NATURALIZING MORAL REASONING IN BIOETHICS By Daniel Beck        A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of  PhilosophyDoctor of Philosophy  2016              ABSTRACT NATURALIZING MORAL REASONING IN BIOETHICS By Daniel Beck This dissertation is motivated by the hunch that current treatments of methodology in bioethics rest on inaccurate and one-sided pictures of the social practices of moral reasoning, in part because of their general avoidance of questions about the constitution of the we that reasons about moral issues. These approaches uncritically take the perspective of the doctor or administrator and unduly focus on one aspect of moral reasoningits purported goal of producing definitive judgments. These limitations rarely produce considerations that are useful and usable by most people who face moral dilemmas concerning health care decisions, especially people who do not find medical institutions to be empowering places. In this dissertation I contribute to the painting of a different pictureone that provides more usable resources for dealing with the problems that confront people in a morally messy world. I by no means claim artistic originality here. This alternative picture has been painted in several different shades and variations by many others. Though each variation places a different gloss on the relationship between ethical theory and practice, all share a commitment to modeling ethics on the variety of actual social practices in which moral reasoning occurs. I focus on a naturalized and feminist variation on this theme. More specifically, this variation combines politically critical and socially reflexive analysis with a commitment to starting moral reflection from the actual moral experiences of human beingsmost often from the experiences of people excluded from mainstream moral discourse on account of their social position (e.g., gender, race, class, or disability status). In this dissertation, I aim at the modest task of clarifying the details of the portion of this picture relevant to moral reasoning in bioethics.  I begin with a critical examination of dominant methodologies in bioethics and outline their problems in terms of their inability to accommodate the significance for moral agents of three kinds of social positioning: the positioning of agents (1) in institutions, (2) along axes of social oppression, and (3) as temporally, culturally, and psychologically constrained human beings. I then introduce naturalized moral epistemology as a potential antidote to the idealizing assumptions remaining in dominant methodologies. In the second chapter, I develop the application of naturalized moral epistemology to bioethics by naturalizing the notion of the common morality. I develop three mutually reinforcing interpretations of a naturalized common morality: the common morality as (1) shared ecological predicament, as (2) shared evaluative space, and (3) as external coherence. The third chapter looks more deeply into theoretical issues for the naturalized approach, namely into the problem of locating normativity in a natural world. This chapter also provides a clear expression of the difference between the feminist naturalism developed in this dissertation and the scientific naturalism that is more well-known in the literature. In the fourth chapter, I confront a common objection to naturalized approachesthe charge of moral relativismand show how naturalizing does not lead to relativism. This sets the dissertation up for the final chapter in which I show naturalizing in action by presenting a naturalized approach to the topic of medical cultural competence.iv  ACKNOWLEDGMENTS  I have many debts, both intellectual and personal. I am in debt to my mentor, Hilde Lindemann, whose encouragement and critical attention has improved my writing and philosophical acumen immensely. If not for her, this dissertation would be riddled with errors. I must mention, as well, my committee members, Jamie Lindemann Nelson, Fred Gifford, and Lisa Schwartzman. Not only have they read drafts, discussed my ideas, and provided invaluable advice, but the philosophical contributions of each have shaped the course of my own intellectual development.  I must acknowledge, as well, my friends and peers in the graduate philosophy program at Michigan State. You cannot get through a graduate program without friends, and I have learned as much about philosophy talking at the bar with fellow-travelers as I have in the seminar room. You know who you are.  Both the philosophy department and the graduate school have provided me with the institutional and material support needed to write a dissertation and survive at the same time. Thank you for the fellowships, teaching assistantships, office space, and professional development.  I owe my greatest debt to my family. To mom and dad, I could not possibly express all the ways in which you have supported my intellectual passions. Most recently, you have given me a place to write this past year and a half (as well as free coffee!). All of my education I owe to you. To my son, Levi, you have given me the focus and drive needed to bring this dissertation to fruition. To Megan, I am quite certain I would have chucked the whole project in the trash bin by now if I did not have your love, patience, and encouragement. Thank you for sticking through with me to the end. v  TABLE OF CONTENTS  LIST OF FIGURES ...................................................................................................................... vii  CHAPTER 1: ACCOUNTING FOR THE NON-IDEAL IN BIOETHICS ................................... 1 A Note on Terminology ...................................................................................................... 3 Shared Moral Epistemological Assumptions ...................................................................... 4 Strongly Idealized Methodology......................................................................................... 5 The Logical Priority of Moral Principles ................................................................ 5 Deductivism ............................................................................................................ 6 Epistemological Priority of Theorizing for Ideal Conditions ................................. 7 Non-Ideal Methodology in Bioethics: Strengths and Limitations .................................... 13 General Characteristics ......................................................................................... 13 Pluralistic Principlism ........................................................................................... 14 Non-Particularist Casuistry ................................................................................... 15 Morality as a Public System ................................................................................. 17 Idealizing Assumptions about Principles and the Common Morality .................. 20 Anti-Theory and Anti-Method Bioethics .......................................................................... 25 Naturalized Moral Epistemology ...................................................................................... 29 Conclusion ........................................................................................................................ 32  CHAPTER 2: NATURALIZING THE COMMON MORALITY ............................................... 34 The Varieties of Naturalism .............................................................................................. 35 Problems for Common Morality in Mainstream Bioethics............................................... 37 Naturalized Common Morality I: Shared Ecological Predicaments ................................. 39 Naturalized Common Morality II: Shared Evaluative Spaces .......................................... 50 Naturalized Common Morality III: External Coherence .................................................. 61 Conclusion ........................................................................................................................ 67  CHAPTER 3: A SECOND-NATURE APPROACH TO NATURALISM AND NORMATIVITY....................................................................................................................................................... 71 Scientific Naturalism and the Problem of Normativity .................................................... 73 J.L. Mackie and the Objectivity of Value ......................................................................... 74 Values and the First-Person Perspective on to the World ................................................. 79 The First Person Perspective as Second Nature ................................................................ 85 Normativity and Second Nature........................................................................................ 89 Second Nature and Conservatism ..................................................................................... 94 Conclusion ...................................................................................................................... 103  CHAPTER 4: SECOND-NATURE, RELATIVISM, AND CROSS-CULTURAL MORAL CONVERSATION ..................................................................................................................... 105 Relativism as Multimundialism ...................................................................................... 108 Relativism, Cultural Imperialism, and Tolerance ........................................................... 119 vi  McDowell and Davidson against Global Conceptual Relativism................................... 124 McDowell as Ethical Relativist? ..................................................................................... 132 Conclusion ...................................................................................................................... 142  CHAPTER 5: NATURALIZING CULTURAL COMPETENCE ............................................. 144 Key Elements of a Naturalized Approach ...................................................................... 146 A Criterion of Empirical Adequacy .................................................................... 146 Emphasis on the Ethical-Epistemic Effects of Power and Privilege .................. 147 Moral reflection occurs from within a moral form of life .................................. 148 Motivations for Cultural Competence ............................................................................ 148 The Errors of the Categorical Model .............................................................................. 150 Hans-Georg Gadamer and The New Models of Cultural Competence .......................... 158 Supplementation of Knowledge with Attitudes and Skills ................................. 162 Community Specific and Evidence-Based Knowledge ...................................... 163 Further Supplementation with Inclusion of Power-sensitive Analyses .............. 164 Implicit Bias and the Opacity of Human Motivation...................................................... 165 Incorporating Implicit Bias Research into Cultural Competence ................................... 170 Pedagogical Interventions ................................................................................... 171 Organizational Interventions ............................................................................... 175 Caveat: Structural Issues ..................................................................................... 177 The Spirit Catches You and You Fall Down: A Case Study of Cross-Cultural Conversations .................................................................................................................. 178 Lesson 1 .............................................................................................................. 180 Lesson 2 .............................................................................................................. 181 Lesson 3 .............................................................................................................. 183 Lesson 4 .............................................................................................................. 185 Conclusion ...................................................................................................................... 186  WORKS CITED ......................................................................................................................... 188         vii  LIST OF FIGURES  Figure 1: The Müller-Lyer illusion: This figure depicts an optical illusion consisting of a set of arrow-like figures. ......................................................................................................................... 87 1  CHAPTER 1: ACCOUNTING FOR THE NON-IDEAL IN BIOETHICS Much of bioethics is concerned with making moral judgments about both personal and political issues concerning medicine and health. These judgments are oftentimes wracked with emotional stress and uncertainty. We wonder, often in retrospect, whether we made the right judgment. How would we know if we made the right judgment? Is there a wayperhaps a procedure we could followthat could maximize the likelihood of making right judgments in ethical issues concerning medicine and health? This line of thought forms the motivation for the interest in identifying a defensible method for bioethical judgment. Academic discussions on this topic have produced a wide variety of useful frameworks for guiding ethical judgments in health care. However, no convergence on a single appropriate method has emerged, despite the proponents' own ambitions for their preferred approach.  I suggest that some of the difficulties in this line of inquiry emerge from shared but flawed moral epistemological assumptions concerning the relationship between ethical theory and best practices of judgment for moral problems in non-ideal circumstances. Since virtually all real world ethical problems occur under non-ideal circumstances, a methodology that applies well only under ideal circumstances will not satisfy the need to identify workable methods for bioethics.  Though many current dominant methodologies reject the standard model of ethics that naively tries to apply idealized theory to non-ideal circumstances, none of them fully diagnose the problem with idealized theory.1 I argue that non-ideal circumstances call for attention to be                                                   1. Idealized theory is not completely out of vogue. Utilitarianism and other forms of consequentialism (2007) application of a liberal utilit(2002) rule-based consequentialism (1993) well-known preference utilitarian approach to the rights of animals and of newborns. 2  paid to three kinds of positioning of moral agents: (1) positioning within institutions (2) positioning along axes of social oppression, and (3) positioning as psychologically, culturally, and historically constrained human beings. Ultimately, I claim that a bioethics methodology that aims to be relevant for non-ideal circumstances will be best served by a naturalized moral epistemology. Naturalized moral epistemology, which I describe more fully at the end of this chapter, is the approach to the study of moral knowledge that takes as its subject actually existing phenomena of moral knowledge rather than some idealized representations and, therefore, eschews armchair a priori philosophizing in favor of empirically informed research (Walker 2007, 65). The organization of this chapter is as follows. First, I describe the idealized methodology that most current bioethical methods reject. Since utilitarianism is still popular among some Practical Ethics (1993) as an example of an idealized methodology. Second, I provide my diagnosis of the problem with idealized methodologies in terms of the kinds of positioning that idealization ignores. Third, I canvass popular approaches to methodMorality as a Public SClouser, and Charles Culver (1997); the pluralistic principlism of Tom Beauchamp and James Childress (2013); and non-particularist forms of casuistryand evaluate them according to how well they handle issues of positioning. I identify within their conceptions of the common morality and moral principles several idealizing epistemological assumptions. After having argued that none seem to adequately handle non-ideal positioning, I make the case that methodologies underwritten by a naturalized moral epistemology are best suited to perform this task. 3  A Note on Terminology Before I begin, I need to outline some terminology. Several terms that are often used interchangeably need to be distinguished: theory, method, and methodology. My understanding of these terms is drawn from Allison Jaggar and Theresa Tobin (2013), Margaret Urban Walker (2007), and Annette Baier (1985). A method for moral reasoning is just any regularized procedure for reaching a conclusion about some moral question. If I read tea leaves in order to ascertain answers to a moral question, then that counts as a method, though perhaps not a very good one. Jaggar and Tobin (2013) define methodology as the systematic analysis and  producing reliable conclusions (385).2 So, a methodology focuses on preferred models of reasoning, analyzes their constituent parts in terms of their contribution to the production of reliable conclusions, and explains how these preferred models relate to each other. Jaggar and Tobin further distinguish moral methodology from moral epistemology. One of the central questions of moral epistemology concerns how these models of moral reasoning analyzed by our methodology actually confer moral authority, or normativity, on the conclusions reached. We will track throughout this chapter the difference in approach to moral authority between idealized, mainstream, and naturalized moral epistemologies. With regards to theory, Baier (1985) discriminates between the usage of this term in its fairly comprehensive account of what morality is and when and why it merits our acceptance and support (55). fairly large area of morality, with a keystone supporting all the rest (55). The wider sense of                                                    2.  4  theory is not so controversial since it only identifies several minimal conditions on what counts as theoryinternal consistency, some degree of comprehensiveness, and some account of while leaving quite open how the theory is to be developed and structured. While any moral methodology will be theoretical in this wider sense, though to different degrees, the methodologies that adopt theory in the narrower sense are more likely to be idealized methodologies. I develop this connection in more detail below in the section on strongly idealized methodologies. Walker's description of the theoretical-juridical model provides a similar but more specific view on theory in the narrow sense. She (2007) writes, [It is] a consistent (and usually very compact) set of law-like moral principles or procedures for decision that is intended to yield by deduction or instantiation (with the support of adequate collateral information) some determinate judgment for an agent in a given situation about what is right, or at least morally justifiable to do (43). Both Baier and Walker characterize the idealizing assumption as one that conceptualizes the moral landscape as flat; moral problems are resolvable by only one or a small and ordered number of codifiable moral principles. What I aim to track through the various methodologies canvassed is the degree to which each endorses different aspects of this narrower conception of theory. Shared Moral Epistemological Assumptions It is worth mentioning at the outset of my treatment of bioethics methodologies what will remain largely unchallenged. None of the methodologies considered are nihilistic or skeptical. That is, they all assume that there are moral facts to be known (not nihilistic) and that human beings do have some kind of access to them (not skeptical). Since each purports to provide a correct account of bioethical judgment, each presumes that bioethical judgment can be subject to some kind of evaluative standard. I do consider in a later chapter the deflationary challenge to moral 5  knowledge represented by relativism because the naturalized approach to moral epistemology that I articulate has been accused of falling into a pernicious form of relativism.3 Strongly Idealized Methodology Even though strongly idealized methodologies are rejected by most bioethicists today, providing a characterization of them will help us diagnose how approaches to method can fail to capture the non-(Arras 2013), (Baier 1985)-(Walker 2007), and (Shafer-Landau 2003). There are several characteristics widely shared among the members of this class. The Logical Priority of Moral Principles  In the first half of the 20th century, philosophers interested in ethics focused on issues in metaethics, such as identifying the correct definitions of ethical terms or determining whether or not ethical propositions had cognitive content, while largely ignoring substantive ethical issues. Many believed that conclusions in metaethics were irrelevant to substantive normative issues and, therefore, did not attempt to explore the practical implications of their research. This trend began to reverse in the 1970s as philosophers increasingly brought philosophical theory to bear on the social and political issues of the day (Arras 2013). These early attempts to approach social and political issues in a philosophical manner all expressed a conviction that philosophical theories could clarify and provide concrete solutions to muddled practical problems. This conviction pictures philosophy primarily as an intellectual pursuit of general and abstract truths. Philosophy, if it is to be successful in ethics, should provide normative truths that are ideally                                                   3. Though moral relativism is not really nihilistic or skeptical, I am grouping it with both because it can take a similarly debunking attitude towards moral knowledge. According to moral relativism, moral knowledge is merely the parochial knowledge of getting around in a particular moral-cultural world or merely the knowledge of one's purely subjective moral attitudes. 6  universally applicable and could serve to inferentially ground truths about particular moral questions. These normative truths would be moral principles, understood as absolute standards to which behavior ought to conform. Moreover, and given the widespread acceptance of a standard of simplicity, the smaller the number of principles needed to ground ever larger swaths of moral judgments, the better would the account be. Shafer-Landau (2003) provides a succinct characterization of this: The standard model says that all truths about the moral status of act types and tokens are derivable from an ultimate ethical first principle. The standard model is hierarchical ethically relevant considerations are ordered in increasing generality and fixed by reference to some higher-order principle. This is basically an endorsement of ethical absolutismthe first principle of an ethical system is claimed to be absolute and ultimate. A principle is absolute if and only if it is such that no other moral principle or consideration can override its force. (268)  Deductivism This conviction concerning the priority of universal and absolute moral principles pairs only if it is absolute and such that all other principles are derivable (Shafer-Landau 2003, 268). Given the penchant for a hierarchical model of ethics that derives particular ethical truths from established general moral principles, philosophical accounts of moral reasoning strongly emphasize the logic of deduction. Deductivism in moral reasoning pictures the appropriate relationship between the premises and the conclusion in a good moral argument as one of logical validity; given that the premises are true, the conclusion must necessarily be true as well. Moreover, the moral principle cited in the premise functions as a covering-law along the same lines as we might think scientific laws function to justify predictions of the behavior of physical objects. 7  Epistemological Priority of Theorizing for Ideal Conditions John Rawls's work in political philosophy has been influential in guiding strongly idealized methodology's conception of the relationship between the ideal and the non-ideal. We first theorize under idealized assumptions about the agents and institutions who will be guided by our moral and political theory. We do this because we need a systematic picture of the best that can be hoped for in the way of a just society or a perfectly moral agent; this picture serves as a standard against which we judge the comparative merits of incremental improvements from non-ideal situations. Rawls (1999) ideal conception of justice has been chosen; only then do the parties ask which principles to adopt under less happy conditions(216). Note that strongly idealized theories do not ignore the non-ideal completely. Rather, they have a view that conceives the non-ideal solutions as ultimately derivative from and secondary to the ideal picture. Practical Ethics provides a representative example of a strongly idealized methodology in bioethics. Tom Tomlinson (2012) Practical Ethics reflects the idea that the establishment (30). The work begins with a defense of the ultimate moral principle of utility, interpreted by Singer to mean that one ought to maximize the satisfaction of preferences and minimize their frustration. Since moral reasoning conforms primarily to a deductive-of the ultimate moral principle must come first. After this is accomplished, more specific principles governing the moral status of animals and fetuses are derived in later chapters from the ultimate principle. The third characteristicthat of prioritizing theorizing from an ideal perspectiveing attitude towards the universalistic 8  characterization of the ethical point of view. He (1993) f the impartial spectator or ideal observer, or wha (12). Properly moral reasoning requires us to leave behind the particular interests and relationships we happen to have in order to take up a point of view that sees those particularities as irrelevant.  It is worth noting why a strongly idealized methodology would seem appealing. These approaches have a high explanatory ambition, place a premium on consistency, and value clarity to a strong degree. Rather than leaving substantive normative judgment up to individualized emotional appeals or uniquely applicable intuitions about particular cases, strongly idealized methodologies provide generalizable reasons that unify whole classes of ethical judgments. This , and these answers seem less ad hoc than if explanation relied on a wide variety of loosely related, particularized moral reasons.  The authority of moral judgments is secured by reference to features of hypothetical situations or to a priori conditions, and so the authority of these reasoning models is not subject to the contingencies of features of the real world. Moreover, the emphasis on universal principles as opposed to particularized moral sensitivities excludes the possibility that a moral justification might only be accessible to a particular, specially placed individual. Now, these are only strengths if the strongly idealized picture retains an accurate conception of the field to which it applies. However, it falls short here. A number of commentators have identified particular issues with strongly idealized theories. First, the ambition toward consistency and explanatory completeness is inappropriate for a practical field like bioethics where one cann. Susan Sherwin (1992) Broad principles are difficult to instantiate in the complexities of 9  daily life because they often obscure some of the most telling features of a situation (77). Albert Jonsen and Stephen Toulmin (1988) identify the exclusion of context in these approaches to be the result of a mistaken assimilation of ethics to the sciences. Drawing from Aristotle, they argue that ethics is a practical field to which the degree of certainty found in especially the mathematical sciences simply cannot be achieved. Such theoretical certainty is only achieved by abstracting away from particulars. For example, geometric truths only apply perfectly to idealized geometric entities. Their application to real physical objects is only approximate. The second objection takes issue with strongly idealized theory's lack of connection to facts about actually existing moral systems, both in terms of widely shared areas of moral agreement and sites of moral contestation. Though Tom Beauchamp and James Childress (2013) do not directly level this objection against ethical theory, they do claim that the kind of division among theorists concerning ultimate ethical justification does not similarly infect the general convergence on substantive mid-level principles. The reason is that these mid-level principles emerge from nearly universally held considered moral judgments. We can develop a bioethical methodology, but we need to base it on our actually existing morality rather than on untethered theory. Gert, Culver, and Clouser (1997) also invoke common morality to critique the pretensions of strongly idealized theory. They moral theory to generate a moral system(31). In contrast, these authors think that moral theory needs to start with a close description of our actually existing moral systems and then build from that description. A third objection challenges the claim that strongly idealized theory can actually be applied to situations involving imperfect agents and institutions. Several potential problems have been identified. First, the costs and benefits of proposed norms or policies will change depending 10  on the level of compliance with them in society. Strongly idealized theories cannot account for this because they presume the level of compliance with norms to be near universal (Arras 2013). Second, societal efforts to redress imperfections might treat unjustly those who have played fairly by the less than perfect rules (Simmons 2010, 20-2). Finally, strongly idealized theories are not fine grained enough to yield uniquely correct answers for all situations. Especially with respect to decisions about the design of public policy, the existence of such border-line cases for the application of moral and political principles calls for an account of acceptable deliberative procedures, which strongly idealized theories do not provide (Gutmann and Thompson 1996). Of course, agreement that strongly idealized theory is problematic does not imply that there is agreement on how methodology should proceed without it. I will consider a number of proposals. In order to ground my evaluation of the alternatives to strongly idealized theory, I first offer my own diagnosis of what strongly idealized theory misses in the way of adequately capturing non-ideal circumstances. Most critiques of idealized theories have focused on the negative characteristics of idealization without much substantive to say about what makes --ideal circumstances will enable us to consider whether or not the proffered alternatives fully capture morality in a non-ideal world. The absolutist and universalist conception of principles presumes that the ethical point of view is independent of any and all particular perspectives. Further, deductivism rules out as epistemically irrelevant any contingent facts about the moral-epistemic agents making the argument. Finally, the epistemological priority of the ideal presumes we can theorize about the ideal in a way that is independent of the non-ideal circumstances in which we find ourselves. Yet, a primary feature of our non-ideal circumstances is our unavoidable epistemic position. 11  When we engage in moral reflection, we do so from within socially and historically constraining factors. We cannot achieve a perspective free from cognitive limitations. There are at least three kinds of positioning that bioethical methodology needs to account for. First, moral agents, especially bioethicists, are positioned within particular institutions. The kinds of priorities that institutions have and the kinds of experiences that institutions make available partially determine the kinds of bioethical problems we find relevant. That most clinical bioethicists work in university medical institutions partly explains why issues in public and global health are relatively ignored (Buchanan 2007, 293). These just are not the problems they directly face in their practice. Moreover, bioethicists inherit some of the authority and prestige of their institutions. Their work receives social uptake. Just as scientists cannot ignore the social consequences of their research, so too does the perceived expertise of bioethicists create social consequences. An inquiry into the methods by which bioethicists make judgments ought to include consideration of how well or poorly the social processes that maintain reflection. Second, moral agents are positioned along axes of social oppression. This positioning has two consequences. The social position of moral agents affects the epistemic access these agents have to basic moral facts. For example, because of my social positioning as a white man, everyday instances of racial and gender injustice often go unnoticed by me. Part of the way that my white male privilege works is by making itself invisible to me. I am not claiming that my social position makes it impossible to access these truths, but I am saying that it makes it harder for me to notice them in my everyday life. Thus, the point is not to absolve me from responsibility but to increase responsibility on my part to foster attention and seek out more 12  authoritative sources on everyday instances of oppression. Bioethical reflection is not immune to this phenomenon. Discussion of the moral and epistemic responsibilities related to moral perception will return in chapter 3.  Second, certain styles of moral deliberation can serve to unwittingly reinforce relations of social oppression. Moral values perceived as universal and culturally neutral often have specifically Western provenances. Insistence on limiting the terms of moral and political debate to these termsas some versions of a liberal neutrality principle insistcan reinforce the hegemony of Western culture over marginalized communities by forcing them to converse in terms alien to their way of life and by falsely portraying their terms of moral life to be less universally authoritative than the Western terms of moral life.4 Jackie Leach Scully (2008) describes a similar phenomenon with respect to implicit ableist biases embedded in moral terms. Some metaphorical terms of moral evaluation associate goodness, rightness, or justice with autonomy, honesty, and pride. Using such language devalues the bodily comportment of many people with disabilities by implicitly excluding their bodies from association with positive evaluative terms (100-1). Finally, moral agents are positioned as psychologically, historically, and culturally constrained human beings. We are not demigods with perfect information, impeccable reasoning skills, and unlimited time to reflect before acting. We rarely know everything relevant to a situation. We suffer from identifiable cognitive biases, like selection and confirmation biases. We are forced to make practical decisions before we have been able to think through to satisfaction the decision to be made. We inevitably think from within the cultural-linguistic                                                   4. These claims are likely to get me charged of implicitly supporting moral relativism. I understand this objection, but I intend to postpone a fuller treatment of it to a later chapter. 13  resources made available to us, though we are forced to face situations that involve individuals and groups from multiple cultural-linguistic backgrounds. Given that these constraints nearly always apply to any instance of moral reasoning, a methodology for non-ideal methods should be able to say something about how we ought to handle these limiting conditions. Non-Ideal Methodology in Bioethics: Strengths and Limitations a Gert, Clouser, and Culver (1997), the pluralistic principlism of Beauchamp and Childress (2013), and non-particularist forms of casuistry (Brody 2004). All three of these methodologies have moved away from strongly idealized theory, but not far away enough. I fully acknowledge that this does not comprise all of the approaches to bioethical methodology currently in vogue. General Characteristics  I start with the general characteristics of these non-ideal methodologies. There are two interrelated characteristics worth discussing: the grounding of moral theory in the common morality and the softening of moral principles. One of the widely shared criticisms of strongly idealized theory mentioned above is how seemingly untethered idealized methodologies are to current realities of moral practices and behavior. Nearly all of these more modest approaches understand, as a constraint on their methodologies, that they should adequately link appropriate methods to the shared set of moral beliefs that nearly all morally committed people hold, or at least that those methods should be roughly consistent with this common morality. The common morality and the considered judgments that emerge from it play a privileged justificatory role. Not only is grounding in the common morality a methodological constraint on the development of the moral theory that informs a method for resolving bioethical issues, but the model for individual moral justification itself has at its starting point one's considered moral judgments, 14  which emerge from the common morality. These considered judgments, though often still held to be fallible, are taken to have some initial warrant due to their intuitive appeal. This grounding in the common morality is combined with a softening of moral principles. None of these approaches adopt wholesale the view of moral principles that characterizes the strongly idealized theories. Instead, they are softened in some way in terms of their range, level of specification, or normative force. These softened principles almost always drop the absolutist character of idealized moral principles, and they also almost always require supplementation by some other faculty to help decide when a moral principle is justifiably overridden or violated. With regards to these two characteristics, I consider the following questions for each approach: What role does the common morality play in the privileged models of moral justification? What is the content of this common morality? Where do principles fit in to bioethical methods? How are these principles reconceived in terms of scope, level of generality, and normative force? Pluralistic Principlism  For the pluralistic principlist, the common morality(Beauchamp and Childress 2013, 3)is composed mainly of pro tanto moral principles. Pro tanto moral principles identify consistent moral forces in our space of moral reasons. It is a wrong-making feature of any situation that it violates a moral principle, but situations nearly always involve more than one moral principle. Thus, a particular principle can be overridden by the overall weight of reasons. The notion that there is only one ultimate moral principle that identifies the only actual morally wrong-making feature of a situation or that there is even a set of clearly ordered moral principles that could lead to determinate overall judgments is dropped in favor of four pro tanto principlesrespect for autonomy, beneficence, non-maleficence, and justice. The obligations generated by these 15  principles are genuinely morally binding unless an obligation generated by another principle has more weight in a given situation and overrules it. Considerations of weight are judgment calls, and there is no clear ordering in importance for the principles (15-6). The pro tanto principle interpretation of the common morality is combined with a coherentist model of moral justification: wide reflective equilibrium. Wide reflective equilibrium identifies overall coherence of a set of beliefs as the evaluative standard for justification. A moral belief is justified to the extent that it receives justified support from all other beliefs and does not conflict with any other belief. Yet, bare coherence leads to several problems. First, it seems to imply that moral justification is either circular or leads to an infinite regress. Second, it allows that a number of moral codes could be equally coherent, while some of those are nevertheless consistent for all that.  In order to avoid these problems, pluralistic principlism allows the common morality to serve as a starting point for wide reflective equilibrium by providing considered judgments that have some initial warrant prior to their being evaluated for coherence. They anchor the equilibrium to our moral convictions, as observation statements anchor the natural sciences to our sense experiences (407-8). This does not mean they are infallible, because a highly coherent set of considered judgments, principles, and background theories could serve as a reason to modify particular considered judgments that do not neatly fit. In this way, the common morality is not an entirely fixed point, though it is relatively stable. Non-Particularist Casuistry Non-particularist forms of casuistry, like the form developed by Baruch Brody (2004), combine principles, common morality, and case judgments in a way that further weakens moral 16  principles. Moral principles are still pro tanto and plural, but they no longer play a starting role particular individuals, actions, and social arrangements which are based upon our observations of these particular individuals, actions, or arrangements, but which go beyond what is observed or can be deductively or inductively inferred from what is observed (and do so without the aid of (46).  Though non-particularist casuists do not talk explicitly in terms of a common morality, they do make similar appeals when referring to these particularized judgments. Jonsen and Toulmin (1988) illustrate this point with a story about their work on national bioethics commissions. Commissioners would agree on particular judgments about paradigm cases, for example that the Tuskegee experiments were horribly wrong and unjust, but disagree about the principles that explain this locus of certitude in the specifically at stake in (18). Similarly, Brody calls these shared perceptions intuitions, suggesting that these initial judgments would be shared by similarly situated moral observers. Though no longer starting points, principles still have a role to play in a reasoning process that looks very much like wide reflective equilibrium. Brody draws an analogy similar to one drawn by Beauchamp and Childress between moral and scientific method. Common moralitywhich, for Brody, is composed of particular, instead of general, moral judgmentsserves the role of observational data. General principles and rules emerge as generalizations meant to account for the particular intuitions (Brody 2004, 47-8). As in wide reflective equilibrium, the judgments that serve as the starting point are ultimately corrigible in the face of 17  convincing theoretical concerns (48). Finally, these generalizations reveal plural moral concerns (2-3). Even Jonsen and Toulmin, whose discussion of casuistry often emphasizes the analogical reasoning from particular case judgment to particular case judgment over any kind of induction to general moral principles, acknowledges a place for principles in good casuistry. They describe (Jonsen and Toulmin 1988, 16). This characterization seems to apply equally well to pluralistic principlism. Morality as a Public System  The approach of Gert, Culver, and Clouser (1997) provides the most developed account of common morality and its implications for the development of moral theory. Despite this, it shares many of the other characteristics of strongly idealized methodologies. The common morality comprises the widespread areas of agreement about moral matters that are not in dispute. Like the other modest theories considered, Gert and his colleagues argue that moral theory ought to be constrained by how well it adequately captures the content of the common morality. The common morality itself is in need of no moral justification. Moral theories are in need of justification by reference to the common morality, and moral judgments that go beyond firmly based on and tested by clear moral intuitions. Inasmuch as a description of morality is a central feature of a moral theory the accuracy of that description must be continually examined  (3). The content of this common morality is much more extensive and systematically unified on the nature of morality, that it is a public system with the goal of reducing the amount of harm 18  (21). Thus, the agreement in common morality extends to certain features of the nature of morality, namely that it is impartial and public (must be known to all to whom it applies). This public system aimed at reducing harms includes both moral rules and moral ideals. The moral rules are general prohibitions on specific kinds of harms that all people rationally want to avoid. The moral ideals are supererogatory exhortations to go out of one's way to prevent harms and evils. into moral rules. Gert and his colleagues agree that the strongly idealized methodologies paint an overly simplified picture of morality (19-20). Particularly, they agree with both principlism and casuistry that this overly simplified picture mistakenly implies that there will be a single correct answer to every moral problem. However, they part ways with the other modest theorists in asserting that there still is a single unified moral system that provides a means for dealing with all moral problems. Morality is complex, but it is not irreducibly and unexplainably pluralistic. The pluralistic principlist approach softens principles too much. It makes them into mere (75). This checklist approach does not translate into the provision of genuine action-guides, as moral principles in strongly idealized theories do. In order to retain the ability to guide action without oversimplifying morality, Gert and his colleagues replace absolute moral principles with a set of more specific moral rules that are unified under the general prohibition against causing harm. Moral rules are imperatival prohibitions against causing different types of harms or performing actions that are likely to lead to harms (34). One of the moral rules, for -formulation provides a closer link to action than do the general principles of Beauchamp and Childress by specifying a particular type of action as 19  prohibited, but these rules are still softened from the moral principles of strongly idealized theory in that they are not absolute. There are circumstances in which they can be justifiably overridden. For example, the ru-defense. Though the authors provide us with some specific considerations for determining when the overriding of a rule is justified, such determinations cannot be made mechanically and do not provide for uniquely correct answers in all situations (34). Finally, these moral rules that form part of the common morality do not get plugged into a wide reflective equilibrium model of moral justification. Rather, the model is much more avoid, these moral rules are indubitable on pain of irrationality. The authors do acknowledge that more particular rules are needed to guide action in particular contexts, but these particular rules are generated in a quasi-deductive fashion from the general rules. A general moral rule when combined with a description of a cultural institution or practice generates a particular moral rule that can guide action in a particular cultural milieu. For example, the rule prohibiting killing, causing pain, or causing disability combined with the practices of drinking alcoholic beverages and driving cars generates a prohibition against drinking and driving (53). Though imperatives cannot serve as premises in deductive arguments, what justifies the generation of particular rules is a similarly structured deductive chain of arguments. One ought to not engage in practices that increase the likelihood that one will break the rule against killing, causing pain, and causing disability. Drinking and driving increases the likelihood that one will break that rule. Therefore, one ought not drink and drive. 20  Idealizing Assumptions about Principles and the Common Morality I treat these methodologies together and highlight their similarities because they all make similar and still idealizing mistakes about both the common morality and moral principles. Let me start with comments specific to the common morality. The particular conceptions of the common morality outlined in all three of these methodologies invidiously idealize the level of offender. It identifies the prevention of harm as the central guiding concept that underwrites the inclusion of general rules about preventing particular harms in the common morality. Although harm is a very important concept for morality, the claim that harm is the primary unifying concept is not well supported by empirical research. Social psychologist Jonathan Haidt has identified five sepaloyalty, (4) respect of authority, and (5) purity (Haidt and Graham 2007). Though Gert and his colleagues seem to be the strongest supporters of the common morality, it is hard to see how their still idealizing need for a unified system could ever capture the wide variety of moral considerations. The casuist insistence on identifying agreement at the level of particular case judgments fares little better. That one could identify significant agreement on the level of individual case judgments seems as unlikely as finding agreement at general levels. I have similarly pessimistic hopes for the pluralistic principlist view of common morality.  Attempts to find agreement at either the level of principles and rules or at the level of specific judgments suffer from a problem of vacuity. The more vacuous we make the terms of agreement, the more surface-level agreement we can identify. One would be hard pressed to claim that nearly all people interested in morality or something like it do not share a concern for autonomy, beneficence, non-maleficence, and justice (Beauchamp and Childress's principles). 21  However once those principles start to take on specific and substantive meaning, agreements begin to fall apart. Rebecca Kukla (2014) makes a similar objection to Beauchamp and Childress's version of common morality: ere are general rules or to pick some discursive formulation of it. Different formulations will vary in their clarity and connotations to different audiences. It seems unlikely that we could come up with a formulation of any principle that everyone will sign on to. (80)   A similar problem emerges for particular judgmentsfor example, the judgment that the Tuskegee   This way of universalizing the common morality can be seen to underestimate the importance of both the second and third kinds of positioning. It papers over zones of conflict within pluralistic and hierarchically organized societies as well as between culturally distant societies5. Moreover, grounding moral reasoning in the common morality, without also cultivating a politically critical attitude, can potentially propagate widely shared implicit biases about race and gender through to our practical conclusions. Such implicit biases against marginalized groups do not only affect the reasoning of members of dominant social groups, but have also been shown to have detrimental effects on the reasoning of members of the marginalized groups themselves.6 Even if common morality methodologies seek to bolster their accounts by basing their views of the common morality on more empirically informed                                                   5. A similar idea is developed in Turner (2003).   6. I further discuss the philosophical and ethical ramifications of implicit bias with respect to moral perception in chapter 3 and with respect to cross-cultural moral dialogue in chapter 5. 22  descriptions of what people share in the way of moral beliefs, those methodologies are still vulnerable to this objection.7 Beauchamp (1998) develops some possible responses to this line of objection, but they do not come without their own problems. First, it is important to concede that common morality hold the common morality to be infallible and unchanging. So, the concern about implicit biases can at least be handled from within their accounts. Yet, the line of response developed to handle the problem of seemingly moral beliefs that fall outside of the common morality consensus is not satisfying. Beauchamp and Childress (2013, 3) limit the content of the common morality to the moral beliefs held by those committed to morality. Another formulation holds that all morally serious persons are committed to the norms of the common morality. Yet, it is not clear how that does not rely already on his specific understanding of what is in the common morality. This has the effect of excluding people with divergent moral beliefs from moral conversation because they are automatically deemed to not be serious about morality. The bioethical method that licenses this kind of move reinforces a form of social oppression that automatically excludes some from inclusion in the ranks of full moral agents who are worthy of being partners in moral conversation.8 I do think that there is something to the concept of common morality, but current                                                   7. I am indebted to Schwartzman (2012) for this line of argument. Her specific target is the philosophical method of thought experiments, but the argument applies as well to bioethical methods invoking common morality.   8. In Damaged Identities, Narrative Repair, Lindemann (2001) analyzes this same kind of problem much , and this can become a problem when members of a marginalized group are compelled directly or through master troublingly close to licensing this kind of moral wrong. 23  formulations do not fully account for the kinds of positioning in non-ideal circumstances. My approach to common morality is defended in the next chapter. There are idealizing assumptions implicit in the formulation of moral principles and rules hat there is an explicit and clearly demarcated set of rules and ideals guiding moral action, but this does not accurately capture how we actually reason about moral issues. One thing that Gert, Culver, and Clouser insist on is that moral rules be free from ceteris paribus clauses (1997, 6). Yet, the only suitable characterization for how moral principles figure in human moral cognition is as defeasible generalizations. Discursive rule-based reasoning is the exception, rather than the rule, in individual human behavior. Moral cognition is primarily a matter of deploying perceptual skills that outrun in complexity and applicability any sentential representation of them (Churchland 2000, 295).  This is not to deny that discursive moral reasoning has an important role. Clark (2000) provides a compelling account of the role of linguistically mediated moral reasoning as serving both to make possible the social negotiation of moral conflict and to make available as explicit objects of thought morally salient patterns like rights and duties. However, even if we accord an important place for linguistically mediated moral reasoning, only defeasible moral generalizations could accurately capture the complex context-sensitive workings of moral skills.  Pluralistic principlism and non-particularist casuistry fare no better on this account.  Pro tanto moral principles do allow that context-sensitive judgments of balancing and weighing principles play a necessary role, but such principles also claim to identify features as wrong-making or right-making across all situations. None of the modest theories adopt moral reasons holismthe view that in moral matters 24  (Dancy 2013). This view of moral reasons will return as an important component of a naturalized bioethical methodology in chapter two. A third idealistic characteristic worth pointing out emerges in the way in which principles and the common morality are often embedded in the wide reflective equilibrium model of moral reasoning. This model of moral reasoning still carries with it a tendency to view moral reasoning as primarily an individual activity concerned with achieving internal consistency between the evidence of considered judgments and the explanatory framework of theory. Walker (2007) equilibrium between people as well as within them (71). Her model of morality, the expressive-collaborative model, is helpful here because it conceptualizes morality as a social system that functions to make possible ongoing and stable forms of common life.9 This reorients the goal of moral reasoning away from the internal coherence emphasized in wide reflective equilibrium toward the end of securing mutually acceptable forms of common life. It conceives of moral reasoning as an actual social process, a conversation that occurs in real time among members of a community. The internal coherence of moral thought is still important, but it falls short of the further goal of building shared moral understandings through interaction. Common morality is not only a starting point, but also a goal of moral reflection. Let me briefly elaborate on this point. On most, if not all, accounts of moral knowledge, the knowledge of other peopletheir pains, pleasures, needs, etc.is essential for the successful moral agent. Our ability to read other people and even ourselves is not an inborn unlearned trait but rather something we learn, most often informally, through social interaction. Moreover, it is something that people do together through communicative practices. Our subjectivities are                                                   9. Interestingly enough, Gert, Culver, and Clouser come closest in capturing this sentiment with their insistence on morality as an informal public system. 25  constituted through interactions with and reaction from others. Lindemann (2014) describes this social aspect of identity formation, especially but not only in extreme circumstances where it is difficult for us to maintain our own personal identities, as the social practice of holding and letting go of someone's personhood. These socially and personally constituted identities are made up of various interwoven stories that have normative bite. They tell us what kinds of obligations and responsibilities we have to others and others have to us.  Even as fully formed persons, we do not have full authority over the correct characterization of who we are. Consider numerous examples where often times it is people from the outside looking in who can more accurately describe the reasons behind our behaviors, which might initially seem alien to us. Thus, the constitution and construction of knowledge of other people and of situations of human social interaction is a primarily inter-subjective undertaking. This critique concerning the excessively individualistic conceptions of models of moral reasoning reflects again the general concern for positioning that I have claimed is essential to understanding morality in non-ideal circumstances. Positioning just is a concern for the ways in which the social relations of subjects both constrain and make possible moral reflection. Anti-Theory and Anti-Method Bioethics Given the problems with both strongly idealized methodologies and the various failures of its more moderate cousins to successfully rid themselves of all their idealizing assumptions, might a radical rejection of theory and method in bioethics be called for? Or, perhaps there are approaches to method that are as weakly theoretical as possible? Many have gone down this direction and have developed highly particularistic forms of casuistry, care ethics, and narrative ethics to replace the still theory-laden moderate methods discussed above. 26  I view these anti-theory approaches as closely aligned with a radically particularistic theory of moral reasons. I note the apparent contradiction in calling a theory anti-theoretical, but radical particularism is anti-theoretical in that it claims that the moral realm is composed of such diverse and unstable sets of concerns that they resist the systematization of theory that would enable us to project judgments we make here and now to future situations with relevantly similar conditions. Radical particularists like Jonathan Dancy (1993) take the moral reasons holism mentioned earlier to imply that there are no substantive moral principles at all. Casuistry can be taken in more radically particularist directions than the non-particularist version outlined above. The radically particularist casuists do not merely emphasize that principles are not good starting points for moral reflections because particular judgments about paradigm cases have the most initial warrant. For the radical particularist casuist, the principles that eventually get developed out of the analogical case method have only heuristic value, if that. (Arras 1994, 1002). Unlike the non-particularist casuistry of Brody, these heuristic principles do not normatively guide moral reflection in the sense that principles could serve to upend certain intuitive moral judgments about cases. According to particularist casuists, principled moral reasoning, far from being a more mature systematization of the particular level of intuitive judgment, is an immature and simplistic form of moral reasoning. Care ethics can also be developed in a radically particularistic direction.10 Care ethics has been described as a moral orientation rather than a moral theory (Little 1998, Verkerk 2001). When seeking moral resolutions, care ethicists generally attend to the quality of relationships                                                   10. Just as I have made clear that there are both particularist and non-particularist forms of casuistry, so too are there non-particularist forms of care ethics. Here I have tried to outline what a quite radically particularist care ethic might be like. 27  between individuals rather than to the correctness of moral judgments. Little (1998) and Verkerk (2001, 290) Verkerk identify this caring orientation as a perspective from which to analyze and evaluate the results of theorizing. One could imagine care ethics stopping with the orientation alone. Rather than developing theory shaped by a caring orientation, it might be that the caring orientation eschews theory altogether, for theorizing as a process of generalization already implies that we must be effacing the irreducibly particular aspects of other people. What serves as moral reasons are particular perceptions of which actions best embody a caring orientation rather than general moral principles that identify right making properties. I do not think endorsing a radically particularist response to theory in bioethical method will be profitable in helping us capture the non-ideal circumstances of everyday ethical life. For one thing, the radical particularism underwriting these anti-theoretical approaches goes too far by way of leaving morality an utterly confounding domain of human action. Concerning this form of particularism, Lindemann (2014) be left with nothing but one-off judgments; it's wrong to cause pain here, good to break a (25). This is not an accurate characterization of human moral life either. We appeal to principles in justifying our actions to others and in teaching our children how to be morally responsible adults. We mean these principles to apply to not only all of the cases we have so far evaluated, but to future situations as well. A view that can save substantive principles without denying the holism mentioned earlier would seem to have the advantage of most closely capturing our moral lives. 28  Luckily, I think that such a plausible view exists. It involves substantive but irreducibly defeasible moral principles.  There are further problems with theory-free approaches to bioethics. For one thing, they also ignore the contexts of moral problems. Whereas the strongly idealized methodologies ignored moral contexts by applying absolute moral principles in ways that ignored the varying contributions of contextual differences in situations, theory-free approaches are in danger of focusing on specific instances of moral wrongs and rights while neglecting their location within (1983) birdcage metaphor for oppression. A birdcage is composed of an interlocking set of individual metal wires to imprison the bird. Similarly, a system of oppression is a system of individual but interlocking barriers that or kind of practice implicated in a system of oppression will likely lead to a failure to recognize said instance as contributing to the overall system of oppression, just as looking at one wire of a birdcage does not give you a full view of how the birdcage works to keep the bird imprisoned.  Consider the particular cultural practice of men opening up doors for women. Understanding such an action as morally harmful requires some kind of moral generalization that places that action as an instance of oppression, as a repetition of a ritual with symbolic meaning that represents women as dependent on men. Otherwise it would be difficult to understand it as anything other than an instance of kindness. Moral theory of some sort enables us to take a macroscopic view of the moral landscape and to see specific moral harms in the context of larger patterns of harms and benefits. 29  Naturalized Moral Epistemology Naturalized moral epistemology (NME) can provide the appropriate middle ground between the modestly non-ideal methodologies and the radically non-ideal anti-methodologies because it provides the resources for capturing the normative effects of positioning in non-ideal circumstances. 11 Now, NME is not itself a full-fledged methodology. Rather it is a loose set of methodological and epistemological considerations that serve to underwrite a naturalized bioethical methodology. It provides a general orientation towards how one ought to approach methodology in morality, but does not prescribe a particular set of answers to methodological questions. The reason for this is that there are a variety of ways of naturalizing. What follows is a for how naturalizing can be specified to most adequately meet concerns for non-ideal positioning.  Generally speaking, NME seeks to discover and understand appropriate standards of justification for moral knowledge from within empirical investigation alone into human behaviors, psychologies, sociologies, and any other natural knowledge deemed relevant (Campbell and Hunter 2000, 1).  a priori approach to the moral authority question; instead, it embraces the idea that we can identify models of reasoning that confer authority on moral conclusions wholly from within investigations into the contingent features of human social life. A priori methods of discovering standards of moral justification are at best viewed with extreme suspicion and at worst ruled out entirely as illegitimate methods.                                                   11. Consider it a modestly radical approach. 30   Varieties of naturalizing differ on how much they emphasize the role of scientific knowledge versus other kinds of knowledge in the construction of moral knowledge. Closely following W.V.O. Quine, the original source for naturalized epistemology, scientific naturalized moral epistemology understands knowledge produced by scientific methods to be the most reliable form of empirical knowledge. From this scientistic assumption, combined with the naturalized assumption that we should not use a priori methods for discovering standards of moral justification, it follows for the scientific naturalized moral epistemologist that NME falls into place as another branch of scienceprobably somewhere among the disciplines of psychology, sociology, anthropology, and economics (Walker 2000, 81-2).  This is not the only option for naturalizing moral epistemology, however. We might reject the view that scientific knowledge captures all of what we learn from experience. Scientific practice is but one way of experiencing the world, and it is a particular culturally formed kind of experience at that. Because moral practices permeate nearly all forms of human practice, there are many other forms of experience that give us access to the moral understandings that inform our social lives (Lindemann and Verkerk 2012, 292). Combined with an expanded view of experience and a rejection of the view that moral practice can be isolated from other forms of social interaction, naturalizing moral knowledge opens the door to uncovering moral understandings in pretty much any form of social interaction in which norms inherewhich is to say virtually all of them. This variety of naturalizing can be said to naturalize to society instead of science because it does not set up science as another tribunal of reason by which all moral claims must be judged. Rather, it looks to the social practices themselves in which morality inheres to discover what moral reasons are made available, to whom they are made available, and what other moral reasons there might be but are not currently 31  available given the current shape of the social practice. I defend this approach to naturalized normativity in chapter three. Another line of differentiation concerns the relationship of moral naturalism to moral realism. Many take the naturalistic approach to philosophy and ethics to imply that moral judgments cannot be about mind-independent reality. If the only things in our ontology are natural things, and moral values seem not to behave like natural things, then moral values will not be allowed into our ontology. In fact, Quine (1979) himself adopts an anti-realist approach to moral values. He argues that while science can still claim a correspondence theory of truth by being anchored in observations of the world, ethics can only anchor itself in already moralized judgments of actions. Thus, it can only lay claim to a coherentist theory of truth unanchored in an independent reality (477). On Quine's view, moral values are grouped with sensual and aesthetic values and therefore represent a complex but subjective projection of human sentiment rather than a truth-apt attempt to represent some feature of reality. Not all naturalizers are anti-realists though. Richmond Campbell (1998) and Louise Antony (2000) both argue in favor of realist versions of naturalized moral epistemologies. Most versions of NME do well with capturing the third kind of positioning (the positioning of moral agents as psychologically, historically, and culturally constrained human beings) because of the emphasis on grounding approaches to moral justification in broadly empirical methods. This involves understanding moral justification as a practice engaged in by human beings who are cognitively limited in the many ways that psychology and evolutionary biology have shown us. However, this leaves out the second and third kinds of positioning (the positioning of agents within institutions and along axes of social oppression, respectively). To account for these kinds of positioning a third line of differentiation, often less noted in the 32  literature but just as important, needs to be brought in to the picture. It concerns what kind of role social reflexivity plays in naturalized accounts of moral knowledge.  Here is where the distinct contribution of feminist naturalism to NME comes into play. Not only feminist naturalism, but also other society-centric approaches to knowledge, accept versions of the following claim: socially constructed context (Campbell 1998, 65). portions of this dissertation a view that makes moral reason transcendentally relative to essentially social background forms of life. However, it is to feminist theorists that we owe a more politically oriented focus on social reflexivity. They get us to ask how background forms of life are socially constructed and who is excluded or marginalized within them. Walker (2009) formulation is especially helpful: of race often advance yet another and specifically pointed kind of naturalism about ethics: they demand that in ethical theorizing we look at society in addition to science and at the dominance of some voices and exclusion of others within societal and professional conversations about morality and ethics (3). Feminist naturalized moral epistemology asks not only about the authority of models of moral reasoning but also about the distinct individuals and social classes in whom authority to develop and use these models is invested.  Conclusion In this chapter, I have examined some of the main methodologies proposed for bioethical judgment in the past few decades and have critiqued them for not adequately accounting for the three kinds of positioning that characterize the non-ideal circumstances in which bioethical reasoning occurs in the real world. I have offered naturalized feminist moral epistemology 33  (NFME) as the starting point for developing a suitably non-ideal and naturalized methodology for bioethics because its emphasis on socially reflexive knowledge enables us to capture all three aspects of the kinds of positioning inherent in non-ideal circumstances.  Much remains to be said about how one can translate this naturalized feminist moral epistemology into a more specific and substantive approach to bioethical methodology. In the next chapter, I aim to develop this kind of account. Several questions will need to be addressed. First, what kind of role does the common morality play in the methodology of a naturalized feminist bioethics? This question depends on how we answer the moral epistemological question judgments issuing from it. Does NFME repudiate, reaffirm, or reconfigure the relationship between common morality and moral authority? Second, will the content of this naturalized common morality be substantive moral principles or irreducibly particular moral perceptions? Third, how will a socially reflexive form of moral reasoning incorporate the aforementioned elements, and will this form of moral reasoning be interpreted in a realist or anti-realist way? Providing answers to these questions will make clearer the contributions that NFME has to make to the problems outlined in this chapter.   34  CHAPTER 2: NATURALIZING THE COMMON MORALITY In chapter one, I argued that several mainstream methodologies in bioethics are still too idealized. Despite their generally unified opposition to abstract, top-down, and theory-heavy models, these newer approaches still fail to account for the ways in which a moral agents essentially social nature affects the usability and appropriateness of moral reasoning strategies. These failures emerge in distorted accounts of the roles played by principles and the common morality in models of moral reflection and decision-making.          I suggested toward the end of the chapter that a naturalized moral epistemology can provide the background moral epistemological assumptions for a suitably non-idealized bioethical methodology, one that provides a justifiable place for positioning in moral reflection. However, naturalizing programs in philosophy are widespread and theoretically diverse. Many agree with naturalizing, but few agree on what naturalizing entails. So, in this chapter I specify a version of naturalizing that best corrects for the idealizing assumptions in bioethics methodology. Recall from chapter one that conceptions of the role and content of the common morality figured principally as the main source of the still remaining idealizing assumptions in mainstream bioethics. And yet, the common morality approach to bioethical methodology is naturalistic in spirit because it recognizes that both abstract and concrete moral reflection must start from a position of shared moral understandings among the deliberators. Thus, I do not reject the use of the notion of the common morality in bioethics. Rather, I insist that we make its naturalistic spirit central to its articulation. 35  There are three notions of a naturalized common morality that roughly correspond to three different kinds of naturalizing moves possible in bioethics methodology.12 Each notion on its own is necessary, but incomplete in terms of specifying a naturalized and non-ideal conception of the common morality. A naturalized approach that successfully combines all three can best avoid the idealizing assumptions of the conception of the common morality in mainstream bioethics. The three notions of common morality that I develop are (1) the common morality as shared ecological predicament, (2) the common morality as shared evaluative space of reasons, and (3) the common morality as external coherence. I will discuss these notions in order, stopping after each one to explain why the notion under discussion is not on its own adequate for the purposes laid out. By the end of the chapter, I hope to have developed a complex but methodologically useable notion of common morality and to have provided the main struts of a naturalized-feminist moral epistemology that supports it and could support the naturalization of other elements of bioethical methodology. The Varieties of Naturalism One issue with discussing naturalism in Anglo-American philosophical contexts is that (almost) everyone professes to endorse it, and yet (almost) everyone means something different by the (2006, 430-1) lists fifteen distinct formulations of naturalist theses found in the philosophical literature.13 Naturalism has come to stand for a number of both epistemological and ontological theses. Many formulations focus on describing either a close relationship between philosophy and science, a relationship where                                                   12. Though I focus on the common morality, I will briefly mention a more naturalized view of principles insofar as one of the specifications of the common morality that I develop helps explain why defeasibility holism about moral principles fits well within naturalism.   13. In a footnote to this already extensive list, he comments that he has developed even longer lists of kinds (431n). 36  philosophy reduces to science, or a relationship where science is depicted as epistemically superior to philosophy. Other formulations merely stipulate that ontologies ought not invoke immaterial or supernatural entities.  Barry Stroud (1996) identifies one characteristic of naturalism that applies to most if not all of its uses in philosophy. This common characteristic is the general commitment to reject supernaturalismfamiliar natural world and (44).14 Though this negative characterization of naturalism embodies a nowadays non-controversial commitment among Anglo-American philosophers,15 there are many ways to extend this rejection of supernaturalism into a positive program. This general but negative characterization gives us some indication as to why there would be a close relationship between naturalism and non-idealized theory. Idealized theory deals primarily with models of agents and societies that are not actually ever realized in the world as we know it. This is not quite supernaturalism in the realm of demons and angels, but it almost is. Idealized ethical and political theory often relies on models of moral agents with inhuman levels of knowledge or unswervingly strong commitments to a moral code or conception of justice. By the end of this chapter, it is hoped that a version of naturalizing that accounts for non-ideal                                                   14. It is possible as well to endorse naturalism in some but not all domains of discourse. Practicing scientists might implicitly or explicitly endorse naturalism when acting as natural scientists, but they may still accept some version of a divine command theory where the commands of a deity that stands outside the physical universe are morally authoritative for us. Likewise, it is conceptually coherent to accept a secular ethics that does not invoke supernatural entities and yet still think that such entities exist and do intervene in the physical universe of cause and are not invoked in the theories of that domain.    15. Of course, Anglo-American philosophers are an idiosyncratic bunch in relation to the general populace. According to a 2008 Pew Survey 37  positioning will emerge through the discussion of the three notions of naturalized common morality. I ignore the non-cognitivist family of ethical naturalism in this chapter and dissertation. Non-cognitivist naturalism claims that, because all there is in this world are the entities and properties identified by the natural sciences and the natural sciences do not identify anything like real moral properties about which our moral discourse could be, it must be the case that our talk of moral properties is not actually descriptive but that Susan has independent of our subjective tastes and attitudes towards her. I do not respond in depth to non-cognitivist naturalism, but one could read the entire project as a response. That is, if I can develop a sensible naturalized approach that takes moral epistemology seriously in the sense that normative knowledge about values is possible, then I have shown that non-cognitivist naturalism is not the only or the most plausible version of naturalism in ethics. Problems for Common Morality in Mainstream Bioethics To recall, the notion of a common morality played explicit roles in two of the methodologies (the chapter and an implicit role in the other (non-particularist casuistry). All these methodologies want to lay claim to the position that their theory best models the shared sense of morality that underlies common non-theoretical moral discussion. In fact, this kind of claim is common in the history of Western moral philosophy. Even Kant ([1785] 1989) claims in the Foundation of the Metaphysics of Morals of ordina (20). 38  Beauchamp and Childress (2013)  [It] is applicable to all persons and in all places, and we rightly judge all human conduct by its standards (3). This set of norms also serves as the source material for the content of principlism. Beauchamp and Childress claim that the four principles are generated from this common morality. Thus, the common morality serves as both the source of content of a moral theory and the general standard by which we judge human behavior. perspective of non-ideal positioning. For one, it invidiously idealizes the level and scope of agreement among morally serious people concerning their moral beliefs. This runs afoul of our positioning as psychologically, historically, and culturally constrained human beings in that the level of and kind of agreement premised lacks descriptive adequacy. Beauchamp and Childress When confronted with counter-examples to their account of the content of common morality, their responses tend towards two strategies. One strategy further generalizes the moral principles they claim to be part of the common morality. This means they can correctly be described as characterizing a larger number of more specific moral beliefs, but the abstraction required to do this comes at the cost of emptying those moral principles of action-guiding substance. Nearly everyone will identify beneficence as an important moral principle. Meaningful disagreement does not show up until you specify the meanings orelation to other moral principles. The other strategy delimits the scope of moral agents whose views count as part of the moral consensus. For example, people who think that it is permissible to enslave non-adherents 39  of a certain religious tradition simply are not counted as morally committed persons. This strategy runs afoul of our positioning along axes of social oppression (e.g., race, gender, class, and disability status) in that it ignores the ways in which master narratives about the common morality work to disenfranchise some from the class of worthy participants in moral conversation. The move to exclude some moral worldviews from a supposed global moral consensus denigrates groups of people as not yet or not quite serious moral agents and hence unworthy of joining in moral conversation. Perhaps we are willing to not seriously converse with those whose moral views explicitly deny the moral worth of other human beings, but the position under consideration also threatens to exclude others with not so clearly abominable yet nevertheless radically different views from the consensus in Western nations. One example might be moral communities with different views on the correct moral relationships between individuals and larger social units like families, tribes, ethnic groups, or states.16 Naturalized Common Morality I: Shared Ecological Predicaments One alternative way to talk about the common morality is to focus not on the content of moral beliefs held in common, but rather on the shared human predicament that gives rise to moral responses. Human beings developed moral systems in response to very similar ecological circumstances and human cognitive and affective endowments. This suggests that moral responses are likely to develop in similar patterns across the globe. Where they differ, we can understand the differences as a response to slightly different local circumstances or compare them on the basis of how well they respond to similar ecological predicaments.                                                    16. Irrespective of the problems with Beauchamp and the perspective of non-ideal positioning, it is also question-begging. They identify the common morality as the norms shared by all persons committed to morality, but the only way they provide us for identifying which persons are committed to morality are in terms of examining whether or not the norms of the common morality are part of their moral belief set. See Beck (2015, 1-3) for a closer analysis of this issue. 40   Two naturalists who develop similar approaches to the relationship between human nature and morality are W.V.O. Quine and Owen Flanagan. In a discussion on the similarities and differences between languages and moral codes, Quine (1979) he most basic problems are bound to run to type. Morality (477). Owen Flanagan, David Wong, and Hagop Sarkissian (2008) animals with certain innate capacities and interests.  Although the kinds of play, work, recreation, knowledge, communication, and friendship we seek have much to do with local socialization, the general fact that we like to play, work, recreate, know, communicate, and  One influential version of naturalism that underwrites this common morality approach draws heavily from roots in American pragmatism. For my purposes, I start the story at the point where Quine picks up American pragmatism to develop his program of naturalizing epistemology. In "Epistemology Naturalized" Quine (1969) begins by laying out what he takes to be the re(69). He focuses on the empiricist variant of these projects that sought to provide epistemic foundations for science in our sense perceptions. For the empiricist, it was hoped that scientific terms (especially basic physical terms like body and force) could be exhaustively defined in terms of sense impressions and that the natural laws governing them could be derived from statements about sensations. Quine does not understand the failures of these projects as a failure of empiricism. He himself remains an empiricist. For him, both scientific evidence and the learning of the meaning of words rest on sensory input (1969, 75). The problem, rather, resides in the foundationalist and 41  reductionist form of these traditional empiricist projects. The problematic assumption is one of ingful statement is held to be translatable into a statement (Quine 1951, 36). This assumption is needed in order to think it feasible that scientific statements could be deduced from sensory evidence.  Consider impression from these statements that the meaning of each individual term could be cashed out in terms of simple statements about sense data. And so, the truth of the statement could be confirmed directly on the basis of having certain sensory stimulations correlated with the statements.  The problem is the conceptual leap that supposes these examples to provide a template for all statements about nature. Though many will be more complex, none will differ in form from the relationship sketched in the example. Put aside for the moment the question of whether or not radical reductionism makes sense for even simple statements about nature. It does not make sense of more complex statements about nature. For nearly all observations, one has a choice with respect to whether we read that observation as falsifying our hypothesis or revealing a miscalibration in our observational equipment. A well-known example concerns the failures of challenge the background assumption that there were only seven planets, rather than reject (Stanford 2013). Instead of a radically reductionist empiricism, Quine suggests a holistic view of the relationship between empirical theory and observation. Theories as a whole, or at least 42  substantial parts of them, will have empirical consequences that can be used to test the theory, but not to test individual statements. Individual observations will not completely constrain our choice of what parts of the theory to jettison without assuming some background piece of theory that explains why said observation is evidentially relevant. Holism applies to questions of meaning as well. When we talk about linguistic meaning, we cannot meaningfully talk about individual words as the basic units of meaning. Rather, words get their meaning from the linguistic context in which they are embedded. So, epistemology is not going to be able to place science on a firm footing by deducing scientific statements from observational simples. Epistemological theory is itself part of the overall web of belief subject to empirical testing. Quine still retains the empiricist bent of the traditional epistemological projects. Instead of trying to deduce science from sensory experience, epistemology should see its project of explaining the relationship between our sensory access to the world and our knowledge of the world as continuous with the sciences it aims to explain and vindicate in the first place. Quine (1969) into place as a chapter of psychology and hence of natura(83). Naturalizing epistemologists after Quine have taken up this description and provided more substance to the nature and method of this investigation. Hilary Kornblith (1999) provides a useful account. The naturalized epistemologist is concerned with knowledge as a natural phenomenon rather than knowledge as a concept, since our concept of knowledge might be inaccurate. We start with the clearest instances of knowledge in order to see what they have in common. Through an iterative process of comparing and contrasting cases of knowledge we come to refine our concept of knowledge so that it more closely corresponds to the natural phenomena. Though we start with an assumption about what knowledge is, through successive 43  investigation even those first assumptions can be revised. What we thought was clearly knowledge at the beginning may get reclassified as we identify different features and define characteristics. This process is meant to mirror kinds of empirical investigation we are already familiar with. Consider an investigation into what gold is. The investigation is meant to help us refine our concept of gold so that we can pick out with more reliability real gold from that which merely resembles gold. We might start with an initially simplistic concept of gold (It's that shiny yellow-colored metal). However, we find that this is not specific enough (pyrite is also a shiny yellow metal). So, what, if anything, distinguishes gold from pyrite? Well, it appears through successive empirical testing that gold is a much softer material than pyrite. Through this iterative empirical process of developing the criteria for gold, we end up with a quite specific and quite accurate concept of gold that distinguishes it from all other things (a concept of the atomic structure of it). Moreover, we develop a place for it in a conceptual system of interlocking definitions (e.g. in terms of its atomic structure). We cannot come to a more accurate concept of gold by merely reflecting on the concept we have. You have to go out, as it were, and investigate it. allegedly jettisoning the traditionally normative component of epistemology. This attack claims that, by reducing epistemology to the descriptive sciences like psychology, naturalized epistemology is no longer anything like the epistemology of old. For example, Jaegwon Kim (1988) claims that justification is central to the project of epistemology and makes the discipline an essentially normative one, but justification drops out of naturalized epistemology because the normative dimension is eliminated in the move to the descriptive realm of cognitive psychology. However, Quine (1986) does not see the normative side of epistemology so much eliminated as 44  -(665). Given the ulterior end of gaining truth, normative epistemology seeks to understand the standards for probabilistic thinking expressed in statistics and mathematics, as well as the common psychological biases or errors that habitually get in the way of attaining truth. Normative epistemology naturalized still seeks to provide resources for improving our current epistemic state, but always from the perspective of f efficacy for an ulterior end, truth (665). What does this imply for the epistemology of morality for Quine? The kind of descriptive inquiry sketched above can still be carried outin evolutionary biology, psychology, and related fields. That is, we can investigate instances of purported moral knowledge, belief, and feeling. We can use the sciences to try to understand how we humans go from the combination of the limited amount of sensory information and our innate psycho-biological equipment to full-blown social moral codes and individually regulated behavior. We can develop schemes of classification for different kinds of moral systems, and we can refine the concept of a moral system to help distinguish it from other closely related normative systems, such as aesthetics, etiquette, or law. We can look at psychological barriers to moral motivation as well. This seems like a promising and important area of research into the complex combination of individual altruistic feelings and complex social regimentation. Much work in evolutionary biology has studied the ways in which altruistic behaviors might have evolved, given that it appears that such altruistic behavior does not directly benefit the organism in terms of reproductive success. This work on the evolution of morality is representative of what descriptive moral epistemology deals with under a Quinean paradigm. 45  So, descriptive moral epistemology seems robust enough for Quine, but the prospects of a normative moral epistemology are not so good. Whereas science is unified by the shared ulterior end  (1986, 665). Since the ulterior end of science is given, normative epistemology becomes a primarily instrumental and applied discipline devoted to answering the question: How do we most effectively gain truth about the natural world and increase the accuracy of our predictions about its causal happenings? Quine likens normative epistemology to a branch of engineering (664-5). Knowing what we know about the science of cognition, how do we design intellectual tools, such as methods, or even institutional structures, such as peer review processes, to maximize the production of new knowledge? But, normative moral epistemology cannot similarly become a branch of engineering because ethics is not so unified behind one value or set of values. If it were, then normative moral epistemology could also become the applied technological discipline of figuring out how to maximize the production of that value by avoiding the psychological biases that prevent us from seeing which actions or social policies are best. However, people disagree about the ultimate end for ethics. So, we will have as many different moral epistemologies as we do fundamental conceptions of ethics. Hedonistic utilitarian normative moral epistemology will explore how some cognitive biases prevent us from seeing the true balance of pleasures and pains in any possible action, whereas the Kantian normative moral epistemology will explore how other cognitive biases present us from seeing which maxims of action are truly universalizable. Quine draws a further distinction in terms of the theory-evidence relationship. While both the epistemology of natural sciences and moral theory are shaped by the holism of the web of 46  belief and the underdetermination of evidence, the natural sciences at least have a foothold in independent observable events. Such a foothold lends some credence to the idea that they have a correspondence theory of truth behind them. Nature provides some independent feedback for our theories about nature, but does not provide the same kind of feedback for our moral theories. (1986) observation sentence is an occasion sentence that commands the same verdict from all witnesses (664). The convergence in agreement on observation sentences is cly accessible (664). Sensations that give rise to the utterance of observation statements are experienced alike by nearly all human beings placed in the position to receive the sensory stimulations correlated with them. Only rarely, be it because of perceptual illusions or hallucinations, do the sensations occur without the stimulations. For Quine, there are no such intersubjectively verifiable moral observation sentences to objectively ground ethics.  Quine provides us with some consolation prizes. Though moral theory does not have an objective basis in observation, it can rely on science for help with systematization. He (1979) (482). We can simplify our moral system to identify a smaller clearer set of values under which the actions we deem valuable can be justified. So, some apparent disagreements can be resolved by reverting to higher values that the disputants do agree on. Let us not forget as well that a further level of conformity in value-attitudes exists for Quine because of the similarity in types of ecological and social situations in response to which human beings develop moral codes. However, others have carved out a place for an objective naturalized ethics within the Quinean naturalizing program. Owen Flanagan (2006) develops a version of Quinean naturalized 47  is not concerned with the norms of thought or action, but only with the description and explanation of human cognition. Both epistemology and ethics will have two related but distinct components: a descriptive-genealogical one and a normative one. For naturalized ethics, the descriptive-genealogical component contains investigations of the basic capacities that human beings have for moral reactions, of how people teach their young moral lessons, and of how people handle moral disagreements (441). This component draws from psychology, but not from psychology alone. It draws from any source it can get help from. Deep truths about ethics have been expressed in art, literature, and religious texts (to name only a few), not just in science. including those covering choosing normsvalues, virtues, are (Flanagan 1996, 21). Descriptive-genealogical claims will matter to normative ethics, but the normative cannot be derived from the descriptive. Like the relationship between scientific theory and evidence, normative theory is underdetermined by the descriptive-genealogical evidence. But just as the underdetermination thesis does not doom science, neither does it doom a naturalistic ethics. For, deduction is not the only rational means of reaching ethical conclusions on the basis of descriptive information. Flanagan (2006) and revised by examining all the available information in the light of standards we have evolved (447). Taking all the evidence of successful practice, we use inductive and abductive17 methods to determine which norms best support those successful practices.                                                   17. These are also known as inferences to the best explanation. 48  This naturalist strategy locates what is common not in the explicitly moral content of otivational tendencies, and the common problems that emerge in social living and collective action. Because people share basic moral-psychological characteristics and face similar social and environmental problems, the norms constructed to respond to these shared circumstances will likely be similar. One obvious strength of this conception of common morality in relation to the goals of empirical realities of human life. In this sense, we can see it as responding to the third kind of positioning. Non-ideal theory enjoins us to theorize from the position of real human beings, and a recognition of the environmental, psychological, and biological limits helps ensure that our moral reflection is reflection for real people. Second, it avoids the problematic move of claiming that a significant chunk of meaningful and universally shared moral beliefs can be identified. Instead, it takes a common backdrop against which it can compare and evaluate moral differences. Some moral responses might come out as better than others as responses to the same or similar situations. Some might be considered simply different because they can be construed as responses to different ecological situations. Finally, some moral responses might be identified as roughly equal in legitimacy but still different moral responses to the same situations. That is, owing to the underdetermination thesis, this version of naturalized common morality is able to acknowledge that different moral outlooks might be equally acceptable. But, the common morality as shared ecological predicament alone does not provide us with the resources for navigating difficult moral situations. Many ways of organizing human lives and communities might turn out to be stable over the long term and relatively successful in 49  meeting both basic human biological needs and even more complex psychological and social needs for meaning and purpose. But for all that, these ways of living might still be genuinely unjustifiable from a moral standpoint. To be sure, some extremely immoral forms of social life will in all likelihood be extremely unstable in the long term from a psychological and sociological standpoint. It is hard to see, for example, how the moral-political ideology of Nazism could be humanly sustained for a long period of time without tearing itself apart. However, there are long standing and socially sustainable forms of life that, for example, assign inferior social positions to certain classes of people on the basis of religious or mythological meaning-value systems that rationalized such hierarchies. My point is that morally bad forms of social organization can, for all that, still be ecologically sustainable. If we want means for rationally criticizing these forms of social organization, then we will have to introduce a basis that goes beyond this first notion of common morality.          In criticizing a Quinean and scientistic model for naturalizing moral epistemology, Margaret Urban Walker (2000) identifies what would still be missing in its depiction of moral leaves us one question short of philosophical ethics. This missing question is: no matter how successfully some group of people sustain a way of life they happen to live, is the way they live how they ought (85). You do not need to suppose that there is only one valid way to live in order to see this point. You need only grant that there might be sustainable ways of living that are invalid. -introduce normativity into the Quinean approach fails. One of the benefits in the version of common morality used by Beauchamp and Childress is that it grounds moral justification in content that is already specifically moral. So, they are not 50  limited to criticizing moral systems solely on the basis of concerns for empirical adequacy and social sustainability. The problem for the Quinean and Flanagan-inspired version of common morality stems from its specifically naturalist agenda. It is assumed that moral properties, in order to secure their naturalist credentials, must be explained in terms of some scientifically discoverable empirical facts. Even if we admit that religious and literary texts can reveal important moral truths, the naturalism of this first version of common morality only admits them insofar as they can be ultimately explained in scientific and non-supernatural terms. This discussion raises a serious problem: How can we maintain a naturalistic approach and yet still expand the resources for moral knowledge beyond the kinds of facts discoverable by the natural and social sciences? The second notion of common morality introduces a more robust conception of nature that can defuse this apparent tension. Naturalized Common Morality II: Shared Evaluative Spaces Rebecca Kukla (2014) stable web of embodied normative responses, coping techniques, perceptual skills, (81). What is held in common are not explicitly stated moral beliefs, nor is it simply the shared natural environment that the moral system responds to, but rather it is a shared background of meaning in which moral practices get their life and applicability. It is a largely unspoken of but definitely shared set of practices that enable us to make meaningful moral gestures towards each other. appr51  Aristotelian concept of second nature.18  (1998) rational appeal of the virtues in terms of their supposedly necessary relation to securing human happiness, where human happiness is defined in terms of natural facts independent of moral virtue. This has an affinity with the first notion of common morality in that it too secures the rationality of morality on the basis of its ability to secure human goods like sustainable human communities. For McDowell, the problem with this account is that facts about what humans need do not on their own imply that one ought to act on their basis.  The capacity for rational thought is inextricably linked to the capacity of freedom in action. (170)mere citation of facts about what the creature needs in order to be a good creature of its kind does not provide members of the animal species we belong to; it also enables us and even obliges us to step back (172). McDowell invokes the Aristotelian concept of second nature in order to reconcile a naturalistic ethics with the idea that our critical-rational capacities distance us from our own natures. The facts of first nature are those biological, psychological, and evolutionary facts about ushuman beings have an evolved tendency towards limited altruism, for example.19 Second                                                   18. McDowell is also highly influenced by Wittgenstein. Though I do not explore this here, I think this of significance and of fulfillment, of what is outrageous, of what is similar to what else, what a rebuke, what forgiveness, of when an utterance is an assertion, when an appeal, when an explanation(1969, 52).    19. This is roughly what I identified as the first notion of common morality. 52  to moral reasons and also enables us to question the rational credentials of any putative reason before us. We become responsive to not just the first natural facts but also distinctively moral reasons that we perceive as there independently of our particular desires or needs.  The facts of first nature are not transcended in the sense that they are completely left behind. If they were, it would be hard to see how this spells out a naturalism worthy of its name. McDowell (1998) details a couple ways in which the facts of first nature influence ethics. The first concerns the limits that first nature places on potentially intelligible moral outlooks. He (190). Moral outlooks are always open to reflective scrutiny and, in order for a moral outlook to pass reflective scrutiny, it cannot posit a way of living that is psychologically and sociologically impossible for human beings to actually live. (1998) situationist critique of virtue ethics as an example of this. The situationist critique looks to undermine virtue theories of ethics by pointing out empirical inaccuracies in their moral psychologies. Virtue ethics, so the critique goes, understands virtues as cross-situationally stable dispositions to act in certain ways. A number of replicated studies in situationist social psychology, however, call into question the psychological validity of this construction of virtue by showing correlated with situational variables than with stable personality traits. Some studies show this to be the case even with such presumably virtuous people as Princeton seminarians (Darley and Batson 1973). If virtues are psychologically impossible or improbable for human beings to have, then a moral outlook based on virtues could not survive reflective scrutiny. We can see how, if 53  this critique goes through, a naturalist who thinks that ethics should be responsive to the way human beings actually are would be quite persuaded. McDowell (1998) -natural facts can be part of what reflection takes (190). First-natural facts can have a positive role to play in providing rational reassurance for a particular moral outlook. When it so happens to turn out that the kinds of actions commended by our moral outlook are also the kinds of actions that help humans secure their basic psychological, social, and physiological needs, this connection provides reassurance that the moral reasons we have are the right ones. Though the fact that, for example, altruistic behavior helps secure the kind of companionable and cooperative human society that promotes all kinds of worthwhile human activities cannot on its own rationally ground the moral value of altruism, such a fact still belongs in the reflective background of an altruistic second nature.   Let us review the second approach to common morality described so far. We are brought up to inhabit a space of reasons with others where ethical demands are perceived by us as reasons for actions. This space of reasons is not so uniform that these reasons could be codified as principles. In addition, though these reasons are not perceived as relative to a particular outlook, we owe our access to them to the communities that raised us to see moral reality for what it is. Though I do not deny that moral norms with universal scope exist, no universal common morality exists that contains a set of these universal principles sincerely believed by all morally serious persons. Contra Beauchamp and Childress, cross-cultural moral conversations will not be so straightforward as discovering prior agreement on universal principles. Rather, it will involve the more arduous process of building new lines of connection between established moral outlooks through successive fusions of background forms of life. I discuss this difficult process in more detail in chapters four and five.  54  The second-nature view of common morality also plays a different methodological role than does the common morality of Beauchamp and Childress, or even the first, ecological notion of common morality. The common morality of Beauchamp and Childress is dogmatically grounding. The specific moral conclusions reached in reflective equilibrium gain their moral legitimacy through their relation to the universal norms of the common morality because the norms of the common morality are independently justified. Similarly, the common morality as shared ecological predicament seeks to ground the rational legitimacy of moral norms in their capacity to respond effectively to shared ecological problemsthus, in instrumental rationality. Both seek a justifying ground for moral standards that is itself justified independently of moral practice.  In contrast, the second-nature notion of common morality is transcendentally justified. The background mesh of meanings, habits, and patterns of perception is a non-optional starting point for moral reflection with others (Kukla 2014, 82-3).  One already has to be within the shared space of reasons in order to see the point of various moves made in moral justification, but every individual piece of that spaceevery strut in its architectureis up for re-evaluation. Lindemann and Verkerk (2012) approach clinical ethics through a naturalized lens that is akin to this second naturalized understanding of common morality. In their prescriptions for improving clinical ethics, the ethicist ought not be pictured as someone who has specialized moral knowledge that clinicians do not have. That is, it is wrong on the naturalized picture to conceive of ethicists as experts on morality as oncologists are experts on the medical care of cancer patients. Health care providers already have the moral understandings they need in order to navigate the social world they inhabit, primarily as a consequence of both their upbringing as competent speaking adults and their "upbringing" in the more specialized world of health care. 55  Though the first is more properly what I refer to as second nature, one could understand the particular way of seeing the world as a medical professional as a further specification of a second nature.20 If we follow Lindemann and Verkerk's approach to clinical ethics a bit further, we can tease out some specific methodological suggestions that are afforded by this second conception of naturalized common morality. First, the moral facts made available to us through our second natures are not to be discovered in the same way as the first-nature facts of the previous conception of common morality. Those facts privilege scientific methods of investigation. Though the moral facts of second interactions with the world, they often do so implicitlyin the background. It takes practices of reflection to help bring them to the forefront. This is not only philosophical reflection but also narrative and artistic reflection, as well as psychological reflection. Moral philosophers and clinical ethicists, if they have a contribution to make, engage in reflection of their own to reveal how moralities function and also help provide reflective space, time, and guidance for clinicians and patients. Lindemann and Verkerk describe this role as helping clinicians enhance their own moral perception (303). Second, the common morality of shared evaluative spaces has the advantage of providing a more autonomous but still naturalized conception of practical rationality. Practical reasoning under the first notion of common morality as shared ecological predicament was primarily instrumentalist in character. The reasons recommending a particular social practice were ultimately contingent on their connection to some innate human drive or desire. Manifestly                                                   20. Recall the first kind of positioning I mentioned in the previous chapterthe positioning of agents within specific institutions. This second notion of common morality provides some resources for understanding the modification of second nature. 56  immoral social practices that could meet those innate human desires would come out just as reasonable as practices that were kind and ennobling. Second-nature common morality explains how facility in navigating a world of moral predicates and actions is just as natural as the more stripped down conception that links moral properties to independent facts of human nature. Furthermore, the notion of a common morality as shared evaluative space connects up with the criticism made in the previous chapter of the pro tanto conception of moral principles because it provides a satisfying picture of how both irreducibly defeasible moral principles and particularistic moral perception can work together21 In my criticism, I argued that the way we make decisions about moral situations principally involves the deployment of perceptual skills far more particularized than are pro tanto moral principles. The notion of common morality as shared evaluative space provides a particular role for those particularistic perceptual skills. They enable us to discern when the privileged conditions obtain under which a defeasible moral principle genuinely applies. Here is a quick example. Let us say that, ordinarily, lying is morally wrong. The moral perceptual skills developed via inculcation into a form of life enable us to see, for example, that ordinary conditions are not in place when an axe murderer rings our doorbell to ask us if his intended victim is indeed hiding in our attic.   I will now make three observations about potential limitations in this common morality approach. Just as is the case with my criticism of the first notion of common morality, my discussion of limitations here points to what is needed to supplement the second notion of common morality. It does not point us to reject the notion of the common morality as shared evaluative space. My observations are meant to contribute to resisting a temptation to understand                                                   21. This was the idea that the norms of moral life could be expressed as principles that identified constant -making feature. It may be overruled by other relevant considerations, but its wrong-making force is invariant. 57  the space of reasons as an ideal space. Although we are all brought up to inhabit a space of reasons that is already there for us and that we learn to navigate seamlessly (in most instances), it is not a perfectly stable architectural space. Rather, it is one still under construction and in need of maintenance in many ways.  The first observation is that, although a second nature is an essentially social space where the observations and reasons that constitute it presuppose a particular community not all individuals are equally placed at the center of the epistemic community with respect to having some authority to define what counts as a correct observation or genuine reason. Recall n that human embodiment puts limits on the possible shapings of second nature. One consequence of this, generally ignored by McDowell, is that variation in types of embodiment among human beings influences the shape of second nature as much as do universally shared aspects of our embodiment. Among other effects, oppression places some people at the margins and some people at the center with respect to authority on moral matters. Historically, those with non-white, female, and disabled bodies have been systematically marginalized in conversations about issues of social justice.  concept of habitus to discuss the ways in which anomalous embodiments can affect moral understandings. Scully (2008) describes habitus better than I could: Habitus is pretheoretical, pre-reflexive knowledge that we absorb from behavior and practices that are demonstrated, rarely articulated, by the people around us. By means of the habitus the subject acquires a set of dispositions that are manifested both physically in the bodily hexis. . . and also mentally in tendencies towards perceiving and interpreting the world . . . Habitus then is best seen as an entanglement of physicality and mental life. (65)  58  Habitus helps make explicit the two-way interaction between the shaping of the body and the  body within a horizon of meanings such that evaluative perceptions become feelings that are distinctively embodied. An example would be the morally laden emotional reaction of disgust, which is manifested in recognizable facial expressions and reactions of turning away.   But the body also shapes second nature. Scully argues in her conception of disability material world generate subtly different structures of meaning, we have to consider seriously the possibility that having/being an anomalous embodiment might shape the language and concepts (101). Our bodies play a role in shaping the space of reasons that we come to inhabit through acquiring a second nature, and this is reflected in our moral language. For example, consider the established metaphorical relationship between the bodily positioning of being upright and moral notions of honesty and integrity. Our conceptions of normal bodies and abnormal bodies shape our moral perceptions of character traits like honesty in others. People whose bodies do not conform to the norm are alienated from the dominant moral discourse, and people who associate integrity with uprightness, for example, may reflexively harbor biases against people who are unable to stand upright. Such people with non-normative body shapes will struggle to be heard and respected on a par with other in moral conversations.22                                                   22. I think Jamie Lindemann Nelson (2003) expresses a similar observation. She specifically discusses this kind of observation in relation to the metaethical views of John McDowell and Sabina Lovibond. Drawing from Emmarelationship between an agent and the moral understandings considered authoritative in her moral-(88)motivating action depends on whether or not your second nature enables you to be fully integrated into your own evaluative culture. 59  Again, this is not to reject the transcendental necessity of a shared space of reasons. Rather, this is to say that we should resist the temptation that there is complete conformity within that space. Recognizing the internal diversity of subject positions within a second nature can actually help expand the epistemic resources for objectively criticizing and improving it. Naomi Scheman (2011) e. Scheman explores what Stanley Cavell calls the of rule-about rule-following is that there is really nothing behind how we know how to correctly follow rules besides the fact that it sense is the only thing that grounds the rationality of the practice. If you interpret forms of life as internally homogeneous, then you are bound to see this conclusion as relativistic.23 One is either inside a form of life, or outside of it. If inside, then the way you do things just are the way you do things. No amount of criticism can achieve any rational bite because the very standards of rationality that you criticize are presupposed in your act of criticizing them. If outside, then any criticism will referentially miss the mark because they will operate according to standards of rationality that the participants of the form of life under criticism do not accept. We can avoid the Manichean and relativistic interpretation of accounts that ground standards of rationality in forms of life if we hallmark of reality, however, is th(Scheman                                                   23. I am eliding form of life with second nature. Though they are not quite the same thing, they are close enough to make this comparison work. What becomes second nature to us is a specific culturally shaped view of the world as a rationally ordered sphere of human action. The second nature that one gains is a functioning part of a ing, cursing, (Wittgenstein [1958] 1973, §23). If a form of life is a particular interconnected set of language-games, then a second nature is a particular subset of those language-games having to do with practical reasoning. This is how I generally understand the relationship between the two terms, but I cannot defend that interpretation here. I do not think anything central to my account relies on the specifics of it. 60  2011, 156). This observation recognizes that the notion of a multiplicity of viewpoints does not, on its own, threaten the possibility of realism. In fact, the multiplicity of viewpoints within a form of life provides the rational friction necessary for criticizing the different standards in competition.  McDowell, of course, recognizes the place of criticism within a second nature and even insists on the necessity of the capacity to criticize for any second nature. This capacity is a capacity for determinate critique. Determinate critique uses the resources of the going second nature to criticize it for existing incoherencies in its structure or for lack of correspondence between what kind of social life the second nature recommends and what kind of social life is is internal diversity within an evaluative space means that there is already more than one way we do things within an evaluative space, and this underlies one possibility for how evaluative spaces can be transformed and improved from within.  Second to note, second natures are cultural-historical products that have developed in relation to and in interaction with other second natures. Not only is there internal diversity of second natures, but the boundaries between them are quite porous. Developmental histories often overlap significantly since cultural groups that come in contact with other groups often share and take ideas, customs, and habits from each other. It would be an idealized view to conceptualize evaluative spaces as self-contained wholes. This has the benefit of further deflating the worry of relativism that second-nature naturalism usually causes for some. Though the substantive terms of rational debate emerge from a background second nature, we should not conclude that there is absolutely no overlap in moral terms between cultural groups that have a past history of interaction. Thus, there will be something for rational cross-cultural conversation to grab on. This observation will be explored in more depth in later chapters. 61  Third, on its own, one is tempted to understand the space of moral reasons afforded by second nature as a sort of logical space that connects reasons to actions on a conceptual level. However, this misses the crucial naturalized insight to investigate moral knowledge and forms of moral justification as real-time activities in which real people engage with one another. This means we look at moral reasoning as an activity, rather than as a distinct faculty (Laden 2012, 11). The notion that moral reasoning is not just a question of logico-conceptual relations between reasons and practices, but also an issue of an actual cooperative activity, implies that moral reasoning is itself a form of interaction governed by norms concerning relations between people (13-4). The distinction between distinctively moral norms and distinctively epistemic norms is blurred when we think of moral reasoning from this naturalized perspective. This brings us to the final notion of a naturalized common morality: common morality as external coherence.  Naturalized Common Morality III: External Coherence The limitations of second-nature common morality point to the reality that shared evaluative spaces are neither self-contained nor internally homogeneous realms of pure ideas, but rather internally differentiated and externally porous social spaces of collective deliberation, conversation, and sometimes conflict. It would be helpful if we had some rough guidelines for how activity in this space might be conducted to ensure that the tension and conflict that results from the internal diversity and porous borders results in progressive moral reflection rather than all-out conflict. For this role, I suggest the addition of a third notion of common morality that I call external coherence. I identify this third notion of common morality as external coherence to make its implications for moral justification clear. Wide reflective equilibriumthe currently dominant model of moral reasoning in bioethicsevokes coherence as the major if not exclusive standard 62  consistency of each element in the overall belief system, including both moral and empirical beliefs, vis-à-(Arras 2007, 58). External coherence, does not replace this idea of coherence, since we do not want to reject the importance of being consistent in the reasons one gives in favor of or against a proposed course of action. Rather, external coherence is meant as a supplementary standard in the evaluation of stretches of moral justification. The notion of external coherence recognizes that moral reasoning is a collaborative and expressive activity that aims at building moral relationships between people, not just ensuring that individuals correctly identify objective moral reasons. A concern for engaging in morally and epistemically responsible moral reasoning requires a concern for understanding where the participants of moral reasoning already stand in relation to each other, especially in terms of whose voice is already heard the loudest and out of whose life-way the going second nature is construc (2007) short but insightful discussion of reflective equilibrium in Moral Understandings. When you drop the picture of ethics as just another kind of science and instead think of it as social negotiation, then maintaining and extending relations between the people involved becomes just as central to the evaluation of the activity as does getting right the logical and conceptual relationships between ideas. In moral-(71). An important part of the negotiation includes the very practices of responsibility and accountability that negotiation aims to shape. How we hold ourselves and others accountable expresses to others our own self-understanding of our place in the moral-social world. 63  ExterWith respect to the space of reasons, external coherence depicts the space as one inhabited by living breathing people, not just as an architectural space to be admired for its beauty and (1983) illustrates his non-foundationalist epistemology with a metaphor of a boat continually out at sea where the mariners have to constantly rebuild the boat in order to keep it afloat but cannot bring it into a dry dock to dismantle the whole thing at once and replace it with the best parts. The external coherence version of this metaphor emphasizes that there is more than one mariner on the boat. The process of repairing the boat of moral knowledge is a cooperative activity, and we need to be cognizant of which planks others are standing on before we pull them up for repair. This concept of external coherence as another naturalized concept of common morality emerges out of the new and distinctive ways of doing moral philosophy introduced by feminist moral philosophers. Feminist critiques, both in moral theory and epistemology, point to masculinist biases and assumptions that actually underlie theory purporting to be gender neutral. The innovation introduced by these feminist critiques is to look at theory as a socio-historical phenomenon that is shaped by the socio-political realities affecting those theorists. This feminist approach looks at morality as a situated discourse and emphasizes that, when we move away from epistemologies that associate objectivity and rationality with transcending a point of view, we can begin to see how the social identities of the participants in a discourse shape its internal logic (Jaggar 2000, 462). Though the possibility of this move is implicit in both the Quinean and McDowellian forms of naturalism, it is not made explicit and exploited effectively in the way that it is by feminist naturalism. 64  Examples abound, but I will focus a bit more in depth on an aspect of Walker's (2003) criticism of life-planning ethics in order to help elucidate the naturalizing features of this form of autonomous individuality as a culturally thick moral value is made unavailable to older people, especially older women. In much of her work, she situates autonomy within the broader theme of  (192)Renaissance through the rise of industrialism in Northern Europe. The idea is that a life well-lived is one that proceeds through certain socially defined and personally planned steps where the individual person makes progress in achieving increasing control over himself and his environment for the purpose of the production of goods. This cultural ideal, then, places the final productivity has been achieved. This careerist ideal has been doubly marginalizing for older women, whose socially defined life paths have always placed them in a position where the culturally valued ideal life was either simply off limits to them or nearly impossible to achieve, given the inconsistent or conflicting demands placed upon them. Up until recent times in Western European and North American cultures, middle-class women were expected to situate their lives exclusively as caregivers for their husbands and children so that men were able to pursue their life plans without the burden of domestic work. Though women now have increasing access to the public life in which people pursue their plans, the expectation that they will also be caregivers remains. have culturally defined roles persists in popular discourse. This question rarely arises for men, nor is it often asked whether men should be culturally valued for engaging in care work or expected to do 65  it. This persistent social demand for care-giving continues for women who enter the age of retirement. Thus, they are denied even the notion that the age of retirement could be a leisurely  -feminist analyses like it show us how, despite pretensions to universality, the construction of the moral point of view has proceeded unevenly, second-McDowellat least not explicitlyis a historical and cultural analysis of how second natures have been constructed in systematically biased ways. Morality is not socially modular in the sense that it could be practically isolated from all the other social practices shaping norms and behavior. Although the systematic bias can be conceptually analyzed in both epistemic and moral termsthese differences cannot be located in different social practices. I call this notion a common morality notion because it recognizes that even in shared evaluative spaces not everyone is placed on common ground. It works as a standard for evaluating past stretches of moral reasoning and for guiding present ones because extending moral understandings in a community can have a positive epistemic effect and because moral reasoning is itself a real-time communal process evaluable by moral standards of respect and inclusivity. What specific norms, then, does external coherence entail? Let me start with one it does not entail. First, extending moral understandings does not require conformity in moral belief. So, external coherence does not entail that moral reasoning is always better if it results in the 66  persuasion of one person by another to come over to their side. It is sometimes enough for mutual understanding that I understand why your reasons make sense for you given where you are positioned in the space of reasons, even if I cannot see myself to be in a similar relation to the reasons that there are. For those to whom I owe a justification for my actions, I ought to make my reasons as intelligible as possible. Broadly speaking, external coherence prescribes norms having to do with the intelligibility of your contributions to your interlocutors. This means, at a minimum, that you owe it to those in your moral community to make sure you speak in a way that they can understand. Second, it matters for external coherence who exactly is included in the moral conversation. External coherence seeks to make both the process of moral reasoning and its about particular actions or policies does not include as co-participants all whose interests are substantially affected by proposed courses of action. Moral understandings fail to be externally coherent in so far as they represent the goals, experiences, and interests of only a limited group of people but are considered authoritative for people outside of that group. The power of feminist how certain moral understandings primarily represent a male point of view. It might be the case that some people whose interests are affected by a possible course of action cannot be included in the conversation. These norms of inclusion might then license an imaginative projection of what contributions they might make to reasoning with respect to the issue at hand.24                                                   24. This suggestion is meant to be accepted with the following caveat. Imaginative projections of how another person might contribute to a moral discussion should nearly always be scrutinized closely because of the ease in which pre-existing biases in the projector might affect the results. 67  Finally, it matters also how people are included in the conversation, not just who is included. So, external coherence generates norms prescribing equal participation and respect. In the mutual co-construction of moral understandings that enable ongoing social life, no one -moral negotiations. These norms are defeasible and context-sensitive. The social history, for example, of interactions between formerly excluded peoples and socially dominant groups plays an important role in determining just what equality in participation and recognition require in any given instance. Given a history of one-sided contributions to the moral discourse by a dominant group, equality in participation and recognition could require that people from those dominant groups take a back seat for a while going forward. Discussion of this point will return in chapter 5 when I discuss the differential moral obligations people may face in initiating cross-cultural moral conversations. Conclusion The picture I have painted of a naturalized common morality is somewhat complex, but I think it is now nicely adapted to work for a non-idealized methodology in bioethics. Let me start with bringing together the various pieces of the naturalized approach that underlies the three-tiered naturalized common morality. A minimal characterization of naturalized ethics holds that it is ing moral judgments and moral agency in terms of natural facts about (Walker 2009, 1). This characterization leaves open for specification nd my three-tiered common morality works as an answer to that question. The reason why I exploit the concept of common morality in order to develop a specification of naturalized bioethics is because the preoccupation with the common morality in 68  bioethics and Western philosophical ethics already evinces a widely felt naturalistic concern to make ethical theory responsive to on-the-ground realities of how we go about engaging in moralityby distributing responsibilities, holding people accountable, and deciding what to do in difficult cases. Thus, the concept is already ripe for naturalizing. The first level of naturalized common morality, the shared ecological predicament, captures one sense of natural facts in terms of which we can understand moral judgment. Those are facts about how we are biologically, psychologically, and sociologically constituted such that we could respond in recognizable moral ways in the first place. McDowell would call these facts of first nature. By themselves, they are not enough to provide an adequate account of our place in the non-ideal picture of bioethical methodology. Thus, we have a second category of natural facts we call, following McDowell, the facts of second nature. Our learning a specific language and attendant participation in a community for example, that such and such behavior would be cruel or that Susan is admirably courageous. It becomes second nature to us to perceive actions as cowardly or certain people as generous and to see those facts as figuring autonomy from the facts of first nature, though not complete autonomy. The facts of first nature still figure in moral reflection, and they play a limiting role in the variety of possible second natures we could have. Because second nature is shared in common with others in spaces where moral reasons come to light and are capable of playing a role in moral deliberation and reflection, I called this second layer of naturalized common morality the shared evaluative space. These first two senses of common morality adequately account for the third kind of positioning (our positioning as biologically, psychologically, and culturally constrained human 69  beings). What they do not do nearly well enough is account for the first and especially the second kinds of positioning (institutional positioning and positioning along axes of social oppression). For that, I introduce thcommon morality that draws from an explicitly feminist naturalism thatdemand[s] that in ethical theorizing we look at society in addition to science and at the dominance of some voices and the exclusion of others within societal and professional  I call this external coherence because, by emphasizing the view of moral reflection as a real-time social practice, it underscores the need to evaluate stretches of moral reasoning not just but also in terms of how well the practice is conducted for the sake of promoting mutual moral understandings. Morality as an on-going social practice aimed at solving particular moral problems and figuring out where we stand in relation to each other not only starts from a common position but is also pulled of necessity towards building relationships of understanding among people. Social situations of exclusion and marginalization actively work against the forging of mutual moral understandings. The first two senses of common morality still remain and still figure in reasoning about moral issues. But, just as the second sense of common morality resituated the first sense of common morality, so too does this third sense of common morality resituate the second sense. The moral reasons we are aware of due to our second nature are still pretty much all we have to work with, but those moral reasons are deployed in the context of negotiations with others concerning how we are going to go on living together. Who is included (and how they are included) in the construction of mutual moral understandingsnot just specific ongoing moral 70  reflections but also the background of the deeper and more fixed elements of the second nature against which these reflections take placematters to whether or not these moral understandings can ground stable and mutually enriching forms of social interaction. That is why, with regard to the evaluation of moral reflection, external coherence among people ought to be considered a standard additional to the evaluation of the internal coherence of reasons and conclusions. I hope this extended summary brings together the main elements of the account presented in the chapter so that a clearer picture of what I mean by a naturalized-feminist bioethics has emerged. I have left to the side several serious theoretical objections to the kind of approach I have developed. I turn to these in the following two chapters in hopes that the approach I defend will appear both plausible and capable of handling common theoretical obstacles.   71  CHAPTER 3: A SECOND-NATURE APPROACH TO NATURALISM AND NORMATIVITY  So far, I have motivated the need for a different approach to methodology in bioethics on the basis that mainstream methodologies are still too idealized and do not take full account of the role that positioning plays in non-ideal situations. I suggested that a naturalized approach to methodology could replace these idealizing assumptions. In chapter two, I developed a naturalized approach to the notion of the common morality. I argued that there are three ways to naturalize the common morality, and when suitably combined, these three naturalizing moves are capable of handling issues of non-ideal positioning.  The conception of second nature that motivates the second level of common moralityunderstood as a shared evaluative space of reasonsserves a central role in the naturalized moral epistemology that I favor. The naturalism of second nature represents an alternative to the strand of scientific naturalism dominant in Anglo-American philosophy today, and it provides a suitable basis for developing some crucial feminist insights about the relationship between social identity, political power, and moral objectivity. The notion of second nature also highlights the methodological usefulness of the common morality in a new way. What we believe in common is not morally right in virtue of its commonness. Rather, only because morality is a common endeavor in which we engage together in response to shared ecological problems is it possible that standards of correctness can be applied to moral reasoning in the first place. To the extent that there is agreement between people at the ground of morality, it is not agreement in belief but rather in form of life. Such agreement is what opens up to our view a rationally structured world. Much more needs to be said about how this second-nature common morality makes sense of the normativity, or legitimate authority, of our moral life. The final remarks in the previous 72  paragraph are suggestive but do not yet put the issue clearly in view. Many naturalistic approaches in philosophy have had a difficult time making sense of normativity since, for some popular versions of naturalism, no recourse is left for adequately explaining our experience of  In particular, this is the case for scientific naturalism. This is why I introduced the second-nature approach to naturalizing the common morality. Second-nature naturalism places ethical values in our natural world as independent from more familiar natural-scientific properties. Yet, just stating this does not allay fears that either I have re-introduced the non-natural into my metaphysics or that I have again reduced the normative to the natural by way of identifying what we ought to do merely with what we, as a matter of fact, do.  The goal of this chapter is to explain how second nature accounts for naturalized normativity.25 This goal will be accomplished in two main parts: one part exposition and the other part a limited defense. First, I explain in more detail the Aristotelian thesis developed by John McDowell that moral rationality is a kind of perceptual capacity for reliably detecting features of situations that demand a moral response. The key maneuver I make is to argue that values show up to us as features of the world that demand response from our perspective as agents, and this perspective of agency cannot be eliminated from the account, nor can it be reduced to another perspective. The second portion of the chapter considers a set of challenges to the moral epistemology of second nature motivated by concerns that originate from the feminist naturalism behind the third approach to naturalizing common morality.26 The concerns have to do with potentially conservative elements of the account of moral perception. I do not think these                                                   25. I focus on the normativity of ethical norms, though I believe the same explanation can be used for other kinds of norms (logical, aesthetic, and epistemic).   26. The third approach to common morality emphasized the need for morality to be oriented toward creating shared understandings in a moral-social world marked by uneven distributions of political and epistemic privilege. 73  concerns have been adequately addressed, and by doing so I aim to develop a model of moral perception more friendly to empirical concerns about the bias-laden character of our cognitive-reasoning faculties. Scientific Naturalism and the Problem of Normativity I begin with the basic case for why scientific naturalism struggles to account for normativity. distinguished from the descriptive in that normative statements tell us how things ought to be, how we ought to act and feel, or how things ought not to have been, while descriptive statements tell us how things are, how they were, how we did act, or will act and feel. Normativity abounds in our usual way of talking about things. Logic is normative: if an argument follows the form of a valid syllogism and the premises are true, then we ought to accept the conclusion. The central concepts of epistemology are normative: epistemic justification concerns standards that help us sort true propositions from false ones, and true propositions are the ones we ought to accept. There are prudential norms, aesthetic norms, and of course, moral norms. When asking normative moral questions, e are asking what justifies the claims that morality makes on us (Korsgaard 1996, 23). Scientific naturalism is the metaphysical view that reality is identical with nature and nature just is that which is revealed by the natural sciences. Rendered as a methodological doctrine, the view claims that there are no distinctive philosophical methods and the best or only methods for achieving knowledge are the scientific methods used in our most successful natural sciences. All other methods for achieving knowledge can either be reduced to scientific methods or retained as second-rate alternatives (De Caro and Macarthur 2010, 4).  The problem that emerges for normativity and scientific naturalism is that the objective normativity presupposed in our talk about moral, logical, and epistemic matters is not a property 74  that figures in successful scientific explanations of natural phenomena. And yet, such normativity pervades our discourse. Since objective normativity is not a property discoverable by the natural sciences, normativity is not natural and, hence, not real. This is a difficult conclusion to swallow from the perspective of our common sense commitments. Scientific naturalists have developed a number othat scientific naturalists have recognized that normativity is at least prima facie a problem for their metaphysical commitments that is in need of explanation. Instead of exploring these in more detail, I consider the prospects of non-scientistic forms of naturalism. Since my approach to methodology in bioethics calls itself naturalistic and yet also presumes the existence of autonomous ethical norms, I need to show how a more liberal naturalism, to use DeCaro and  They alism, or some versions of it, offers a broader, more expansive conception of nature that makes room for a class of nonscientific, but nonetheless non-(4). The sticking point for scientific naturalism is its scientism. Liberal naturalism drops the equation between the natural sciences to the placement problem. What still needs to be done is to explain where normativity gets placed on this account and how it still properly gets to call itself naturalistic. J.L. Mackie and the Objectivity of Value I argue that the best strategy for vindicating the ethical as natural but not scientific is by invoking the Aristotelian concept of second nature as the way in which human beings gain access to a first-person perspective on the world. Although human beings are not naturally born with an 75  ethical character, it is natural and normal that they acquire one by becoming habituated by the people around them to perceive the world in a certain way.27 I prepare the groundwork for this theory, then move on to introduce the notion of the first-person view on the world as a way to dissolve these metaphysical worries. I end by connecting the first-person view with second nature. The concerns that motivate Macki (1977) error theory in Ethics: Inventing Right and Wrong help frame what is at stake for the possibility of a liberal naturalism that relies on second theory of ethics concludes that, though ordinary moral discourse purports to be about objective values, ethical statements are all false. Ordinary moral discourse does posit the existence of objective ethical properties, rather than merely expressing some subjective attitudes, but we have reason to think that objective values do not exist; they are not part of the fabric of the world (15). Therefore, ethical statements are false. One major argument Mackie deploys against the existence of objective values exploits the idea that objective values are strange. would be entities or qualities or relations of a very strange sort, utterly different from anything  (38). In epistemological terms, objective values would also imply a faculty of moral intuition that would work in ways utterly different from ordinary ways of knowing. Once we characterize just how strange these objective values would be, it becomes increasingly difficult to see how we could find space for them in the real world as we know it. What does Mackie think ordinary moral discourse is committed to in the way of objective values, and how then does this render them strange? Mackie claims:                                                    27. ither by nature nor against nature. Rather, we are by nature able to (Aristotle 1999, 1103a). 76  The ordinary user of moral language means to say something about whatever it is that he characterizes morally, for example a possible action, as it is in itself, or would be if it or relation to it. But the something he wants to say is not purely descriptive, certainly not inert, but something that involves a call for action or for the refraining from action, and one that is absolute, not contingent upon any desire or preference or policy or choice, his own o (33)   So, objective values combine two features. First, they are there to be apprehended and characterized as independent being objective consists in its being definable without reference to its effects on subjectivity (McDowell 1998, 114). Second, they are internally connected to action such that they make a claim on the perceiver to respond, regardless of what the perceiver antecedently wanted to do. Values are intrinsically prescriptive. It is unclear how Mackie understands the relation between value and action in the phenomenology of value, but one possible interpretation is that values when apprehended provide motivation for action, by themselves. The strangeness is the combination of objectivity and prescriptiveness. How is it that entities, properties, or relations could brutely motivate actionby themselves, without some antecedent subjective state of the will, whether we characterize that as a particular desire, a refined moral sentiment, or an attitude of commitment to a particular moral tradition? For Mackie, there is something at stake for important difference between a world with objective values and one without objective values:  In the one there is something that backs up and validates some of the subjective concerns fabric of the world that validated certain kinds of concern, then it would be possible to e controlled by how things were. (Mackie 1977, 22)   77  If intrinsically prescriptive and completely non-subjective values were impossible, then morality would invite an anti-realist interpretation wherein moral thought could not be said to respond to a    be part of the objective fabric of the world, they must be conceivable independently of how they affect a subject (McDowell 1998, 113). Mackie often contrasts objectivity with subjectivity. This is evident in the selection cited above. Objective values would make a difference because they subjective is in need of validation from something else in order for it to count as tracking reality.   There are many ways that subjectivity might be involved in the conception of a property,  status. With respect to subjectivity, a claim is true or a property is real. This is evident when Mackie contrasts objectivity with (Mackie 1977, 30). Yet, subjectivity can be involved in the conception of a property without its being a matter of a subject choosing to recognize the property in a certain way.   McDowell provides motivation for this view by directing our attention to the perception of color. There is no way to characterize, for example, the color red except with reference to the particular perceptual experience of redness. However, this does not prevent s quality of looking red from being independent of whether or not it actually looks red to a particular person on a particular occasion (McDowell 1998, 134). Color experiences do qualify as objective on the To call a putative object of awareness objective is to say that it is there to be experienced, as opposed to being a mere figment of the subjective state that purports 78   (136). So, there is a sense in which subjectivity threatens objectivity, but this sense of subjectivity captures the quality of somethsubjectivity plays in the conception of color is one of being disposed correctly to receive a particular experiencehaving the right equipment to detect the propertynot one of deciding to see an object in a certain way. Despite their label as secondary properties, colors still retain a claim to objectivity. When Mackie identifies a claim to objectivity in the phenomenology of values, why not interpret it along the same lines? This will put us on a path to defusing Macstrangeness of objective values. Of course, values are not colors and their objectivity requires its own treatment. Colors are not intrinsically linked to action in any way similar to how values seem to be. elps show how values might be characterized as objective even though they have some connection to human subjectivity. Yet, what is left unexamined is how this link to subjectivity explains their normative characteristicthat they provide reasons for action. Once that is done, it is hoped that no longer will objective values seem strange, nor will it seem impossible to see normativity as both natural and non-reducible.  In addition, accounting for normativity in terms of second nature will help to defuse the second epistemological  . epistemological form gets some purchase if we are stuck with an unexplained and mysterious faculty of moral intuition as our access point to moral reality (McDowell 1998, 116n6). We inheritors of the scientific world-view are in an epistemologically different position from that of Aristotle. Western science does paint a particular picture of the world that many find compelling, given the centrality of technology in daily life and the history of scientific successes.28 Moral                                                   28. History is much more complicated of course than the conventional story of continual progress. I do not chapter, 79  perception still needs to earn its right to truth. To do this, I will draw on the notion of the first-person view of the world and its emergence through the inculcation of a second nature. This will also be worth it for methodological purposes because it will remind us that moral perception is a respectable enough mode of access to moral truths that should not be automatically discounted in the course of ethical reflections. That is not to say that some people might not perceive things correctly, but their claims to perceive some moral truth without reaching it through some other acceptable method should not automatically be taken as suspicious. I remain committed to intuitions as an ineradicable piece of moral reflection because they register the idea that good discursive moral reasoning presupposes awareness in the first place of the salient features of a situation. Before we are able to reason discursively about a moral situation, before we are able to act purposively and intentionally in a moral direction, we have to perceive the moral situation accurately (Kukla 2003, 320). The perceptions themselves seem normative in our phenomenology in that what we perceive in a moral situation is some kind of rational pull to action. Values and the First-Person Perspective on to the World Allow me to recall the naturalistic strictures on this account. In order for a moral epistemology to count as naturalistic, it cannot invoke supernatural entities or processes. Supernatural entities, for the purposes of this dissertation, are defined as entities that can and do intervene in the causal sphere but are not themselves susceptible of being influenced by the causal world (e.g., unmoved movers). Though supernatural entities influence the world as studied by the natural sciences, they are also understood as not epistemically accessible through empirical-scientific methods.                                                  my argument is pitched towards those who generally view science as an institution that has had much success in providing accurate details about the workings of the world. 80  Traditionally, epistemic access to supernatural entities is understood to be either a priori and rational or mystical and non-rational.  In order to find values in the world in a place where they will not interfere in the scientific world of causal interaction, it is necessary to look at the world as it is disclosed from the first-person perspective. Akeel Bilgrami (2010, 24-6) explains the usefulness of a distinction between first- and third-person perspectives by remarking on a familiar distinction between predicting and intending. Predictions I make about myself are often a kind of estimation of what I will likely do, and these estimates can contradict what I plan or intend to do. To see the intuitive distinction here, imagine a boxer who purposefully throws a match in order to win a bet riend has misunderstood him to be making a prediction when he is in fact expressing an intention. Predictions take a third-person perspective where one views oneself from the outside as an object that is subject to causal, behavioral, and instinctual forces. Intentions take a first-person perspective in that one views oneself from the inside as an actor deliberating on reasons, making plans, and engaging with the world. The first-person and third-person perspectives are not just perspectives one takes of oneself, but also perspectives on to the world. The world can be approached as an object of detached investigation, or it can be approached as something that engages us on a practical levelby calling for certain responses, by being attractive or repulsive, by providing us with reasons for actions (Bilgrami 2010, 25). A third-person perspective on the world views the world as a collection of objects that are inert in themselves but are pushed and pulled around by uniform physical forces. In contrast, the 81  first-person perspective views the world as also including entities that can prompt responses from agents. Bilgrami asks what the world must be like such that it can prompt responses and demand engagement from us (26). Well, it must contain something over and above what is revealed as part of the world by third-personal detached inquiry. It must contain something that makes normative demands on us. We can call these things, generically, values. Following McDowell (1998), to say that something has valueor to say that someone possesses a certain virtueis to say that the valuable thing or person has the disposition to merit a certain evaluative attitude or response in the person perceiving the value. The argument here is that values exist because the first-person perspective on the world is unavoidable and not reducible to the third-person perspective on the world, and the first-person perspective requires that there be things like values out there in the world. One may object that we do not need to postulate independent values to make sense of practical engagement with the world. Desires can do the job just as well. Desires direct our engagement with the world in a self-standing way. Values are just the subjective states of valuing different objects, outcomes, or people. They are not found in the world but rather projected on to the world. While a first-person view of oneself is still necessary on this account, it is an unfounded leap to posit a necessary first-person view on the world. But desires are not self-standing, at least not all of them. Gareth Evans (1982, 225) makes whether or not it is raining. In this way the question clearly figured as responding to a world that is to be apprehended. The same goes for desires, 82  more or less, so Bilgrami argues. Questions about what we desire often, but not always, prompt us to consider the desirability of the thing we desire. Consider if there is much difference both instances, you may look to the table to see if it needs setting or to the clock to see if the guests as it were, for an antecedent desire. Scanning our mental interiors for the desires we do have is as if we are taking the third person perspective on ourselves. To find out what we will do or will have done on our behalf, we look to find some causally efficacious interior mental state. Since this does not make clear sense of the way in which we are directed outwards to the world when we reflect on our desiring or intending, we need to posit the first-person and value-oriented view of the world.  I do not mean the aforesaid remarks to be decisive, but they do show that the view I am advocating is not wholly unmoored from the practices of reason-giving and value-seeking that it attempts to characterize. This is enough because the realist view of value here does not have any extra burden of proof to shoulder against the non-cognitivist and projectivist view. One might enough to explain the first person perspective on the world presumes that the third person perspective in which the question is framed has some privileged status as a frame on the world. My view, as is evident, is that it does not. None of what I have said so far conflicts with a scientific picture of the worldjust so long as the scientific picture does not claim to be the picture of the world. The reason is that the first person perspective on the world in which values come into view is distinct from the third 83  person perspective in which causation and physical forces characterize the relationships that obtain between entities. Nor, therefore, does the view bring into play supernatural entities with mysterious causal powers. Values do not cause anything. Rather, they merit response. So, the realist view of value I am defending still counts as naturalistic according to the strictures laid out above. Now, talk of this being a first-person perspective on the world is a bit misleading. Values do not only appear to the agent from my perspective but also from your perspective and our perspective. Let me refer to this wider perspective from which value comes into view as the social agent perspective. Whereas some values can be characterized as there to be responded to by the individual, regardless of who she is, not all values are like this. For shorthand, I call these other values you-values and we-values. Let me elaborate on these kinds of values. P. F. (1974)  is motivated by an important commonplace observation: importance that we attach to the attitudes and intentions towards us of other human beings, and the great extent to which our personal feelings and reactions depend upon, or involve, our beliefs (5). We are not alone as we navigate the world as agents. We are intensely attuned to other people as agents who are also responding to the same values we find in the world, and this intense attunement gives rise to what Strawson calls reactive attitudes, resentment and gratitude, to name a couple. These reactive attitudes presuppose that we ally authoritative in making claims on others. With you-values I mean to emphasize that the agent perspective of the world does not merely require values, such as the aesthetic value of a beautiful 84  landscape. It also requires that there be other people we interact with and recognize as valuable by respecting their needs, plans, and desires. There is an extension here to make regarding -person perspective on oneself and on to the world, but so is there a first-person perspective on to other people.29  The natural recognition of others as persons, as co-responders to the values in the world, finally gives rise to the possibility that we might share reasons by recognizing that we are responding together to the same values. We do this by sharing identities as members of the same social institutions.30 These we-values only come into view from these shared perspectives and cannot be so viewed antecedently from the individualist first-person perspective. Becoming a member of an institution can be an epistemically and personally transformative experience such that my imaginative capacities prior to the change in identity would be too limited to adequately picture the revised layout of values (Paul 2015, 6-7). It is from the perspective of a member of a group or institution that I take up a particular role that goods internal to that practice can come into view (Laden 2012, 236). I call these we-values because the actions, attitudes, and policies show up as valuable under the light of the purposes and continued existence of the plural subject  grounded in the particular role he or she has in the plural subject. The secondary quality conception of value advanced by McDowell that I favor claims that values have a necessarily subjective element: values are such as to merit a certain evaluative                                                   29. Likewise, there is a third-attitudepeople are treated as objects of social policy.   30. Institutions are meant here pretty broadly to include families, clubs, political parties, schools, nations, and so on. 85  response just as colors are such as to cause a certain color experience. One implication of this is that, like color experiences, evaluative attitudes are unintelligible except as modifications of sensibilities like ours. One way our sensibilities are modified is by our taking up new social identitiesnew memberships in different institutions. So, certain evaluative responses are not completely intelligible outside of participation in those institutions. When I became a father, I occupied a new role in our plural subject, our family, and the good of the family itself changed with the addition of this new member. In turn, this reorientation produced new responsibilities for me as a father and reoriented my conception of what being a good person is. It is hard to describe the good of having and raising children from a standpoint external to being a parent because it involves responding to the needs of a particular child with love and sensitivity. Becoming a parent is a paradigmatic example of an epistemically and personally transformative experience. The First Person Perspective as Second Nature Lest my order of presentation suggest that I find the first person singular to be foundational or generative of the you- and the we-values, it is, if anything, the other way around. We are not born persons with a first-person agential perspective on the world. Rather, we become them. One other way of putting this is that agency is an achievement, and primarily it is the achievement of others who raised that agent. One way behind the view of a world of value is to explain how we become agents through being .  I also do not want to write an epistemological check I cannot cash by postulating a moral perceptual capacity without explaining its genesis in a way that does not violate our naturalistic 86  strictures. Jonathan Dancy repeats a telling observation from personal communication with John McDowell relevant to this point:  It is the immediacy of the supposed cognition, not its object that makes the epistemology a mere pretense. There is nothing wrong with objective, and so knowable, rational supposed quasi-perceptual faculty. The idea of being on to objective rational connections is all right if you put it in a context in which you talk about acquired capacities to reason. (as cited in Dancy 2014, 799)   We become agents through the inculcation of a form of life as second nature, and we get inculcated into a form of life by way of being brought up by other people. The epistemology of moral perception will not appear so mysterious if set in the context of this story of moral education. Let me first lay out some features of the capacity of moral perception that is developed through second-nature formation. First moral perception is a receptive capacity. Perception does not construct what it purports to present, but rather it takes in the features that are really there to be received. Second, since moral perception is what opens the world up to view as a morally shaped place, it is what enables us to view the world as a place of practically significant particulars. Since practical significance calls for the exercise of judgment, moral perception must also -(Kukla 2003, 334). Perceptions, therefore, must also be conceptually structured.  This amounts to a view of moral perception that avoids the strange features over which Mackie worried. Moral perceptions do not intrinsically motivate as if they were a causal force acting on human beings. Rather, what we are receptive to are features of situations that appear to us as rationally significant and thus call fornot causesome kind of response. Because this is an engagement of a rational capacity, how one responds is still importantly up to the agent. Dancy characterizes most moral perceptions as practical seemings, and this idea best captures the 87  two features I have so far attributed to moral perception. One of the more salient debates in the literature on moral intuition and perception concerns whether or not intuitions are to be characterized as beliefs or seemings. The main difference between the two is that seemings are presentational, whereas beliefs are not.  To understand this difference, consider the Müller-Lyer illusion as represented below by these two parallel lines:  Though the shafts of each line are of equal length, the two lines are presented in perception to the viewer as unequal. This is regardless of whether or not one believes the lines to be unequal. In fact, we know the lines to be equal in length, but our belief that the lines are equal does not change the way they are presented to us (Dancy 2014, 792)presentational state, like perceptual states, but what they present are considerations as reasons.  This conception combines the receptive characteristic of perception with the rational characteristic, and the distance opened up between how reasons are presented to us and what beliefs we have about our practical reasons captures the way in which, though moral reality is out there demanding a response, it is still up to us to critically deliberate on how to respond.   Finally, owing to the fact that moral reality is conceptually structured, our capacity to discriminate features of situations as reasons is an acquired capacity closely connected to linguistic capacities. Without wading too far into the question as to whether or not one can possess concepts without language, it is clear that complex moral concepts possessed by humans Figure 1: The Müller-Lyer illusion: This figure depicts an optical illusion consisting of a set of arrow-like figures. 88  require induction into a linguistic community. Two things need to be noted about this characteristic. First, its status as an acquired capacity does not imply that latent potentialities to develop the capacity need not exist in the first place. If humans were not highly social beings with evolved capacities for (limited) altruism and abstract linguistic representation, then they would not have been able to be brought up into any moral culture whatsoever. Research into these evolved capacities is not only significant in terms of revealing to ourselves who we are as a species, but also in understanding why certain weak spots in our moral perceptual capacities continually reappear. For example, an understanding of the evolution of innate biases in favor of  own group and against members of other groups would be relevant for understanding why people may consistently fail to perceive injustices inflicted upon those they do not see as sufficiently similar to themselves. In turn, this may aid in designing interventions or correctives for such narrow minded moral perception. from emotional responses. Moral perception is acquired in the sense that it is a capacity we develop in the normal course of growing up in a caring family. I emphasize caring because of well-researched connections between learning a language and emotionally identifying with caregivers. Lindemann (2014) sums up the researthinking] requires us to take up multiple perspectives, which in turn requires us to adopt at least identify emotionally with that person (72). Some basic emotional capacities need to be there in the infant, but these basic capacities need someone else to respond lovingly in order for them to develop and mature. Being cared for shapes your patterns of emotional response and trains these responses to engage intelligently and reliably with moral properties in the world. Of course, 89  nothing guarantees that this process proceeds smoothly. For example, owing to the moral sensibiliti-sex relationships. This does not stop the person from realizing later on that the emotion felt is seriously misplaced. Despite that realization, the reaction of disgust may linger for a time though the person rationally repudiates it. In this kind of case, we have something similar to the Müller-Lyer illusion occurring in the moral sphere (Dancy 2014, 800). What is hopefully evident by now but still worth reiterating, conceiving of the learned capacity of moral perception as rational does not mean its deliverances can be summed up into tidy generalizations. Moral generalizations are learned, formulated, and do have a use. They can serve as aids for when we are forced to respond to situations with unexpected features. They play a role in moral deliberations with others who do not share the same intuitive grasp on moral reality. However, learned moral perception captures a cognitive skill that underlies moral generalization. Lindemann (2014) among concepts, but we also acquire the things that undergird rationality: we get a sense for what is ordinary and uncommon, what we can take for granted and what requires investigation, (76). Normativity and Second Nature So, then, what of normativity on this picture? The normativity question is greatly deflated because the authoritative call of morality is built into the first-person perspective from the get-go. Our being responsive to moral values is a condition of our agency, and our capacity to detect normative properties develops in the process of normal human development. An objector could grant that responsiveness might be built into the first person perspective. However, what compels us to respond in a morally appropriate way? I see the moral reality as it is revealed to me, but I 90  choose not to respond morally. What would keep me from that? In a word, nothingexcept your own second-nature training that instills in you a recognition of what a situation really does call for.  This answer may not be satisfying if the objector take herself to be calling into question all of morality from a standpoint external to it, but this I take to be an incoherent extension of the normative question. Certain parts of morality may come in for normative questioning, but the whole cannot, as Walker (2000) (92). This externally situated normative question has in common with the idealized methods rejected in chapter one the view that subjectivity, external standpoint from whiauthority will be undercut and morality will not command the universal respect and observance we think morality deserves. Its intellectual and practical merits will not be recognized. In response to this, we need to defend two conclusions. First, the view from nowhere is not a coherent perspective. Second, the objectivity of moralityat least the kind we want for securing the possible authority of moralityis not thereby lessened.  Let me take these conclusions in order. Earlier, I briefly argued that there is still a sense to objectivity for certain modes of discourse even if that discourse includes a subjective element that is ineliminable. I then went on to defend a view of morality as necessarily involving background forms of life that provide the perceptual equipment needed for detecting moral features. Even if one accepts that this does not doom all hope of objectivity for morality, one might still hold to the idea that the best form of objectivity rids itself completely from subjective 91  of a view from nowhere? It is the idea that we could take up a position external to the mode of discourse or methodology being examined from which we could judge how accurately the mode, methodology, or model fits reality. An objective view of morality, on this absolute conception, would be a view of morality from outside it that could secure its rational credentials by using resources not already implicated in morality itself. Though there are other versions, I am mainly interested in the version that bedevils us todaythat natural scientific inquiry can provide a view from nowhere, or a transparent mode of access to reality. For, if we think that it is so, and we think as seems evident that objective values do not even so much as appear in the natural-scientific view of the world, then objective morality is doomed. The idea that natural-scientific methods provide a transparent mode of access to reality is the idea that the correct application of these methods yields knowledge about the world as it is in itself, uncontaminated by any peculiar facts about human subjectivity or history. Yet, substantive views of scientific method are part of particular views of what the world is like. Far from being independent of the content of the current scientific consensus, the methods of scientists rather reflect what working scientists assume about reality (McDowell 1998, 126). Take for example the standard of simplicity often evoked in evaluating competing scientific theories. One version of the standard of simplicity claims that theories that invoke a smaller number of entities in their explanations of physical phenomena are to be preferred to theories that invoke a larger number of entities, all else being equal. Why though? This is not obvious. In fact, the value of simplicity has been questioned at least in some domains of scientific inquiry. Owing to the complexity of the phenomena of life, Francis Crick (1988, 138) wonders why a simpler biological explanation would have a prima facie advantage over a more complex one. The case for simplicity as an epistemic standard involves an assumption about the nature of realitythat it is simple. None of 92  this is meant to call into question that we have reason to prefer, most of the time, simpler theories, but the epistemic standards we adopt are not independent of the body of knowledge we built through the application of those standards.  If the epistemic standards are not independent, then they cannot be said to provide an external or transparent mode of access to realitymoral or otherwise.  So, the worry at this point is that if there is no external standpoint from which to adjudge moralityand here perhaps even to judge competing explanations of phenomenathen there is nothing, objectively speaking, with which we can differentiate the merits of our moral system from, say, the evils of an overtly racist moral system. We are meant to feel uncomfortable or ill at ease with this kind of conclusion, and it is reasonable that we do given that there is a palpable  a moral system that justifies treating some  I readily assent to the claims that any belief is going to be justified by another belief and that there is no outside to the conceptual sphere in which we operate, but why should our confidence in our views as being accurate be undermined by these seemingly trivial truths? It is not as if any other conceptual schema has achieved a view from nowhere, nor has acquiring a possibility of rational moral criticism. We can and do engage in rational criticism of the various bits of morality, and we are not left speechless in describing the moral abominations of racism. A lack of external standpoint does not imply a lack of a vocabulary to describe what strikes us as hinking and talking, but that is where we must start in any case. This does not mean that the authority of morality 93  cannot come under questioning in pretty radical ways. When juxtaposed against radically different forms of moral life, we might begin to wonder why our own form of moral life is superior to another. Or perhaps we conclude that it is, morally speaking, just as goodso why then cleave to our own moral form of life? This is a different and real questionthe specter of relativismthat will come in for a fuller treatment in the next chapter. Let me summarize the view that has emerged in this section. Values show up in the world from the perspective of the first personor, from the social agent perspective. This is not a perspective we antecedently apply to the worldand can just as easily remove; it is an unavoidable part of experience that the world demands practical engagement. This is a view that can be described as realistdesires or inclinationsbut this realism is not opposed to the idea that there is an inescapably subjective element to values. They only show up from the perspective of an agent and so resist rigorous definition in terms external to the subjective experiences of an agent. What moderates this subjective element is that the social agent perspective is not primarily the perspective of an agent as an isolated individual since the individual becomes an agent through the social process of initiation into second nature individual to perceive value) are more often than not social identities as members of different plural subjects.   This moral epistemology has a strong affinity with the epistemology of perception, in the sense that values are features of situations that are detected, and our ability to detect morally salient features of a situation are a result of our learning from other people in our community how to project concepts into new situations. This does not mean that explicit discursive reasoning plays no important role in morality. We have to explain and justify ourselves to others, 94  and we do this by talking to them. Sometimes they do not see what we see. Sometimes we do not see what they see either. We bring them around to our point of view by trying to re-describe to them the situation in the terms we see it, and these re-descriptions often take narrative form (Dancy 1993, 112-4). Such narratives are open to dispute. Sometimes what we do not see is just how different reasons might be related to each otherhow they each contribute to the overall evaluation of a situation and how their co-contributions. And getting ourselves and others to see how the reasons add up can take argumentation. Second Nature and Conservatism In this chapter, I have been concerned primarily with working out a conflict between scientific naturalism and second-nature naturalism. But naturalism originating in feminist and critical race theory also makes particular trouble for second-nature naturalism. In this section, I turn to address this trouble. From the perspective of feminist and anti-racist naturalism, several difficulties emerge for elements of the project as it has been developed so far, and these difficulties need to be addressed and the project modified so as to meet them. In general, these difficulties have to do with the potentially conservative characteristics of second-nature naturalism. Given that it starts from the perspective of a world already enchanted with value and our epistemic access to the layout of value is dependent on our particular historical and cultural location, the prospects of radical or total reform of a moral outlook by rational means seems ruled out from the start. This conservatism is methodological. The denial of an external sideways-on standpoint from which to criticize and evaluate the proposed layout of moral reality means that any criticism will have to take some other part of the proposed moral 95  layout as given in order for it to have any rational substance. Radical critiques will always be in danger of appearing either irrational or nonsensical.  Besides the methodological conservatism, there may be another conservative element of second-nature naturalism that could easily make partners with authoritarian political trends. In contrast to liberal emphases on the subjective autonomy of the individual to define for himself the values to be acted upon, second-nature naturalism claims that moral values exist outside of the individual acting agent. These values are not identified as part of some unbending supernatural reality, but rather they are values whose authority resides in the community of persons that maintain and transmit them to the young. We learn the layout of moral reality by uncritically imitating other human beings, and an initially unquestioning acceptance of authority grounds the possibility of the critical moral rationality that develops later on. In rejecting the individual as ultimate arbiter of moral authority for herself, we may risk rejecting the value of diversity and non-conformity in moral and social life. Lovibond (1983) sums up the potential worry related to this move:  The demystification of intellectual authority, which I have applauded as a means by which we can free ourselves from covert moral control, can also tip into a kind of celebration of such authority, and of its energetic use against eccentric or subversive elements. A moral realism of that description would be well suited to form part of the ary and unphilosophical sense. (97)  One might worry about the effects moral reality of the combination of methodological conservatism with such authoritarian oppression. Even if internal critical reflection leads to the reform of abominable norms that sit at the root of an oppressive culture, it might not lead to enough reform, for slightly less abominable norms can still be quite abominable. Quine's (1961) naturalistic view of theory change in science 96  favoring the reevaluation of peripheral beliefs with more immediate empirical reference points over more centrally located theoretical beliefs (44).  An application of this conservative standard to moral theory has the implication that if morally outrageous views have a central position in our moral web of beliefs, experience that challenges such views will have a hard time dislodging them.  Take for example a moral-political system that associates privileged access to moral knowledge with one's social identification as white or male. Such assumptions might become deeply embedded in the overall picture of moral knowledge. From the point of view of conservativeness in theory change, it might make more sense to reject evidence that points to the problems of assigning limited moral competence to individuals along racial or gender lines than to actually change those views. The experiences of marginalized agents in a perverted moral order will be systematically ignored or excluded. A moral epistemology that preserves a bias towards norms in need of radical change is seriously flawed. The worries about moral progress in a conservative second-nature account carry over to concerns for the credibility of moral perception as a reliable detector of moral properties. Second-nature naturalism deploys an intuitionistic moral epistemology; moral requirements are said to be real features of situations, and these moral requirements are directly perceived rather than inferred. Moral perceptions are like philosophical intuitions in that they are presented to us as true, without concern for the reasons or evidence that may justify them. Intuitions in philosophy have come under fire recently from a multitude of directions.  Two concerns raised by critical theorists and feminists focus on how intuition pumping philosophical method ignores the effects that systems of power have on the consciousness (Schwartzman 2012, 308). First, intuitions are not as uniform as supposed; it is the 97  homogeneity in social backgrounds of philosophers that makes it look so. This has the function of discounting the perceptions of marginalized groups where they importantly differ from the majority. Second, oppressive social structurnot just those of the open and inveterate racist. This seriously undercuts the trustworthiness of intuitions in a racist or sexist society. Schwartzman writes that treating intuitions as evidence for a philosophical theory is problematic because it functions to naturalize and reify the intuitions that are raised in evidence of their effects on everyone, intuitions (of philosophers and of others) are likely to (Schwartzman 2012, 310).  These points apply equally as well to moral perception and its use in moral philosophy. Let me introduce a topic that I will return to in more detail in the final chapter: implicit bias. Implicit bias in moral perception is suggested by reviews of the results of the Implicit task of sorting words or pictures into categories as fast as possible, while making as few mistakes as possible. Thus, IATs tap into the same intuitive cognitive systems that underlie our immediate apprehension of moral properties. Moreover, IATs have focused on associations between social categories like race and gender and evaluative language. Results from these IATs show that subjects are quicker to react when asked to sort positive evaluative language with faces or names identified as white than when they are asked to do the same with faces or names identified as black. This implicit bias remainsthough somewhat weakenedeven with people who self-report explicit anti-racist views (Banaji and Greenwald 2013, 47). Even black respondents show a weak bias in favor of white faces. Implicit biases revealed in controlled experimental studies have also been shown to have an effect on behavior (221n6). For example, Green et. al. (2007) 98  have documented a positive correlation between implicit bias in favor of white names and faces and likelihood of treating thrombolysis in white patients, but not in black patients. How are individuals supposed to trust their moral perceptions if implicit bias likely influences these perceptions at an unconscious level? Before replying directly to worries about the relationship between second-nature naturalism and conservative authoritarianism, let me first explain how critical dimensions in forms of life necessarily emerge. This is relevant because if standards of correctness are only external to the individual in the sense that they reside in social institutions, then the authority of the institutions themselves seems beyond rational criticism. Accounting for the emergence of a critical dimension helps temper the suggestion that the second-nature form of moral realism identifies moral objectivity with the dogmatic authority of the dominant majority.  For this account, I take a broad view of social institutions. They include any continuing social practice that regulates human behavior and relies on the participation of individuals for their continued existence. Language is a social institution, on this account. What this brings to light is the contingency of the social institutions that regulate our access to moral reality. The conclusion to this line of thought is captured by Lovibond. She (1983) writes, acknowledging that we could do something other than what we actually do, we acknowledge the openness of our actual practices to a form of critical scrutiny which we could not previously have (118). If our forms of life play an ineliminable role in how moral reality is revealed to us and our form of life is itself a historical and cultural product, then the possibility of its being otherwise is open to us. Whether or not we affirm the going social institutions and on what grounds becomes a question that confronts us. To be sure, rational 99  criticism is still limited to the terms of debate recognized by the moral community, but there is nothing that stops these tools from being turned against the institutions that sustain them.  Though internal rational critique is possible and also necessary, this feature does not completely respond to the worries of conservatism, given that the suppression of two sources of criticismmoral dissidents and marginalized groupsis what is at issue. Can internal rational critique carve out space for these two sources? Let us start with the case of moral dissidents. From the point of view of inquiry as a social practice, there is something to be said for promoting and protecting as much as possible a diversity of approaches, especially for unsettled areas. This sensibility is most notably defended by John Stuart Mill ([1859] 1982)s it is useful that while mankind are imperfect there should be different opinions, so it is that there should be different experiments in livi (120). Elizabeth Anderson (1991) describes Mill as adopting a post-of the good an empirically grounded one is that it leaves itself vulnerable to criticism by the felt experiences of those who attempt to live up to it (26). For a naturalized approach to moral knowledge, a conservative policy towards moral dissidents would be unjustified because it would limit the possibilities of moral experiments and would defend the current moral web of belief only by artificially limiting access to experiences that might upend it. Though second-nature naturalism resists attempts to reduce goodness to one or more natural-scientific properties, this does not mean that attempts to reflect on the nature of goodness should not be subject to conditions of empirical adequacy. Some things that seem open to evidence include whether or not a proposed social institution could be sustained over the long term by a human community or whether living with that social institution would produce distrust, conflict, and vice. From the 100  point of view of a form of life committed to its own improvement, a relatively liberal and tolerant policy towards moral dissidents makes sense.  What about the suppression of the moral experiences of socially marginalized peoples? Well, the moral epistemology of second-nature naturalism lends itself to development in the direction of key themes in feminist standpoint theory, and pushing it in this direction helps the approach conceptualize the important role for the improvement of moral perception played by the experiences of marginalized people. Both second-nature naturalism and standpoint epistemology deny the traditional presupposition that objective knowledge claims are incompatible with those claims being socially situated. The key claim behind standpoint ed by race, ethnicity, class, gender, sexuality or some other such politics shaping the very structure of society, the activities of those at the top both organize and set limits on what persons who perform such activities can understand about themselves a(Harding 1993, 54). Contrariwise, the experiences and activities of those nearer the bottom can provide epistemically fruitful starting points for research into human relations. The reason for this is rooted in the relationship between oppression, ignorance, and privilege. The social world is set up for dominant classes so as to ease their transactions and interactions in the world with as few obstacles as possible, while oppression works to create obstacles directly experienced by members of oppressed groups. When it comes, then, to knowledge about the character of oppressive social relations, members of oppressed groups have a defeasible epistemic advantage owing to the increased likelihood of their having direct experience of oppression.   A key component of the moral epistemology of second nature is that moral perception is an educable skill. Moreover, by dint of the fact that ethical formation is a historically contingent 101  process, the distribution of skills in moral perception can be uneven across a population. To a certain degree, nearly all humans who have made it to mature adulthood will share basic capacities for moral perception (excepting psychopathic individuals). However, there will be differences between individuals with regard to perceiving certain moral distinctions or perceiving moral reality accurately in different domains. The central claims of standpoint epistemology illustrate how these differences may be distributed when it comes to the perception of the moral and political character of oppressive social relations. The educability of moral perception does not only mean that some people may be better at perceiving certain things than others, but also that improvement in moral perception is still possible through more education. The improvement of moral perceptual abilities becomes itself a moral responsibility. Kukla (2003) dispositions . . . is a precondition for appropriate moral response, moral blindness and its correction are themselves moral issues and not just epistemic issues. Likewise, overcoming moral blindness is itself a moral responsibility, whose pragmatic contours need to be interroga(339). If this connection between standpoint epistemology and second nature holds up, then the intellectual authorities themselves (the guardians of social institutions) have a moral responsibility related to improving their own capacities for moral perception; one way of doing this will be recognizing the special authority marginalized people have in expressing what it is like to experience oppression. Finally, I want to respond to potential worries that moral perceptions are not a trustworthy source of moral knowledge in a patriarchal and racist society. While second-nature naturalism can be developed in the direction of standpoint epistemology such that what emerges 102  abilities of society by learning from and about the experiences of marginalized peoples, the account still needs to deal with implicit bias and stereotype threat. The reason is that social psychological work on implicit bias reveals that racist and sexist bias can and does operate in the behaviors and attitudes even of individuals who consciously and sincerely endorse anti-sexist or anti-racist positions. This argument is a species of arguments developed against moral intuitions from the perspective of social psyjudgments. I think that Dancy (2014) has roughly the right answer to these arguments: We know of courseand if wments would have told usthat the emotions are likely to be affected by circumstances in ways that introspection is not likely to reveal. Information about the surprising ways in which this can work is certainly helpful, though knowledge of this sort in no way guarantees some sort of immunity to the relevant phenomena. But none of this means that a well-trained (that is, well brought up) moral agent is not in a position to trust her emotions over a wide range of cases. We have to trust our emotions, and we can trust them, just as we have to, and can, trust our judgment, in the knowledge that this trust will sometimes be betrayed. The recommended attitude for the competent moral agent is thus a sort of wary confidence. (803)   The form of moral perception advanced within the second-nature picture does not represent moral perceptions as infallible or dogmatically foundational. They are open to the process of reflective inquiry just like any other piece of moral reasoning. Second, the addition of insights from standpoint epistemology underscore the conclusion that intuitional capacities are not uniformly distributed. We can and do have certain weak points in our capacities for moral perception, and one widely shared weak point is explained in terms of implicit bias. Earlier I claimed there to be iesand perhaps a social responsibility to improve the moral perception of the wider community. What work on implicit bias shows usas if we did not already knowis that improving moral perception in situations where unconscious stereotypes about race and gender are functioning 103  will involve much more than being brought to explicitly and even sincerely accept arguments for racial and gender equality. It will involve both work on the individual level and work on the social and institutional level. Moral perception is an ineliminable part of the way we approach situations that demand response, but that does not mean we ought to adopt a complete confidence in the accuracy of what we perceive. Some things we perceive poorly, or not at all.  If we have a moral responsibility to improve our own moral character, and moral character involves accurate perception of moral reality, and moral perception is an educable capacity that can be improved, we have some moral responsibility in improving our own moral perception. That is straightforward enough. I want to extend the line of reasoning a bit farther. If implicit bias is identified as one cause of weak spots in moral perception, then one implication of the aforementioned moral responsibility is a responsibility to reduce or control for the effects of implicit bias. Experimental research on reducing and controlling for implicit bias is still relatively new, but a recent study comparing effectiveness of 17 different interventions suggests certain strategies are available that reduce implicit bias (Lai, et al. 2014). I review some of these strategies in more depth in the final chapter of this dissertation on cross-cultural moral conversations. Conclusion  I hope that this chapter has provided a thorough picture of how the moral epistemology of second nature differs from the moral epistemology of scientific naturalism, as well as how it can accommodate the contributions made by feminist naturalism and standpoint epistemology. In the course of situating the epistemology of second-nature naturalism between scientific naturalism and feminist naturalism, I hope I have made it evident that moral perception plays a significant role in moral rationality, though an appreciation of the social and political influence on the 104  workings of moral perception ought not to be lost on this account. I also hope to have eased concerns of some for the placement of naturalized normativity in this account.  What remains is to confront the final worry for a naturalized moral epistemology of this kind, namely, whether or not it implies moral relativism. If it does, to what extent does the account have relativistic features? Is moral relativism of this kind even a bad thing for the prospects of making a positive contribution to methodology in bioethics? This concern will be broached in the next chapter and the implications of it for the specific moral skill of cultural competence will be explored in the final chapter of the dissertation.   105  CHAPTER 4: SECOND NATURE, RELATIVISM, AND CROSS-CULTURAL MORAL CONVERSATION In this dissertation I have woven insights from metaphysical and epistemological issues in ethics into concerns for the prospects of methodology for bioethics. I faulted mainstream methodologies for being too idealized, and I suggested that insights from naturalized moral epistemology might help us fashion suggestions for methods that are more relevant to the complex political and ethical problems faced by individuals in medical systems. Notice the shift from talk of methodology to talk of methods. This shift is meant to register the rejection embodied in this dissertation of the hope that a single unified theory of bioethical knowledge might be forthcoming and could resolve moral conflicts once and for all. Instead, what I aim for is an approach, identified as naturalistic, that can provide multiple suggestions for methods whose usefulness varies depending on context. Chapter two took that suggestion and applied it to the role of the common morality in bioethics methods. I explored three different ways a naturalized common morality might guide our ethical thinking and argued that all three approaches could be respected in an integrated fashion. In chapter three I supplied some necessary epistemological background for the second-nature naturalism that anchors my approach to bioethics methods, focusing both on how this approapproach to ethical thinking in second nature, I argued, neither threatens the normativity of the approach nor does it present us with an overly conservative starting point. In sum, what I have intended to outline in this dissertation is an approach to bioethical knowledge that is objective, but does not take that objectivism to imply that bioethical knowledge reduces to a single formula. 106   I suspect that the moral objectivity I associate with second-nature naturalism will still come under suspicion, and the reason is that the approach has certain affinities with relativism. Second-nature naturalism conceives moral experience as an openness to moral reality but also conceives this openness as partially constituted by the inheritance of a tradition or form of life. This opens up the account to charges of relativism. Since people inherit different traditions there will be a difference in how people perceive moral reality, but there will be no tradition-independent standards for adjudicating these differences. If objectivity concerns the distinction between how things seem to be and how things really are, then the lack of tradition-independent standards for adjudicating differences in moral perception seems to undercut the possibility that moral experience could be objective. than a disadvantage. The history of contact between the peoples of Europe and the indigenous populations of the rest of the world has been violent and exploitative. The ideology that supported the imperialist policies of European nations included the idea that European civilization represesocieties that European colonists were meant to enlighten. The values of European nations were viewed as universally applicable, beneficial, and rational, while the values of non-European peoples were dismissed as superstitious, irrational, or downright harmful. Since the Europeans Relativism might serve as a useful corrective to this arrogant imperialism by providing the basis for a respect for the diversity of moral experiences and values.   And yet, there is some ambivalence about the supposed value of relativism in ethics. Relativism seems to give up the game in the face of difficult moral conflicts since its ready-made 107  culture. At worst, this provides cover for truly horrible social practices and undercuts our own rational credentials to criticize them. So, what are we to do? This chapter confronts two related questions. Is second-nature naturalism relativistic? is central to my characterization of naturalism, I consider two separate criticismsone from Michael Friedman (2002) and the other from Bernard Williams (1988)that each attack his approach for being relativ(2011, 2005) formulation of relativism as multimundialismthe view that not all truths are logically connected to each other. Both Williams and -nature approach implies that there is more than one space of reasons that humans inhabit and that these spaces may be mutually inaccessible.  I argue that the possible multiplicity of spaces of reasons would be problematic for the objectivity would be thereby threatened. This has to do with how multimundialism undermines the rational validity of critical reflection. Second, although relativism is sometimes hailed as an antidote to arrogant ethnocentrism, it does not actually imply a tolerant and anti-imperialist epistemology. The reason for this is that the relativistic attitude has several negative implications for the educational and political value of engaging in cross-cultural conversations. Luckily, second-nature naturalism does not imply multimundialist relativism. I separate this defense into two prongs: one against global relativism and one against ethical relativism. My (1973) effective attack on conceptual relativism is equally available to second-nature naturalism. Second, relativist 108  hypotheses rely too heavily on misguided assumptions about the unity and homogeneity of culture. I now proceed to make good on these claims. Relativism as Multimundialism I frame what is at stake in this chapter in relation to two different criticisms that accuse second-nature naturalism of implying a form of relativism. Since relativism is a notoriously slippery concept, let me start by clarifying the formulation of relativism that I find most relevant to second-nature naturalism.31 To do this, I turn to Carol Rovane. Rovane (2011) seeks to clarify the content of the doctrine of relativism so that it satisfies the following intuitive conceptionwith our truths(34). Now, there seems to be an obvious objection to the coherence of this conception. Any set of statements is either consistent or inconsistent. If a set of statements is inconsistent, then the statements in the set cannot all be embraced together and held to be true. If a set of statements is consistent, then the statements in the set can be all true, but they also can be all embraced together. So, neither horn of the dilemma provides a coherent account of the relativist intuition above. Rovane proposes that the relativist intuition might be saved by rejecting the assumption that a set of statements must be either consistent or inconsistent. For a set of statements that is (36). This stakes out a distinctive and controversial metaphysical position that Rovane calls multimundialism. Multimundialism is the view that logical relations do not connect every truth to every other truth. There are more than one incomplete bodies of truth, and these                                                   31. There are of course many formulations of relativism on offer. Each one deserves its own special scrutiny. My intent is to focus on a formulation that may seem initially compatible with the second-nature naturalism outlined in this dissertation.  109  separate bodies cannot be logically conjoined. This nicely contrasts with unimundialism, the view that logical relations do run everywhere and there is a single totality of truths that can be conjoined.    We can further clarify the distinction between multimundialism and unimundialism in practical terms. Logical relations impose normative constraints on our inquiry. If two statements turn out to be inconsistent with each other, then this is a reason for me to reject at least one of them. If we are unimundialists, then every statement bears a normative relationship to the beliefs we hold true. This is for the reason that each statement is either consistent with our beliefs and therefore a potential candidate belief or inconsistent with our beliefs and therefore calling for either its rejection or a revision in our own belief system. For multimundialists, some true statements are just normatively irrelevant to our belief systems since they are neither consistent nor inconsistent with our beliefs. Rovane calls this relationship one of normative insularity (37).  intuition that truth is relative. Proponents of the view that relativism requires the relativity of truth in a domain want to preserve a sense of irresolvable disagreement without violating the principle of non-contradiction. The consensus view holds that relativism arises in the context of a certain kind of irresolvable disagreementthe kind where both parties to the disagreement are right. Since a disagreement requires that there be at least one proposition that one party affirms and the other denies, the idea of irresolvable disagreements does not seem to respect the principle of non-contradiction. If both parties are right about p and one party affirms p while the other denies p, then p is both true and false. In order to rescue the notion of irresolvable disagreement from its potential conflict with the principle of non-contradiction, defenders of the consensus view bring in the idea that truth is relative to a context. Now, there are different accounts of 110   (2005) account that relativizes truth to the context of assessment. The context of assessment consists in the normative standards a person accepts and uses to assess the truth of a statement. So, p can both standards of assessment. This is meant to preserve the sense of irresolvable disagreement because it retains the idea that it is p over which they disagree. Multimundialism is different from the relative truth account because it disregards the need to maintain a sense of disagreement in cases of relativism-inducing difference (Rovane 2011, 39). The point of relativizing truth is to maintain the idea that though the truth of p is relative, an irresolvable disagreement still exists because it is still p that is at issue. Yet, the usual point of registering disagreement is to prompt an engaged response to a shared realization that we both cannot be right. This does not always mean a response to resolve the disagreement; we significance only emerges against the background of some thin agreement about how to characterize the issue at stake. Multimundialism reads situations of relativism-inducing difference as situations where there would be no point to registering disagreement in the first place. The relativism-inducing differences may be so vast that there are no shared meanings of terms and statements that could be the subject of a disagreement in the first place. It would be more accurate to describe the differences in belief as not between believing that p and believing that not-p, but rather as two people believing different statements formulated in different and untranslatable languages. Rovane asks us to imagine an encounter between two people: An American woman who believes that self-determination is a moral ideal and that individuals have no obligation to follow 111  the wishes of their parents and an Indian woman parents (42). Under the multimundialist interpretation, the American woman and the Indian woman are not disagreeing about some identical statementmorally obligatory. Rather, the moral terms they use are embedded in completely different moral and linguistic worlds such that they do not in the end take themselves to be talking about the of self-determination, whereas the meaning of the term used by the Indian women is bound up with a communalist conception of self-identity. It would be more accurate to use the actual Hindi word katarvya to refer to the moral concept she invokes and to insist that katarvya and moral obligation are not inter-translatable terms.   This characterization of relativism in terms of normative insularity is adaptable to either global or domain-specific forms of relativism (38). We might say that all the truths of the way of life of a group of people are normatively insulated from all the other culturally self-contained sets of beliefs out there. Or, we could characterize the insulation as emanating from only one domain of discourse. Perhaps only ethical beliefs are normatively insulated from the ethical belief systems of others, while most other beliefs are never insulated in the same way. Mind and World (1994) has been criticized by some, including Michael Friedman (2002), for leading to conceptual relativism. The kind of relativism of which McDowell is accused specification of relativism as multimundialism. first need some background concerning 112  approaches to the role concepts play in mediating the relationship between experience and reality.  In Mind and World, McDowell takes up philosophical anxieties about the role played by concepts in meditating between the experiencing mind and the experienced world. One familiar way of thinking about this relationship holds that the experiencing mind passively receives empirical content from the world and then organizes it with concepts in order to put it in a form appropriate for standing in logical relations to other beliefs. We want to suppose that the world makes an external impact on experience that is separable from the free play of conceptual thought and thereby can realistically constrain it. And yet, this view runs into the following problem: what we want is for the impacts that the world makes on us to be able to serve as rational constraints on our thinking, but insofar as what the world brings to experience is non-conceptual, it does not have a form that could place the content into rational relations with other beliefs. Thus, the familiar story does not explain away the anxiety over how the world constrains the mind. McDowell and Davidson provide two different responses to this conundrum. Davidson accepts the thrust of the problem and claims that the world really does only have a causal impact on our beliefs. McDowell, on the other hand, is not satisfied with this answer because it still leaves it as a mystery as to how we can take our thoughts to be about the world in any case. non-conceptual contribution to experience. For him, there is no boundary between the realm of concepts and the world. What we take in in experience is already conceptually organized. Now, Friedman (2002) traditional idealist doctrine that the world to which our thought relates is a creature of our own 113  conceptual(46) since McDowell insists that the world does not exist outside of the concepts.  Idealism is not relativiconceptual relativism, according to Friedman. McDowell insists that it is our inheritance of a particular linguistic tradition that opens us up to reality, but since we cannot separate reality from the conceptual apparatus bequeathed to us by a linguistic tradition, it seems we are stuck with the conclusion that there are as many realities as there are linguistic traditions. Friedman writes, f would respond to the threat of cultural or linguistic relativism. Are we not faced, in particular, with the threat that there is not one space of reasons but many different oneseach adapted to its own cultural tradition and each (47).  McDowell cites approvingly of Hans- (1993) notion of the possibility Horizons refer to the outer limit of understanding that is available to someone from a particular historical and social vantage point (301). What sets our initial horizons are the cultural and linguistic traditions in which we are raised. Yet, Friedman argues, whereas the principle of charity in Davidsonto be discussed laterensures that understanding can occur between speakers of different languages, the possibility in Gadamer and McDowell that the speakers might initially come to a situation with conceptually divergent horizons does not ensure that these two speakers might be engaging with the same world in the first place, let alone be able to converge on an understanding of that world. In what way might two speakers not be engaging with the same worldstems from the possibility that there might be more than one space of reason. If there is more 114  than one space of reasons, then the reasons of one space would be unconnected to the reasons of another. The idea of a space of reasons is meant to emphasize the view that characterizing a content-bearing mental state as an instance of knowledge means putting that content into normative relations of justification with other content-bearing states. To suggest that there may be more than one space implies that knowledge cannot be put in logical relations with all other possible beliefs. This is tantamount to saying that the normative insularity posited by multimundialism is possible. So, it is appropriate to draw a connection between the multimundialist relativism described by Rovane and the kind of relativism of which Friedman accuses McDowell. Why does Friedman find this to be a bad thing? I return to that question after I present W Bernard Williams (1988) focuses specifically on comments made by McDowell on the objectivity of value experiences. His concerns . Williams presents us with an imaginative example of the kind of value incommensurability at issue:  Consider a people who are filled with terror, perhaps of a rather special, numinous kind, by certain features of their environment. They have a word to pick out things to which they react in this way, it is not a blankly causal, still less a merely individual, reaction, and children are instructed in what does and does not merit it. Wethe ethnographerscome to understand these reactions, and the word that picks out things in terms of that reaction. We do not share the reaction except to the extent that we imaginatively enter into their view of things: for instance, we do not share beliefs and attitudes that makes this reaction intelligible. Is the quality for which they have this tthe world? Or--we may put it another way-- there are no others? (193)  Williams breaks his analysis of these kinds of disagreements down into three levels. First, there is a shared linguistic practice that can be identified and analyzed in terms of the linguistic items that are taught to children and applied to the world in a patterned way. Second, the existence of 115  the shared linguistic practice raises a psychological question as to why some things rather than others elicit this linguistic response. Finally, there is an additional question concerning objectivitywhether or not this shared practice and the related psychological explanation of the rules underlying it are best understood in terms of picking out some real feature in the (193). McDowell (1998) draws between secondary qualities, like color, and value. McDowell draws this analogy to show that a quality can both be objective and also essentially involve reference to subjective capacities. Though having a particular color experience requires having the correct perceptual apparatus on the part of the subject, we can still describe the color as a disposition that  whether or not we can form a picture of one world, in which reside both the qualities we can perceive and the qualities the people of the other culture can perceive (Williams 1988, 194). If colors can pass this test but values cannot, then Williams has effectively the test. If color is a disposition to cause a certain color experience in an appropriate perceiver, then we can make sense of objects that have multiple color dispositions. Different dispositions are actualized depending on the perceptual equipment of the perceiver. That ball looks red to us human beings with all of our rods and cones but looks light gray to the canine next to us (Dancy 2012, 281-2). Since we understand colors to be dispositions, we are not caught in a contradiction by saying that the ball is dispositionally both red all over and light gray all over. 116  But in the case of values, Williams claims that we cannot so form a picture of one world. Recall that the McDowellian conception of value includes the idea that the valued object not only elicits a particular response but also merits some features of the world cause terror in some but not in others. This might be all right so far as it goes, but are we then supposed to say that both responses are merited (in so far as they are correct identifications in the respective cultures in which they emerge)? We cannot form a picture of one world where both conflicting values are identified as co-existing objectively, and if these are meant to be perceptions of value it is not clear that we have some means by which we could determine which perception of value is correct and which mistaken. Thus, Williams is inclined to think that the correct explanation of the difference is rather in psychological and cultural terms (Dancy 2012, 284). So, the objectivity of value is thereby threatened. In this we can see one of the reasons why relativism (of the sort that threatens McDowell) is viewed to be so problematicit again threatens us with the extinction of moral objectivity.  whether the domain of values can be characterized as unimundial. Though the criticism is framed in terms of value properties and not reasons, values are closely connected to reasons. So, the idea that the perceptions of value of one group of people might not be intelligible to another group of people implies that their reasons for acting are similarly unintelligible. We may understand their actions as reliable responses to certain features of the environment, but we will not be able to understand why those environmental features justifiably call for that kind of response. Since their practical reasons are unintelligible to us, they cannot be normatively significant for us in the sense of logically bearing on our own conception of what reasons we have. Thus, of worry about normative insularity. 117  But Williams explicitly connects the threat of normative insularity with the possible loss of objectivity. I think the same concern also motiva. Though Williams makes the connection explicit, he does not provide a clear defense of the connection. I do think he is right to draw it, and it is important to defend it. This will help clarify why I situate relativism as a threat to objectivity. Recall that I reject in the previous chapter the coherence of an external standpoint from which we can judge alternative moral outlooks, but I held fast to the view that this does not thereby threaten moral objectivity. No domain or discourse can lay claim to being properly secured to objective reality by a neutral and external standpoint. Objectivity implies a distinction between things seeming to be the case and things actually being the case, and what enables us to achieve such a distinction in any domain is the ability to subject to rational criticism the claims made in that domain. This view of rational criticism is similar to the boat simile developed by Otto Neurath to capture our epistemic predicament. We do not achieve objective knowledge by deriving truth-claims from indubitable foundations; we do so by subjecting our body of knowledge to continual revision. We always have to assume the truth of some beliefs as given so that we may rationally revise others. Multimundialism threatens objectivity because it threatens to limit the scope of Neurathian reflection. The claim that some statements that are true for others are normatively insulated from our truths implies that those normatively insulated worldviews are not open to rational criticism and reflection from our perspective. This holds true even if multimundialism is confined to a single domain. I cannot earn the right to claim that my moral outlook has some grasp on the actual shape of moral reality if there are alternative ways of conceiving moral reality that are just as true but not intelligible to me.   118   I have not yet made mention of another term often identified as the opposite of relativismuniversalism. For morality, universalism states that there are moral truths that apply for all persons, regardless of membership in a culture or community. Human rights are widely regarded as examples of universal moral truths. In this regard, multimundialism also rules out universalism. Recall the example of American moral obligation and Indian katarvya. Multimundialism attempts to incorporate the idea that, though these two different notions cannot be embraced together, they are true and normatively binding for members of the respective moral communities. If human rights only have a place in American and other Western moral worlds,  In one sense, unimundialism requires that truths be universal. If it is true that the , then it is true for everyone that the American is not so obligated. It is true for the Indian woman that the American is not with something recognizable as moral relativism. It could turn out that moral obligations only bind people who belong to the culture that accepts them. The American is not bound to be dutiful to her parents because that obligation is not accepted by her culture, while the Indian is so bound because of the accepted norms of her culture. However, notice that this is a specific form of universalism that holds that all people are morally bound by their culture. I do not think most moral norms operate that way, and the reason is that it assumes cultures to be morally homogenous and people to be attached to one and only one culture. I deal with these assumptions later. 119  Relativism, Cultural Imperialism, and Tolerance  I have defended the claim that objectivity requires unimundialism. This might not be enough for some to see unimundialism as an advantage. What moral and political disadvantages might unimundialism have? To approach this question, I veer slightly into discussions of relativism and essentialism that emerged in the context of internationstrands of feminism came under criticism from the perspectives of women of color, women living in non-Western nations, and women living in poverty for promoting generalizations of women and their needs that represented the particular material and social needs of economically privileged white women in the Western world as the needs of women, globally (Narayan 1998, 86). These generalizations are hegemonic by virtue of excluding from political discussion the unique problems of marginalization faced by women who are not white, Western, or economically privileged. In response to these worries, Lorraine Code (1998) argues that a properly mitigated form of relativism might not be perfect but is the best intellectual alternative. She characterizes the Relativism's opponents have to assume that "we" are identically and, for epistemological purposes, only incidentally constrained and enabled by material-locational circumstances; that "we" all make sense of the world in the same way; that "knowledge" has a univocal, universal meaning (73). Further, she writes, t is precisely the supremely privileged who claim to have access to the one true story, presume to speak from nowhere and for everyone, and assume the material detachment that sustains the objectivist illusion in whose name relativism is condemned as irrational(75).  Relativism of some form is presented as the only option that avoids the harmful universalizing and homogenizing theories that implicitly promoted the systematic exclusion of 120  previous section is a form of relativism that acknowledges that material-locational circumstancese.g., the rural village of the Indian woman and the urban Western environment of the American womando play an integral role in qualifying considerations as moral reasons for action for either of these women. Depicting moral worlds as normatively insulated from each other suggests further that moral knowledge does not have a universal univocal meaning, but rather as many meanings as there are moral worlds. Multimundialism meets the requirements set forth by Code.  One issue with this narrative is that the history of imperialism in relation to the ideology of difference and sameness is more complicated. The narrative identifies the denial of differences as the ideological tactic at the heart of cultural imperialism and goes on to claim that relativism is the only moral and political attitude that avoids denying differences. Yet, it is too simple to say that the (1998, 100) claims that emphasizing both difference and sameness, in the also deficient in many ways, was central to the justification of the colonial project. So, we need a more nuanced understanding of the relationship between cultural imperialism and the moral evaluation of cultural differences. Iris Young (1990, 58-61) claims that cultural imperialism concerns the universalization  whose experience or culture deviates from the dominant group are automatically viewed as degenerate, dishonest, or misled. What happens is that difference is not denied but rather transformed on the basis of a single evaluative scale, wherein the dominant group way of life 121  stands at one endas pinnacle of human developmentand everything else is arranged somewhere lower on the scale. Cultural imperialism involves a complex interplay of enforcing sameness and re-inscribing difference as inferiority.32 We can see this in the liberal ideology dominant in the West in the 19th century. A core doctrine of this view was that all men have equal capacities for reason (sameness), but these capacities are only actualized at certain stages of civilization (difference).  (Mehta 1999).  This way of putting things implies that the problem arises when evaluation is introduced further imply that relativism is the only possible response to the problem. Just because moral evaluation is inappropriate for some cultural differences does not mean it is inappropriate for all cultural differences. It is an important skill of moral perception to know which differences have moral salience and which do not. Cultural imperialism can be understood as a moral-perceptual deficit.33 (Kukla 2003, 329). Specifically, they misconstrue any kind of cultural difference from them as moral inferiority.   One reason why the move to relativism does not actually help accomplish the goal of appropriately affirming the distinct interests and experiences of diversely situated women is that it is not so easy to distinguish the normative tools of colonial oppressors and those of local                                                   32. Another aspect of this complex interplay of difference and sameness is that while the civilization of the imperialist is viewed as robust, progressive, and full of complex diversity, the culture of the colonized people is viewed as homogenous and simple.    33. moral perception, but I do not think it is in conflict with anything she says about cultural imperialism. 122  oppressors. Narayan notes that relativistic appeals to the moral importance of upholding traditions have been used by locally oppressive groups in non-Western countries to charge local (Narayan 1998, 102)argument implies that relativism is the only alternative to a difference-denying cultural imperialism, but relativist appeals threaten to deny difference as wellthe difference that emerges within communities when certain community understandings are critically contested. The fault of assuming too much homogeneity within cultures is a major stumbling block for overcoming the appeal of relativism. I will deal with it more directly toward the end of this chapter.  cross-cultural conflict and understanding is in its practical implications. The practical implication of relativism is one of indifference to the culturally different approaches of other people. Recall the characterization of multimundialism wherein some truths are understood as normatively insulated from other truths. If some truth is normatively insulated from my belief set, then its truth value and logical implications can play no rational role in leading me to revise my set of beliefs (Rovane 2005, 113-4). I might be interested to learn about why a group of people, different from me, act in the way they do according to their own systems of belief, but the interest I take here is one of curious observer rather than conversational participant. I can learn about them and their beliefs, but the possibility of my learning from themthat is, learning something that affects the way in which I relate to the worldis ruled out from the start. Thus, relativism harms efforts at cross-cultural understanding rather than aids it. by necessity a historically contingent fact about 123  when and where you happened to be born. By moral confidence, I do not mean something like moral arrogancean unreflective self-the wrongness of all others. To be sure, this is an attitude that ought to be deflated. I mean, r(Moody-Adams 1997, 23). If you consider relativism to be the order of the day in the realm of morality, then it is hard for you to avoid a certain line of thought that starts with the realization that it was just a coincidence that you happened to be born to a particular society and subject to the norms of those society. But for that fact, you might have been born to a society subject to different normsnorms that may now strike you as appalling, disgusting, or obviously wrong. But now you have no basis to criticize those norms, and contrariwise, you have no basis to valorize the norms of your own society. Normatively insulated norms that cannot be embraced together cannot also even be compared together. It is hard to understand how one might have confidence eparate your normative system from another cannot be rationally resolvable differences but rather merely contingent happenstance.34 It is hard to see unless you are able to simply ignore this line of thought. My criticism of this defense of relativism does not deny the advantages of the characteristics it associates with relativism; rather, I claim that relativism does not actually secure these advantages. Cultural imperialism must be avoided by any minimally sufficient account of cross-cultural moral conversation. Discussion of it shows us that my view of the                                                   34. Richard Rorty (1986) is a notable exception here. He embraces the thought that the difference between cultures might not be rationally judicable, but nonetheless asserts confidence in the liberal political morality of the Western world. I think Rorty is compelled to draw this conclusion because he still ascribes to the idea that at least some cultures are more or less homogenous and relatively self-contained integrated wholes. 124  second-nature objectivity of moral values must be careful to avoid introducing evaluation into certain areas where the cultural differences at issue do not actually constitute morally relevant differences, and it must not downplay the importance of self-critical reflection in light of cultural differences. Oftentimes, when we look to other possible and actual forms of social organization, we should not focus on perceived faults compared to our own social forms, but rather we should note the advantages of alternative systems that are not available in ours. Both of these characteristics describe aspects of moral tolerance, but moral relativism does not imply moral tolerance. Yet, does the unimundialist objectivity of second-nature implications will go some way to recommending the view as a positive approach to disagreement in cross-cultural circumstances. I now turn to this defense. McDowell and Davidson against Global Conceptual Relativism Mind and World suggests there are multiple spaces of reason and therefore implies a global relativist view. Friedman criticizes  Friedman because if global relativism goes through, then a fortiori, so will any specific value domain relativism.  Friedman thinks that Donald Davidson develops an approach that can successfully avoid global relativism, but this approach is not open to McDowell because of his theoretical he succeeds in showing that McDowell cannot also make use of some of the same conceptual resources as Davidson does. Since D (1973) approach to global relativism is relevant, 125   In the essay, Davidson confronts the following assumption animating conceptual relativism: people have different conceptual schemes, and content within these schemes can fail to translate (both totally and partially) into other schemes. Davidson is worried that the is relative to a sche (5).  Davidson is concerned here with the consequences of this conceptual relativism for the commonsense view that we are in contact with objective reality. Not much is left of the notion of objectivity if the criteria for what counts as real differs according to conceptual system and there are no shared criteria to adjudicate those differences.  ent conceptual schemes is seems to betray an underlying paradox. Different points of view make sense, but only if there is a common coordinate system on which to plot them; yet the existence of a common system belies  (6). I point this out only to draw a comparison with the language I favor in describing our moral relations in terms of social locations and points-of-view. Far from supporting the idea that there are radically incomparable conceptual schemes, such rhetoric makes sense only if you interpret them against the background of a shared objective reality. As we will see, Davidson does not try to rehabilitate this metaphor. I hope it becomes clearer that, with a little help from McDowell, we can rehabilitate it without contradiction. The first move to note is that Davidson associates conceptual schemes with languages because a difference in conceptual schemes implies a difference in language. However, speakers 126  of different languages may still share conceptual schemes. If we want to determine if speakers of different languages share a conceptual scheme, then we would want to determine if the languages are inter-translatable. So, the possibility of different conceptual schemes for Davidson  (6). Davidson considers two possible breakdowns: complete failure of translation and partial failure of translation.  The idea of a total translation failure implies that there are or could be languages we could identify as languages even if they were in no way translatable into the language we speak. And yet, translatability seems to be our best criterion for identifying something as a language in the first place. So, Davidson is skeptical right away of the possibility of our identifying something as a language but not translatable and therefore a different conceptual scheme. oncern is an assumed dualism he sees as generating most of the versions of conceptual relativism at issuea dualism between conceptual scheme and empirical content. The idea that these two terms are arranged against each other in a dualistic fashion gives rise to the following common characterization: The idea is then that something is a language, and associated with a conceptual scheme, whether we can translate it or not, if it stands in a certain relation (predicting, organizing, facing or fitting) to experience (nature, reality, sensory promptings). The problem is to say what the relation is, and to be clearer about the entities related (13). two prominent metaphors used for describing this connection between scheme and content are unworkable. These two metaphors are (1) that conceptual schemes organize reality or experience and (2) that they fit reality or experience. 127  Davidson starts with the organizing metaphor (14). First, simple objects cannot be have a conception of reality as already individuated into parts. But, if you need to understand reality as already composed of a number of different familiar parts in need of organization in order to make sense of the idea of conceptual schemes organizing reality, then you have already presupposed that different organizing schemes will generally share the same familiar ontologythat the reality in need of organization is made up of familiar things like rocks, people, butterflies, and rabbits.35 As regards schemes fitting reality, what we are concerned with primarily is how well our sentences and theories account for the totality of evidence. Davidson interprets this to mean that for a theory to fit all total possible evidence from our senses, is just for that theory to be deemed true (16). The notion of fitting adds nothing to the picture over and above the question of whether or not a theory is true. So, it appears on this metaphor that for something to be identified as an acceptable conceptual system is just for it to be deemed true, or at least mostly true. Yet, translation into a familiar language. This is because Davidson follows Alfred Tarski in thinking that any adequate theory of truth must entail, for all of the true sentences in a language (L), a and p is a translation of s into English (or whatever is your familiar language). If you follow Tarski, then one cannot make sense of a notion of truth in a language where the true sentences in that language were not translatable into a familiar language (17). Thus, we cannot make sense of the idea that different untranslatable conceptual schemes each fit reality.                                                   35. Davidson also considers the idea of schemes organizing experience but dismisses it for quite similar reasons. 128  What about partial translation failures where not all but a substantial part of one language is not translatable into another language? This is relevant for the possibility of a conceptual relativism with respect to value claims. Davidson approaches this through how we might go about interpreting an initially alien speaker. First, he reiterates the claim that we cannot attribute mental states to a speaker prior to attributing meanings to his sentences, nor can we attribute meaning to his sentences without knowing a whole lot about his mental states. The reason is that speech behavior requires a complex array of intentions and beliefs. So, interpretation requires a theory that assumes neither belief nor meaning, but goes for both at the same time (17-8).  Davidson makes one more crucial assumption: that we are entitled to assume that we can know initially which sentences a speaker accepts as true. This does not involve circularity with respect to interpretation because merely knowing which sentences the speaker accepts as true tells us nothing about the meaning of those sentences nor what the content of the belief that the sentence is true amounts to (18). Since we cannot know what the meaning of her words are without also having a handle on what beliefs the speaker holds, we are left with no other option than to assume that the speakerwho is confronting the same world as we doholds roughly the same beliefs about the world to be true as we do. This principle of charitythat the speaker we are interpreting is mostly rightprovides the background against which we interpret the meaning of her utterances. This does not eliminate disagreement, but rather makes meaningful disagreement possible because it is only against the background of agreement, especially about what words mean, that we can identify which claims we disagree over (19). There will be no general principle for determining if a difference, so isolated against a background of agreement, will amount to a difference in scheme or a difference in opinion. So, there will be no general and decisive principle for deciding in translation that a significant porti129  scheme is untranslatable. Davidson takes his results to show neither that we can communicate not a workable concept when we think about differences in thought. that since McDowell, unlike Davidson, views shared linguistic traditions as mediating our understanding of the world, the move of rejecting conceptual relativism on the basis of rejecting  fusion of horizons does not help. The fusion of horizons between two speakers with initially divergent linguistic traditions changes both the horizon of the speakers and the world that is in view. Yet, the horizon of linguistic tradition which opens us up to reality does not function the same way as does the notion of a conceptual scheme dualistically set up over an initially McDowell includes in it the idea that horizons are not bounded off from each other (McDowell 2002, 176). I will not go into specifically how this is developed in Gadamer, but McDowell constantly emphasizes this in his writing when he talks about the close relationship between conceptual capacities and freedom. In one notable line,  (1994, 5). The inheritance of a traditionif we understand that to be the inheritance of a scheme of concepts that opens us up to realityby necessity opens us up to self-critical reflection on the way we go about making sense of what we experience. The confrontation by others who approach reality in perhaps strikingly different ways is one way in which our own view of reality may be potentially challenged. 130  the possibility of languages completely unintelligible to us. As long as one understands that linguistic traditions have porous borders, the idea that shared linguistic traditions mediate understanding will not imply that people may be operating with incommensurable conceptual ents to buttress the Gadamerian idea of  But, the role of linguistic tradition in McDowell seems very close to the role played by conceptual schemes in the conceptual relativism that Davidson rejects. Here, it is important to note that McDowell himself does not have so much of a problem with the idea of conceptual schemes. The issue, rather, is that they should not get set up as one term in a dualism where the other side is some conceptually neutral reality. For, recall that McDowell tries very hard to disabuse us of the notion of non-conceptual empirical content in our conception of the relation between mind and world. McDowell (1994) perspectives can be seen as embodied in language or cultural traditions. So languages and tertia(155). The idea of being open to the world presumes that we are taking on a particular perspective or point of view in itthat we are located with respect to others at a particular point in what we see and what we do not see. The important thing is that we conceive of these points of view provided by schemes or linguistic traditions not as standing outside of the world, serving as mediators between us and the previously uninterpreted world, but rather as themselves embedded in the world. Whereas Davidson wants to drop the whole metaphor of points of view, 131  scheme rather than the notion of conceptual scheme itself helps us see how we can retain a place for the perspectival metaphor in our second-nature naturalism. Multimundialism holds that there might be truths that cannot be embraced together because they are normatively insulated from each otherthe truth of one truth-bearer is neither consistent nor inconsistent with the truth of another. Now, either the normatively insulated truths are translatable or untranslatable into a familiar language. If you follow Davidson and Tarski, it is not coherent to say that there are truths that are untranslatable into a familiar language. So, we are left with the possibility that there are true worldviews translatable into my familiar language but normatively insulated from my worldview in the sense that they are neither consistent nor inconsistent with my worldview.  I do not see a way to make sense of this possibility. The idea of an intelligible but normatively insulated competing worldview is inconsistent with second-nature naturalism developed so far. Rovane actually supplies us with the first part of this argument. She recognizes (Rovane 2005, 115). Davidson makes a connection between understanding the meaning of a concept and holding a number of beliefs that place that concept within an interconnected nexus of beliefs. Possessing a concept, say of cateliefs. For example, a cat is an animal with four legs, and a cat is not a dog. So, understanding a concept and, in turn, understanding a sentence that makes use of those concepts requires that I have a sufficient number of beliefs related to that concept. If I understand the claim you are making, then I understand the concepts your claim employs. If I understand your concepts, then I must 132  have a number of beliefs that I share with you that place the concept within a whole system of beliefs. This is meaning-belief holism. seeing how they all relate to each other and still maintain that that rival system is logically cut off from my system? Not unless you think it is possible to get a picture of a conceptual system from outside of it, but this possibility is ruled out by our earlier rejection of the view that the world makes a non-conceptual contribution to experience. Systems of concepts and beliefs purport to be about the world. If I understand a rival conceptual system, I must understand how it purports to be about the world. But the world is not separated off from the concepts that make it manifest to me. So, in understanding a system of concepts I must understand how it relates to how I take the world to be. In so far as they differ, I must understand this difference as rival ways of portraying aspects of the world. Now, it may be the case that this confrontation reveals to me that I do not have any reason to suppose my view is right and their view is wrong. Yet, this is because of lack of evidence and not because of any metaphysical separateness between my world and their world. McDowell as Ethical Relativist? Suppose you follow so far in rejecting the possibility of a global relativism where reality is seen as relative to a conceptual scheme or linguistic tradition. That does not rule out the possibility principle of charity against potential translation failures are meant to save us here, but does it get us rid of the specific style of criticism we see in Bernard Williams? Is there something different or special about value claims that undercuts anti-relativist arguments in that area but not others? 133  experiences by analogizing them to color experiences. Yet the analogy falls apart, claims Williams, because while we can fit differing color perceptions into a picture of one world we cannot fit differing value perceptions together in the same way, because our perceptions of value are not just reactions to dispositions but also merited reactions, and conflicts in value perceptions would lead us to suppose intolerable conflicts in the reality of value. Williams illustrates this with an example of a people filled with terror at certain features of the environment that a group of anthropologists do not also fear though they understand the pattern of application. One thing that Williams dismisses too easily is the possibility that the people in the example might just be objectively wrong in their estimation. Fear is merited as a response to entities that are dangerousthat have a disposition to hurt or damage. It is possible that they fear something that does not merit fearhere, meaning that it is not actually dangerous. Dancy (2012) to fear, and the quality for which they have the term is not part of the (282). If this is the case, then there is no worry about a conflict or contradiction in reality between values. Williams describeenvironment are seen in a fearful way has something to do with supernatural entities. Furthermore, Williams posits that the ethnographers have an understanding of the reaction and the features it picks out, but that the ethnographers do not share the beliefs and attitudes that make the reaction intelligible. Why is this not then just a case of ordinary disagreement as to whether or not the supernatural forces imbuing these features with fearfulness actually exist and are causing some kind of danger? No doubt disagreements of this sort can lead to a pretty large divergence in practices and attitudes, but this does not shake our right to suppose that what we 134  are doing and what they are doing is purporting to pick up on real features of the world. Either one of us or both could turn out to be wrong. One reason why Williams and others might be hesitant to consider this possibility is the suggestion that it seems to make: that some cultural groups exhibit a kind of simple inability to perceive an aspect of morality that others do not, akin to the phenomena of color blindness. Again, we have worries of colonialist-imperialist overtones or, at the least, an oversimplification of disagreements between peoples. If perceiving value is just like seeing color, and these people do not see some value we see, then they must be stricken with some kind of perceptual defect. This does not seem at all like a faithful explanation of the divergence in moral views because, unlike the case of color blindness, there is no simple defect in psychological or cultural mechanism to point to. Moreover, in any given case of radical disagreement like this, either cultural milieu will have a host of stories to make sense of the way the layout of values appears to them. Even more so, accusing other people of culturally induced moral perceptual deficits does not mesh well with the overall goal of applying a naturalizing approach to cross-cultural disagreementthat of stimulating productive cross-cultural conversation. First, it is important to recall the form of moral intuitionism I defend in this dissertation. Moral intuitions are perceptions of reasons, where perceptions are understood as seemingsseems that element of judgment in moral reasoning since one has to judge whether moral reality is as it seems in this case. Insofar as moral reasoning occurs in the context of conversation and deliberation, making a claim that someone does not perceive the moral reasons that are there does not have to be the end of the social reasoning process. Someone can be brought to the conclusion that moral reality differs from how they perceive it. So, the charge of moral 135  perceptual deficit does not automatically imply an end to the possibility of rational moral conversation.  We can appeal even further to the notion of semantic depth to blunt this conclusion. This notion is owed to Mark Platts (1997, 249). Semantic depth refers to the ways that our experience may enrich our understanding of a moral concept without it thereby being the case that we have come to grasp a different concept. On a realist interpretation, concepts figure in our grasp of an exceedingly complex world. I may understand the dictionary definition of a concept like "honesty," but my sensitivity in detecting its instantiations or knowing to whom it is owed and when it requires tact instead of bluntness are all honed through experience in grappling with the world. Owing to the complexity of the moral world, a realist would expect differences in experience to result in different conceptions of the same concept. At least some difference in understanding across cultures can be understood as differences in access to different parts of the semantic depth of moral concepts. Widely shared experiences can have demonstrable effects on the moral norms operative in different communities, and these communities have as a result of those experiences a better institutionalized sense of the contours of a moral value. What we have is not necessarily culturally induced moral perceptual deficit, but rather culturally induced differences in capacities to pay attention to different aspects of the same moral concept.  This picture of societal moral progressone where collective experiences do contribute to deeper understandings of moral conceptsdoes not imply that the process is smooth or uncontested. Oftentimes, these improvements come about through the exposure of systematic and long-running abuses, and so those whose hold on power and authority relies in part on these abuses are likely to oppose such changes. The evolution of the role of informed consent in 136  morally acceptable medical practice is one of many examples of the kind of experience-based changes I have in mind. It is not as if the moral importance of the disclosure of information was a completely new concept that emerged only in the 20th century, but our nuanced understanding of what information needs to be disclosed and its moral importance in medical research does emerge in the 20th century in part as a reaction to systematic abuses of patients and research subjects. In the United States, the history of such experiences making their way into the larger social understanding of the moral concept unfolds through a series of legal decisions imposed on the medical establishmentrather than the medical establishment initiating changes themselves (Beauchamp 2011, 515-7). Cross-cultural moral conversation is revealed as a way in which we can learn from urs of a moral value we may have failed to notice and appreciate, and just maybe, we may have something to teach others about aspects of the moral world we have a good grasp on. McDowell follows Gadamer in conceptualizing languages as repositories of the historical experience accumulated into a tradition. I think this notion meshes nicely with the idea that it is the semantic depth of concepts that different linguistic traditions may understand at different levels and therefore genuinely have something to teach each other. A final assumption needs to be dealt with that causes the greatest obstacle for resisting the allure of cultural relativism. One might still be reluctant to think that it makes sense to talk about semantic depth issues across cultures because we owe our concepts to the community that taught them to us. Communities may seem like closed units that develop moral systems to navigate the particularities of their own local moral-social worlds. Yet, McDowell constantly points out what seems to be an obvious point but at other times appears as exactly what is at 137  issue in the relativism debatethat different traditions are critically open to the challenges of others. Being open to reality by way of language opens us up at the same time to the ability to critically revise our own beliefs about the world. And yet, how can the critical revision process make sense in the context of a confrontation coming from outside Though linguistic capacities may, by necessity, bring along with them the capacity for critical revision of beliefs, are cultures and linguistic traditions actually porous enough to regularly allow for and cultivate such critical cross-stunted in the face of observed distance between cultural heritages.  I think the reluctance to accept rational cross-cultural conversation on its face stems from an orthodox view among philosophers and anthropologists that cultures are highly integrated and self-contained wholese seemingly disparate elements of the way of life of any groupits culture(Moody-Adams 1997, 44). If cultures function like this, then it makes it easy to see how cultures could operate with whole systems of mutually unintelligible concepts. But this thesis of cultural integration has numerous problems in light of our experience of cultural change and cultural interaction, the first of which is that the thesis does not cohere with a plausible picture of what we know exists in nearly all communitiesdissent, disagreement, and social differentiation. First, for any given value supposedly emblematic of a culture, you can nearly always find its counterpart at work. We often talk in generalizations about the values of a culturethe culture of the United States highly values rugged individualism, whereas many Asian cultures place a high premium on community solidarity. However, other plausible stories can be told of American culture that emphasize community solidarity and historical and cultural evidence can be found in Asian cultures that support individualistic values. Amartya Sen (1997) 138  has examined the simplifying contrasts placed between intellectual traditions in the West versus defining characteristics of the Indian intellectual traditions (2), and yet different groups or individuals at different times have attempted to emphasize particular aspects of that tradition as the representative of Indian intellectual thought for ideological purposesboth imperialistic and nationalistic. This leads naturally to a second observationwhom you ask to describe a culture matters a whole lot in what picture of the culture you get. We cannot know what the elements of another culture are without asking the participant-insiders to describe them to us, but one is bound to get differing accounts from different participant-insiders situated in different places in the community on the meaning and significance of different cultural elements. Michele Moody Adams (1997, 48-9) describes a well-known controversy in anthropology illustrating this issue Coming of Age in Samoa. Mead claims that Samoans have a guilt-free casual attitude towards sex, and Samoan adolescence does not include the then-supposed universal characteristic of sexual angst. Over half a century later, another anthropologist, Derek Freeman, claims to show the exact opposite about Samoan attitudes towards sexthat Samoans indeed do have repressive and guilt-ridden attitudes toward sex. Both Mead and Freeman worked among the Samoans, but their informants were not from the same gender or social class. Mead mostly interviewed adolescent females of non-elite classes, while Freeman had contact with male, middle-aged, and socially well-placed informants. Pointing this outthat owing to the complexity of social organizations, it is likely that much diversity in mores would be found within the same culture along different social positions139  seems obvious but for the assumption that cultures are tightly integrated wholes. Rather, it seems that internal friction within cultures is the norm. The second point to note is that, as a corollary to the internal friction of human communities, the boundaries of cultural groups are quite porous. The existence of a discipline like anthropology is partial evidence for this. Given that it is possible for members of other cultures to go live with other human groups (even the most geographically remotes ones), learn their language, interact with them, and participate in their rituals shows that there is at least some porosity of boundaries. Human communities have histories. They move around. They trade with others for goods. Only if one ignores the historical aspect of human social life could one plausibly assume that (most) cultures are self-contained wholes. It seems, even more so, that the porosity of cultural boundaries has increased in recent history as the means for communication and travel have increased. To understand any large industrial society today, one needs to understand them as places of daily interaction between people with different cultural histories. I take these observations about cultural processes to be pretty obvious empirical generalizations, not a priori claims about the logic of the concept of culture. It seems entirely possible that communities of people could exist in isolated and culturally homogenous communities. Such societies do populate the fictional worlds we have dreamed up. But, it really would be a bad habit to construct our understanding of cross-cultural moral conversations on mere logical possibilities. Clifford Geertz has eloquently expressed the claim I have been defending. He (1986) writes,  with whom we can empathize, however much we differ with whom we cannot, however much we defend to the death their right to differ from (262). 140  It is worthwhile to consider how the construction of our philosophical examples and thought experiments influences which intuitions play important roles in our theories. Wittgenstein ([1958] 1973, §593) writesa one-sided disease affecting discussions of relativism that originates, in part, from the prevalence of examples of extremely alien cultures in thought experiments having to do with relativism. Let   First, note that it is an imaginative example not drawn from history or any ethnographic recording of contact. This gives Williams free play to construct the example so as to emphasize ahead of time the sheer amount of intellectual and emotional distance between the imagined people and the readersother philosophers and intellectuals in Western Europe and North America. He does this by, right away, describing the kind of terror as numinous, which already works to put a serious distance between them and the Western European intellectual, who presumably does not experience any feature of an environment as having a numinous quality. His account of the cultural difference here plays right into the assumption that is at issue concerning how closed off cultures might be to others. Perhaps we can heal ourselves with a more nourishing diet of examples. We might take a more nuanced and optimistic view of the prospects and possibilities of cross-cultural moral communication if we counterpose Williams-type examples with the kind of cross-cultural moral learning illustrated in the following real-life account from Hilde Lindemann (2009). The story concerns a research collaboration between a Dutch and an American bioethicist and the various assumptions and misunderstandings that complicated their conversations on moral issues. Hilde Lindemann, the American bioethicist, and Marian Verkerk, the Dutch bioethicist, began working 141  together on an article concerning a Dutch protocol on the direct physician killing of severely damaged newborns. The protocol had been recently attacked in an article in the Hastings Center Report, and both Verkerk and Lindemann intended to respond to the inaccuracies in the critical piece and represent the protocol in a more positive light. So, Verkerk and Lindemann read together several articles regarding the new protocol and had detailed discussions together about the different categories of newborns for which the protocol was designed. Afterwards and after feeling that both had come to an agreement on a conclusion and outline of the article, Lindemann went home to compose a first draft. But after having typed up and sent a draft along to Verkerk for her to review it, it became clear that some misunderstandings existed between the two about which infants the protocol was designed to protect. Lindemann had assumed that the protocol did not apply to infants who were being kept alive by life support mechanisms because they could be allowed to die by removal of life support, and the real controversy existed for those infants who did not need life support and whose life was ended directly through physician intervention. In fact, the protocol is meant to apply to infants on life support as well, in case removing life support does not actually result in their quick and relatively painless death. Neither Lindemann nor Verkerk discussed explicitly moral issues about infant euthanasia in their initial conversations because both assumed rough agreement existed already on these issues. However, most Dutch physicians see that the larger moral issue revolves less around the differences between killing and letting die and more so around initial decisions to place infants on life-support, thus potentially prolonging needless suffering.  Lindemann identifies the mistake (42). Specifically, this had to do with differences in relationship to 142  technology. Doctors in the U.S. are generally more enamored with the lifesaving potential of technology than are doctors in most other parts of the world. The other kind of difference not attended to is that if one community is still struggling with the moral issues of a practice that the other community already accepts, then the moral valence assigned to the concepts used to describe these difference will likely differ as well (43). The Dutch medical community does not struggle as much with the potential moral differences between killing and letting die as does the American medical community. What I want to highlight in this example is that, though there are noticeable differences between the two national medical cultures, there is also much in the way of overlap and agreement that sets the foundation for the possibility of a future productive conversation. Further, when we recognize certain cultural generalizations, we recognize areas of contestations, exists an unbridgeable conceptual gap between the two sides. This more complex interplay between what is shared and what is not shared between cultures provides a more realistic example of the kind of conversational difficulties we might expect as we go about interacting with others. One difficulty in navigating these conversations is, first, coming to an understanding on where agreement exists and where it ends. These lines of demarcation are more transparent in the case of individuals who largely share cultural backgrounds than they are when unexpected cultural encounters occur.  Conclusion I have tried to respond to worries of relativism in the second-nature naturalism inspired by John McDowell and largely defended in this dissertation. Note that geographic and spatial metaphors abound. There is talk of spaces of reasons, worlds, points of view, and variegated moral 143  topographies. It may be helpful to put my view in these metaphorical terms. There is only one world, or space of reason, but the terrain is marvelously complex and variegated. There are mountains, valleys, rivers, and micro-climates. Given this variegation, it is not surprising that different people stake out different points of view from which the landscape might look wildly different.  But despite this, the metaphor still forces us to see these points of view as surveying the same landscape; it allows for the possibility that we might be able to take similar points of view and perceive the world together. But certainly this is a challenge, and I have not said much about what strategies might be intend to take this task up more fully in the next and final chapter of my dissertation. Specifically, I will explore cross-cultural moral communication in the context of the clinical skill    144  CHAPTER 5: NATURALIZING CULTURAL COMPETENCE We have so far followed a parabolic trajectory. The first chapter started at ground level with the concern in bioethics for identifying a rational methodology. I critiqued the dominant methodologies for harboring idealized assumptions about ethics and moral agency, and I suggested that we might avoid idealizing by adopting a naturalized approach. The next chapter moved us upwards to outlining some theoretical details of this naturalized approach. Framed in terms of the notion of the common morality, I presented a tripartite approach to naturalizing that included the following elements: a concern for empirical adequacy, a grounding in our ethical form of life, and a politically critical reflexive stance. The chapter that followed moved us further upwards into theoretical discussions about second-normativity and moral perception. Chapter four focused specifically on saving naturalism from the charges of moral and conceptual relativism. This final chapter brings us down the parabolic trajectory back to more concrete concerns for bioethics. I aim to show that the naturalized approach can make a positive contribution to issues pertinent to patients and doctors. To that end, I explore the difference that the naturalized approach can make to how we conceptualize the goals, structure, and focus of cultural competence training.  Why is cultural competence a topic for bioethicists? The oft-stated purposes and motivations for cultural competence initiatives are closely aligned with the humanistic goals of bioethics. Health care institutions can be alienating and depersonalizing. Medical professionals face pressure to focus on the individual primarily as an organic body and not as a whole person with beliefs, desires, affiliations, and knowledge. Many of those who promoted the establishment of bioethics as a distinct discipline saw bioethics as a movement aimed at accounting for the 145  whole person in medicine and science. Van Rensselaer Potter (1975), one of the first to use the hilosophy.... I chose bio- to represent biological knowledge, the science of living systems; and I chose -ethics to represent knowledge of human value systems (2279). Since health care institutions tend to be more alienating for individuals with cultural is especially suited to help medical professionals figure out how to resist this alienation. In fact, promoters of cultural competence already see it as a concerted effort to restore acknowledgment of the cultural aspects of the patients identity and explore the ethical challenges that such differences can generate. Much controversy, however, remains about how such competence should be conceptualized, what content should be incorporated into its curriculum, and whether cultural competence training as it is currently implemented actually improves the quality of care for members of marginalized racial and ethnic groups.  In this chapter, I diagnose two idealizing assumptions about knowledge of self and of others that lurk in various conceptualizations of cultural competence. The first assumption shows up in the once prominent categorical approach to cultural competence, which focusses on teaching generalizations about the cultural practices of different groups to doctors. This approach implicitly assumes that our understanding of the cultural background of other people can take the same form as the natural-scientific model used so successfully to understand the human body. Alternative models have overcome the most problematic parts of the categorical model. Yet, they still harbor a further epistemic assumption about the self-transparency of our own motivations. This assumption, I argue, explains why the widespread phenomenon of implicit bias is still widely ignored in their pedagogical approaches.  146  I begin with a diagnosis of the epistemic assumptions of the categorical approach and argue that its bias in favor of a natural-scientific model of knowledge makes it especially vulnerable to stereotyping and other similarly objectionable uses of cultural generalizations about others. I rely on Hans-Georg Gadamer (1993) to help describe what a more appropriate approach to human knowledge looks like, and I connect this to some of the helpful changes in conceptualization of cultural competence represented by newer models. Then, I argue that this shift, while helpful, is not enough for adequately conceptualizing cultural competence because it does not provide tools for dealing with implicit bias. I suggest that implicit bias has been ignored in part because of a lingering assumption that we have a transparent access to the motivations for our actionseven if we acknowledge we cannot completely control them. I end with some suggestions based on social psychological research concerning how we might counteract the effects of implicit bias on cross-cultural communication as well as a case study to highlight practical lessons for fostering the conditions needed for cross-cultural understanding. Key Elements of a Naturalized Approach Since my analysis is guided by the naturalistic theory developed in this dissertation, allow me to provide brief reminders of three of its themes: a criterion of empirical adequacy, an emphasis on the ethical-epistemic effects of power and privilege, and a commitment to Neurathian reflection. A Criterion of Empirical Adequacy  A criterion of empirical adequacy means that we should always be wary of the soundness of the empirical assumptions that inform our accounts. If a normative theory relies on false empirical assumptions or models of human behavior that are not actually realizable, then the soundness of the theory for presently existing people is called into question. This condition is (1991) Make sure 147  when constructing a moral theory or projecting a moral ideal that the character, decision processing, and behavior prescribed are possible, or are perceived to be possible, for creatures  (32). s (2005, 168) conception of non-ideal moral agents cognitive abilities and motivational structures that no real human being has. Feminist moral philosophy has also sought to challenge traditional male dominated moral philosophy for its empirical inaccuracies, especially around conceptions of gender (Jaggar 2000).  There is also more to empirical adequacy than just ensuring that our ethical theories comport with the facts and do not violate our best psychological theories. We also have the resources of our collective experience in implementing different personal and social policies (experiments in living); our proposed character ideals and ethical theories need also to be responsive to the historical evidence so far collected concerning the various benefits and harms of different life-plans or forms of social organization. Thus, empirical adequacy requires responsiveness to a number of different scientific and humanistic lines of inquiryany responsible line of inquiry that can be of help to figuring out how we ought to live together. Emphasis on the Ethical-Epistemic Effects of Power and Privilege  I have drawn heavily from feminist naturalism, which emphasizes paying attention to one particular empirical concern that has been historically excluded from most moral and political analyses in the West: the effects that social relations of power, privilege, and oppression have had on both moral theory and the moral agents it attempts to model.  Idealized theories presume they can get to moral and political truths by constructing their theories with ideal agents operating in relatively egalitarian societies in mind. Since the society we live in is not so egalitarian, idealized theories provide little in terms of concrete guidance for us. Margaret Urban 148  Walker (2003) provides a clear model for this naturalized and non-idealized ethical critique: ity of our practices means discovering how they actually go, what they actually mean, what it is actually like to live them from particular places within them. It means examining the power-bound social arrangements which necessarily embody morality (110).  Moral reflection occurs from within a moral form of life  Finally, naturalized moral reflection does not try to provide a foundation for morality in natural scientific facts; rather, it recognizes that moral reflection cannot help but start from within a rich conceptual and linguistic constellation of moral terms inherited from a form of life that is second nature to us. The empirical concerns mentioned above find their place within moral discourse only because we have a moral language to help us place them. What affords legitimacy to a moral vocabulary that is not foundationally grounded is its ongoing capacity to provide accurate and useful ways of representing moral experience and making practical decisions. Of course, any rational reform of one part of our conceptual inheritance will take some other parts as given. We cannot rationally evaluate our moral forms of life from outside of the system, but then, no area of human discourse can be evaluated from outside itself. Rational moral reflection looks more like the Neurathian picture of the marinerwe must repair our moral boat always while at sea. Motivations for Cultural Competence Sustained attention to cultural diversity in medicine did not begin until tthe (Saha, Beach and Cooper 2008, 1178). This spike in interest corresponded to a spike in immigration to the United States that was a result of economic expansion. As a matter of 149  everyday experience, an increasing number of doctors and nurses were treating patients who did not speak English as their first language and had little familiarity with the culture of biomedicine. Another reason for the spike in concern for cultural competence was an increasing awareness of persistent racial and ethnic disparities in health that affected well-established minority populations in the U.S. These disparities are now well documented. According to the Centers for Disease C Health Disparities and Inequalities Report (2013), prevalence rates for diabetes, HIV infection, obesity, and hypertension are higher for Hispanic people and non-Hispanic African-Americans in the United States. This is only a sample of a number of different health-related outcomes and conditions for which disparities exist.  Though members of minority groups have lower rates of insurance than the white population,36 differences in insurance rates and other socio-economic indicators are not the sole causes of the health disparities. Disparities remain even controlling for health insurance and socio-economic status. Numerous studies, for example, show that African-American men and women are consistently less likely to be offered helpful treatment regimens and diagnostic procedures for controlling coronary disease in comparison to white men and women (Institute of Medicine 2003, 42).  One possible source of these remaining disparities is the quality of communication and feelings of trust between doctors and patients with different racial or ethnic backgrounds. Cultural competence emerged as a movement within medical education to help improve the quality of communication between doctor and patient as well as to help establish conditions for                                                   36. In 2010, 41% of Hispanic adults aged 18-64 and 26.2% of non-Hispanic black adults did not have health insurance. In comparison, the uninsured rate for non-Hispanic white adults was 16.1% (Centers for Disease Control 2013). Though rates of un-insurance have dropped significantly since key provisions of the Affordable Care Act have gone into effect, people of color are still disproportionately likely to be uninsured. According to an analysis of data provided by the U.S. Census Bureau performed by the Kaiser Foundation (Majerol, Newkirk and Garfield 2015), the un-insurance rate for Hispanic people is 21% and for non-Hispanic black people is 13%. Comparatively, the un-insurance rate for white people in the U.S. is down to 9%. 150  trust so that medical treatment would improve for minority patients. The rationale is that, if doctors learn to understand how culturally influenced values, beliefs, and attitudes play of how to treat illness, then more culturally sensitive or appropriate medical treatment regimens will be designed and patients will be more likely to follow them. The Errors of the Categorical Model  Today, cultural competence has been incorporated into the standards for accreditation of major accrediting bodies, including the Liaison Committee on Medical Education, the chief accrediting agency of medical colleges in the United States (Liaison Committee on Medical Education 2015), but these pedagogical standards are written broadly enough to admit a number of different conceptual approaches. Therein lies the ongoing academic controversy. initial efforts in cultural competence training followed what Joseph Betancourt (2003, 562) calls the categorical model. Health care providers were taught broad generalizations about the beliefs, attitudes, and values of different cultural groups. These generalizations were translated into fairly  For example, medical students might be taught that Asian patients often under-express the pain they experience, while Hispanic patients over-express pain (Galanti 2004, 205, 208).  Melanie Tervalon and Jann Murray-Garcia (1998, 118-9) provide an instructive anecdote of how this training translates into practice. They tell of a nurse caring for a middle-aged Latina woman who had just undergone surgery. A consulting physician noted to the nurse that the patient appeared to be experiencing a lot of pain, but tmoaning as a sign of great pain becaus-151  - The nurse felt confident in her cultural knowledge and was difficult to persuade from this perspective. Patients like the woman mentioned in this anecdote are understood in the categorical model is viewed as strongly determining their behaviors and beliefs, and this influence of culture is viewed primarily as an obstacle to good medical care. Culture both obscures to accurately diagnose and treat illness and obstructs patients from faithfully complying with e indicator of pain, becomes an obstacle to determining how much pain relief a patient really needs. Rarely is the cultural milieu of the doctor considered a complicating factor, even though it is implicitly being els of pain expression. epistemological stance. Owing to the dominance of the biomedical model of health and disease in Western medical institutions, this functions to legitimate  status as knowledge. As long as culture is conceived as functioning just like another complicating factor that prevents compliance with a biomedically sound treatment plan, then cultural competence training can garner some legitimacy in the eyes of the medical community that privileges scientific medical knowledge.  Let me describe two features that the categorical model borrows from the natural-scientific epistemic model. First, knowledge is viewed as a one-way relationship between knower and known. Charles Taylor (2002) describes of me or of my knowing activity (280). In the categorical model, cultural knowledge is always knowledge of other cultures. These cultures are viewed as 152  deviations from the normthe culture of biomedicine. The role that biomedicine as a cultural system (or even the cultural milieu of the doctor if he is a secular Westerner) might play in the clinical encounter does not enter into the picture. The second feature concerns the purported goal of knowledge. On this model, knowledge aims at a fully adequate explanatory theory of its object. Once such an ideal is reached, the object can no longer surprise us, and its future behavior can be predicted and controlled (C. Taylor 2002, 280). This is an ideal and not actually attainable in practice, but its influence can be seen in the categorical model as well. The reduction of the culture of a social group to lists of cultural generalizations denies the historical dynamism of cultural change and attempts to provide a comprehensive picture of the role that cultural beHowever, cultures do have histories, and their future paths are determined by people engaged in continually remaking them. Individual members of a culture each have idiosyncratic relationships to this history such that the goal of fully adequate explanatory theory is -making activities. Applying the features associated with the natural-scientific model of knowledge to situations of understanding others has moral costs as well. The anecdote noted above suggests that the primary moral issue with the categorical model is its potential for promoting the stereotyping of patients. Why is this? Older versions of the categorical model may have been less scrupulous about avoiding broad over-generalizations, but newer categorical models do at least acknowledge that stereotyping is a danger when relying on cultural generalization. In Caring for Patients from Different Cultures, Geri-Ann Galanti (2004, 201-212) provides the following 153  Caution: These are broad generalizations and should not be used to stereotype any individuals. Before I argue that the categorical model has a high potential for promoting stereotyping or closely related misuses of cultural generalizations, let us take a look at what is wrong with stereotyping itself. Following Lawrence Blum (2004, 256), I understand a stereotype to be a kind of generalization about a social group that is false or misleading and is largely immune to counter-evidence. Most stereotypes are unfavorable to the stereotyped group (Banaji and Greenwald 2013, 78). If these negative stereotypes are deployed in practice, then members of the stereotyped groups are more likely to face unjustified harsh treatment and disadvantage in the allocation of social goods. This can occur on an individual level if a particular individual with an idiosyncratic stereotype denies someone a benefit or treats them harshly, and it can occur on a social level if a particular negative stereotype is widespread and contributes to a general treatment disparity between members of a stereotyped group and others.  Not all stereotypes are negative, and it may seem less clear why positive stereotypes are generally morally objectionable. People who openly profess positive stereotypes of other groups will often vehemently deny that they are prejudiced towards the stereotyped group. Moreover, positive stereotypes are often explicitly deployed as a rationale for treating the stereotyped person more favorably and providing them with more social benefits than otherwise. Consider they are pushed the wrong way, combative, but they are not combative. A lot of we men are (Nagourney 2015). What is morally wrong with stereotypes like this? 154  First, seeing someone through the lens of any stereotype (including positive ones) means seeing them wronglyin both an epistemic and moral sense. It is a moral-perceptual mistake, or as Lawrence Blum (2004) identifies it, regard of persons (271). Hilde (2001) account of the connection between personal identity and moral agency illustrates the moral-epistemic fault in stereotyping. Personal identities are connected to moral agency because who we think we are determines what we think we are capable of doing (22). Personal identities also require social uptake for their validation. Identities are performed and such performances often require collaboration with others. If I see myself as a surgeon but no one else does, then I will not be permitted to cut into people (23-28). So, other people can limit our moral agency by refusing to acknowledge our personal identities.  In turn, people ought to exercise responsibility in employing this power. One defeasible obligcredible self-conceptions.37 The reason is that an individual stands in a different kind of relation to her own acts than does anyone else. They are her acts. She initiates them. She is held responsible for them. She is the one who uses the stories that define her past to help guide her future actions (104-105). Seeing someone through the lens of a stereotype unjustly denies the -conceptions because stereotypes deny the person the initial possibility of expressing to others her chosen self-conception. Further, because stereotypes are unusually resistant to counter-evidence, they obstruct any future opportunities a person might have in disproving the stereotypes.                                                     37. For an extensive description of what goes into determining the credibility of narrative self-conceptions, see Lindemann (2001, 92-104)about me, the fact that they are my stories weighs in favor of their validity in relation to equally credible stories about me told by others. 155  Stereotypes also overemphasize uniformity within a social group, and this feature can be seen as another form of disrespect for individuals who associate with the stereotyped group. In so far as respecting a person means respecting the groups they associate with, a stereotype denies -identity.  Though I have focused primarily on stereotyping as an individual psychological phenomenon, stereotypes also have cultural and historical resonance and are embedded in master (Lindemann 2001, 6). When we examine the historical and cultural significance of stereotypes, it becomes clear that even so-called positive invocation of women as more patient then men. Patriarchal representations in U.S. culture depict the supposed submissiveness of women as one rationale for confining women to spheres of domesticity. Stereotypes are embedded in more complex social narratives and need to be evaluated in light of the role they play in these larger narratives. Even stereotypes that may seem positive when viewed in isolation are often associated with damaging negative stereotypes and exhibit a similar tendency to justify oppressive social restrictions.38    Now, not all generalizations about particular social groups are stereotypes. Stereotypes are understood as false, or at least, misleading, but there certainly are generalizations that can be true about social groups. For example, coining is a medical therapy for common illnesses that is still widely practiced in parts of China and Southeast Asia. This is a true generalization. Newer                                                   38. Sutton, Douglas, and McClellan (2011) conducted a study on female undergraduate psychology students where they were asked to complete a series of separate tests. One test measured their agreement with statements of benevolent or hostile forms of sexism. Benevolent sexism roughly corresponds to positive stereotypes about women. Another test measured their perceptions of the safety of different behaviors during pregnancy. A third test measured their willingness to intervene in pregnanto be risky. The study showed a correlation between acceptance of statements that were benevolently sexist and a  156  versions of the categorical model purport to teach medical students about cultural generalizations that are not stereotypes because they are true and useful for treating culturally different patients. Do we have reason to think that the kinds of cultural generalizations promoted by the categorical model do not stereotype and do not lead to similar harmful moral effects as stereotyping?  I think we have reasons to be skeptical that it can avoid stereotyping or its harmful moral effects. First, most versions of the categorical model do not employ appropriately specific and historically sensitive generalizations. Owing to the historically dynamic and socially differentiated nature of culture, cultural generalizations that respect the individual members of those cultures will require a high level of specificity in order to be accurate and not misleading.  However, these are not the kinds of generalizations that will likely be communicated in a cultural competence course based on the categorical model. Here are a few examples from Geri-Ann (2004) recent textbook: Middle E- The likely format of cultural competence education only compounds reliance on broad cultural generalizations. It is likely to be brieftoo brief to gain the in-depth knowledge about a particular cultural group that would afford specific and accurate generalizations. If a medical student takes a course in cultural competence for a semester that provides brief overviews of various cultural groups and the beliefs and practices, it is highly unlikely that there would be enough time to go in depth into any one cultural group (Shapiro and Lenahan 1996, 251). The medical student is likely to be left with only the broadest of cultural generalizations, rather than any of the nuances an educator might provide.  157  Even if the broad cultural generalizations mentioned above are true, their potential to mislead is great because of common human psychological biases, like confirmation bias.  initially hypothesis. Medical professionals equipped with broad cultural generalizations are likely to suffer from a bias in favor of evidence that affirms the validity of the cultural generalization rather than disconfirm it, and this makes it more likely that the doctor will get it wrong in cases where the patient does not perfectly fit the generalization. Categorizing things, people, and events is an essential psychological tool that humans have evolved to help deal with the enormous complexity of information presented to them. Classifying entities as belonging to larger groups that share certain traits enables us to ignore detail and focus on relevant features in a way that allows us to interact successfully without being overwhelmed. Categorization also allows us to extrapolate from limited experiential information to predict the existence of other features not revealed in experience (Gendler 2011, 38-9). Categorization is driven by the goal of simplicity, and so its tendency will be to emphasize intra-category similarity and inter-category variation. Thus, a tendency to categorize already makes stereotyping likely, and the communication of ready-made cultural categories with easily identifiable traits provides the tools to do it. One might think that sufficient time spent with patients  reliance on broad generalizations to make sense of patient symptoms and their experience of illness. This may be true, but most clinical encounters are too brief to allow for such interaction. The brevity of most clinical encounters is likely to further promote reliance on these broad 158  generalizations.39  Even if the possibility for more prolonged encounters exist, they will still be  all the warnings about stereotyping we want, but these do not of themselves change the situational features that encourage professional reliance on broad generalizations as assumptively true rather than as means for further exploration. Hans-Georg Gadamer and The New Models of Cultural Competence Most health care educators recognize that proper cultural competence training requires more than just the transmission of broad cultural generalizations to medical students. (Betancourt, Green, et al. 2003, 298-9, Tervalon and Murray-Garcia 1998, 119).  Medical students also need the tools to help use those generalizations appropriately and conscientiously. These models reflect a broader epistemic shift in conceptualizing knowledge in the human sciences. Hans-Georg Gadamer (1993) has outlined several aspects of this new paradigm that are relevant to our interest here in cultural competence. Gadamer depicts the understanding proper to the human sciences on the model of a conversation between speech partners (C. Taylor 2002, 280). He differentiates this not only from the methods of the natural sciences but also from an earlier hermeneutic model  a person says is . . . to come to an understanding about the subject (Gadamer 1993, 383).   Taylor elaborates on two features of the conversational model of understanding that differentiates it from the natural scientific model. First, understandings are party-dependent. Party-dependence means that the understandings that emerge will differ from situation to                                                   39. In a related area, a study conducted by Richard Martell (1991) showed that when time pressures were made salience for research participants who were asked to read a vignette and rate the work performance of the subject of the vignette, they were more likely to show gender bias in their evaluation of men and women.  159  situation because each participant brings her own initial understandings, her own concerns, and her own abilities to the situation (C. Taylor 2002, 280-1). The success of the natural sciences in achieving an understanding of the behavior of natural objects is owed in part to its achievement in expunging notions bound up with human meaning from its languagenotions such as purpose and value. Since the human sciencesand in our particular case, cultural competenceaim to achieve understanding about meaning in human life, a scientific language abstracted from human meaning cannot possibly provide the medium of achieving it. So, every conversational event of understanding starts a new movement toward building a common language and so will reflect the pre-suppositions and concerns of the parties involved.  -existing language to account for the is goal revision, the second feature. It is a requirement of the conversational model because in possibility, a real alternative. This changes the relation we have to our own cultural standpoint, which prior to the conversational transformation represented itselfperhaps implicitlyas obvious or natural (C. Taylor 2002, 295).   These two features can be further elucidated if we return to understanding as a fusion of horizons, first discussed in the previous chapter. Recall that horizons are the background understandings we inherit, often implicitly, in the course of being inculcated into a form of life. Horizons are distinguishable from each other, though not completely, but they are not static. So, conversational partners can come to fuse horizons through 160  (C. Taylor 2002, 285). This process inevitably requires that we come to explicitly acknowledge that we have horizons, and these horizons differ from others. , mentioned in the previous chapter,  of our own horizons. She writes in conclusion to her narrativeto suppose that you and your interlocutor have achieved mutual understanding when it turns out  (Lindemann 2009, 45). This mistake is easy because of the way in which horizons of meaning operate in the implicit . Explicit and thick moral concepts do not need to be employed because agreement on most evaluative matters is already settled. Instead, relatively superficial evaluativ get used. The complex rules for applying those general moral terms will differ slightly between person to person, but the difference becomes pronounced when cultural and historical distance separates the interlocutors. The background consensus on most general evaluative matters that exists among those who share a form of life may not also exist among those who share different forms of life.  For Lindemann and Verkerk, the main difference involved the moral line of demarcation drawn between (impermissible) killing and (permissible) letting die. This difference mattered less in Dutch medical culture than in the American context. When discussing Dutch protocols for end-of-life issues with respect to infant patients, Lindemann assumed that the protocols guiding direct killing by physicians only applied to the category of infants whose life could not be ended by removing life support. This was a misunderstanding, according to Verkerk. The protocol is meant to apply to all groups of infant patients, including those sustained by life support. What 161  matters most is that Dutch physicians take responsibility for any actions that may have made the situation worse. The processes of fusing horizons will operate in fits and starts. There is no magic bullet to leaping ahead to a complete mutual understanding. One has to work painstakingly to identify explicitly what has operated implicitly for so long. Only once both Verkerk and Lindemann did the work of identifying where their forms of life did and did not overlap were they able to have the conversation they needed to have about the morality of direct physician killing. The newer models of cultural competence recognize that the natural-scientific knowledge model does not work. Under these newer models, the patient is reconceived as the de facto authority on his or her cultural identity, and the medical professional seeks to understand the  by consulting a textbook of cultural generalization but by talking to the patient directly. These new models have taken to heart the idea that human knowledge is the outcome of a conversation between partners working towards mutual understanding. Moreover, including the culture of biomedicinerenders as normal and abnormal and, like the goal revision feature mentioned above, acknowledge that our biomedical culture may need revision in order to bring about mutually acceptable treatment regimens. Cultural competence is understood now to be more a matter of skillfully collaborating with the patient to design treatment plans together that will meet  needs. Let me highlight two specific changes implied by this shift: the supplementation of generalizations with skills and attitudes, and a focus on community-specific and evidence-based generalizations. 162  Supplementation of Knowledge with Attitudes and Skills  The newer models understand that knowledge in the form of broad cultural generalizations alone has a higher potential of leading to stereotyping, but neither model rejects the value of the judicious use of some cultural generalizations. In order to ensure that using these generalizations will not lead to stereotyping, they introduce skills and attitudes that must accompany their use. Tervalon and Murray-Garcia (1998, 118-9) diagnose one problem with reliance on broad cultural generalizations alone as providing a false sense of securitysecurity this false sense of security by adopting an attitude of cultural humility. This attitude entails self-reflection, self-monitoring (How are my own cultural biases affecting my ability to deliver care? Am I stereotyping this patient?), and a commitment to understanding cultural competence as something that requires life-long learning, for culture is dynamic and presents itself differently in nearly every case.  -legged relevant areas of focus for cross-cultural medical education: attitudes, knowledge, and skills. While these are all conceptually distinct areas, an adequate education in cultural competence requires all three to be present, just as a three-legged stool requires all legs in order to stand. The relevant skills are primarily interviewing skills that are patient-explanatory model of disease. Rather than the deductive method often applied with generalizations, the interviewing skills Betancourt emphasizes are inductive, designed to help elicit the actual beliefs and values the patients hold without simply assuming them on the basis of a prior identification of cultural membership.  163  These newer models borrow from the ethnographic approaches of anthropologists. One anthropologist, Arthur Kleinman (Kleinman and Benson 2006), has adapted ethnography to the . This approach teaches medical students a series of six steps designed to help them elicit from the patient herself her understanding of the relationship between her illness and the social world. This is just one way that the painstaking process of fusing horizons may be facilitated in the clinic. Community Specific and Evidence-Based Knowledge  Newer models also recommend focusing on different kinds of information about cultural groups. While the categorical model preferred broad generalizations, often not placed in any kind of historical or comparative frame, newer models of cultural competence emphasize the importance of information that is both based on sound evidence and specific to the community with which one is involved. Betancourt (2003) summarizes the relevant information:  The social and historic context of the population (new immigrants or longstanding residents), the predominant socioeconomic status, the immigration experience (Was common occupations (e.g., blue collar or service industry), patterns of housing (e.g., housing development), folk illnesses and healing practices (e.g., empacho, coining), and disease incidence and prevalence, among others. (562)  The totality of this information is intended to provide a more nuanced, holistic picture of the experience within larger historical and political frames of reference. The quality of this informational picture is higher and, therefore, more likely to provide a complex representation of members of the community, rather than more one-dimensional sketches that we get from generalizations about such broadly defined groups as Asians or Hispanics. 164  Further Supplementation with Inclusion of Power-sensitive Analyses It is worth highlighting one further and more recent addition to cultural competence models, though these may be currently less mainstream than cultural humility or the three-legged stool model mentioned above. Recently, there have been calls to include in cultural competence education a critical focus on the way in which cultural differences are politically structured and interact with other inequalities and forms of discrimination (racism, classism, and sexism). Delease Wear (2003) critiques most approaches to cultural competence for focusing on the individual attitudes and skills of doctors and patients, rather than the sources of inequality. Wear borrows a term from Henry Giroux to describe her approach: insurgent multiculturalism. This approach emphasizes the structural forces that reproduce inequality in health care, rather than the individual attitudes of student-doctors. In contrast to a multicultural approach that presumes political and social equality among different cultural groups, it emphasizes how unequal power relations structure different racial and ethnic groups (Giroux 1993, 23). Rebecca Hester (2012) provides a similar critique with a bit more detail about the complicated interplay between the dual focus on culture and race embedded in cultural competence models. The main defect in most models of cultural competence, according to Hester, is a failure to understand the complex interplay between the categories of race and culture. Mainstream models see culture as synonymous with race, and this diverts attention away from the political connotations of race and racism. Hester does not dwell too much on what changes should be made to cultural competence trainingor whatever we call the thing to replace it. She suggests incorporating critical race studies and whiteness studies into the 165  curriculum. She further suggests intersectional analyses examining how race works in conjunction with other categories of social identity like gender, religion, nationality, class, etc.  Implicit Bias and the Opacity of Human Motivation While there is much to be applauded in the improvements made in cultural competence models over the old categorical model, a significant and recalcitrant problem in cultural and ethnic identities is still missed. The main concern of cultural competence is for the effects that prejudice has on the quality of clinical encounters and health outcomes. It is curious to me, therefore, how little the literature on cultural competence consults the robust research in social psychology into implicit bias. The pervasiveness and behavioral effects of implicit bias must play some role in explaining why mistrust and an inability to respectfully communicate still exists between doctors and patients of different cultural and ethnic backgrounds. The laudable addition of skills, attitudes, and power-sensitivity are not enough to effectively deal with implicit bias. So, new strategies need to be developed.  sociological study , titudes towards race has relied on common research tools: toward racial differences were gauged simply by asking them. In the early years, these methods were more reliable, since Americans were far more willing to openly report their biased attitudes towards members of different races (Banaji and Greenwald 2013, 32). However, as the 20th century rolled on, it became less and less socially acceptable to openly express racial bias. that the survey questions they answer will not be linked to personally identifiable information, a large subset still answers questions in a way that they regard as socially acceptable or expected, 166  rather than in a truthful fashion (26-9). In addition to this deception, psychology began to take seriously again the idea that attitudes might exist on an unconscious level, such that even those people who sincerely report egalitarian attitudes on surveys might still harbor unconscious biased attitudes. Surveys and interviews were poor methods for eliciting these unconscious and hidden attitudes. So, psychologists had to come up with new methods. Anthony Greenwald was responsible for developing a new research toolthe Implicit Association Test (IAT)aimed at measuring implicit associations that work on an unconscious level. The typical IAT is administered on computer and provides the subject with 4 lists of words grouped into 4 different categories. One category is usually a set of words with positive valence, and another is a set of words with negative valence. The two other categories could be anything. The participant is asked to sort the words as they appear randomly into either of two combinations of categories, and the participant does this multiple times as the combined categories vary. In the computerized version of the test, you will see one combination of categories on the left side of the screen and the other combination of categories on the right side. For example, the categories may be pleasant words, unpleasant words, flowers, and insects. Your first task may divide up the categories this way: (flower, pleasant) on the left side and (insects, unpleasant) on the right side. In the next round, the categories may be divided up with the valence categories switched: (flowers, unpleasant) on the left side and (insects, pleasant) on the right side. When a word appears in the middle of the screen, you are instructed to sort it into the left side combination of 167  keyboard. The test measures how long it takes for you to sort each individual word as well as how many errors in sorting you make (32-8).40 The test measures the strength of the evaluative mental associations that individuals have developed through experience. It is a way to study have a positive attitude toward flowers and a negative attitude toward insects, then it will be easier for us to sort words into a combined (flowers, pleasant words) category than it will be for us to sort words into a combined (insects, pleasant words) category because we already implicitly associate flowers and pleasant words as both sharing positive valence. Unsurprisingly, this Insect-Flower IAT shows exactly that (39-41).  Researchers are not so much interested in our bias towards insects as they are in our bias towards African-Americans, the elderly, Muslims, women, and other oft-stereotyped groups and has shown widespread bias against all of these groups. Repeated use of the Race IAT, for example, has shown that an implicit bias in favor of whites is widespreadnearly 75 percent of those who take the test reveal some level of automatic preference for whites (47).41 Evidence from the IAT of generally widespread implicit bias among the population would be reason to suspect that implicit bias infects physicians as well. However, it is possible that such implicit bias does not generally leak over into actual discriminatory behavior, or it may do so, but not in the arena of medicine. Yet, in the past decade and a half, research into the implicit biases of physicians and nurses has demonstrated its impact on medical decision-making                                                   40. unpleasant) category, then that would be an error. You are instructed prior to taking the test which words belong in which category.   41. Though not nearly as widespread, about one-third of those self-described as at least partly African-American still show an automatic white preference (Banaji and Greenwald 2013, 221n6).  168  and health care disparities. In 2002, the Unequal Treatment concluded (among other things) that there is strong circumstantial evidence that unconscious biases are a contributing factor to health care disparities (2003, 178). Studies have been conducted to date on implicit biases against African-Americans and people with obesity, but some research has been conducted suggesting that implicit bias plays a similar role in the medical treatment of women, elderly people, and Hispanic people. Implicit bias in favor of white patients has been found consistently, while implicit bias against black patients has also been found. The evidence is less strong with respect to the role this implicit bias played in clinical decision making, but various studies do show a correlation between high levels of pro-white implicit bias in physicians and perceptions of lower quality of care and communication by African-American patients (Chapman, Kaatz and Carnes 2013). Implicit bias against marginalized groups is widespread. It affects even those people who sincerely hold egalitarian beliefs, and it has demonstrable impact on our behaviors. It should be clear then that implicit bias presents a significant threat to cultural competence and the goals of cross-cultural understanding. Recall that the process of fusing horizons requires a patient dedication to painstaking conversational work to reveal the differences in background understanding between you and your interlocutor. Revealing these differences also requires seeing them in a potentially favorable light. Your task is to understand what the other does as itself an intelligible response to the world. This requires seeing the person who you are trying to understand in a favorable light as someone who is generally rational. Implicit biases frustrate this by painting members of the stereotyped group automatically in a negative light.  Further, it is unlikely that existing models of cultural competence have the resources to handle implicit biases. Despite recognizing the potential effects of unconscious implicit bias, the 169  IOM report recommendations do not directly address ways for handling it. The report recommends that cultural competence education be integrated into all medical education programs, but dominant cultural competence models and curricula do not include strategies to help lessen or avoid implicit bias. Since implicit biases have been shown to persist even among individuals who sincerely hold egalitarian attitudes and beliefs, it seems unlikely that didactic education about cultural issues in medicine will uproot them. Though the more critical-focused approaches of Wear and Hester directly address issues of oppression and structural injustices, they also have the same problem of focusing on conscious attitudes and beliefs, rather than unconscious ones. If implicit bias plays an important role in ethnic disparities in health, then current models of cultural competence are failing to meet their stated goal of helping to reduce this.  A simple addition to cultural competence models of a new content section on implicit biases and their effects is unlikely to be sufficient. Self-biases does not appear to significantly dislodge those unconscious associations. People who retake IATs still register the same levels of implicit bias. implicit biases, while perhaps necessary to motivate someone to want to work to counter-act them, does not on its own extinguish the effects of implicit bias.  The exclusion of reflection on implicit bias in cultural competence models highlights a lingering assumption about the extent of rational control that human beings can exercise over their own motives and behaviors. A fairly common family of views holds that what motivates action are beliefs, desires, or complexes of the two. To the extent that somebody acts incompetently with respect to negotiating cultural differences, her incompetence is the result of her beliefs, desires, or bothshe either has the wrong beliefs and desires or she lacks the correct 170  ones. Or, her lack of skill in translating her consciously held intentions into successful interventions is the cause of her failure to act appropriately. Either way, it is assumed that the beliefs, desires are both available to consciousness and can therefore be modified by education and rational persuasion.  The existence of motivational states like implicit biases challenge this view of human psychology. Implicit biases appear to be what Tamar Gendler (2011) habitual propensit[ies] to respond to an apparent stimulus, often with an automatized representational-affective-behavioral triad (41). Implicit biases play a role in shaping our behavior, and yet, we are not generally aware of them when they are activated. Because they happen to activate automatically in the presence of a stimulus, awareness of them does not prevent them from operating, and so, education about implicit biases will not on its own extinguish them by bringing them to consciousness.  When we begin to think of ourselves less as disembodied minds and more as embodied brains, the idea that our behavior and cognitive processes are running on scripts that we have less control over than we do of our conscious attention seems more palatable. We have evolved over time through pressures of natural selection, but the evolutionary process works on a time line slower than the process of social change. We find ourselves now in social and ecological situations that differ wildly from the situations in which our cognitive processing equipment evolved. Our attempts to regulate these implicit biases require exploiting capacities other than our purely rational ones. Incorporating Implicit Bias Research into Cultural Competence Unfortunately, research into interventions designed to reduce prejudice have, to date, suffered from a variety of methodological issues related to design and measurement. Some types of 171  commonly practiced prejudice reduction strategies have not been tested experimentally. Others have been rigorously tested in laboratory settings, but their application to real world environments has not been examined (Paluck and Green 2009, 360). More rigorous and comprehensive research into this area is needed, given the demonstrated pervasiveness, influence, and intractability of implicit prejudice. Nonetheless, it is still worthwhile to look at what evidence we have on effective strategies for reducing implicit bias. I divide this up into interventions at the pedagogical level and at the organizational level. Pedagogical Interventions  One promising method for reducing the strength of stereotype-linked implicit biases is exposure to counter-stereotypes. In laboratory experiments conducted by Nilanjana Dasgupta, automatic preferences for whites on the race IAT could be reduced in research participants if they were asked prior to the test to identify positive descriptions of famous black Americans and then to identify negative descriptions of infamous white Americans.42 Dasgupta followed up with a similar experiment involving stereotypes of the elderly with similar results. Research conducted by Irene Blair also demonstrated a weakening in an IAT-strong woman is like, why she is considered strong, what she is capable of doing, and what kinds  (Banaji and Greenwald 2013, 149-151).  Such research suggests that pedagogical methods to teach cultural competence should include exposure to counter-stereotypes, whether through media images, exercises of imagining                                                   42. In Damaged Identities, Narrative Repair, Lindemann (2001) story that resists an oppressive identity and attempts to replace it with one that -stereotypes, counterstories aim to resist the dominant master narrative defining a stereotyped group and correct the perception that both oppressor and oppressed groups have of the stereotyped group. The research on counter-counterstories.  172  counter-stereotypic people, or actual interaction with individuals who clearly exhibit counter-stereotypes. An educator could, for example, introduce counter-stereotypes through case studies. It is very easy to find plenty of case studies in cross-cultural medicine that depict people with stereotypical cultural attitudes. For example, how should the culturally competent doctor or nurse body? Or, how should the medical team incorporate the family of a Japanese man into the medical decision-making process, given that he understands their needs and opinions to be as authoritative as his own with respect to his treatment? No doubt, cases like these occur, but it becomes too easy for us to slide into a frame of mind where we presume all Muslim women to be subservient to their husbands or all Japanese patients to want their family involved in providing consent. Medical students would be well-served by being asked to respond to case studies that challenge these stereotypical cultural associations. Such a method, however, should not be left to just a single discrete educational experience, but should be ongoing. It is suspected that the decrease in implicit bias through counter-stereotypic exposure is elastic; the implicit bias is likely to return in the absence of repeated counter-stereotypic exposure (Banaji and Greenwald 2013, 152).  Another clear lesson from the research is that implicit biases are quite resistant to mere changes in beliefs. The reason is that implicit biases are not themselves beliefs. Someone who undergoes a conversion from racist to anti-racist is likely to still harbor implicit biases in favor of members of one race over another. Even people who never consciously held racist beliefs still exhibit racial implicit biases. This suggests that we ought to develop strategies for counteracting 173  activated implicit biases or preventing implicit biases from being activated in the first place, rather than focusing on complete elimination of the implicit biases.43  One moderately well researched strategy in this vain is the use of -then plans that specify a goal-directed response an individual will perform on encountering an anticipated cue. Instead of waiting for an implicit bias to become activated and then applying conscious and reflective control to it, implementation intentions are intended to become routinized so that they themselves get activated automatically in place of the implicit bias. For example, in the Shooter Task, participants are presented in a computer simulation with images of black and white people holding either a gun or some other object that is not a gun and are given the goal to shoot all and only those individuals shown holding guns. Participants in the experimental group are instructed to adopt ahead of time an implementation intention, like, f I see a person, I will ed to repeat this to himself several times and write it in an open-ended question box. (Mendoza, Gollwitzer and Amodio 2010).  Kelly, Faucher, and Machery (2010, 313) suggest that implementation intentions work by breaking the initial link set up by the implicit bias such that it is not activated or its activation is noticeably weakened. Given that the shooter task also tests participants in situations where judgments are made quickly, implementation intentions may have relevance for clinical encounters that are also relatively brief. Mendoza, Gollwitzer, and Amodio (2010, 520-1) stress, however, that it is not yet clear how well implementation intentions would generalize to real life -                                                  43. Lawrence Lengbeyer (2004) also recommends focusing on management strategies rather than elimination strategies for curing racism. The idea is to render racist beliefs ineffectual.  174  encounters, and medical professionals would have to be taught how to incorporate them into their professional lives.   Not all self-regulatory strategies are equally effective, and education into how some strategies can backfire is important as well. Medical students may be susceptible to finding attractive the adoption of a policy of so called color-blindness (Beagan 2003). A personal policy of trying to be color-blind would mean the -doctor would set out to never explicitly acknowledge or consider race as a relevant factor in evaluating the quality of a clinical interaction. Apfelbaum, Sommers, and Norton (2008) have shown that despite good intentions for such a color blind policy, people pursuing this strategy were more likely to engage in unfriendly non-verbal behavior.   The third pedagogical strategy calls for the incorporation of cooperative learning techniques. The contact hypothesis states that increasing the amount of contact between members of different groups can reduce racial and ethnic prejudice of both explicit and implicit kinds. The validity of the contact hypothesis has been examined numerous times, and a recent review of the experimental literature concludes that intergroup contact does usually reduce intergroup prejudice (Pettigrew and Tropp 2006). More recent research has examined the relationship between contact and the reduction of implicit racial biases, and it suggests that interracial contact also reduces implicit biases. For example, Natalie Shook and Russell Fazio (2008) found that implicit bias in favor of whites was reduced in white undergraduate students randomly assigned to a dorm with a black roommate in comparison to white undergraduates assigned to a dorm with another white student.  Though there is evidence supporting the hypothesis that mere interracial contact works to reduce prejudice (the warm body variant of the contact hypothesis), ensuring that the conditions 175  are in place to promote the best kinds of interracial interaction positively reinforce the effect of reducing prejudice (Pettigrew and Tropp 2006). What conditions support the best kinds of interaction are still a question of some debate among prejudice researchers, but most proposals are in the vein of Gord (1952) seminal research into the contact hypothesis. He equal status in the pursuit of common objectives (21).  Strategies for increasing high quality interracial contact in the classroom have a comparatively long history of implementation. Cultural competence courses ought to make an effort to incorporate these pedagogical methods. One well researched cooperative learning technique that  is the jigsaw classroom (Aronson, et al. 1978). In a jigsaw classroom, the competitive individualistic nature of classroom learning is transformed into a cooperative social endeavor. Students are divided into diverse teams, and each team is assigned some portion of the educational project to research and present on. This requires students to work together, p Each individual team member is given an individual task to research that he or she will have to, in turn, teach to his team members and the class. Given the amount of pre-existing resources for this teaching technique and the already well-established place of cultural competence in medical school curricula, this intervention could be easily introduced. Organizational Interventions  On an institutional and organizational level, the contact hypothesis provides rationale for increasing diversity in both hiring and medical school admissions. In the context of professional interactions, a diverse workforce reproduces some of the positive conditions of inter-group contact, such as equality of status and cooperation toward a common goal. Proactive measures on 176  the part of institutional administrators will also be important in properly designing the environment in which these professionals interact. Like the jigsaw classroom, ensuring that medical professionals are encouraged to work together in teams toward common goals rather than as competitors will help encourage positive contact. Because the positive effects of intergroup contact typically generalize to the entire outgroup, professional diversity is likely to improve the relationship between doctors and patients of different ethnic or cultural groups (Pettigrew and Tropp 2006).  Contact can go wrong, of course, and even reinforce pre-existing negative stereotypes. It is worthwhile to be cautious of the potential impacts of increased contact especially in light of the clinical encounter that is at issue in this chapter. Given that patients are often placed in a , it is unlikely that mosThose stereotypes that portray groups as submissive or unintelligent are especially likely to be reinforced.  Two possible improvements come to mind. First, we can encourage that the interaction between doctor and patient, especially concerning treatment of complex illnesses, be viewed by all parties as a collaboration to devise the best possible treatment plan. The medical professionals and their support staff are not the only members of the treatment team. The patient, her family, and others she chooses to bring into the picture also need to be included as equally important. Second, proactive engagement of the community served by the medical institution seems a likely source for positive intergroup contact. Community members ought to be encouraged to serve on hospital boards and committees. To the extent possible, hiring medical professionals from the community served should be encouraged. Besides ensuring the likelihood that the needs of the 177  community will be heard by hospital administrators and doctors, such proactive engagement will also create the conditions Allport lays out for positive inter-group contact.  Caveat: Structural Issues  Some may object to my general approach to cultural competence because it seems to privilege interventions at the level of individual attitudes at the expense of structural reform. Rebecca Hester (2012, 288) and Delease Wear (2003, 551) both criticize other models of cultural competence for skirting the more important structural issues contributing to racism and xenophobia in favor of solutions tailored to intervening at the level of the individual doctor. My turn to implicit bias also seems to favor focusing on individual psychology, rather than social structure. Even my suggestions at the organizational level are geared toward changing the psychology of individuals. At best, my suggestions for cultural competence will be ineffective in the grand scheme of things because the primary causes of health disparities are structural. At worst, my suggestions will provide ideological cover for people and institutions to pretend they are doing something to combat racism and xenophobia, when in fact they leave the harmful structures in place.  Allow me to clarify my views on the relationship between individual prejudice and structural oppression. First, addressing the effects of implicit bias should not mean that we ignore all other possible sources of health disparities, including structural ones. I do not claim that  working assumption is that health disparities between different social groups are a result of a complex and interlocking set of both structural features and psychological attitudes. Racist structures may be caused by racist attitudes, and in turn racist attitudes may be reinforced by racist structures. I cannot now explore a more detailed discussion of the various contributions of 178  either source, but implicit bias provides an interesting example of a phenomenon that is intertwined in both structural and psychological issues. While a partial explanation of implicit bias will include discussion of universal features of human psychology like our reliance on social categories, implicit biases against marginalized groups are not inevitable and unchangeable. Structural features of society, like the level of segregation socially encouraged or legally enforced, plays a role in how widespread and strong some implicit biases are. Reducing implicit bias, then, involves dealing with both structural and individual instances of racism. As for the claim that focusing on individual psychology provides ideological cover for institutions to skirt their responsibility for confronting structural issues, my suggestions would only do that if I did not also think structural issues were important. Any medical institution claiming that they are doing enough to combat ethnic disparities in health by teaching cultural competence is wrong if they are not also contributing to redressing structural features, like those that cause lower rates of health insurance among non-white populations and contribute to higher levels of public health hazards in majority non-white communities. The Spirit Catches You and You Fall Down: A Case Study of Cross-Cultural Conversations I now want to bring all of this to bear on a case study in cross-cultural medicine. For this, I focus on the story (1997) The Spirit Catches You and You Fall Down. story recounts both the medical case of Lia Lee, a young Hmong child diagnosed with a severe form of epilepsy, as well as the social and political history of the Hmong refugees who fled from s.   This case story has several advantageous features for my purposes. First, it is well-known and has been a popular educational element in many cultural competence programs since its publication in 1997. Second, it is unlike many case studies in medical ethics in that its narrative 179  stretches over many years and provides crucial context about the history of Hmong migration and the social situation of Hmong refugees in the United States. A substantial fusion of horizons, the desired outcome of cross-cultural communications, will virtually never come about in the course of a single clinical interaction. In order to test whether or not these naturalized reflections have relevance to concrete examples, it is necessary to look at examples of ongoing conversations and relationship building. It is important to understand not just how discrete conversational events ought to be handled, but also both how a community or institution might prepare in advance for cross-cultural interactions and how one might proceed to improve cross-cultural interactions after the occurrence of setbacks.  Let me be clear about what I am not going to do with this case. My naturalistic analysis will not conclude in a definitive judgment based on ethical principles about how the individuals in the case ought to have acted. As a moral realist, I do not deny that there really were moral mistakes made, that it is appropriate to assign moral blame to various actors, or that ethical principles have some relevance for moral reasoning. However, I want to stress the feature of party-dependence that characterizes cross-cultural understanding. Answers concerning the appropriate assignment of moral blame are principally for the parties involved to work out, and drawing general conclusions is difficultcertainly too difficult to do from the position of someone whose familiarity with the case comes through only one, albeit well-researched, account of it. Rather, what I aim to doand what I think is within the power of the naturalized approach to dois to gFadiman, on improving future attempts at cross-cultural communication. Lia was born in 1982 in Merced, California to Hmong immigrants from Laos. From around three months, she began suffering from terrifying seizures. Fadiman focusses in her 180  as well as the tragic consequences that result from the culturally tinged disagreements between required life-long management with anti-epileptic medication, wlarge number of medications she was prescribed, and the best treatment for it required the ritual interventions of a txiv neeb, a Hmong shaman.44  Because of the conflict in diagnoses and extreme difficulties in communication, a number of tragic consequences followed. Lia received inadequate and inconsistent doses of her anti-roceedings that removed Lia from her family for a period of a year because they perceived her inadequate dosing to be evidence of child abuse. Ultimately, Lia experienced in 1986 an extremely prolonged series of epileptic seizures along with other complicating illnesses that left her in a persistent vegetative state. Though not expected to survive for long, she lived with her family without ever regaining the abilities to move and speak until she passed away in 2012 at the age of 30 (Fox 2012). The story that Fadiman tells is rich and complex. The naturalizing approach helps us draw four lessons from it for the prospects of making and implementing good, collaborative cross-cultural judgments.  Lesson 1 It is easy to overlook cultural differences in preferred means of deliberating and reasoning in favor of focusing on controversial substantive differences, but negotiating                                                   44. Txiv neeb  181  differences in process matter as much if not more to successful cross-cultural conversations. By process differences, I mean a number of things. Are decisions made quickly or slowly? Who is assumed responsible for taking part in making decisions? Are reasons offered in direct terms? Are they often placed in narrative or mythological context? For many Hmong patients, including the Lees, the preferred means of making collaborative medical decisions did not align well with expectations in the clinical setting: Decisionsespecially about procedures, such as surgery, that violated Hmong taboosoften took hours. Wives had to ask their husbands, husbands had to ask their elder brothers, elder brothers had to ask their clan leaders, and sometimes the clan leaders had to telephone even more important leaders in other states. In emergency situations, the doctors sometimes feared their patients would die before permission could be obtained for life-will sit back and watch and sort of mentally chew it over, and then they may or may not do it. (Fadiman 1997, 71)   This actually strikes a positive note to me about the prospects of cross-cultural communication. Though not necessarily easy, negotiating process differences seems more tractable in the beginning than does negotiating differences in substance. If parties can work out together the agreed upon means of conducting a conversation, then the parties will have built trust in each other that can be relied upon for future deliberations about more intractable substantive issues. Trust is necessary for these conversations to go well, especially in the context of making medical decisions with members of refugee communities whose trust in authority figures is already damaged. Lesson 2 The excerpt above helps illustrate the second lesson as well. Productive cross-cultural relationships do not emerge in the course of a single interaction. The process of fusing horizons is long, arduous, and socially diffuse. Although the doctors have a point in worrying about 182  securing consent for emergency procedures when the decision making process for members of a community require such extensive consultation, there are many pro-active means that a medical institution could undertake to ease this conflict in schedules. It is perhaps obvious, but still in need of saying, that reliable interpretation services need to be available so that the doctors, patients, and families have the basic means of communication open to them. However, translation is not enough, especially when medical terminology is not shared between the languages. The Hmong language does not have direct translations for many common medical terms.45 Likewise, the language of biomedicine does not have fully adequate terms to translate txiv neeb.  One preventive partial remedy for these are educational measures, including education of doctors by Hmong people of typical Hmong views about illness and education of Hmong people concerning basic medical terminology and the view of illness predominant in the culture of biomedicine.46 Such educational efforts need to be focused at the level of the whole community. life, it is important that any attempt to fuse horizons pays attention to the way these changes in outlook can be socially disseminated. It will be difficult to create a fusion of horizons between this doctor and this patient if the potential for transforming the background forms of life that undergird our meaningful interaction with the world and others is ignored.                                                   45. Fadiman (1997, 68) Hmong-English medical glossary, the twenty-horm-one words; and for -   46. Better yet, this education should explicitly include discussion of the multiple competing views about illness that exist within these cultural groups. It should also be careful to place any generalizations in comparative contexts with the practices of other cultural groups. See my critique of the categorical model above for more guidance as to how cultural information ought to be handled. 183  Another pro-active measure would be for the hospital administrators to reach out to influential figures in the local Hmong community concerning the development of protocols for facilitating the extensive chain of consultation mentioned above. Though the individual Hmong patients and the families know whom they prefer to consult with on difficult medical decisions, hospital administration may be able to ensure the technological and organizational means for having these conversations in a quicker fashion. Lesson 3 Ignore the socio-political context at your own peril. One problem with the Gadamerian model is that it fails to consider how the unequal political position of parties to a cross-cultural conversation changes the calculations on how to most effectively conduct the conversation. The Gadamerian model acknowledges that equality, trust, and respect between co-participants are important but does not address how parties of unequal political status can best approximate relations of equality under conditions of oppression. The position of Hmong refugees in have clear effects on the prospects and possibilities of cross-cultural understanding. The vast majority of the Hmong refugees in Merced, California in the 1fleeing the aftermath of a disastrous civil war in Laos. During the war, the Hmong were recruited, backed, and trained by American CIA operatives to fight against Communist forces in the country, the Pathet Lao. The Pathet Lao ultimately won that war. After the Americans withdrew their political and military support from the anti-communist forces in Laos, many Hmong fled the country for fear of political reprisals. After long and arduous journeys involving extended periods in crowded refugee camps, a large number of Hmong were resettled in American towns and cities (Fadiman 1997, 119-39).  184  Life in refugee camps and in American urban areas differed greatly from life in Laos. In Laos, most Hmong lived in rural mountainous regions where they practiced slash-and-burn agriculture to produce subsistence and cash crops. Consider for a moment the sheer level of disorientation that many Hmong refugees must have felt on being resettled in the United States.  mother, Foua, explaining to Fadiman her disorientation:  l because they could get hurt . . . We had never seen a toilet before and we thought maybe the water in it was to drink or cook with . . . Our relatives said in America the food you to waste it like that. (Fadiman 1997, 181-2) Many of the Hmong refugees were suffering from illnesses and conditions developed in the course of a violent civil war and migration. Nearly all of them were dealing with a profound level of disorientation as a result of moving to the United States. Many were also victims of the violent racism and xenophobia of which the United States has a history with respect to the treatment of its refugee and immigrant populations (191-2).  These circumstances provide a partial explanation for the distrust that many Hmong refugees held for American figures of authorities, doctors included. In situations where parties to a cross-cultural conversation are equal, it is reasonable to think that neither party should expect the other to shift their horizon any more than they intend to shift their own. In situations where such equality does not exist, an expectation of equal conversational burden will likely backfire. If one party does not trust the otherand for legitimate reasonsthen it is reasonable to expect that the untrusted partyhere the medical doctorsought to make a greater effort in accommodating the vulnerable party. What kinds of efforts this requires will be specific to the situation and the parties involved, but examples include conducting the initial conversations 185  wholly in the language of the vulnerable party or molding the procedures of the conversation closely according to the preferred means of the vulnerable party. Lesson 4 Finally, we ought to be critical of the rhetorical effects of the narrative construction of the cases we rely on in cross-cultural medicine, just as we ought to for all case studies in medicine and medical ethics. Thougher deep respect of Hmong culture, she frames the story in terms of a tragic conflict between two competing cultures. This frame promotes the static and homogenizing conception of cultural integration that I have previously criticized and that most anthropologists today reject (J. Taylor 2003)ough centuries of fighting with oppressive out-groups (Fadiman 1997, 13). It is this cultural trait, near-universal among the Hmong, that purportedly ver, it is Western practitioners, at least most of them, blind to the particular world-view of the Hmong, who make no distinction between the spiritual and the physical.  The issue is not that we cannot draw meaningful generalizations about cultural attitudes or practices. I think we can, though I also think that doing so is difficult and fraught with a number of potential pitfalls that lead to unhelpful uses of generalizations or even stereotyping. Rather, the issue is when cultural generalizations play an outsized and deterministic role in our homogenous and externally heterogeneous force determining behavior, even though the image of a clash of cultures that this assumption licenses provides a satisfying narrative arc. The dominant 186   sets of competing discourses and practices, within situations characterized by the unequal distribution of power" (Frank 1999, 48). This fits well with the Gadamerian conversational model of cross-cultural understanding. Parties to the cross-cultural conversation bring different sets of discourses to bear on the issues, and a true fusion of horizons occurs through the process of stitching new discourses together from the old ones. This strikes a more hopeful image for the prospects of building shared understandings than does the image of clashing cultures. Conclusion The main contribution to cultural competence that the naturalizing approach offers is an analysis of the idealizing epistemological assumptions that still hinder the effectiveness of cultural competence initiatives. I borrow heavily from a competing epistemological model for the human sciences developed by Hans-Georg Gadamer to show how these epistemological assumptions differ under a naturalizing approach. The case study of Lia Lee and other Hmong refugees provides a concrete situation in which the naturalized epistemological assumptions show their relevance for conducting actual cross-cultural conversations. This collaborative model stresses nd process of cross-cultural conversations. Unlike the natural scientific model where the ideal is for the knower to cancel out the particularities of her situation by achieving a view from nowhere, the conversational paradigm emphasizes that both parties need to be explicit about building a shared understanding on the basis of the assumptions and social positions they bring to the conversation. Both doctors and bioethicists ought not try to erase their own social and cultural backgrounds from practical reflection. 187  The second main contribution of the naturalizing approach is its emphasis on the actual psychological and social conditions we face, and this emphasis has led us to see the importance of social psychological research into phenomena like implicit bias for resolving practical moral issues. Though research into the psychology of prejudice and implicit bias thoroughly establishes the widespread existence of implicit bias and its effects on actual discriminatory behavior in medicine and other areas of life, research documenting effective methods of counteracting implicit bias is less thorough. Thus, my suggestions for improving cultural competence education by incorporating methods to fight implicit bias are not as well supported empirically as might be desired. Consider this dissertation a call to arms, so to speak, for increased cooperation between social psychology researchers, medical professionals, and bioethicists in the area of designing effective cultural competence initiatives.   188             WORKS CITED            189  WORKS CITED  Allport, Gordon. 1952. The Resolution of Intergroup Tensions: A Critical Appraisal of Methods. New York: National Conference of Christians and Jews.  Anderson, Elizabeth. 1991. "John Stuart Mill and Experiments in Living." Ethics 102 (1): 4-26.  Antony, Louise. 2000. "Naturalized Epistemology, Morality, and the Real World." Canadian Journal of Philosophy 30 (Supp 1): 103-137.  Aristotle. 1999. Nicomachean Ethics. 2nd ed. Translated by Terence Irwin. Indianapolis: Hackett Publishing Company.  Aronson, E, N Blaney, W Stephan, J Sikes, and M Snapp. 1978. The Jigsaw Classroom. Thousand Oaks, CA: Sage.  Arras, John. 1994. "Principles and Particularity: The Roles of Cases in Bioethics." Indiana Law Journal 69 (4): 983-1014.  . 2007. "The Way We Reason Now: Reflective Equilibrium in Bioethics." In The Oxford Handbook of Bioethics, edited by Bonnie Steinbock, 46-71. Oxford: Oxford University Press.  . 2013. "Theory and Bioethics." The Stanford Encyclopedia of Philosophy, Summer 2013 ed. http://plato.stanford.edu/archives/sum2013/entriestheory-bioethics/.  Baghramian, Maria, and Adam Carter. 2015. "Relativism." In Stanford Encyclopedia of Philosophy, edited by Edward Zalta. http://plato.stanford.edu/archives/fall2015/entries/relativism/.  Baier, Annette. 1985. "What Do Women Want in a Moral Theory?" Noûs 19 (March): 53-63.  Banaji, Mahzarin R, and Anthony G Greenwald. 2013. Blind Spot: Hidden Biases of Good People. New York: Delacorte Press.  Beagan, Brenda L. 2003. "Teaching Social and Cultural Awareness to Medical Students: 'It's All Very Nice to Talk about It in Theory, but Ultimately It Makes No Difference'." Academic Medicine 78 (6): 605-14.  Beauchamp, Tom. 1998. "The Mettle of Moral Fundamentalism: A Reply to Robert Baker." Kennedy Institute of Ethics Journal 8: 389-400.  . 2011. "Informed Consent: Its History, Meaning, and Present Challenges." Cambridge Quarterly of Healthcare Ethics 20: 515-23. 190   Beauchamp, Tom, and James Childress. 2013. Principles of Biomedical Ethics. 7th ed. Oxford: Oxford University Press.  Beck, Daniel. 2015. "Between Relativism and Imperialism: Navigating Moral Diversity in Cross-Cultural Bioethics." Developing World Bioethics 15 (3): 162-171.  Betancourt, Joseph. 2003. "Cross-cultural Medical Education: Conceptual Approaches and Frameworks for Evaluation." Academic Medicine 78 (6): 560-9.  Betancourt, Joseph, Alexander Green, J Emilio Carrillo, and Owusu Ananeh-Firempong. 2003. "Defining Cultural Competence: A Practical Framework for Addressing Racial/Ethnic Disparities in Health and Healthcare." Public Health Reports 118: 293-302.  Bilgrami, Akeel. 2010. "The Wider Significance of Naturalism: A Geneaological Essay." In Naturalism and Normativity, edited by Mario De Caro and David Macarthur. New York: Columbia University Press.  Blum, Lawrence. 2004. "Stereotypes and Stereotyping: a Moral Analysis." Philosophical Papers 33 (3): 251-289.  Brody, Baruch. 2004. Taking Issue: Pluralism and Casuistry in Bioethics. Washington, DC: Georgetown University Press.  Buchanan, Allan. 2007. "Social Moral Epistemology and the Role of Bioethicists." In The Ethics of Bioethics: Mapping the Moral Landscape, edited by Lisa Eckenwiler and Felicia Cohn, 288-296. Baltimore: John Hopkins University Press.  Campbell, Richmond. 1998. Illusions of Paradox: A Feminist Epistemology Naturalized. Lanham, MD: Rowman and Littlefield Publishers.  Campbell, Richmond, and Bruce Hunter. 2000. "Introduction." Canadian Journal of Philosophy 30 (Supp 1): 1-28.  Cavell, Stanley. 1969. Must We Mean What We Say? New York: Charles Scribner's Sons.  Centers for Disease Control. 2013. "CDC Health Disparities and Inequalities Report - United States, 2013." Morbidity and Mortality Weekly Report 62 (Suppl 3): 1-187.  Chapman, Elizabeth N., Anna Kaatz, and Molly Carnes. 2013. "Physicians and Implicit Bias: How Doctors May Unwittingly Perpetuate Health Care Disparities." Journal of General Internal Medicine 28 (11): 1504-10.  Churchland, Paul. 2000. "Rules, Know-how, and the Future of Moral Cognition." Canadian Journal of Philosophy 30 (Supp 1): 291-306.  191  Clark, Andy. 2000. "Word and Action: Reconciling Rules and Know-How in Moral Cognition." Canadian Journal of Philosophy 30 (Supp 1): 267-289.  Code, Lorraine. 1998. "How to Think Globally: Stretching the Limits of Imagination." Hypatia 13 (2): 73-85.  Crick, Francis. 1988. What Mad Pursuit: A Personal View of Scientific Discovery. New York: Basic Books.  Culver, Charles, Bernard Gert, and Danner Clouser. 1997. Bioethics: A Return to Fundamentals. Oxford: Oxford University Press.  Dancy, Jonathan. 1993. Moral Reasons. Oxford: Blackwell Publishers.  . 2012. "McDowell, Williams, and Intuitionism." In Luck, Value, and Commitment: Themes from the Ethics of Bernard Williams, edited by Ulrich Heuer and Gerald Lang, 269-92. Oxford: Oxford University Press.  . 2013. "Moral Particularism." The Stanford Encyclopedia of Philosophy, Fall 2013 ed. http://plato.stanford.edu/archives/fall2013/entries/moral-particularism/.  . 2014. "Intuition and Emotion." Ethics 124 (4): 787-812.  Darley, John M, and C. Daniel Batson. 1973. "'From Jerusalem to Jericho': A Study of Situational and Dispositional Variables in Helping Behavior." Journal of Personality and Social Psychology 27: 100-108.  Davidson, Donald. 1973. "On the Very Idea of a Conceptual Scheme." Proceedings and Addresses of the American Philosophical Association 47: 5-20.  De Caro, Mario, and David Macarthur. 2010. "Introduction: Science, Naturalism, and the Problem of Normativity." In Naturalism and Normativity, edited by Mario De Caro and David Macarthur. New York: Columbia University Press.  Doris, John. 1998. "Persons, Situations, and Virtue Ethics." Noûs 32 (4): 504-530.  Evans, Gareth. 1982. The Varieties of Reference. Oxford: Oxford University Press.  Fadiman, Anne. 1997. The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures. New York: Farrar, Straus, and Giroux.  Flanagan, Owen. 1991. Varieties of Moral Personality: Ethics and Psychological Realism. Cambridge, MA: Harvard University Press.  192  . 1996. "Ethics Naturalized: Ethics as Human Ecology." In Mind and Morals: Essays on Cognitive Science and Ethics, edited by Larry May, Marilyn Friedman and Andy Clark. Cambridge, MA: MIT Press.  . 2006. "Varieties of Naturalism." In The Oxford Handbook of Religion and Science, edited by Philip Clayton and Zachary Simpson, 430-452. Oxford: Oxford University Press.  Flanagan, Owen, David Wong, and Hagop Sarkissian. 2008. Naturalizing Ethics. Vol. I, in Moral Psychology, edited by Walter Sinnott-Armstrong. Cambridge, MA: MIT Press.  Fox, Margalit. 2012. "Lia Lee Dies; Life Went on Around Her, Redefining Care." The New York Times, September 14. Accessed January 26, 2016. http://www.nytimes.com/2012/09/15/us/life-went-on-around-her-redefining-care-by-bridging-a-divide.html?_r=0.  Frank, Gelya. 1999. Venus on Wheels: Two Decades of Dialogue on Disability, Biography, and Being Female in America. Berkeley: University of California Press.  Friedman, Michael. 2002. "Exorcising the philosophical tradition." In Reading McDowell: on Mind and World, edited by Nicholas H Smith, 25-57. London: Routledge.  Frye, Marilyn. 1983. The Politics of Reality: Essays in Feminist Theory. Trumansburg, NY: The Crossing Press.  Gadamer, Hans-Georg. 1993. Truth and Method. 2nd ed. Translated by Joel Weinsheimer and Donald Marshall. New York: Continuum Publishing Company.  Galanti, Geri-Ann. 2004. Caring for Patients from Different Cultures. 3rd ed. Philadelpia: University of Pennsylvania Press.  Geertz, Clifford. 1986. The Uses of Diversity. Vol. 7, in The Tanner Lectures on Human Values, edited by S. McMurrin. Cambridge: Cambridge University Press.  Gendler, Tamar Szabo. 2011. "On the Epistemic Costs of Implicit Bias." Philosophical Studies 156: 33-63.  Giroux, Henry. 1993. "The Politics of Insurgent Multiculturalism in the Era of the Los Angeles Uprising." The Journal of the Midwestern Modern Language Association 26 (1): 12-30.  Green, Alexander R, Dana R Carney, Daniel J Pallin, Long H Ngo, Kristal L Raymond, Lisa I Iezzoni, and Mahzarin R Banaji. 2007. "Implicit Bias among Physicians and Its Prediction of Thrombolysis Decisions for Black and White Patients." Journal of General Internal Medicine 22 (9): 1231-38.  Gutman, Amy, and Dennis Thompson. 2009. Democracy and Disagreement. Cambridge, MA: Harvard University Press. 193   Haidt, Jonathan, and Jesse Graham. 2007. "When Morality Opposes Justices: Conservatives Have Moral Intuitions that Liberals May Not Recognize." Social Justice Research 20 (1): 98-116.  Harding, Sandra. 1993. "Rethinking Standpoint Epistemology: What is 'Strong Objectivity?'" In Feminist Epistemologies, edited by Linda Alcoff and Elizabeth Potter. New York: Routledge.  Hester, Rebecca J. 2012. "The Promise and Paradox of Cultural Competence." HEC Forum 24: 279-91.  Hooker, Brad. 2002. Ideal Code, Real World: A Rule Consequentialist Theory of Morality. Oxford: Oxford University Press.  Institute of Medicine. 2003. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Edited by Brian D. Smedley, Adrienne Y. Stith and Alan R. Nelson. Washington, D.C.: The National Academies Press.  Jaggar, Alison. 2000. "Ethics Naturalized: Feminism's Contribution to Moral Epistemology." Metaphilosophy 31 (5): 452-468.  Jaggar, Alison, and Theresa Tobin. 2013. "Situating Moral Justification: Rethinking the Mission of Moral Epistemology." Metaphilosophy 44 (4): 383-408.  Jonsen, Albert, and Stephen Toulmin. 1988. The Abuse of Casuistry: A History of Moral Reasoning. Berkeley, CA: University of California Press.  Kant, Immanuel. 1989. Foundations of the Metaphysics of Morals. 2nd ed. Translated by Lewis White Beck. New Yok: Pearson.  Kelly, Daniel, Luc Faucher, and Edouard Machery. 2010. "Getting Rid of Racism: Assessing Three Proposals in Light of Psychological Evidence." Journal of Social Philosophy 41 (3): 293-322.  Kim, Jaegwon. 1988. "What is 'Naturalized Epistemology?'." Philosophical Perspectives 2 (January): 381-405.  Kleinman, Arthur, and Peter Benson. 2006. "Anthropology in the Clinic: the Problem of Cultural Competency and How to Fix It." PLoS Medicine 3 (10): 1673-6.  Kornblith, Hilary. 1999. "In Defense of a Naturalized Epistemology." In Blackwell Guide to Epistemology, edited by John Greco. Malden, MA: Blackwell.  Korsgaard, Christine. 1996. The Sources of Normativity. Cambridge: Cambridge University Press. 194   Kukla, Rebecca. 2003. "Attention and Blindness: Objectivity and Contingency in Moral Perception." Canadian Journal of Philosophy, Supplementary Volume 28: 319-346.  . 2014. "Living with Pirates: Common Morality and Embodied Practice." Cambridge Quarterly of Healthcare Ethics 23 (1): 75-85.  Laden, Anthony. 2012. Reasoning: A Social Picture. Oxford: Oxford University Press.  Lai, Calvin K, Maddalena Marini, Steven A Lehr, Carlo Cerruti, Jiyun-Elizabeth L Shin, Jennifer A Joy-Gaba, Arnold K Ho, et al. 2014. "Reducing Implicit Racial Preferences: I. A Comparative Investigation of 17 Interventions." Journal of Experimental Psychology: General 143 (4): 1765-85.  Lengbeyer, Laurence. 2004. "Racism and Impure Hearts." In Racism in Mind: Philosophical Explanations of Racism and Its Implications, edited by Michael Levine and Tamas Pataki, 158-78. Ithaca, N.Y.: Cornell University Press.  Liaison Committee on Medical Education. 2015. "Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree." Liaison Committee on Medical Education Website. April. Accessed November 17, 2015. http://www.lcme.org/publications/2016-17-functions-and-structure.doc.  Lindemann Nelson, James. 2003. "The Social Situation of Sincerity: Austen's Emma and Lovibond's Ethical Formation." In Moral Psychology: Feminist Ethics and Social Theory, edited by Peggy DesAutels and Margaret Urban Walker. Lanham, MD: Rowman and Littlefield Publishers, Inc.  Lindemann, Hilde. 2001. Damaged Identities, Narrative Repair. Ithaca, NY: Cornell University Press.  . 2009. "Autonomy, Beneficence, and Gezelligheid: Lessons in Moral Theory from the Dutch." Hastings Center Report 39 (5): 39-45.  . 2014. Holding and Letting Go: The Social Practice of Personal Identities. Oxford: Oxford University Press.  Lindemann, Hilde, and Marian Verkerk. 2012. "Toward a Naturalized Clinical Ethics." Kennedy Institute of Ethics Journal 22 (4): 289-306.  Little, Margaret Olivia. 1998. "Care: From Theory to Orientation and Back." Journal of Medicine and Philosophy 23 (2): 190-209.  Lovibond, Sabina. 1983. Realism and Imagination in Ethics. Minneapolis: University of Minnesota Press.  195  MacFarlane, John. 2005. "Making Sense of Relative Truth." Proceedings of the Aristotelian Society 105: 321-339.  Mackie, J.L. 1977. Ethics: Inventing Right and Wrong. London: Penguin Press.  Majerol, Melissa, Vann Newkirk, and Rachel Garfield. 2015. The Uninsured: A Primer - Key Facts about Health Insurance and the Uninsured in the Era of Health Reform. Policy Report, Menlo Park, CA: The Kaiser Commission on Medicaid and the Uninsured. http://files.kff.org/attachment/primer-the-uninsured-a-primer-key-facts-about-health-insurance-and-the-uninsured-in-the-era-of-health-reform.  Martell, Richard. 1991. "Sex Bias at Work: The Effects of Attentional and Memory Demands on Performance Ratings of Men and Women." Journal of Applied Social Psychology 21 (23): 1939-1960.  McDowell, John. 1994. Mind and World. Cammbridge, MA: Harvard University Press.  . 1998. Mind, Value, and Reality. Cambridge, MA: Harvard University Press.  . 2002. "Gadamer and Davidson on Understanding and Relativism." In Gadamer's Century: Essays in Honor of Hans-Georg Gadamer, edited by Jeff Malpas, Ulrich Arnswald and Jens Kertscher, 173-93. Cambridge, MA: The MIT Press.  Mehta, Uday Singh. 1999. Liberalism and Empire: A Study in Nineteenth Century British Liberal Thought. Chicago: University of Chicago Press.  Mendoza, S., P. Gollwitzer, and D. Amodio. 2010. "Reducing the Expression of Implicit Stereotypes: Reflexive Control Through Implementation Intentions." Personality and Social Psychology Bulletin 36 (4): 512-523.  Mill, John Stuart. [1859] 1982. On Liberty. New York: Penguin Press.  Mills, Charles. 2005. "'Ideal Theory' as Ideology." Hypatia 20 (5): 165-84.  Moody-Adams, Michele. 1997. Fieldword in Familiar Places: Morality, Culture, and Philosophy. Cambridge, MA: Harvard University Press.  Nagourney, Adam. 2015. "Harry Reid Hopes to Ensure Democrats' Success as Tenure Winds Down." The New York Times, April 2. Accessed December 21, 2015. http://www.nytimes.com/2015/04/03/us/harry-reid-hopes-to-ensure-democrats-success-as-tenure-winds-down.html?hp&action=click&pgtype=Homepage&module=photo-spot-region&region=top-news&WT.nav=top-news&_r=3.  Narayan, Uma. 1998. "Essence of Culture and a Sense of History: A Feminist Critique of Cultural Essentialism." Hypatia 13 (2): 86-106.  196  Neurath, Otto. 1983. Philosophical Papers 1913-1946. Edited by RS Cohen and M Neurath. Dordrecht: Reidel.  Paluck, Elizabeth Levy, and Donald P. Green. 2009. "Prejudice Reduction: What works? A Review and Assesment of Research and Practice." Annual Review of Psychology 60: 339-67.  Paul, L.A. 2015. "What You Can't Expect When You're Expecting." Res Philosophica 92 (2): 1-23.  Pettigrew, Thomas F, and Linda R. Tropp. 2006. "A Meta-Analytic Test of Intergroup Contact Theory." Journal of Personality and Social Psychology 90 (5): 751-783.  Platts, Mark de Bretton. 1997. Ways of Meaning: an Introduction to a Philosophy of Language. 2nd ed. Cambridge, MA: The MIT Press.  Potter, Van Rensselaer. 1975. "Humility with Responsiblity--A Bioethic for Oncologists: Presidential Address." Cancer Research 35: 2297-2306.  Quine, W.V.O. 1951. "Two Dogmas of Empiricism." The Philosophical Review 60: 20-43.  . 1961. From a Logical Point of View. 2nd ed. Cambridge, MA: Harvard University Press.  . 1969. Ontological Relativity and Other Essays. New York: Columbia University Press.  . 1979. "On the Nature of Moral Values." Critical Inquiry 5 (3): 471-480.  . 1986. "Reply to Morton White." In The Philosophy of W.V. Quine, edited by LE Hahn and PA Schilpp, 663-665. LaSalle, Ill: Open Court.  Rawls, John. 1999. A Theory of Justice. Revised ed. Cambridge, MA: Belknap Press of Harvard University Press.  Rorty, Richard. 1986. "On Ethnocentrism: a Reply to Clifford Geertz." Michigan Quarterly Review 525-534.  Rovane, Carol. 2005. "On the Very Idea of an Ethical Scheme." Iyyun: the Jerusalem Philosophical Quarterly 54: 109-28.  . 2011. "Relativism Requires Alternative, Not Disagreement or Relative Truth." In A Companion to Relativism, edited by Steven D Hales, 31-52. New York: Blackwell Publishing Ltd.  Saha, Somnath, Mary Catherine Beach, and Lisa Cooper. 2008. "Patient Centeredness, Cultural Competence and Healthcare Quality." Journal of the National Medical Association 100 (11): 1275-1285. 197   Savulescu, Julian. 2007. "Genetic Interventions and the Ethics of Enhancement of Human Beings." In The Oxford Handbook of Bioethics, edited by Bonnie Steinbock, 516-535. Oxford: Oxford University Press.  Scheman, Naomi. 2011. Shifting Ground: Knowledge and Reality, Transgression and Trustworthiness. Oxford: Oxford University Press.  Schwartzman, Lisa H. 2012. "Intuition, Thought Experiments, and Philosophical Method: Feminism and Experimental Philosophy." Journal of Social Philosophy 43 (3): 307-316.  Scully, Jackie Leach. 2008. Disability Bioethics: Moral Bodies, Moral Difference. Lanham, MD: Rowman and Littlefield Publishers Inc.  Sen, Amartya. 1997. "Indian Traditions and the Western Imagination." Daedelus 126 (2): 1-26.  Shafer-Landau, Russ. 2003. Moral Realism: A Defence. Oxford: Oxford University Press.  Shapiro, J, and P Lenahan. 1996. "Family Medicine in a Culturally Diverse World: a Solution-oriented Approach to Common Cross-Cultural Problems in Medical Encounters." Family Medicine 28 (4): 249-255.  Sherwin, Susan. 1992. No Longer Patient: Feminist Ethics and Health Care. Philadelphia, PA: Temple University Press.  Shook, Natalie J, and Russell H Fazio. 2008. "Interracial Roommate Relationships: An Experimental Field Test of the Contact Hypothesis." Psychological Science 19 (7): 717-723.  Simmons, John A. 2010. "Ideal and Nonideal Theory." Philosophy and Public Affairs 38 (1): 5-36.  Singer, Peter. 1993. Practical Ethics. 2nd ed. Cambridge: Cambridge University Press.  Stanford, Kyle. 2013. "Underdetermination of Scientific Theory." In The Stanford Encyclopedia of Philosophy, edited by Edward N Zalta. http://plato.stanford.edu/archives/win2013/entries/scientific-underdetermination/.  Strawson, Peter. 1974. Freedom and Resentment and Other Essays. London: Methuen and Co. Ltd.  Stroud, Barry. 1996. "The Charm of Naturalism." Proceedings and Addresses of the American Philosophical Association 70 (2): 43-55.  198  Sutton, Robbie M, Karen M Douglas, and Leigh M McClellan. 2011. "Benevolent Sexism, Perceived Health Risks, and the Inclination to Restrict Pregnant Women's Freedoms." Sex Roles 65: 596-605.  Taylor, Charles. 2002. "Understanding the Other: A Gadamerian View on Conceptual Schemes." In Gadamer's Century: Essays in Honor of Hans-Georg Gadamer, edited by Jeff Malpas, Ulrich Arnswald and Jens Kertscher, 279-298. Cambridge, MA: The MIT Press.  Taylor, Janelle. 2003. "The Story Catches You and You Fall Down: Tragedy, Ethnography, and "Cultural Competence"." Medical Anthropology Quarterly 17 (2): 159-181.  Tervalon, Melanie, and Jann Murray-Garcia. 1998. "Cultural Humility Versus Cultural Competence: A Critical Distinction in Defining Physician Training Outcomes in Multicultural Education." Journal of Healthcare for the Poor and Underserved 9 (2): 117-25.  The Pew Forum on Religious and Public Life. 2008. U.S. Religious Landscape Survey: Religious Beliefs and Practices: Diverse and Politically Relevant. Survey, Washington, D.C.: Pew Research Center.  Tomlinson, Tom. 2012. Methods in Medical Ethics: Critical Perspectives. Oxford: Oxford University Press.  Turner, Leigh. 2003. "Zones of Consensus and Zones of Conflict: Questioning the "Common  Morality" Presumption in Bioethics." Kennedy Institute of Ethics Journal 13 (3): 193- 218.  Verkerk, Marian. 2001. "The Care Perspective and Autonomy." Medicine, Healthcare, and Philosophy: A European Journal 4 (3): 289-294.  Walker, Margaret Urban. 2000. "Naturalizing, Normativity, and Using What "We" Know in Ethics." Canadian Journal of Philosophy 30 (Supp 1): 75-101.  . 2003. Moral Contexts. Lanham, MD: Rowman and Littlefield Publishers, Inc.  . 2007. Moral Understandings: A Feminist Study in Ethics. Oxford: Oxford University Press.  . 2009. "Introduction: Groningen Naturalism in Bioethics." In Naturalized Bioethics: Toward Responsible Knowing and Practice, edited by Hilde Lindemann, Marian Verkerk and Margaret Urban Walker, 1-22. Cambridge: Cambridge University Press.  Wear, Delease. 2003. "Insurgent Multiculturalism: Rethinking How and Why we Teach Culture in Medical Education." Academic Medicine 78 (6): 549-554.  199  Williams, Bernard. 1988. "What does Intuitionism Imply?"." In Human Agency: Language, Duty, and Value: philosophical essays in honor of J.O. Urmson, edited by J. Dancy, J. Moravscik and C.C.W. Taylor, 189-98. Stanford: Stanford University Press.  Wittgenstein, Ludwig. [1958] 1973. Philosophical Investigations. Translated by G.E.M. Anscombe. New York: Pearson Press.  Young, Iris. 1990. Justice and the Politics of Difference. Princeton, NJ: Princeton University Press.