Elselijn Kingma

A 2017 Nature report was widely touted as hailing the arrival of the artificial womb. But the scientists involved claim their technology is merely an improvement in neonatal care. This raises an under-considered question: what differentiates neonatal incubation from artificial womb technology? Considering the nature of gestation—or metaphysics of pregnancy—(a) identifies more profound differences between fetuses and neonates/babies than their location (in or outside the maternal body) alone: fetuses and neonates have different physiological and physical characteristics; (b) characterizes birth as a physiological, mereological and topological transformation as well as a (morally relevant) change of location; and (c) delivers a clear distinction between neonatal incubation and ectogestation: the former supports neonatal physiology; the latter preserves fetal physiology. This allows a detailed conceptual classification of ectogenetive and ectogestative technologies according to which the 2017 system is not just improved neonatal incubation, but genuine ectogestation. But it is not an artificial womb, which is a term that is better put to rest. The analysis reveals that any ethical discussion involving ectogestation must always involve considerations of possible risks to the mother as well as her autonomy and rights. It also adds a third and potentially important dimension to debates in reproductive ethics: the physiological transition from fetus/gestateling to baby/neonate.

Is the mammalian embryo/fetus a part of the organism that gestates it? According to the containment view, the fetus is not a part of, but merely contained within or surrounded by, the gestating organism. According to the parthood view, the fetus is a part of the gestating organism. This paper proceeds in two stages. First, I argue that the containment view is the received view; that it is generally assumed without good reason; and that it needs substantial support if it is to be taken seriously. Second, I argue that the parthood view derives considerable support from a range of biological and physiological considerations. I tentatively conclude in favour of the parthood view, and end by identifying some of the interesting questions it raises.

Christopher Boorse's Bio Statistical Theory (BST) defines health as the absence of disease, and disease as the adverse departure from normal species functioning. This paper presents a two-pronged problem for this account. First I demonstrate that, in order to accurately account for dynamic physiological functions, Boorse's account of normal function needs to be modified to index functions against situations. I then demonstrate that if functions are indexed against situations, the BST can no longer account for diseases that result from specific environmental factors. The BST is impaled on either horn of this dilemma and therefore must be dismissed

What is the metaphysical relationship between the fetus/embryo and the pregnant organism? In this paper I apply a substance metaphysics view developed by Barry Smith and Berit Brogaard to argue, on the basis of topological connectedness, that fetuses/embryos are Lady-Parts: part of the maternal organism up until birth. This leaves two options. Either mammalian organisms begin at birth, or we revise our conception of organisms such that mammalian organisms can be part of other mammals. The first option has some advantages: it is numerically neat; aligns with an intuitive picture of organisms as physically distinct individuals; and ties ‘coming into existence’ to a suitably recognisable and important event: birth. But it denies that the fetus survives birth, or that human organisms existed prior to their birth. The second option allows us to recognise that human organisms exist prior to and survive their birth, but at a cost: it leaves the question of when an organism comes into existence unanswered, and demands potentially far-reaching conceptual revision across a range of domains.

The literature on health and diseases is usually presented as an opposition between naturalism and normativism. This article argues that such a picture is too simplistic: there is not one opposition between naturalism and normativism, but many. I distinguish four different domains where naturalist and normativist claims can be contrasted: (1) ordinary usage, (2) conceptually clean versions of “health” and “disease,” (3) the operationalization of dysfunction, and (4) the justification for that operationalization. In the process I present new arguments in response to Schwartz (2007) and Hausman (2012) and expose a link between the arguments made by Schwartz (2007) and Kingma (2010). Distinguishing naturalist claims at these four domains will allow us to make progress by (1) providing more nuanced, intermediate positions about a possible role for values in health and disease; and (2) assisting in the addressing of relativistic worries about the value-ladenness of health and disease

This chapter examines naturalistic accounts of mental disorder: accounts that define disorder as biological dysfunction. There are three such accounts: an eliminativist account ; a forward-looking or goal-contribution account and a backward-looking or evolutionary account. I argue first, and contra Szasz, that biological functions can be attributed at a mental level. But our mental architecture might simultaneously support many different ways of attributing function claims, which might undermine a strong naturalism about mental disorder. Second, I argue that Boorse's forward-looking account of disorder as dysfunction is not value-free. Third, I argue that Wakefield's backward-looking account does not accurately map onto our disorder judgments or medical purposes. I conclude that whilst Boorse's forward-looking account of disorder as dysfunction tracks medical usage better than Wakefield's evolutionary account, a truly value-free account of mental disorder cannot be sustained

In, I argued that Boorse's biostatistical theory of health is unable to accommodate diseases that are the normal result of harmful environments. Hausman disagrees: if the BST compares normal dispositional function against the whole population or reference class, rather than against organisms in similar circumstances as I proposed, then my challenge can be avoided. In this paper, I argue that Hausman's response fails: his proposal cannot accommodate a series of common physiological processes, such as sleep and those involved in reproduction. In the course of this argument, I also offer a detailed discussion of the concept of functional efficiency, and reveal a link between the problem of environments and that of reference classes. 1 Introduction2 Kingma on Boorse3 Hausman on Kingma4 Response to Hausman5 Three Possible Replies5.1 Reference classes5.2 Temporary pathologies5.3 Adequacy of function6 Concluding Discussion.

Synthetic biology promises to eliminate the distinction between biology and engineering by delivering a philosophically interesting new kind of entity: a biological organism that is wholly designed and constructed by humans. The possibility of such organisms raises interesting questions in three domains: the analysis of (1) biological functions, (2) engineering functions, and (3) health and disease. This paper identifies and systematically answers these questions. This does not only establish how we should think about functions and health and disease in synthetic biological organisms, but it also reveals insights that are of broader relevance: (1) aetiological accounts of biological function need to omit or reinterpret reference to natural selection. This results in complete continuity between aetiological analyses of function in engineering and philosophy; (2) considering synthetic biology prompts interesting further questions about heritability, ancestry, and biological individuals; and (3) accounts of disease as biological dysfunction do not straightforwardly map onto our intuitive health and disease judgments regarding non‐human animals. In response to the latter point I examine three possible avenues, and tentatively defend one on behalf of the ‘disease as dysfunction’ theorist.

Ectogestation—that is, ‘artificial’ or extramammalian pregnancy—may soon be within technological reach. This confronts us with questions about the correct moral and legal attitude towards the subjects of this technology, which are called ‘gestatelings’. Colgrove argues that gestatelings are a kind of newborn, and consequently should have the same moral and legal protections as newborns. This paper responds that both claims are unsupported by his arguments, which equivocate on two understandings of the term ‘newborn’. Questions about the appropriate moral and legal status of gestatelings are therefore left unanswered, but in the course of attempting to answer them, we are well advised to continue using the term gestateling.

This paper critically analyses ‘the paradox of autonomy and consent in maternity care’. It argues that maternity care has certain features that increase the need for explicit attention to, and respect for, both autonomy and rigorous informed consent processes. And, moreover, that the resulting need is considerably greater than in almost all other areas of medicine. These features are as follows: (1) maternity care involves particularly socially sensitive body parts that are regularly implicated in consent‐centred procedures, as well as in unconsented interventions, in ordinary, non‐medical life; and (2) much of maternity care (especially intervening in childbirth) is medically unique, in that it harms one patient (the mother) not primarily for the promotion of her own health but for the benefit of another (the baby). The apt comparison, within medicine, is therefore with non‐therapeutic research and transplantation medicine—both of which have elevated consent requirements characterized by very rigorous consent processes. At the same time—and this delivers the titular paradox—the importance of autonomy and consent in maternity care is at particular risk of being denied or disregarded. Jointly, these considerations make a very strong case for change: attention to and respect for autonomy and consent should be (1) core values; (2) key points of practical attention in the years ahead; and (3) central quality indicators in maternity care.

When did we begin to exist? Barry Smith and Berit Brogaard argue that a new human organism comes into existence neither earlier nor later than the moment of gastrulation: 16 days after conception. Several critics have responded that the onset of the organism must happen earlier; closer to conception. This article makes a radically different claim: if we accept Smith and Brogaard’s ontological commitments, then human organisms start, on average, roughly nine months after conception. The main point of contention is whether the fetus is or is not part of the maternal organism. Smith and Brogaard argue that it is not; I demonstrate that it is. This claim in combination with Smith and Brogaard’s own criteria commits to the view that human organisms begin, precisely, at birth.

On the 13th June 2014, the Centre for the Humanities and Health (CHH) at King’s College London hosted a one-day workshop on ‘Parentalism and Trust.’ This workshop was the sixth in a series of workshops whose aim is to provide a new model for high-quality open interdisciplinary engagement between medical professionals and philosophers. The term ‘Parentalism’ rather than paternalism is chosen and used throughout because of some of the derisory and unfortunate gender connotations associated with paternalism (and/or its counterpart ‘maternalism’). Medical Parentalism is the position that unwanted interference with a patient’s choices and actions in order to protect and promote her best interests is morally justified. Whilst there are many problems with its justification and implementation, the workshop addressed how such interference depends on a trusting relationship between the doctor and patient, and the extent to which parentalist interferences might undermine this trust.

Whether it is morally permissible to compel women to undergo a caesarean section is a topic of longstanding debate. Despite plenty of arguments against the moral permissibility of a forced caesarean section, the question keeps cropping up. This paper seeks to scrutinise a particular moral argument in favour of compulsion: the appeal to parental obligation. We present what we take to be a distillation of the basic form of this argument. We then argue that, in the absence of an exhaustive theory of parental obligation, the question of whether a labouring woman is morally obliged to undergo emergency surgery—and especially the further question of it is morally permissible for third parties to compel this—cannot be answered via ready-made theory. We propose that the most viable option for settling both questions is by analogy. We follow earlier writers in presenting an analogous case—that of fathers being compelled to undergo non-consensual invasive surgery to save their children—but expand the analogy by considering objections that appeal to the ownership of the fetus. We offer two lines of response: the parthood view of pregnancy and chimaera dad. We argue that it is clear in the analogous case that compulsion cannot be justified. We also offer this analogy as a useful tool for assessing whether mothers have a moral duty to undergo caesarean sections, both in general and in particular cases, even if such a duty is insufficient to warrant compulsion.

Unconsented episiotomies and other procedures during labour are commonly reported by women in several countries, and often highlighted in birth activism. Yet, forced caesarean sections aside, the ethics of consent during labour has received little attention. Focusing on episiotomies, this paper addresses whether and how consent in labour should be obtained. We briefly review the rationale for informed consent, distinguishing its intrinsic and instrumental relevance for respecting autonomy. We also emphasise two non-explicit ways of giving consent: implied and opt-out consent. We then discuss challenges and opportunities for obtaining consent in labour and birth, given its unique position in medicine.We argue that consent for procedures in labour is always necessary, but this consent does not always have to be fully informed or explicit. We recommend an individualised approach where the antenatal period is used to exchange information and explore values and preferences with respect to the relevant procedures. Explicit consent should always be sought at the point of intervening, unless women antenatally insist otherwise. We caution against implied consent. However, if a woman does not give a conclusive response during labour and the stakes are high, care providers can move to clearly communicated opt-out consent. Our discussion is focused on episiotomies, but also provides a useful starting point for addressing the ethics of consent for other procedures during labour, as well as general time-critical medical procedures.

We read commentaries on our feature article ‘The ethics of consent during labour and birth: episiotomies’1 with gratitude and interest. Nearly all commenting authors agree that consent for in-labour procedures is necessary and ideally given at the point of intervening. Both Shalowitz & Ralston and Stirrat note that this is already required by professional statements and guidelines in the USA2 and UK3, respectively, but also note that practice does not yet conform. The Americans authors helpfully emphasise the importance of multilevel institutional measures for closing this gap, including consent policies and reporting mechanisms, as well as ongoing education.2 The UK writer seconds the role for education within wider shared decision-making and informed choice approaches, and generously commends our paper for close study by all maternity care providers. Others add a cautionary note. Lee applauds all our recommendations, but notes our proposals cannot fully secure autonomy because of, among others, epistemic injustice and other power differentials.4 Kumar-Hazard and Dahlen worry that opt-out consent is equal to substitute decision-making; weakens women’s rights; and is open to abuse.5 Nelson and Clough object to our willlingness to work within a flawed conceptual framework, which ought to be challenged.6 We agree that there are limits to what our proposal can do. It cannot rectify unequal distributions of epistemic credibilities, either in general or in any particular interaction. Risk communication is never neutral;7 “even the most well-meaning healthcare professionals …