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What is this thing called Metaethics?

• What makes something morally right? Where do our ethical

standards come from? Are they relative to cultures or timeless and
universal? Are there any objective moral facts? What is goodness? If
there are moral facts, how do we learn about them? What do we
mean when we say someone ought to do something? These are all
questions in metaethics, the branch of ethics that investigates the
status of morality, the nature of ethical value, the possibility of
ethical knowledge, and the meaning of ethical statements. To the
uninitiated, it can appear abstract and far removed from its two
more concrete cousins, ethical theory and applied ethics, yet it is
one of the fastest-growing and most exciting areas of ethics.

What is this thing called Metaethics? demystifies this important

subject and is ideal for students coming to it for the first time.
Beginning with a brief overview of metaethics and the development
of a “conceptual toolkit,” Matthew Chrisman introduces and assesses
the following key topics:

ethical reality: including questions about naturalism and

nonnaturalism, moral facts, and the distinction between realism
and antirealism
ethical language: does language represent reality? What mental
states are expressed by moral statements?
moral psychology: the theory of motivation and the connection
between moral judgment and motivation
moral knowledge: intuitionist and coherentist moral
epistemologies, and theories of objectivity and relativism in
metaethics
prominent metaethical theories: naturalism, nonnaturalism,
error theory, and expressivism
 new directions in metaethics, including nontraditional theories,
thick ethical concepts, and extensions to metaepistemology and
metanormative theory.

The Second Edition has been completely revised and updated

throughout. This includes a new thematic organization of the core
chapters, many new examples, a newly written final chapter
including discussion of thick ethical concepts and all-things-
considered normativity, updated references to recent scholarly
literature, improved learning resources, an expanded glossary of
terms, and much more.

Additional features such as chapter summaries, questions of

understanding, and suggestions for further reading make What is
this thing called Metaethics? an ideal introduction to metaethics.

Matthew Chrisman is Professor in the Department of Philosophy

at the University of Edinburgh, UK. He teaches and researches in
social-ethical-political theory, epistemology, and philosophy of
language. He is the author of Belief, Agency, and Knowledge: Essays
on Epistemic Normativity (2022) and The Meaning of ‘Ought’ (2016).
seriespage

What is this thing called?

The Routledge Philosophy What is this thing called? series of concise

textbooks have been designed for use by students coming to a core
area of the discipline for the first time. Each volume explores the
relevant central questions with clear explanation of complex ideas
and engaging contemporary examples. Features to aid study include
text boxes, chapter summaries, study questions, further reading and
glossaries.
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Available:

What is this thing called Ethics? Second edition Christopher

Bennett

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What is this thing called Philosophy of Religion? Elizabeth

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edition Gary Kemp

What is this thing called The Meaning of Life? Stewart Goetz

and Joshua W. Seachris
What is this thing called Global Justice? Second edition Kok-
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What is this thing called Knowledge? Fifth edition Duncan

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What is this thing called Metaethics? Second edition Matthew

Chrisman

For more information about this series, please visit:

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MATTHEW CHRISMAN
What is this thing called
Metaethics?
SECOND EDITION
• Cover image: Reflections, © Charles B. Chrisman, Jr.
Second edition published 2023
by Routledge
4 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
and by Routledge
605 Third Avenue, New York, NY 10158
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2023 Matthew Chrisman
The right of Matthew Chrisman to be identified as authors of this work has been asserted
by them in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act
1988.
All rights reserved. No part of this book may be reprinted or reproduced or utilised in any
form or by any electronic, mechanical, or other means, now known or hereafter invented,
including photocopying and recording, or in any information storage or retrieval system,
without permission in writing from the publishers.
Trademark notice: Product or corporate names may be trademarks or registered
trademarks, and are used only for identification and explanation without intent to infringe.
First edition published by Routledge, 2016
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging-in-Publication Data
A catalog record has been requested for this book
ISBN: 978-1-032-07201-2 (hbk)
ISBN: 978-1-032-07200-5 (pbk)
ISBN: 978-1-003-20589-0 (ebk)
DOI: 10.4324/9781003205890
Typeset in Berling and Arial Rounded
by Apex CoVantage LLC
dedication

• For my parents Chris and Sharon, who have supported me so

much.
CONTENTS

Preface to the Second Edition

Introduction
1 Four Key Issues
2 Naturalism
3 Nonnaturalism
4 Error Theory and Fictionalism
5 Expressivism
6 Summary and Chart
7 Theories That Are Hard to Classify in Traditional Terms
8 Refocusing Metaethics?
Glossary
Index
• preface to the second edition

Is morality a matter of objective fact or a subjective creation of the

human mind? Do ethical statements express beliefs about reality or
emotive reactions to a world devoid of objective value? Does the
development of human nature undermine or support the view that
there are universal moral principles? Assuming there are ethical
facts, are they discoverable by methods broadly contiguous with the
methods of science, or does moral knowledge require a special form
of intuition or wisdom? What is the connection between thinking
something is the right thing to do and being motivated to do it?
What does it take for an ethical statement to be true?

These sorts of questions have been a part of the study of ethics

since the beginning of philosophy. They are as interesting and
pressing today as they have ever been. They are the sorts of
questions that lead one to do metaethics. This book is about
metaethics.

The book is a general introduction meant to be suitable as a

textbook for an undergraduate course on the subject matter, though
it could also be used for self-study or as groundwork for a graduate-
level course. (The study resources are discussed more later.) This
book will introduce you to the way contemporary philosophers have
sought to systematize their approach to metaethics and develop
general metaethical theories capable of making progress on the
sorts of questions earlier. We won’t try to answer those questions
once and for all. But we will develop a much richer understanding of
what’s at stake in answering them, and we will examine methods for
answering them for ourselves.

One of the exciting things about metaethics is the way it is a

crossroad for a lot of other areas of philosophy. I think of it as the
intersubdisciplinary area of philosophy comprising questions in
metaphysics, epistemology, philosophy of language, and philosophy
of mind as they apply to ethics. Where a metaphysician might ask
about the nature of the fundamental constituents of reality, in
metaethics we ask about whether ethical facts and values fit into
reality, and if so how. Where an epistemologist might ask about the
nature of knowledge, in metaethics we ask about the nature of
moral knowledge. Where a philosopher of language might ask about
how sentences get their meanings, in metaethics we ask about how
paradigmatically ethical words contribute to the meaning of the
sentences in which they figure. Where a philosopher of mind might
ask about what happens in our psychologies when we perform an
action, in metaethics we ask about the role of ethical judgment in
motivating action.

Metaethics is the place where general theories in these other areas

of philosophy can be tested on especially thorny terrain. Doing
metaethics helps us to remember that all of the philosophical ideas
we develop, be it about ethics, metaphysics, epistemology,
philosophy of language, or philosophy of mind, must in the end hang
together as an attractive package with the rest of the views we
develop in these other areas (as well as with other areas of human
knowledge).

The book contains a number of study resources that have helped my

previous students in their study of metaethics. First, there is a
glossary of key terms. When a term is first used, if it’s in the
glossary, then it is in bold. And if it’s not used for a while and used
again several chapters later in a way that might be unfamiliar to the
beginning reader, I have placed it in bold again. Second, each
chapter contains quick “questions of understanding” sprinkled
throughout the text. I encourage you to try to answer these when
you encounter them. You can check your answers at the end of the
chapter. I have found that this helps to maintain a focus on reading
the text closely. Third, each chapter is dotted throughout with text
boxes containing “key points” and a “chapter summary” at the end
that should be helpful for reviewing the material. Fourth, each
chapter concludes with some “study questions” which are the sorts
of questions that might make for anything from a short writing
assignment to a full-fledged topic for a final essay. If you’re feeling
confident with answering all of the study questions, you are probably
pretty close to mastering the material. Fifth, each chapter also has a
list of “further resources” where you can go to deepen the
knowledge you acquire by reading the chapter. In some cases, these
are other introductory articles or encyclopedia entries that I
recommend you read. In other cases, there are videos or other
multimedia that I think also help one to understand the material.

Many people have helped me along the journey I have taken into
metaethics. I had the great fortune to study metaethics as a
graduate student at the University of North Carolina at Chapel Hill.
My Ph.D. thesis was directed by Geoffrey SayreMcCord, who was
hugely influential on my interest in and knowledge of the topic. I
also learned a lot during those years from Dorit Bar-On, Simon
Blackburn, Thomas Hill, Jr., William Lycan, Ram Neta, Gerald
Postema, Jesse Prinz, David Reeve, Michael Resnik, and Jay
Rosenberg.

Since graduate school, I have been on the philosophy faculty at the

University of Edinburgh, where there is currently a hotbed of
metaethicists all defending different viewpoints. This book has
benefited from interaction with many inspiring metaethicists, both
colleagues and students. Material for this book originally grew out of
lecture notes developed for an undergraduate metaethics course
that I have taught many times with Michael Ridge. In addition to
shaping my way of thinking of the subject matter, Mike generously
read full drafts of all of the chapters and gave me extensive and
extremely helpful feedback. The first seven chapters were trialed on
our cotaught metaethics class at the University of Edinburgh in
autumn 2015. Also, two Ph.D. students, Samuel Dishaw and Silvan
Wittwer, formed a reading group to work through full drafts of most
of the chapters with me, providing many useful and detailed
comments. Colleagues such as Selim Berker, Campbell Brown, Guy
Fletcher, Graham Hubbs, Sebastian Köhler, Elinor Mason, Debbie
Roberts, and Daniel Weltman have generously discussed particular
elements of this material with me, influencing not only how I teach
metaethics but also how I think about the relevant philosophical
issues.

The first edition of the book has been used in many classes in
Edinburgh and elsewhere. I acted on feedback from earlier users of
the book to reorganize and revise the material for the second
edition. Nick Laskowski deserves special mention for his suggestion
to begin my account of various metaethical theories with naturalism,
rather than nonnaturalism. I believe this reorganization of the
material makes the ideas in naturalism and nonnaturalism more
accessible. There are also new discussions of evolutionary
approaches to understanding morality, the mathematics-morality
analogy, and “thick” ethical concepts. Three anonymous readers for
Routledge also gave me extremely helpful feedback on my proposal
for reorganizing and rewriting the material in this book. The cover
art – “Reflections” – is a painting by my talented father Chris
Chrisman, who, along with my mother Sharon Chrisman, has been
extremely supportive. To all of these people, I say a hearty thank-
you.

In the dark moments of metaethics, it can seem like a series of

sectarian skirmishes between proponents of various -isms
representing vague and unfalsifiable theoretical persuasions, rather
than concrete philosophical theses. But in its light moments, the way
the very terms of the ongoing debate come up themselves for
regular review and revision indicates what I see as a healthy self-
consciousness of the mutability of the theoretical terrain on which all
philosophy is pursued. I wrote the first edition of this book in an
attempt to get down on paper my own map of the theoretical terrain
I found when I started doing metaethics 16 years ago. I did so
because I hoped it will be helpful for understanding how the terrain
is shifting and new theories are quickly emerging. I decided to write
a second edition in part to improve on my initial map but also
because the theoretical terrain has been shifting in interesting ways
in the six years since I wrote the original.

In any case, I hope that joining the evolution of metaethics – even if

only for a semester or a year – will lead more and more people into
thinking in philosophically careful ways for themselves about all sorts
of topics.

Matthew Chrisman,
Edinburgh, November 2022
• introduction

DOI: 10.4324/9781003205890-1

Richard Branson and Jeff Bezos, two of the richest people in the
world, chartered the first commercial flights into space in 2021. A
ticket on one of these flights sold for $28 million, even though they
lasted only a few minutes. They have inspired new optimism about
space travel. However, it has also been demonstrated that this
amount of money could prevent around 6,000 children from dying
from malaria.

In the same year, Frances Haugen, a recently hired data engineer

and product manager at Facebook, violated her nondisclosure
agreement with the company. She leaked internal documents
revealing that the company had been monitoring the negative
effects of Instagram on the mental health of teenage girls. She did
this because spokespeople for Facebook had repeatedly denied what
the company knew, and profit was prioritized over people in
decisions about whether to change the app.

In 2022, Vladimir Putin, the President of Russia, ordered the invasion

of the Donbas region of Ukraine. This caused the largest refugee
crisis in Europe since World War II, with more than 6 million
Ukrainians fleeing their homes. Later in the year, the U.S. military
supplied Ukraine with expensive, long-range missiles, an action that
slowed the Russian advance but also threatened to drastically
escalate and extend the conflict.

Would you say that space tourism is morally good or bad, overall?
Do we have an ethical obligation to spend our money on saving
people’s lives when they could easily be saved? What do you think,
did Haugen’s violation of her nondisclosure agreement demonstrate
moral virtue or vice? Do technology companies have an ethical duty
to protect user wellbeing even if it diminishes profits? Do you agree
with many commentators in the West that Putin’s invasion was
morally depraved? Was the decision to provide long-range missiles to
Ukraine the right thing to do, morally speaking?

When we answer questions like these, we make ethical

judgments. As a matter of course, we also make ethical judgments
about less controversial issues every day. Should you keep your
promise to meet a friend tonight, even if you really don’t want to?
Would it be good to give a regular donation to a local charity that
helps the homeless? What would be the kind way to treat your
parents when you disagree with them?

Ethics1 concern these sorts of questions. The philosophical study of

ethics can be divided into three areas. In normative ethics, we
seek general theories of what it is to be morally right/wrong,
good/bad, virtuous/vicious – that is, theories that might explain why,
in general, some acts are right and others wrong, some outcomes
are good and others bad, and some people are virtuous and others
vicious. For example, two classic normative ethical theories are
utilitarianism and deontology. The first says that we should always
act in ways that maximize overall happiness. The second says that
we should always act in accord with certain supreme moral rules,
such as Kant’s categorical imperative. In practical moral philosophy
or applied ethics, we seek to determine (often by reflecting on
normative ethical theories) the correct moral judgments relevant to
our practical decisions in everyday life. For example, here we might
inquire into whether things such as capital punishment, abortion,
cognitive enhancement, or single-payer healthcare are right or
wrong.
Moving in the other direction toward more abstract questions, in
metaethics, we seek to understand what we are doing when we
make ethical judgments and to integrate this understanding with our
other philosophical views about the nature of reality, the meaning of
language, the psychology of action, the possibility of knowledge, and
related topics. For example, when it comes to our answers to the
ethical questions in the fourth paragraph of this chapter, a
metaethicist will wonder: are we making objective claims about the
nature of reality, expressing evaluative attitudes like preferences,
forming tacit agreements about how to live together, some
combination of the above, or something totally different? If we lump
normative ethics and applied ethics together as the “first-order”
subject matter of ethics, we can think of metaethics as a “meta-
level” or “second-order” investigation into the nature of this subject
matter.

This book is about metaethics, which is a subdiscipline of the

philosophical study of ethics, covering second-order questions about
ethics. It is what emerges when one reflects critically and carefully
about the nature of one’s own ethical opinions. This means that
metaethics doesn’t directly address questions like those above about
what is right/wrong, good/bad, virtuous/vicious, etc. Rather it
addresses questions about the status of the opinions we form when
we answer such questions. And it addresses the grounds that might
render these answers correct or authoritative. It is an exciting area
of contemporary philosophy, where perennial questions about the
nature of morality are brought into contact with important and active
debates in metaphysics, the philosophy of language, moral
psychology, and epistemology.

QU1: Which of the following is a metaethical question: (i) Is

war ever morally legitimate? (ii) What does it mean for
something to be morally legitimate? (iii) How common is
war since the invention of guns?
• BACKGROUND

Many people, both now and for most of human history, have thought
that morality comes from God. Critically examining this idea provides
one way to begin to understand the kinds of questions investigated
in metaethics. We might, of course, wonder whether God really
exists. But even if we assume there is a God and following his
commands is morally right, we can ask: are things morally right
because they are commanded by God, or does God command things
because they are morally right? That is to say, assuming there is a
God, does his commanding something make it morally required, or
does he make his commands because he thinks following them is
required by morality? This is known as the Euthyphro Dilemma,
after Plato’s dialog called the Euthyphro. Both answers to the
question represent metaethical views. On the one hand, morality
might be viewed as a standard for judging actions, people, and
institutions that is enacted by rather than independent of God’s will.
On the other hand, morality might be viewed as an independent
standard for judging actions, people, and institutions (which God, if
he exists, is good at discerning).

Neither answer is completely satisfying. (This is why it is known as a

dilemma.) If God’s command creates morality, then doesn’t that
make morality seem somewhat arbitrary? If God had commanded
selfishness rather than charity, then on this view selfishness would
be morally good rather than charity. That seems wrong, which leads
many people to think that moral actions are good in themselves
rather than because of their relation to someone’s (even God’s)
arbitrary commands. On the other hand, if morality is a standard
independent of God’s command, then where does this standard
come from, what grounds the thought that it has some (even
supreme) authority over how we live our lives?

This challenging question might lead one to skepticism about

morality. In book I of the Republic, Plato’s character Thrasymachus
argues that the things we generally view as ethically right are – as a
matter of fact – whatever tends to promote the interests of the
stronger people in society (e.g., paying our debts, respecting the
property of others, not telling lies). His idea is that morality is
essentially ungrounded because it is a pernicious ideology, emerging
in human societies because of its usefulness for controlling people.
By contrast, in book II, Plato’s character Glaucon defends a more
optimistic view, arguing that morality is a human convention,
grounded in its usefulness for solving the otherwise difficult problem
of living together in a peaceful and cooperative society. Who do you
think is right, Thrasymachus or Glaucon?

Interestingly, Plato’s mouthpiece Socrates rejects both of these

viewpoints, arguing over the course of the rest of the book that
morality is an objective and eternal standard for judging actions,
people, and institutions.

This cluster of views we find in the Republic represents an important

historical antecedent to contemporary metaethics. Others can be
found in Hume, Kant, and Nietzsche. Hume famously argues that
reason is the slave of the passions, and he located the heart of
morality in the natural human sentiments required for our
characteristic modes of social cooperation. Kant, by contrast,
stresses reason and especially practical rationality, which he thought
to be the only possible route to universal truths about ethics.
Nietzsche thinks that morality is a contingent human construction,
and he argued that the origins of the dominant morality of European
cultures should make us skeptical of its authority over how we live
our lives. Throughout this book, we will be considering views like
these, seeking to identify the sorts of considerations that tell for and
against accepting a metaethical theory.
• FOUR KEY ISSUES

By briefly considering some historical ideas, we’ve already seen five

broad metaethical viewpoints about the source and nature of
morality: (i) it comes from God; (ii) it is a pernicious ideology; (iii) it
is founded in the moral sentiments that facilitate cooperation; (iv) it
is a self-founding rational standard for evaluating actions, people,
and institutions; and (v) it is a social construct with dubious origins.
We’ll see remnants of each of these in the contemporary theories we
discuss here. But to assess these theories properly, it will prove
helpful to separate four different issues that are wrapped up in the
overarching question about the source and nature of morality:

Questions about the existence and nature of ethical facts and

properties
Questions about ethical knowledge and disagreement
Questions about the meaning and use of ethical language
Questions about ethical thought and reasoning toward action

You will become much better acquainted with these questions i

chapters, but I will introduce them briefly here. the following

The first set of questions is where ethics comes into contact with
metaphysics. G. E. Moore’s Principia Ethica (1903) is commonly
credited with clearly distinguishing second-order metaethical inquiry
from first-order normative and practical ethics for the first time. In
Chapter 1 of that book, he sets out to identify the subject matter of
ethics, arguing that we need to determine what the word ‘good’
refers to – that is, what is goodness? Relatedly, of course, we might
also ask: what is rightness, or what is virtue? These are
metaphysical questions about the nature of ethical properties.
We could just as well ask about ethical facts. When we think that
something such as charity has the property of being good, we might
put this by saying that it’s a fact that charity is good. So, in the part
of metaethics that’s about metaphysics, we ask things such as: are
there really such facts? Or is it possible that there’s really no such
thing as goodness? If there are ethical facts and properties, are they
natural, supernatural, or classifiable in some other way? Are ethical
facts and properties mind-independent or somehow the product of
human thought?

QU2: True or false: If God doesn’t exist, then there isn’t a fact
about whether murder is wrong.

The second set of questions is where ethics comes into contact with
epistemology. Some philosophers think ethical facts aren’t
knowable by empirical investigation of the natural world, so they
suggest that we must have a special faculty of intuition that we
can use to know what things are good/right/virtuous, etc. However,
other philosophers have turned this argument on its head arguing
that, if ethical claims cannot be verified by empirical investigation,
then there’s no way to settle whose intuition is right when we
disagree, so ethics must not really be in the business of discovering
facts but rather of expressing our emotional reactions. This
theoretical dispute raises a host of interesting philosophical
questions about the possibility and nature of ethical knowledge, and
the status of moral disagreement.

The third set of questions is where ethics comes into contact with
the philosophy of language. Moore asked what the word ‘good’
refers to, but this raises three questions in the philosophy of
language:

1. What is it for a word to refer to something?

2. What concept or idea does a word express?
3. Why should we even think that the word ‘good’ refers to
something?

There is a tendency in some areas of philosophy to think that the

main job of declarative sentences and the thoughts they express is
to represent a way reality could be, and a sentence and the thought
it expresses are true just in case reality is the way they represent it
as being. This is especially plausible when it comes to a sentence
such as “The sun is shining in Edinburgh,” which we might think of
as expressing a belief about the weather and thereby being a
description of the weather in Edinburgh. The key question then is
whether we should think of ethical language this way too. When
someone says “Hauglen’s breaking her nondisclosure agreement
with Facebook was wrong,” are they expressing beliefs about the
wrongness of this action and thereby describing moral reality? Some
philosophers have thought not. For instance, A. J. Ayer (1946) would
say that such claims express emotive reactions. And R. M. Hare
(1952) compares ethical sentences to prescriptions, the kind of
thing we often convey by using an imperative sentence. As we’ll see,
these ideas raise important issues about how to explain meaning, in
particular the role of use in a comprehensive theory of meaning.
They also raise important issues about the relationship between
language and mind.

QU3: Which of the following can be said to represent

something else: [i] a map of the London Underground, (ii)
 an x on a ballot in an election, (iii) the play-by-play
description of a basketball game?

Finally, the fourth set of questions is where ethics comes into contact
with the philosophy of mind. Whatever you conclude in the end
about the existence and nature of moral reality and the explanation
of the meaning of ethical language, you might wonder what is going
on in the minds of people making ethical judgments. How should we
think about the reasoning process that moves from ethical judgment
to action? Unlike judgments about ordinary matters of fact (e.g., the
weather in Edinburgh 100 years ago), ethical judgments seem to be
closely tied up with our motivations to act.

This is true in at least two different senses. First, when someone

sincerely judges that they ought to do something, we can normally
expect them to do it. If they don’t do it, we’ll long for an
explanation. Maybe they changed their mind, they succumbed to
weakness of will, or they were overpowered by emotions. Second,
we tend to think that ethical facts (if such exist) provide us with
reasons to act. That is, if something is the ethically right thing for
you to do, that’s a strong reason (perhaps even a decisive or
overriding reason) for you to do it. Some philosophers have thought
this is true even if you don’t recognize the right thing to do, or even
if doing it wouldn’t connect in any way to things you already want.
Reasons are involved in reasoning from premises to conclusions
about what to do. So, this second connection between ethics and
reasons raises important questions in the theory of practical reasons:
What does it take for something to be a reason for someone to do
something? And how does that bear on our reasoning from moral
considerations to conclusions about what to do?
In Chapter 1, I’ll present each of these four sets of questions in
more detail, seeking to develop a “conceptual toolkit” that we can
use to chart the theoretical terrain of metaethics. We’ll come to
understand several different concepts deriving from metaphysics,
epistemology, philosophy of language, and philosophy of mind and
use these to explain some of the main theoretical viewpoints one
finds in metaethics. Often, particular metaethicists’ commitments
regarding some of the key issues earlier are driven by their
commitments regarding other issues, so we will generally evaluate
metaethical theories via a kind of theoretical cost-benefit
analysis.

Much like one might weigh costs and benefits of different family
vacations, or the government might weigh costs and benefits of
various taxation policies, we philosophers can weigh costs and
benefits of different philosophical theories. These typically consist of
positive reasons to favor the theory (benefits) weighed against
negative reasons against the theory (costs), as well as further
counter-arguments in both directions. In metaethics, philosophers
will disagree about which costs and benefits are attached to a
theory’s commitment in metaphysics, epistemology, philosophy of
language, and philosophy of mind. So it is by outlining various
theories in terms of their commitments across these four domains
that we will begin to understand what motivates some philosophers
to endorse and argue for them and other philosophers to reject and
argue against them.

Key Point: Metaethics is the study of metaphysics,

epistemology, philosophy of language, and philosophy of
mind as they apply to ethics.
• FOUR MAIN THEORIES

The first theoretical tradition we’ll start with in Chapter 2 is

naturalism. It is usually taken for granted in philosophy that the
natural world exists, and it can be known and talked about. Of
course, this idea, like anything other, can be challenged, but in
metaethics we usually assume this is right in order to ask whether
morality fits into a naturalistic worldview. Various philosophers think
it does. And they argue for this conclusion with distinctive accounts
of the source and nature of morality.

In some cases, this idea is pursued by attempting to “reduce” ethical

facts to more obviously natural facts, such as those discoverable by
the broadly empirical methods of science. In other cases, this idea is
pursued by explaining why careful moral reflection encourages us to
broaden the conception of what is natural to include things, such as
ethical virtue and moral value. Either way, if metaethical naturalism
is right, then ethical sentences can be construed as representations
of the natural world, some of which are correct.

In Chapter 3, we’ll turn to nonnaturalism. Proponents of this view

are skeptical that ethical facts could ever be reduced to or even
made to fit among the sorts of facts that are discoverable by
empirical science. These philosophers think the categorical reason-
giving force of ethical facts makes them just too different from
natural facts. But, somewhat confusingly, nonnaturalists also deny
that ethical facts are a species of supernatural fact, the sort that
might be created by the commands of God. Metaethical
nonnaturalism is often motivated by the ordinary thought that
morality is distinctive, important, and objective, but also by
particular commitments in the philosophy of language/mind or moral
psychology. It is paired with a distinctive view about how we come
to have ethical knowledge. And it requires a special account of how
we can resolve moral disagreements.

QU4: If someone thinks that what it is for an act to be right is

for it to be commanded by God, then what are they - a
naturalist, supernaturalist, or nonnaturalist?

The third family of views we’ll discuss in Chapter 4 is exemplified by

the error theory. Philosophers endorsing this view agree with
nonnaturalists that ethical sentences purport to represent distinctive,
important, and objective facts that are just too different from natural
facts to fit within a naturalistic worldview. But they also accept the
broadly naturalistic worldview, which leads error theorists to argue
that there are no objective ethical facts, “out there” in reality. This
means that the view is a form of antirealism. Because of their way
of being antirealist about morality, they embrace the seemingly
radical conclusion that many intuitively correct ordinary ethical
claims are false.

To make their way of endorsing antirealism more palatable, error-

theorists usually go on to argue that these ethical claims are false
because ethical thought and discourse rest on a fundamental but
explicable error: we often think we know things to be right/wrong or
good/bad, but that’s because we’ve been tricked or misled in some
understandable way (as Thrasymachus argued). Fictionalism is a
closely allied view that says instead that ethical thought and
discourse involve a kind of useful fiction. Fictionalists think that
rather than having been tricked or misled, we have been deploying a
kind of useful fiction (objective morality) when engaged in ordinary
ethical discourse.

The final family of metaethical views we’ll discuss in detail is

expressivism, which is covered in Chapter 5. The basic approach
begins in the philosophy of language and the philosophy of mind
with the claim that the core job of ethical sentences is not to
represent a distinctive piece of reality but to express a distinctive
kind of mental state – one with a distinctive profile in the psychology
of human motivation. The basic idea is that ethical judgment serves
as a kind of emotionally laden spur to or constraint on action, rather
than something like a picture of how things stand in reality.

Because of this, expressivists embrace a different kind of antirealist

than error-theorists and fictionalists. Since expressivists think our
ethical judgments don’t purport to describe reality, they will insist
that ordinary speakers are not engaged in a metaphysical error or
pretense when making ordinary ethical judgments. While attractive
in some ways, this raises different questions about why we say
things like “It’s a fact that exposing extremely harmful corporate
policies is the morally right thing to do” or “I know that poverty is
morally bad.”

QU5: Which of the following express mental states: [i]

blushing, [ii] sleeping, (iii] some scribbles on the wall, (iv)
a high hve, (v] your answer to this question?
• CONCLUSION

Discussing the four main issues and the four main theories will put
us in a position (Chapter 6) to survey the main theoretical terrain of
metaethics by developing a chart outlining each theory’s stance on
each of these issues. There are two points to doing this.

First, it will hopefully give you enough of an understanding of the

main theoretical fault lines of metaethics to begin to apply your own
theoretical cost-benefit analysis to these theories. For example, you
can begin to develop your own answer to questions such as these:
“Are any of the naturalistic reductions of ethical facts plausible
enough to make it acceptable to embrace their controversial views in
the philosophy of mind about moral motivation?” “Is nonnaturalism’s
commitment to the existence of nonnatural properties worth the
seamless treatment this view can give of the meaning of ethical and
non-ethical language?” “Is expressivism’s position in moral
psychology and metaphysics an attractive reason to embrace its
seemingly counterintuitive commitments in the philosophy of
language/mind and epistemology?” “Is the naturalistic worldview so
plausible that it makes it worth viewing morality as based in
metaphysical error or convenient fiction?”

Second, the chart we develop will also expose some gaps, leading us
to ask whether there couldn’t be more theories that take up a
different constellation of commitments across the four main issues.
Hence, in Chapter 7, I will briefly introduce some contemporary
theories that are hard to classify within the four main theories. Then,
in Chapter 8, we will explore several outstanding issues that the
traditional metaethical theories have wrongly neglected. These
cutting-edge topics challenge us to extend and refine the
methodology of metaethics.

Key Point: The four main theories we will consider are

nonnaturalism, expressivism, error theory/fictionalism, and
naturalism. But there are other possible theories and
issues that we’ll consider at the end of the book.
• CHAPTER SUMMARY

The philosophical study of ethics can be divided into three main

areas: normative ethics, applied/practical ethics, and
metaethics.
Metaethics prescinds from first-order questions about what is
right/wrong, good/bad, virtuous/vicious to ask second-order
questions about the “status of morality.”
Four key areas of metaethical reflection are about metaphysics,
epistemology, the philosophy of language, and philosophy of
mind as each of these more general areas of philosophy applies
to specifically ethical thought and discourse.
This book will be organized around four main theoretical
viewpoints: naturalism, nonnaturalism, error theory/fictionalism,
and expressivism.
• STUDY QUESTIONS

1. Explain in your own words the difference between normative

ethics and metaethics.
2. What is the difference between asking whether what Facebook
did was wrong and asking about the nature of wrongness?
3. What is metaphysics about when it comes to morality?
4. What is moral psychology?
5. Do you think most declarative language is representational of
reality? What are the alternatives to this view?
6. Do you think there is always an objectively right answer about
what is right and wrong?
 • FURTHER RESOURCES

• Chrisman, Matthew. 2014. “Morality: Objective, Relative, or

Emotive.” In Philosophy for Everyone, edited by Matthew
Chrisman, Duncan Pritchard, et al. Routledge. [A chapter-length
introduction to questions about the status of morality, which forms
the basis for the Introduction to Philosophy MOOC Lecture
available here: https://youtu.be/R7gHPXnVmac.]
• McPherson, Tristram, and David Plunket. 2018. “The Nature and
Explanatory Ambitions of Metaethics.” In The Routledge Handbook
of Metaethics, edited by Tristram McPherson and David Plunket.
Routledge. [An advanced-level description of the way metaethical
research is currently pursued in academic philosophy.]
• Miller, Christian. 2015. “Overview of Contemporary Metaethics and
Normative Ethical Theory.” In Bloomsbury Companion to Ethics,
edited by Christian Miller. Bloomsbury Academic, pp. xiv–lii. [A
more extensive introductory overview of normative ethics and
metaethics.]
• LaFollette, Hugh (ed.). 2021. International Encyclopedia of Ethics.
Wiley-Blackwell.
http://onlinelibrary.wiley.com/book/10.1002/9781444367072. [A
very comprehensive encyclopedia of articles by top researchers in
the field introducing topics in ethics.]
• Sayre-McCord, Geoffrey. 2014. “Metaethics.” In The Stanford
Encyclopedia of Philosophy (Summer 2014 Edition), edited by
Edward N. Zalta.
https://plato.stanford.edu/archives/sum2014/entries/metaethics/.
• Will Wilkinson interviews Geoffrey Sayre-McCord on Metaethics.
https://bloggingheads.tv/videos/1562.
• ANSWERS TO QUESTIONS OF
UNDERSTANDING

QU1: (ii) is a metaethical question because it is not about which

particular ethical judgment would be correct but rather about
what being correct amounts to. (i) is an applied ethical
question, whereas (iii) is not a question in ethics but rather in
history.
QU2: Some Divine Command Theorists think this is true, but one can
consistently think it is false if one thinks ethical facts exist
independently of God’s will. Just like an atheist can believe that
facts about the color of grass exist independently of God’s will,
an atheist can believe that the fact that murder is wrong exists
independently of God’s will. An interesting and hard question for
those who think this is what these facts are like – are they like
facts discoverable by science, or like facts about our own
subjective reactions to the world, or are they “facts” only in
some lightweight sense?
QU3: They all represent something else, though in subtly different
ways. Example (iii) is the closest to the way philosophers
commonly think of declarative sentences as representing a way
reality could be.
QU4: They’ re a supernaturalist. We might include supernaturalists
within the category of nonnaturalists, as allied against the
naturalist view that what it is for an act to be right is a matter of
it having some natural property. However, Moore’s very
influential arguments that ethical properties are nonnatural work
equally well against the view that what it is for an act to be
right is a matter of it having some supernatural property (such
as being commanded by God). So, it is common to reserve
 “nonnaturalism” to refer to views that deny that ethical
properties are natural or supernatural.
QU5: (i), (iv), and (v) all express mental states though in
interestingly different ways. If you made this or some other
statement as your answer to this question, then that would be
the best example for the way philosophers think of linguistic
acts as expressing our thoughts. Expressivists think that when a
statement is ethical in its content, the mental state is
interestingly different from the sorts of beliefs about reality we
ordinarily express with our statements. It’s worth noting that
(iii) is ambiguous. If those scribbles were created with the
intention of conveying something (either a feeling or a thought)
they may be expressive, but if they were simply the result of an
accident, they wouldn’t express a mental state.

• NOTE
1. In this book I will often use the words ‘ethical’ and ‘moral’
interchangeably with a slight preference for the former over the
latter. It’s worth noting, however, that some authors mark a
distinction between the word ‘moral’ with its origins in Latin and
having to do with social expectations, and ‘ethical’ with its
origins in Greek and having to do with personal character (see
Williams 1985, ch. 1). And this leads some philosophers to
accept that there are various ethical codes, some of which are
legitimate, while being skeptical of any universal morality.

• WORKS CITED
Ayer, A. J. 1946. Language, Truth and Logic. 2nd edn. London: V.
Gollancz Ltd.
Hare, R. M. 1952. The Language of Morals. Oxford: Oxford University
Press.
Moore, G. E. 1903. Principia Ethica. Cambridge: Cambridge University
Press.
Plato. 2002. “Euthyphro.” In Plato: Five Dialogues: Euthyphro,
Apology, Crito, Meno, Phaedo, translated by G. M. A. Grube.
Indianapolis, IN: Hackett.
Plato. 2004. “Republic.” In Republic, translated by C. D. C. Reeve.
Indianapolis, IN: Hackett.
Williams, Bernard. 1985. Ethics and the Limits of Philosophy. London:
Routledge.
1
•four key issues

DOI: 10.4324/9781003205890-2

In this chapter, we’ll discuss in more detail the four key issues on
which any complete metaethical theory would take a stand. In brief,
these are:

Questions in metaphysics about the existence and nature of

ethical facts and properties
Questions in epistemology about the possibility of ethical
knowledge and the nature of ethical disagreement
Questions in philosophy of language about the meaning and
expressive role of ethical words and sentences
Questions in the philosophy of mind about the connection
between ethical thought and action

As I said in the Introduction, these are points where the

philosophical study of ethics connects with other areas of philosophy.
So, one way we might think of metaethics is as the subdiscipline of
ethics that seeks to answer questions in metaphysics, epistemology,
philosophy of language, and philosophy of mind as they apply to
ethics. In the rest of this chapter, I shall explain the general issues
and how they apply to ethics. By the end of this chapter, we will
have developed a “conceptual toolkit” that we can use in future
chapters to probe the interlocking theoretical commitments of
various metaethical viewpoints.

Before we begin, a word of warning: this chapter contains a high

number of technical terms that may sound rather jargony. I explain
these terms as we move along, noting how they are commonly used
in metaethics to mark key distinctions between competing views on
some matter. However, any term in bold is also in the glossary at the
end of this book. So, while it will be helpful for future chapters to
understand the distinctions marked by these technical terms, you
can always consult the glossary if you forget what a particular term
means.
• QUESTIONS ABOUT ETHICS AND
METAPHYSICS

Metaphysics is the area of philosophy concerned with the

fundamental nature of reality. What kinds of things are real, what
are they like, and how do they relate to one another?
Metaphysicians are interested in the difference between particulars
(e.g., the Statue of Liberty) and universals (e.g., being a statue) and
the composition of things (e.g., are statues more than a combination
of their proper parts?). More relevant to metaethics, metaphysicians
are also interested in whether every fact is reducible to a fact about
the physical world or whether there are some nonphysical facts.
Similarly, metaphysicians are interested in whether our being
conscious is grounded in facts that are purely biological. One more
example: we all use mathematics every day, but one might wonder
whether numbers really exist. These are examples of the sorts of
issues investigated in metaphysics.

More generally, we might say that metaphysics is about the reality,

nature, and interrelations of various things such as particulars,
properties, numbers, and facts. When it comes to ethics, it is
common to focus on metaphysical questions about ostensible ethical
properties and facts. In one of the foundational texts of 20th-century
metaethics, G. E. Moore assumes that the property of goodness is
real, and queries its nature (ultimately arguing that it is sui generis
and so irreducible to any other kind of property). Talk of properties,
however, can usually be translated into talk of facts. So, in what
follows, to keep the discussion manageable, I’ll typically focus on
facts rather than properties, under the simplifying assumption that
an ethical fact involves something’s possessing an ethical property.
In response to metaphysical questions about the nature of ethical
reality, metaethicists commonly draw three different distinctions (it’s
a matter of theoretical controversy how exactly they are related):

natural versus supernatural versus nonnatural

reducible versus irreducible
mind-dependent versus mind-independent

The first distinction is born out of one of the key intellectual

advances of the Enlightenment. The sorts of unifying, extendable,
and falsifiable scientific explanations of phenomena we experience
have seemed to many thinkers to be better explanations than
nonscientific appeals to unobservable forces, spirits, and deities.
Because of this, some philosophers have gone so far as to argue
that we should recognize only natural facts as real. For a fact to
count as “natural” is roughly for it to be the sort of fact that could in
principle be discovered by science.

In the context of metaethics, this forces us to ask: are ethical facts

among the natural facts, or would they have to be supernatural facts
(e.g., created by the will of God)? Moore argues that they are
neither. He used the “nonnatural” to capture this idea. (This can be
confusing, since you might think that this just means not natural.
But Moore’s terminology has stuck, so it’s worth remembering that in
metaethics “non-natural” means neither-natural-nor-supernatural.)

The second metaphysical distinction mentioned earlier comes from

the idea that we can ask, for any kind of fact, whether it is
“reducible” to facts of some other kind. The basic idea is that the
target facts are constituted by or made up of facts of the other kind.
For example, facts about how much money various goods are worth
are plausibly thought to be reducible to facts about how much
money consumers are willing to pay for those goods. Facts about the
location of one’s mind might be claimed to be reducible to facts
about the location of one’s brain. In metaethics, the key question is
whether ethical facts are reducible to some other kind of fact.

What other kind of fact might provide the reductive basis for ethical
facts? There are various options: anyone who thinks that physical
facts exhaust reality will want to know whether ethical facts, if any
actually exist, can be reduced to physical facts. More commonly,
metaethicists are interested in whether ethical facts are reducible to
natural facts, where it is left open whether this includes biological,
sociological, and psychological facts that are not themselves
reducible to physical facts. However, some also follow Moore in
thinking the interesting question about reduction is about whether
ethical facts are reducible to any other kind of fact, even including
supernatural facts.

The final distinction mentioned earlier has to do with how objective

morality is. Some philosophers think that ethical facts depend for
their existence on the reactions of people. Indeed, this is one way to
understand Thrasymachus’s view we encountered in the
Introduction. On this understanding, what’s ethically right is largely a
matter of what the powerful people in a society say is ethically right.
Another and perhaps textually more accurate interpretation is that
Thrasymachus thought that nothing is really ethically right, but the
things we call “ethically right” are the things we’re taught to call this
by structures supporting the powerful people in a society. Either way,
the idea is not that being ethically right is merely “in the eye of the
beholder.” For it could be the case that no single individual can
determine what is (called) right. But as long as the standards derive
from the reactions of particular people, the standards of ethical
rightness are at best intersubjective and not objective. Other
philosophers think that ethical facts, if they exist, must be objective
and so not ultimately dependent on the reactions of particular
people.
So, these are three distinctions from metaphysics that can be used
to articulate different views about what ethical facts are like. And
one’s view about what ethical facts would have to be like, if they
exist, will determine whether one thinks ethical facts really exist. To
a first approximation, then, realism is thesis that ethical facts do
exist objectively, as part of the fabric of the reality. A view counts as
realist insofar as it treats ethical facts as “out there” to be discovered
by ethical inquiry rather than something that is projected or
constructed by ethical inquiry.1

Antirealism then can be understood as the rejection of realism.

Metaethicists who are antirealists often think that, if there were any
ethical facts, they would have to have certain features (e.g., be
irreducible to natural facts, generate reasons for action
independently of people’s desires, and establish an objectively
prescriptive standard for action). And they reject realism because
they think – usually inspired by a commitment to a naturalistic
worldview – that such facts are too weird to posit in our overall
picture of what reality is like.

QU1: What does it take to be a realist about beauty?

• QUESTIONS ABOUT ETHICS AND
EPISTEMOLOGY

Epistemology is the area of philosophy concerned with knowledge

and justified belief. One of the main questions epistemologists are
interested in is what more is needed for a belief to count as
knowledge. Almost everyone agrees that knowledge requires true
belief, but if someone forms a true belief by simply guessing, that
doesn’t count as knowledge. A belief has to be based on good
reasons or formed reliably for it to be knowledge.

When it comes to metaethics, realists need to develop an account of

how we might come to know the ethical facts they are committed to
as part of their metaphysics. If we agree that it’s really a fact that
charity is good, for example, what does it take to know this fact?
How one answers this question will depend, in part, on what one
thinks this ethical fact is like. Is knowing this fact like knowing some
empirical matter such as the average temperature of the world’s
oceans in 2010? Or is it more like understanding some cultural norm
such as what kinds of clothes a bank employee is supposed to wear?

Whatever exactly the realist says ethical facts are like, knowing that
charity is good requires believing that charity is good, but it also
requires that this belief be based on good reasons or formed reliably.
How might our ethical beliefs achieve this? Some metaethicists think
the answer to this question will be broadly like the answer we give
to parallel questions about non-ethical beliefs, whereas other
metaethicists think there will need to be a special story about the
reasonableness of ethical beliefs. Intuitionism holds that we have
a special faculty of intuition whereby we can reflectively access
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 Fig. 177. Fig. 178. Fig. 179.
Maas Method.

Haagedorn Method.—Haagedorn’s method does not differ much

from the above. The incisions are shown in Fig. 180, the appearance
of the freed margins in Fig. 181, and the sutured wound in Fig. 182.
The prolabial flaps are somewhat alike in size in this operation, in
which it differs only in the method just considered.

Fig. 180. Fig. 181. Fig. 182.

Haagedorn Method.

Geuzmer Method.—Geuzmer so incised the cicatrized defect that

a small prolabial flap is formed from the median border and a larger
one from the lateral, the very opposite of the Haagedorn technique.
Dieffenbach Method.—To facilitate the mobility of the lip flaps,
Dieffenbach has added two additional incisions on either side of the
nose, in circular fashion, encircling the alæ of the nose, as shown in
Fig. 183. This procedure is hardly ever necessary in harelip, and
truly applies to the restoration of a considerable loss of tissue of the
upper lip occasioned by the extirpation of cancerous growths,
although clefts of the median variety might be corrected thereby.
The wound thus formed appears as in Fig. 184. The sutures are
placed as in Fig. 185.

Fig. 183. Fig. 184. Fig. 185.

Dieffenbach Method.

Instead of the semicircular incisions a horizontal incision on either

side of the cleft may be made just below the nose with the same
object in view, the wound being sutured in angular form similar to the
method of Nélaton.

Congenital Bilateral Labial Cleft

The occurrence of bilateral cleft of the lip is much rarer than the
variety just described. According to Fahrenbach, out of 210 cases he
found only 59 of some degree of the bilateral form.
The degrees of deformity have already been mentioned.
The correction of these types of fissure is very similar to that of the
single cleft variety except that the operations for the latter are simply
duplicated on the opposite side.
 Particularly is this true in cases of the first degree, while in the
severer forms, modifications of such methods as have been
described must be resorted to, according to the nature and extent of
the defect.
It must always be the object of the surgeon to save as much of the
presenting tissues as is possible, to avoid traction on the tissues and
to overcome the consequent thinning out of the entire upper lip or
the flattening so often seen in the lips of these patients.
The correction of this flattening of the lip following operations for
the restoration of the lip will be considered later.
The following operations for the correction of bilateral cleft may be
regarded as fundamental:
Von Esmarch Method.—Von Esmarch advocates an incision
circling the central peninsula just sufficient to remove the bordering
cicatrix. Both lateral borders are vivified along the limit of the
vermilion borders (see Fig. 186). He advises suturing the mucous-
membrane flaps which he retroverts to form a basement membrane,
upon this he slides the skin flaps, and sutures them as shown in Fig.
187.
The best results are obtained when the lip is sufficiently detached
from the jaw by deep incisions beginning at the duplicature of the
mucous membrane. This insures the necessary mobility, and is
considered by him the most important step in the operation.
 Fig. 186. Fig. 187.
Von Esmarch Method.

Maas and von Langenbeck Methods.—Maas and von

Langenbeck vivify the median peninsula in square fashion, as shown
in Fig. 188, and suture the fresh margins of the flaps, as shown in
Fig. 189, according to Fig. 190.

Fig. 188. Fig. 189. Fig. 190.

Maas Method.

Haagedorn Method.—Haagedorn’s method is very similar to the

above except that in cutting square the inferior border of the median
portion he fashions it into a triangular form, with the object of giving
to the prolabium the tiplike prominence found in the normal lip, and
also avoiding the cicatricial notch obtained with the direct suturing of
the vermilion border on a line with its inferior limitation. The various
steps of his method are shown in Figs. 191, 192, 193.
If there be considerable absence of lip tissue he advises making
two lateral incisions sufficient to overcome the tension on the parts.
These secondary wounds are allowed to heal by granulation.

Fig. 191. Fig. 192. Fig. 193.

Haagedorn Method.

Simon Method.—Simon utilizes two curved lateral incisions

encircling the alæ of the nose. This permits of a ready juxtaposition
of the lateral flaps (see Fig. 194). The two flaps are sewn to the
median flap (see Fig. 195) and are allowed to heal into place, the
secondary wounds healing by granulation.
When this has been accomplished, a later operation is undertaken
to correct the prolabial border, the incision for which and the
disposition of the suture are shown in Fig. 196.
 Fig. 194. Fig. 195. Fig. 196.
Simon Method.

This operation is useful only in older children, and has the

disadvantage of requiring a secondary interference. The results are
not as good as those obtained with the operations mentioned
previously, leaving, besides, a disfiguring cicatrix at either border of
the alæ, a serious objection, especially to the cosmetic surgeon.

Post-operative Treatment of Harelip

When the operation has been performed in the infant the wound is
simply kept clean by the local use of warm boric-acid solutions and
the mouth is cleansed from time to time by wiping it out with a piece
of gauze dipped into the solution.
Children do not bear dressings of any kind well, although Heath
employs strips of adhesive plaster to draw the cheeks together to
relieve tension on the sutures.
To keep the child from tearing or picking at the wound Littlewood
advises fixing both elbows in the extended position with a few turns
of a plaster-of-Paris bandage.
Everything should be done to keep the child quiet, as crying often
results in separating the wounds. This is accomplished by giving it
milk immediately after the operation. The mother must ply herself
closely in soothing the child by carrying it about, rocking, and feeding
it.
 The feeding should be done with the spoon. Dark-colored stools
containing swallowed blood will be passed in the first twenty-four
hours; to facilitate this a mild laxative, such as sirup of rhei, can be
given.
In older children a compressor can be applied to the head. That of
Hainsley, shown in Fig. 197, answers very well, yet adhesive plaster
dressings, if carefully removed later, are most commonly used.

Fig. 197.—Hainsley Cheek Compressor.

The sutures may be removed as early as the sixth day, but it is

best to release the wound sutures about this time, and leave the
tension sutures for two or three days later.
It often happens that the entire wound has not healed by primary
union, if this occurs and sufficient union has taken place in part of
the lip, the wound should be allowed to heal by granulation.
Should the entire wound separate on the removal of the sutures,
the operator may attempt to secure healing of the wound by applying
a secondary suture to bring the granulating surfaces together,
although little is gained by this procedure as a rule.
If reoperation becomes necessary, it should not be undertaken
before six weeks or more have elapsed. At any rate not before the lip
tissues have returned to their normal state. Inflamed tissues do not
retain sutures well.
It usually becomes necessary to perform small cosmetic
operations after the healing of harelip wounds. Those should not be
undertaken until the child is of such age as to insure a perfect result.

SUPERIOR CHEILOPLASTY
Plastic operations for the reconstruction of the upper lip are not
met with often in surgery, except in connection with the various forms
of harelip. When the latter is not the cause, deficiencies of the upper
lip are due to the ulcerative forms of syphilis, and are occasioned by
the ablation of epithelioma and carcinoma or the result of burns or
lupus. Rarely the surgeon will meet with such a defect caused by
dog bite or other traumatisms due to direct violence, as in railroad or
automobile accidents.

Classification of Deformities of Upper Lip

Berger has classified three degrees of this deformity, according to

its severity, to wit:
1. The skin only is destroyed and the mucosa remains.
2. The mucosa has been partially destroyed with the skin, but a
part of the free border of the lip remains and is attached to the
cicatrix.
3. All the parts which make up the lip have been destroyed, and
there remains neither skin, mucosa, muscles, nor the prolabium.
The loss of substance of varying degree may involve either of the
outer thirds or the median position of the lip, or its entire structure.
For a more explicit classification the author divided these defects
into:
(a) Unilateral defect of the first, second, or third degree.
(b) Bilateral defect of the first, second, or third degree.
(c) Median defect of the first, second, or third degree.
(d) Total loss of upper lip.
This same classification applies to the defects of the lower lip.

Operative Correction of Deformities of Upper Lip

When the deformity is either of the first or second degree, one or

the other of the operations for the restoration of congenital cleft just
considered may be employed. When these are impracticable other
methods must be resorted to.
Bruns Method.—Bruns advocates making two lateral flaps from
the cheeks, as shown in Fig. 198. He preserves the inferior margin of
these flaps, which contain a cicatricial border which must take the
place of the prolabium. This border can, however, be made up of the
vermilion border of the lower lip, as shown later in the performance
of stomatoplasty, to establish a better cosmetic effect.
The rectangular cheek flaps are sutured, as in Fig. 199, leaving
two small triangular wounds at either side of the alæ to heal by
granulation.
The cheek flaps referred to must be dissected up from the bone,
and be rendered as mobile as possible for a successful issue.
 Fig. 198. Fig. 199.
Bruns Method.

Dieffenbach Method.—The method of Dieffenbach is very similar

to the above. It has been described on page 157. In this the lateral
flaps are made by two curved incisions encircling the alæ of the
nose. Should these be insufficient, two other curved incisions are
added, as shown by the dotted lines in Fig. 183.
Sedillot Method.—Sedillot also employs two rectangular flaps,
but he cuts them from the region of the chin (see Fig. 200).
The advantage of this method lies in the fact that these flaps are
lined throughout with mucous membrane, as the incisions are made
entirely through the tissues involved, beginning at the angle of the
mouth and extending downward to the limitation of the buccal fold
interiorly.
The flaps are twisted into position and sutured, as shown in Fig.
201. The mucous membrane of the inferior border is dissected up to
a required extent and turned outward and stitched to the skin margin
without to provide the prolabium. This is an important matter not only
for cosmetic reasons, but especially because such mucous-
membrane lining overcomes to a great degree the objectionable
cicatricial contraction of this free border.
In certain cases the mucous-membrane grafts of Wölfler may be
employed to cover the raw edge of these newly made lips, or the
Thiersch method of skin-grafting might be employed with the same
object.
Where the defect is unilateral, as is usually the case, a single
cheek or chin flap need only be employed, and this lined with
mucous membrane.

Fig. 200. Fig. 201.

Sedillot Method.

Buck Method.—Buck, in such unilateral defects, employs an

interolateral rectangular flap. It contains a part of the lower lip and its
vermilion border. This flap is twisted upward, so that its outer and
free end comes in apposition at or near the median line as may be,
with the remaining half of the upper lip.
This half of the lip is freely liberated by dividing the buccal mucous
membrane along the reflecting fold. Should the vermilion border be
contracted upward along the median cicatricial line it is carefully cut
away from the lip proper down to its normal margin. This strip is
retained until the flap taken from the under lip is brought into
position, when it is neatly sutured to the prolabium thus brought into
apposition. If there be a redundancy of the freed prolabium after the
median sutures have been applied it is cut away.
The secondary defect in the cheek caused by the rotation of the
flap is closed by suturing the raw surfaces together.
The resulting mouth will be much smaller than normal, having a
puckered appearance. A secondary operation, mentioned later, is
employed to correct this.

Fig. 202.—Buck Method.

Estlander-Abbé Method.—Estlander and Abbé employed a

transplantation flap of triangular form taken from the lower lip to
restore median defects of the upper lip, whether due to a deficiency
of the latter following harelip operation or the extirpation of a
malignant growth.
Where the tissues operated upon warrant such procedure this
operation will give excellent results, leaving the mouth almost normal
in shape and size.
The lower pedunculated flap is made by cutting directly through
the entire thickness of the lip, including the prolabium at A (Fig. 203),
and downward toward the median line to the point B, thence upward
to the margin of the vermilion border at G, leaving the latter to form
the pedicle of the flap F. The defect is freshened by either a median
incision, D, E, or the ablation is made in triangular form.
The flap F is now rotated upward and sutured into the upper lip, as
shown in Fig. 204. The triangular defect thus made in the lower lip is
sutured along the median line.
The prolabial pedicle of the flap F is not divided until about the
eighth day, when the vermilion borders of both the upper and lower
lips are restored by the aid of the free stump ends, which are neatly
sutured into position, as shown in Fig. 205.
 Fig. 203. Fig. 204. Fig. 205.
Estlander Method.

This operation may also be used in the unilateral type of defect. It

will be described in the operation of the lower lip, where it is more
frequently employed than in connection with faults of the upper lip.

INFERIOR CHEILOPLASTY
Apart from harelip operation, those for the separation of the lower
lip are the most common about the mouth. This is due in a great
measure to the fact that malignant growths so frequently attack this
part of the human economy and almost exclusively in the male. Out
of sixty-one cases von Winiwarter found only one female thus
affected. It has not been determined whether the habit of pipe
smoking has been a factor in establishing this unequal proportion,
yet it is acceded to be the fact, so much so that neoplasms of the lip
in men have been commonly termed smoker’s cancer.
The ulcerative forms of syphilis and tuberculosis seem to be met
with more in the lower than in the upper lip; likewise is this true of
burns and acute traumatisms.
Defects in the lower lip are, therefore, due principally to the
extirpation of carcinomata or other malignant growths and less
frequently to the other causes mentioned.
 The classification and extent of such involvement has already
been referred to.
In operations intended to extirpate a growth of malignant nature
the incisions should be made sufficiently distant from the neoplasm
to insure of unaffected or uninvolved tissue to avoid a recurrence of
the disease.
These growths appear at first in wartlike formation, becoming
thicker in time, and bleeding readily upon interference. They seem to
develop horizontally, and invariably in a direction toward the angle of
the mouth. There is more or less involvement of the lymphatic
glands, especially of the submaxillary, quite early in the attack.
An early extirpation of such growths is to be recommended, and
while it is true there may be a question of primary syphilitic induration
instead of the malignant variety no harm is done if the diseased area
be at once excised.
This is especially true of patients beyond the thirtieth year. When
such indurations occur before that age the patient may be put under
a proper course of treatment to determine the nature of the
infiltration for a period of three or four weeks; if this does not resolve
it operative measures should be resorted to. It is to be remembered
that syphilitic induration may involve the upper as frequently as the
lower lip, a fact not as likely referable to cancer.
In sixty-seven cases reported from Billroth’s Clinic there were
sixty-five cases of carcinoma of the lower lip and only two of the
upper. Yet this proportion hardly applies to the experience of most
surgeons. The age factor is not to be overlooked.
The author does not mean to claim that the differential diagnosis
of these diseases is at all difficult, yet in patients beyond the
admissible age early and radical treatment should not be neglected,
considering what great amount of misery and suffering, not to
mention disfigurement, can be overcome by prompt action.
Usually these neoplasms, when superficial, are found directly in
the prolabium, are unilateral, and occupy a place midway between
the angle of the mouth and the median line of the lip.
 Richerand Method.—Very small or superficial neoplasms may be
removed by lifting up the growth with a fixation forceps and cutting
away the convexity so established as deeply as necessary with the
half-round scissors, or the faulty area is neatly outlined in spindle
form (Richerand) with the bistoury, as in Fig. 206, and then excised
according to the method selected by the operator.
The wound is sutured horizontally, as shown in Fig. 207.

Fig. 206. Fig. 207.

Richerand Method.

If the neoplasm or defect is of a more extensive form, involving

most or all of the prolabium, the entire area, including the necessary
allowance of healthy structure, may be raised up by a clamp, as
shown in Fig. 208, and excised. The mucous membrane from the
anterior surface of the lip is then brought forward and sutured to the
skin margin, as in Fig. 209. The disfigurement in this operation is
surprisingly little, and the mucous membrane thus everted takes on
the appearance of the vermilion border of the lip in a short time.
 Fig. 208. Fig. 209.
Extirpation of Entire Vermilion Border.

Celsus Method.—When the neoplasm has become more than

superficial, or the defect or deformity involves more than the
prolabium, it must be ablated by a wedge-shaped incision, the base
upward including the vermilion border and the apex extending
downward upon the anterior chin.
This is best performed by piercing the tissue with a sharp bistoury,
the blade penetrating the mucosa, while an assistant compresses
the coronary vessels with his fingers at either angle of the mouth.
The incision must be made well into the healthy tissue, or at least
1 cm. from the boundary of the defect. The incision is made, as
outlined in Fig. 210, from below upward while the operator draws up
the triangular mass to be removed with the fingers of his left hand.
The same method is followed on the other side. The wound margins
are then to be examined microscopically for any sign of malignant
involvement. If there be any it should at once be removed,
irrespective of the size of the wound occasioned thereby. For this
reason the area excised may be so large as to prevent the ready
apposition of the raw edges. Should this occur, the lip halves may be
made more mobile by adding a horizontal incision continuous from
the angle of the mouth outward and over the cheek, as shown in the
line A, C.
A single incision for a unilateral defect and one on either side for a
median excision, as shown by the lines A, C, and B, C, in the same
figure.
This operation is known as the Celsus method. The parts are
brought together and the sutures placed as in Fig. 211, beginning the
first deeply and nearly to the mucous membrane, just below the
prolabial margin, which controls the bleeding. One or two of the
sutures should be made deeply to overcome the tension of the parts
as far as possible.
A few fine stitches are taken in the vermilion part of the lip and
several in the mucous membrane to permit of close apposition and
to insure primary union. Wounds of the lips heal very well, and the
defects occasioned by even extension operations which involve as
much as one half of the lip soon lose their acute hideous
appearance.

Fig. 210. Fig. 211.

Celsus Method with Additional Horizontal Incisions.

Estlander Method.—Estlander corrects a unilateral defect by

excising the neoplasm in triangular fashion, and cutting out a
triangular flap from the upper and outer third of the upper lip, leaving,
however, the prolabium intact, which answers for the pedicle (see
Fig. 212).
This triangular flap is rotated downward, and is sutured into the
opening in the lower lip, as shown in Fig. 213.
Where this method can be employed it does very well, as it
overcomes the secondary defect so common with most of these
operations, while a small operation may be undertaken later to
correct the mouth formation if necessary.
 Fig. 212. Fig. 213.
Estlander Method.

Bruns Method.—Bruns removes the defect in quadrilateral form

when the disease involves one half or more of the lower lip, as
shown in Fig. 214. He encircles the mouth by two curved incisions to
aid in mobilizing the edges of the wound, which he sutures, as
shown in Fig. 215, leaving two crescentic wounds at either side of
the mouth, which are allowed to heal by granulation.

Fig. 214. Fig. 215.

Bruns Method.

Buck Method.—Buck has corrected a unilateral defect by

employing the wedge-shaped incision, as shown by B, C, D in Fig.
216. After removing the triangular infected area he detaches the
remaining half of the lip from the jaw as low down as its inferior
border and as far back as the last molar tooth. A division of the
buccal mucous membrane along the same line more readily permits
of sliding the remains of the lip over to meet the raw surface
opposite.
If the latter was not possible he obtained additional tissue by
making a transverse incision from the angle of the mouth across the
cheek to the point A, or within a fingers breadth of the muscle. A
second incision is made downward from A and a little forward to the
point E. This quadrilateral flap thus formed, with its upper half lined
with mucous membrane is dissected up from the jaw except at its
lower extremity. It is glided forward edgewise to meet the remaining
half of the lip, where it is sutured into place, as shown in Fig. 217.
To cover the triangular raw space occasioned by the sliding
forward of the flap A, B, C, E, another transverse incision is made
through the skin continuing the line A, D, Fig. 217, to the extent of
one inch. The skin is then dissected up as far as this incision will
allow and is stretched forward until the edge meets the outer skin
margin of the quadrilateral flap, to which it is sutured. A later
operation for the restoration of the mouth has to be made.

Fig. 216. Fig. 217.

Buck Method.
 Dieffenbach Method.—Dieffenbach’s method is very similar to
the above, but is applicable only to cases where the entire lower lip
is involved and is extirpated (see Fig. 218). The wound is sutured as
in Fig. 219. The secondary wounds are either sutured as in Buck’s
method or they are covered immediately by Thiersch grafts (author’s
method).
Dieffenbach allowed these secondary wounds to heal by
granulation.

Fig. 218. Fig. 219.

Dieffenbach Method.

Jäsche Method.—Jäsche’s method is to be preferred to that of

the foregoing author. After a cuneiform excision of the defect he
adds two curved incisions extending downward at either side to
insure mobility of the parts, as shown in Fig. 220.
In bringing the wound together, as shown in Fig. 221, he
overcomes the large secondary defects of the operation last
considered by suturing the skin margins.