Editorial Note

Our lead article in this issue of the Kennedy Institute of Ethics Journal, Jonathan Kaplan’s “Self-Care as Self-Blame Redux: Stress as Personal and Political,” opens up an entirely new and clearly important topic for bioethicists: the concept and role of ‘self-care.’ Advice for ‘self-care’ is everywhere, and often this advice takes the form of a kind of moral imperative: we owe ourselves self-care and have a responsibility to care for ourselves. Meanwhile, typical suggested self-care practices focus on individual behaviors and purchases, rather than social interventions. Moreover, they very often require quite a bit of time, money, organization, and energy to complete. These include yoga classes, meditation, diet changes, vacations, and so forth. It is rare for us to question the wisdom of these self-care imperatives. What no one has done, as far as I know, is take them seriously as care suggestions and then consider them through a bioethical lens. What is the evidence that they work? What risks and burdens do they place on people? Is it paternalistic to insist that people engage in them? Given the omnipresence of the language of self-care, these are pressing and conceptually interesting questions.

Kaplan argues that self-care individualizes approaches to stress and its health consequences, placing the burden on people to fix themselves, often in expensive and challenging ways. Meanwhile, our best evidence shows that stress is largely socially determined and structural, with disadvantaged people experiencing more stress. Thus, individual solutions are unlikely to be the most effective, and insisting on them blames patients for their own, largely socially caused, conditions. Not only is this unfair to individuals, but a culture of self-care imperatives alleviates pressure to address social inequalities. Kaplan writes, “Telling someone that their poor health is their own fault, and that they alone are responsible for fixing it, is one way to make radical social and political change seem both unnecessary, and impossible.” Kaplan’s essay can be read as a strikingly original contribution to the exciting and growing new literature critiquing ‘healthism,’ placing self-care in the bioethical terrain.

In “Face Transplantation and Identity: Hidden Identities, Exceptions, and Exclusions,” Joseph Lee examines the underlying existential, biological, and phenomenological issues that undergird any ethics of face transplantation—one of the riskiest and most contentious of existing medical interventions. Faces are closely linked with personal identity, and hence changing your face is a substantial intervention into identity, with all the ethical complications that ensue. Lee dives deeply into the fundamentally different ways in which our face plays a role in constituting our identity: through our self-conception; through how we are recognized and given uptake by others; and through the biology of our immune system and other subpersonal systems. He argues that medical discussions of face transplantation have tended to reduce identity issues to simple concerns with how we look, and that this dramatically understates the complications involved. He also includes a fascinating discussion of how face transplantation still raises existential issues for blind and prosopagnostic people who cannot visually recognize their own face.

Finally, Nate W. Olson, in “Why Should Medical Care Be Family-Centered? Understanding Ethical Responsibilities for Patients’ Family Members,” goes well beyond the feel-good slogan that medical care should be family-centered. He examines what the ethical role and significance of the family is in a medical context, and how health care providers should think about their duties to family members of a patient. Since families are not necessarily unified and different family members’ interests may not align, this is an important question. Romantic imagery of families as loving units working in harmony are not helpful when parsing out the specific ethics of how different family members should be involved in a medical situation, and what kinds of care and support they should receive. Olson argues that based on both their professional roles and their specific relationships, health care providers have responsibilities to care for the well-being of family members in their own right, independent from any benefits to the patient. He also argues that these responsibilities are always secondary to responsibilities to the...