditions known as Vaishnavism objected to the use of drugs, implants and dressings that contain porcine and bovine constituents [19]. This view may not necessarily be representative of all of the traditions within Hinduism, although the majority are vegetarians and avoid egg. However, the use of any animal-derived products may be problematic for many Hindus, with many categorically rejecting their use [1, 23]. The Christian, Jewish and Buddhist leaders contacted by Eriksson et al. had no objections to any animal-derived products [19]. However, all of the religious groups that objected to the routine use of animal-derived products stated that they would be permissible providing (1) there was no viable alternative and (2) they were required for emergency treatment [19]. However, what is classed as emergency treatment can be ambiguous. Some kinds of surgical procedure containing animal-derived products may not be life-saving, but they may have a substantial positive impact on a patient's long-term quality of life and general wellbeing. Neither religious or secular groups are homogeneous in their views on the use of animal-derived products used in their care. Consequently, there is considerable diversity of opinion, and membership of a particular group does not necessarily dictate an individual's convictions. The increase in the number of religious and secular individuals who might be concerned about the use of animal-derived constituents indicates that this is an issue healthcare professionals can no longer afford to ignore. Drugs, dressings and implants containing animal-derived constituents A number of products used in anaesthesia and surgery contain animal-derived constituents that some patients may object to, were they to know. What is particularly problematic is that patients who may have concerns are rarely informed that some of the products utilised in their care may contain animal-derived constituents. These include a number of anaesthetic drugs, surgical implants and dressings. For instance, some drugs contain animal-derived excipients (substances that do not contribute to the therapeutic action), which can make up 90% of the formulation [24]. These cannot always be easily identified because there is currently no legal requirement for them to be included on the packaging. In one study it was discovered that of the 100 most prescribed drugs in primary care in the UK, 74 contained an animal-derived ingredient (most commonly bovine and porcine sources) [3]. This highlights the scale of the problem for religious and secular patients who may object to the use of products with animal-derived constituents. For instance, amoxicillin capsules can be prescribed postoperatively before discharge, yet they contain porcine or bovine sourced gelatin, which is widely used to encapsulate medication [25]. Some capsules can be opened to avoid ingesting the gelatin, but this is not always advisable, unless clearly stated on the patient information leaflet. However, amoxicillin in oral suspension is suitable for vegans and is one alternative for patients who would prefer to minimise their use of animal-derived constituents. The most commonly used induction agent in anaesthesia-Propofol-contains purified egg phosphatide, which vegans would want to avoid, and as it is likely the eggs used are not free range, many vegetarians would similarly find its use problematic [17, 26]. Avoiding Propofol is not an insurmountable problem and could be managed relatively easily by an anaesthetist but it will depend on the kind of induction that is clinically indicated. There is a formulation of Propofol called Cleofol®, which is manufactured in India and does not contain any egg phosphatide or other animal-derived constituents [27]. However, its use has been associated with excessive pain on injection [28]. This may not be sufficient to rule out the use of Cleofol® as a viable alternative for patients who wish to avoid animal-derived constituents. After all, a well known side-effect of Propofol is pain on injection, which occurs in 60% of untreated patients; pain on injection can be mitigated by using an antecubital vein or pre-treatment with intravenous (IV) Lidocaine [29]. Moreover, Houltram suggests that patients could avoid Propofol by opting for local or regional anaesthesia, or where appropriate by using an induction agent that does not contain any animal-derived constituents such as Thiopentone, or by having a gas rather than IV induction [17]. She does note that having a gas induction may be contraindicated in some cases. Hydrocolloid dressings can contain porcine-derived gelatin and are routinely used for a number of different types of hip and knee surgery [30, 31]. Most commonly in the form of DuoDERM® which can also be used to help secure endotracheal tubes (ETT) or nasopharyngeal airways, and protect skin integrity in neonates and infants [32, 33]. In a study by Enoch et al. published in 2005, it was discovered that very few healthcare professionals were aware of which commonly used dressings contained biological material, and were therefore not necessarily in a position to inform patients [18]. Enoch et al. subsequently recommended that hospitals, higher education institutions and product manufacturers should take immediate action to ensure that healthcare Rodger and Blackshaw BMC Medical Ethics (2019) 20:14 Page 3 of 9 professionals are educated about the biological products they frequently use [18]. The lack of education and easily available information creates a barrier to informing patients who might object to the use of certain biological products, including those with animal-derived constituents. However, there is little evidence to suggest that much has changed in more than a decade. There are also a number of surgical products or implants that could also be objectionable to a number of patients. These include composite and biological mesh commonly used to repair the abdominal wall during hernia surgery and in some types of colorectal surgery [4, 34]. They frequently use ingredients from porcine or bovine sources, and this information is not always easily accessible. Biopolymer sutures can also contain animal-derived constituents, including those from ovine and bovine sources [35]. Other types of surgical products that can contain animal-derived constituents include orthopaedic spacers, heart valves and haemostasis matrix [19]. This brief summary of animal-derived products used in anaesthesia and surgery shows that clinicians are routinely using drugs, dressings and surgical implants that a sizable minority of patients in the UK may have a material interest in being informed of. We are not suggesting that there are any easy answers: we are keenly aware of the existing systemic obstructions, and some of the reasons clinicians may be hesitant to acknowledge that this practice could be ethically problematic enough to warrant any serious concern. The health service is already over-stretched, under-resourced, understaffed and many clinicians are already struggling to provide patient care under those existing constraints. Nevertheless, the General Medical Council's guidance on personal beliefs and medical practice state that when '...assessing what is of overall benefit to adult patients, you must take into account their cultural, religious or other beliefs and values' [36]. In principle, it does not seem unreasonable to us to conclude that this guidance implies that patients should be informed about the use of animal-derived products in their care. Furthermore, surgical (and medical) inpatients are routinely asked about their dietary requirements; there is no expectation that they must self-declare that they require vegan, halal or kosher food. It seems inconsistent to go to the effort and expense of respecting patient's religious or secular dietary choices and then use products in their care that many of them may feel as strongly about. Informing patients can therefore demonstrate a more holistic approach to their religious or secular beliefs, rather than maintaining what could be interpreted as a paternalistic approach to the issue. Applying the four principles approach We indicated that Beauchamp and Childress' four principles approach will be used to examine the issue of disclosure of animal-derived products in anaesthesia and surgery. We will consider what each principle informs us about the problem, and attempt to weigh any competing concerns that are uncovered. Beauchamp and Childress recommend a process of deliberation to decide the relative weights of each norm in this context, so that balancing judgements can be made if conflicts between principles are found when they are applied [13]. Beauchamp and Childress offer some practical conditions for restricting balancing to prevent the process from being too open-ended, such as requiring that any infringement of a principle is the least possible infringement with no better alternative, and has realistic prospects of achieving the objective [13]. Autonomy The first principle is respect for autonomy: acknowledging a patient's right to make choices based on their personal values and beliefs, the paradigmatic example being obtaining their informed consent before treatment. One of the key elements of informed consent is disclosure of relevant information, including 'those facts or descriptions that patients or subjects usually consider material in deciding to refuse or consent to the proposed intervention or research' [13]. Typically, disclosure might involve factors such as risks and benefits of a procedure, but Beauchamp and Childress also suggest disclosure should be ideally tailored to 'the specific informational needs of the individual person', needs which might include 'unconventional beliefs' [13]. Although only a small minority of the population is vegan, there are also significant numbers of people who avoid certain animal-derived foods for religious reasons, and there is widespread acceptance of disclosure of the use of animal-derived products in the food industry. As already noted, it is common practice in UK hospitals to request inpatient preferences for their dietary requirements, religious or otherwise. It seems reasonable to inform patients of the use of animal-derived products in their treatment, even if it is not possible to avoid their use. Although the recent Montgomery v Lanarkshire Health Board [2015] case concerned clinical risks that could lead to patients being harmed, it has established a precedent in the UK that the patient's autonomy must be respected-the patient must be made aware of material risks involved in a recommended treatment as well as reasonable alternatives [9]. A risk is defined as material if the patient is likely to attach significance to this risk. Although in the context of the Montgomery case this refers to risks of the medical procedure, the legal implications could be broader: arguably, some patients could be harmed by being treated with animal-derived products if they have strong moral or religious concerns and they later learn this has Rodger and Blackshaw BMC Medical Ethics (2019) 20:14 Page 4 of 9 occurred. It is not for clinicians to assess the significance of this risk on their patient's behalf. Autonomy as understood by Beauchamp and Childress entails that autonomous agents have the right to act according to their values and beliefs [13]. If a clinician, for instance, knows that their patient is Hindu, Muslim or vegan and fails to disclose the use of known animal-derived products in their care, they may be disrespecting their patient's autonomy. Do patients want to know this information? Respect for patient autonomy entails a presumption that they do, and this has been reinforced by the Montgomery ruling. One study from the United States (US) found that 84% of patients sampled were unaware that over 1000 medications contain animal-derived constituents, and 63% wanted their physicians to inform them about medications that contained these products [37]. This provides empirical support for the claim that many patients would prefer to be informed about the use of animal-derived constituents in their care. Interestingly, 70% of physicians believed that providing their patients with this information was important, although acknowledging this seldom lead to any changes in practice [37]. The available evidence therefore indicates that a significant proportion of patients may want this information disclosed to them, and given the importance of respect for patient autonomy, this implies clinicians should not presume patients are uninterested but rather ascertain if the use of animal-derived constituents is an issue for them. If so, they should, as far as possible, disclose the use of known animal-derived constituents in the patient's care to ensure their concerns are adequately catered for. Nonmaleficence The second principle is nonmaleficence, or the obligation not to inflict harm. According to Beauchamp and Childress, harm is a thwarting, defeating, or setting back of some party's interests, and it is a prima facie principle that harmful actions must be sufficiently justified [13]. While this commonly refers to physical harm, it also encompasses psychological harms, which describes harms that can damage someone's psychological well-being. As we indicated earlier, patients who may be concerned about the use of animal-derived products in their care may consider that they have been psychologically harmed by not having that information disclosed, and later learning they have been treated with animal-derived products without their consent. Clinicians may consider such objections unconventional and obstructive, nevertheless, harm can be very subjective and individualistic, and a clinician cannot presume any resulting psychological harms would be trivial. Some vegetarians have described feeling defiled at the thought of accidentally eating meat-anecdotal accounts describe such an experience as 'upsetting'-and so it is possible that failing to convey the use of an animal-derived product could cause some degree of psychological harm [38, 39]. Of course, there may not be an alternative available, and it might be that a clinician considers it is justified in avoiding disclosing such information on the grounds that the patient may be harmed if they refuse treatment. Potential harm from the patient's refusal to accept treatment does not, however, seem sufficient grounds to trump the combination of respect for patient autonomy and the potential of later psychological harm. Failure to disclose the information on the basis that the patient may make a decision that may not be in their interest is also not compatible with the Montgomery ruling. Unless the patient lacks capacity to make an informed choice, they are entitled to refuse treatment if they believe that doing so would harm them, and even if doing so could lead to additional harms. We have already established that some patients would object to the use of animal-derived products on religious or secular grounds, and it seems likely they may be distressed to learn that products with these constituents were used in their treatment, without their consent. Previous studies have identified that most religions make a provision for the use of animal-derived product in an emergency-such as life-prolonging surgery-or when all options for a clinically appropriate alternative have been exhausted [1, 19]. Nonmaleficence entails an obligation on clinicians to not impose unnecessary harms; disclosing this information and gaining informed consent would be one appropriate measure to avoid causing this kind of harm. Beneficence The principle of beneficence is closely related to nonmaleficence-the requirement to contribute to the welfare of the patient (rather than harm them) by acting in their best interest. It is important to consider if disclosure of the use of animal-derived products in perioperative care will hinder patient welfare in some way. Obviously, the patient's treatment will be intended to benefit them, and it is possible that disclosing this information could result in the patient refusing certain kinds of treatment. This is not just a theoretical concern, as we noted in our introduction and discussed in the previous section. Sattar et al. describe four cases of medication non-adherence because of patients' concerns about the use of certain animal-derived constituents that they believed to be forbidden by their religion [40]. The patients only stopped taking their medication upon finding out for themselves that it contained an animal-derived constituent. This led to either worsening symptoms or relapses of their illness, and therefore a violation of the Rodger and Blackshaw BMC Medical Ethics (2019) 20:14 Page 5 of 9 principle of beneficence. Naively, withholding information might be thought to promote beneficence because of the risk that some patients might decline treatment, but as these examples show, some patients will investigate for themselves. Consequently, in these four cases of medication non-adherence, the cause was the absence of disclosure and any conversation about the contents of their medication prior to them being prescribed. All four patients were subsequently provided with medication that did not contain an animal-derived constituent and that satisfied their religious concerns. Beneficence in these cases would have been achieved by disclosing this information, obtaining informed consent and amending the medication in light of the patient's religious beliefs. A UK questionnaire-based study of a mixed ethnicity inner-city population found that 43% would avoid taking prescribed oral medication containing animal-derived ingredients, even if there was no alternative treatment [41]. However, only 20% of those who preferred vegetarian medication would ask the prescribing doctor if their medication contained animal-derived ingredients. In the perioperative context, this highlights the importance of communicating the possibility of animal-derived constituents being used to pre-empt these concerns. This reinforces our earlier point regarding the potential harm that may eventuate from the use of these constituents and the subsequent discovery of this by patients who have strong religious or secular concerns with their use. There is still the issue of those patients who refuse treatment because of their convictions. What course of action should be taken in these situations? It seems that there is an obligation to ensure that alternative products are available where possible, at least for commonly used products. In addition, patient disclosure should include variations in risks and benefits incurred by using alternative products, and of course if a suitable alternative exists and is available. Alternatives may not be available in emergencies, but we have noted that religious groups and vegans may not object to the use of animal-derived constituents in these situations in the absence of alternatives. Clinicians could also suggest, where possible, that the patient discuss their concerns with a religious leader or secular authority. In instances where a patient still refuses treatment because of unavoidable animal-derived constituents, the patient's wishes must be respected, provided they have capacity to make an informed choice. Justice The final principle is justice, or the equitable distribution of goods-healthcare in this case. We do not have space to discuss different principles of distributive justice that could be employed, or whether there is a general right to healthcare and how it might be implemented. For our purposes, we will assume that all patients deserve a minimum standard of care, and the standard provided should be equivalent for each patient. In practice, healthcare resources are always finite, demands are high, and consequently some form of rationing and setting of priorities is always required. We can grant a prima facie obligation to provide groups with certain religious or moral convictions about animal-derived products with alternative products so they can receive equivalent care, but budgetary limitations may constrain what can be offered. Constraints include the availability and affordability of viable alternatives. Additionally, clinicians must be aware of these alternatives, and be able to provide an assessment of their comparative efficacy and risks. These constraints are considerable, and we must ask, to what extent should clinicians and budgets be required to cater for patients with these convictions? The answer will be dependent on each hospital's budget, as well as the particular product involved-some alternatives may be considerably more expensive than the equivalent animal-derived product. An additional consideration, raised by Newson, is that some synthetic alternatives may have greater efficacy than their equivalent [42]. This may mean that those patients with religious and moral convictions about the use of animal-derived constituents may receive more effective treatment than most patients, which seems unjust. The solution may be to provide the synthetic version to all patients, but if this incurs significantly increased costs, it may impact the provision of health services in other ways, and this may not be acceptable. Of course, some non-animal-derived drugs may well be less effective than their equivalents, but in these scenarios, the patient can be given the choice of either drug. For synthetic alternatives that prove too expensive, there is another approach that could be considered. The minimum standard of care provided could exclude the provision of synthetic drugs except where they incur similar costs, and patients whose convictions require them to avoid animal-derived products could pay for these alternatives themselves, either via a private health insurance policy designed for the purpose, or directly. If such a policy is made widely known, over time those who hold such convictions could ensure they make provision for this. What are the implications for disclosure? If, as a matter of policy, all clinicians were required to disclose the use of animal-derived products to their patients, demand for alternatives would increase and ultimately costs of these alternatives should decrease. In many instances, synthetic alternatives could gradually replace certain animal-derived products for all patients. This would, over time, make healthcare more accessible for those who hold convictions about the use of animal-derived products. There are, however, a number of complications that could ensue and which we now briefly explore. Rodger and Blackshaw BMC Medical Ethics (2019) 20:14 Page 6 of 9 Challenges of disclosure We have sought here to make the ethical case for disclosure by considering the problem using Beauchamp and Childress' four principles approach. We will now review some of the challenges that implementing it might generate in anaesthesia and surgery and beyond. It is primarily problematic for a very practical reason: very few clinicians know whether or not the drugs, surgical products and dressings they use contain any animal-derived constituents. Additionally, as Tatham and Patel note, 'information about animal derived products in medicines is difficult to obtain, unclear, inconsistently reported, and sometimes incorrect' [3]. Even clearer labelling, however, is not sufficient, as a comprehensive knowledge is also required of what acceptable alternatives-should they exist-to each drug or product are available, including efficacy and comparative risks. These types of systemic obstructions mean that clinicians are limited in what they can actually promise a patient if they request that they want their care to be free of animal-derived constituents. Clinicians can undertake to minimise their use, but will need to communicate that insufficient information exists regarding the constituents in every product they are using, and so it is possible that some products may still contain animal-derived constituents. Any more than this may not be practicable until there has been significant changes in product labelling. In some cases, surgeons will know that a product-such as a biological surgical mesh containing porcine tissue-contains a constituent that a patient may object to, and here we have established that patient concerns should be preempted and informed consent should be obtained. In the context of anaesthesia, it may be possible for an anaesthetist to provide an 'animal product free anaesthetic' for patients, providing as we have already discussed, that this is compatible with the kind of induction that is clinically indicated [17]. This does still raise additional clinical concerns: it is conceivable that in trying to meet the demands of patients who want an 'animal product free anaesthetic' that this could lead to an increased risk of anaesthetic complications. For instance, the use of Thiopentone in obstetrics has been associated with increased drug errors, and it is relatively unfamiliar to the newer generation of anaesthetists who most frequently use Propofol to induce patients [43]. The task of disclosure would be far easier if a legal requirement was introduced forcing the declaration of inactive animal-derived constituents. A database of medicines licensed for use in the UK already exists: the electronic Medicines Compendium (eMC) [44]. The eMC contains a Summary of Product Characteristics (SmPC) for each medicine, which is comprised of detailed information supplied by pharmaceutical companies, including active and inactive constituents. This information is checked and approved by the UK or European government agencies which licence medicines. It would be straightforward to augment the existing data to indicate what constituents are animal-derived, and this would be a significant step forward, at least for medicines. However, dressings and surgical implants are not included in this compendium. Additionally, knowledge of acceptable alternatives-should they exist-to each drug or product are required, including efficacy and comparative risks. It seems feasible to include this information, although this would be a more complex task. This would be broadly useful in healthcare far beyond anaesthesia and surgery, and indeed, the case for disclosure presented here is likewise widely applicable. A long-term solution, suggested by Tatham and Patel, would be to eliminate all animal-derived constituents from all drugs and medical products [3]. This may seem unlikely in the short-term, given the number of products that would require modification or replacement, and the potential costs that would ensue. There are also no incentives for medical and pharmaceutical companies to even consider this development. However, were disclosure to be advocated, clinicians and patients could exert pressure on companies to develop products that would alleviate their religious or secular concerns. Finally, an important component of successful disclosure is improved education among healthcare professionals regarding the use of animal-derived constituents. Higher education institutions must consider their responsibility to educate healthcare professionals about the ethical and legal issues surrounding the use of animal-derived products in healthcare. Conclusion The use of animal derived constituents in anaesthesia and surgery is of increasing interest for a growing minority of patients, many of whom have religious or secular concerns about their use. There has been a significant rise in the Muslim and vegan populations in the UK, and we have argued that existing research supports the contention that many of them believe that they should be given the opportunity to provide informed consent. Clinicians should expect to be increasingly confronted by patients who wish to know if any products used in their care contain animal-derived constituents, and whether they can be avoided. Clinicians must therefore consider how they will manage the concerns of such patients. We have applied Beauchamp and Childress' four principles to this issue, and conclude that they provide a strong case for disclosing the use of animal-derived constituents to patients in anaesthesia and surgery, as well as other areas of healthcare. The importance of Rodger and Blackshaw BMC Medical Ethics (2019) 20:14 Page 7 of 9 patient autonomy provides the strongest argument for disclosure. The Montgomery ruling, while a legal motivation rather than an ethical one, also emphasises the importance of patient expectations about disclosure, and we have established that for many patients, the use of animal-derived constituents is a significant issue. We acknowledge that full disclosure faces some practical difficulties at present: there are a number of systemic obstructions that will need to be dealt with which will require significant changes to the law, product development, education and clinical practice. Nevertheless, our analysis strongly supports the contention that informed consent should be gained from patients when animal-derived constituents will be used in their care, and that alternatives should be sought where available and practicable. Acknowledgements We would like to thank Louise Terry, Richard Playford, Charlotte Houltram and James Ip for their helpful comments on an earlier draft. Funding No funding was obtained for this study. Availability of data and materials Not applicable. Authors' contributions DR and BB both drafted the article and have read and approved the final manuscript. Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Author details 1Department of Allied Health Sciences, School of Health and Social Care, London South Bank University, 103 Borough Road, London SE1 0AA, England. 2Department of Philosophy, School of Philosophy, Theology and Religion, University of Birmingham, Birmingham, England. Received: 21 September 2018 Accepted: 13 February 2019 References 1. Easterbrook C, Maddern G. Porcine and Bovine Surgical Products:Jewish, Muslim, and Hindu Perspectives. JAMA Surg. 2008;143(4):366–70. https://doi. org/10.1001/archsurg.143.4.366. 2. Hoesli TM, Smith KM. Effects of religious and personal beliefs on medication regimen design. Orthopedics. 2011;34(4):292–5. https://doi.org/10.3928/ 01477447-20110228-17. 3. Tatham KC, Patel KP. 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