A Philosophical Disease: Bioethics, Culture, and Identity

A Philosophical Disease is a Wittgensteinian critique of Western biomedical culture. Carl Elliott engages the intersection of language and our construction of reality, morality, and relationality.

For an example of how this sort of critique works, Elliott's discussion of the construction of gender is paradigmatic. There are a number of medical conditions--including birth defects, genetic abnormalities, and medical mishaps--which render a person's sexual identity . . . well, complicated.

In one part of the Dominican Republic, one such condition is sufficiently prevalent that there is a name for it: guevedoche. (Penis-at-twelve.) Individuals with this genetic condition are genotypically male, but appear female from birth through puberty. Most guevedoches, although they had been raised as females, make the transition to male societal roles after puberty--including marrying women and taking jobs usually given to men. It is not so much that this culture is blase about gender roles (quite the opposite); it is rather that their experience with a particular condition allows them to code for a third gender, as it were. They have the experience of it, they have a name for it, and they have cultural practices which surround it.

By contrast, the US has retained a more strict understanding of the world as divided into male and female. Thus, their cultural practices surrounding the same genetic condition--or conditions in which gender identity is similarly ambiguous--are different. They have a medical name for the condition (5-alpha-reductase deficiency), but not for persons afflicted with the condition. Indeed, the cultural experience of such conditions is so rare that medical practices surrounding these conditions tend to involve surgery to make the genitalia match the individual's perceived sexual identity. (That is, if the individual feels more "female," the genitalia are surgically altered to match that feeling.) American language and experience is almost exclusively bound by the male/female dyad, such that surgical intervention is required to make one's biology match the linguistic and philosophical convention.

Elliott similarly investigates the way language about identity intersects with psychiatry. These chapters were some of the most interesting, as that intersection has received far less attention than it should in the bioethics literature. How does severe depression affect competence to consent? Do emotional ties reduce or enhance rational decision-making? Why do we have an intuitive sense that a willingness to sacrifice oneself is morally praiseworthy, while a willingness to profit from someone's sacrifice is morally reprehensible?

This is, in addition, an eminently readable book. The motivated amateur could certainly tackle this book, although it is geared toward an academic audience. If your interest is in the culture of medicine--not just the hot topics in bioethics, but the culture in which these topics get discussed--this is a book worth reading.