Scratching the Surface of Bioethics

SCRATCHING THE SURFACE OF BIOETHICS

VIBS Volume 144 Robert Ginsberg Founding Editor Peter A. Redpath Executive Editor Associate Editors G. John M. Abbarno Mary-Rose Barral Gerhold K. Becker Raymond Angelo Belliotti Kenneth A. Bryson C. Stephen Byrum H. G. Callaway Robert A. Delfmo Rem B. Edwards William Gay Dane R. Gordon J. Everet Green Heta Aleksandra Gylling Marti Ha'yry Steven V. Hicks Richard T. Hull

Laura Duhan Kaplan Joseph C. Kunkel Vincent L. Luizzi Alan Milchman George David Miller Jon Mills Alan Rosenberg Arleen L. F. Salles Steven Schroeder John R. Shook Eddy Souffrant Tuija Takala Oscar Vilarroya Anne Waters John R. Welch

a volume in Values in Bioethics ViB Matti Ha'yry and Tuija Takala, Editors

SCRATCHING THE SURFACE OF BIOETHICS

Edited by Matti Hayry and Tuija Takala

Amsterdam - New York, NY 2003

The paper on which this book is printed meets the requirements of "ISO 9706:1994, Information and documentation - Paper for documents - Requirements for permanence". ISBN: 90-420-1006-1 ©Editions Rodopi B.V., Amsterdam - New York, NY 2003 Printed in the Netherlands

CONTENTS frontispiece Foreword by Michael Parker

IX

Preface

XI

Introduction What is Bioethics All About? A Start MATTIHAYRY and TUIJA TAKALA 1. A Start 2. Empirical, Conceptual, or Both? 3. The Role of Reason in Bioethics 4. Principles and Their Use 5. The Limits of Life and Autonomy 6. The Scratches on the Surface ONE

TWO

The Relevance of Empirical Research to Bioethics: Reviewing the Debate REBECCA BENNETT and ALAN CRIBB 1. Introduction 2. Bioethics 3. Skepticism about Model One Bioethics 4. Empirical Research 5. Skepticism about Empirical Research 6. The Role of Empirical Research and the Two Models of Bioethics Better Together? Sociological and Philosophical Perspectives on Bioethics MAIRI LEVITT 1. The Limited Role of Sociologists in Bioethics 2. The Limits of Philosophical Bioethics 3. Philosophical Ethics Answers Back! 4. Better Together in Bioethics?

1 1 1 2 4 5 7

9 9 9 11 13 15 16

19 19 20 24 25

vi THREE

FOUR

FIVE

SIX

SEVEN

The Role of Sense and Sensibility in Bioethics TUIJA TAKALA 1. The Ambiguity in Bioethics 2. Guiding Emotions 3. Rule of Reason 4. Bioethics Revisited 5. Baby Steps

29 29 30 31 32 33

Does Bioethics Need Moral Theory? EVE GARRARD and STEPHEN WILKINSON 1. Introduction 2. Normative Ethical Theory 3. Metaethics 4. Theory and Intution: A Symbiotic Relationship? 5. Conclusion

35 35 35 39 42 44

"Parity of Reasoning" Arguments in Bioethics— Some Methodological Considerations S0REN HOLM 1. The Role of Parity of Reasoning Arguments 2. Some Different Forms of Parity of Reasoning and their Problems 3. Parity of Reasoning and the Use of Examples 4. The Principle of Charity—a Forgotten Principle in Bioethics? 5. Conclusion Anne Maclean's Criticism of Bioethics HARRY LESSER 1. Maclean's Criticisms of "Reason" in Bioethics 2. Replies to Maclean's First Criticism 3. The Second Criticism and Replies to It 4. The Third Criticism and the Reply 5. Consequences of the Above The Principlist Approach to Bioethics, and its Stormy Journey Overseas PETER HERISSONE-KELLY 1. The Global Applicability of Principlism— An Empirical Thesis? 2. The Common Morality and the Favored Subset Model 3. The Morally Serious Person

47 47 47 50 54 55 57 57 58 59 61 62

65 65 67 68

4. 5.

The Favored Subset Model Criticized A Transcendental Argument for the Common Morality 6. Summary

EIGHT

NINE

TEN

vii 72 74 76

Who Needs "the Four Principles?" CHARLES A. ERIN 1. Who, if Anyone, Needs the Four Principles Approach to Bioethics? 2. Legion: For We Are Many; First Among Equals? 3. What Can I Get for £250 (€392; US$365)? 4. Not the Four Principles Approach 5. Whose Common Morality? 6. Wasting Much Time ... Not!

79 80 81 83 85 86

Do Bioscientists Need Professional Ethics? MATTI HAYRY 1. The Questions 2. Professionals and Nonprofessionals 3. Professionals and Their Codes 4. Ethics in Practice 5. Is Bioscience a Profession? 6. Who Cares? 7. Ethics and Moral Concerns 8. The American Approach 9. A European Alternative 10. Ethics for Bioscientists

91 91 91 92 93 93 94 94 95 96 96

Pro-Life is Anti-Life: The Problematic Claims of Pro-Life Positions in Ethics JOHN HARRIS 1. Why Pro-Life? 2. The Hollowness of Pro-Life Positions 3. The Principle of the Sanctity of Life 4. Self Defense 5. Guilt and Innocence 6. When May We Kill in Self Defense? 7. Personhood

79

99 99 100 102 104 106 106 107

Vlll

ELEVEN

TWELVE

The Grounds for Preventing Impairments: A Critique SIMO VEHMAS 1. Different Ways of Preventing Impairments 2. Impairments as Threats to Weil-Being 3. Individuals with Impairments as a Burden 4. Impairments and Limited Opportunities 5. Impairment, Disability, and Discrimination 6. Conclusion Deflating Autonomy MARK P. SHEEHAN 1. Two Claims 2. The Conflict Problem 3. "Autonomy-Trumping" and "Good-Promoting" Versions of a Solution 4. Foundations and Justifications

111 111 112 114 116 118 119 123 123 124 125 130

THIRTEEN Autonomy: Overworked and Under-Valued PAUL BARROW 1. Scope of the Enterprise 2. Jehovah's Witnesses—Then and Now 3. Autonomy Revisited 4. Cost Consciousness and Conscience 5. More Than is Dreamed of

133 133 134 136 138 139

About the Editors and Contributors

141

Index

145

FOREWORD In their introduction to this fascinating and informative book, Matti Hayry and Tuija Takala invite us to consider the question, "what is bioethics all about?"At first glance this seems a very strange question to be asking at the beginning of a book on bioethics, and at the beginning of the twenty-first century when bioethics is literally everywhere. The questions of bioethics are posed for us in headlines on the front pages of every national newspaper. They are the topic of television documentaries every week, and are debated in the parliaments of every country that has one. We are acquainted with the questions of bioethics intimately, even if the answers to such questions are themselves disturbingly elusive. What is the moral status of the embryo? Should cloning be banned? Are genetically modified crops going to solve the problem of world hunger, or damage the global ecosystem beyond repair? Is euthanasia ever morally acceptable? These questions seem both to be new and to have been with us forever. Bioethics is one of the most important and contemporary social phenomena of our time, discussed in every pub and classroom, but its questions are also somehow timeless. Nevertheless, despite the familiarity of the key questions of bioethics, the editors' claim seems right to me. There is indeed a sense in which the question "what is bioethics all about?" is a vitally important and timely one to ask. Why is this? One reason lies in the seemingly essentially contested nature of so many of these questions. Will it ever be the case that we have resolved the question of the moral status of the embryo, or come to a conclusion about the morality of euthanasia? Or are these the kind of profound philosophical questions so intimately part of the human condition, like those of birth, death, love, and loss, that will continue to challenge each and everyone of us to work out our own answers in the context of our own experience of that condition? Are they answerable at all in any generalizable sense? If not, what indeed is bioethics all about? Another reason why the editors' question is so timely is that bioethics has become an increasingly important aspect of policy making, both in government and in the day to day practice of medicine. In these contexts, the use of bioethics is not merely an academic exercise. It is expected to have instrumental value, to produce results, to solve problems. At the same time as bioethics has been taken into the mainstream of public life however, the methods and aims of bioethics are being increasingly contested. Which bioethical approach is the right one? Should we be thinking in consequentialist or deontological terms? If we are unable to avoid having to consider both, or even to consider four competing principles, how are we to resolve the seemingly intractable tensions and conflicts between them in the making of practical decisions? In relation to the use of bioethics in this instrumental sense too then, the question "what is bioethics all about?" seems apposite.

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SCRATCHING THE SURFACE OF BIOETHICS

Finally, the question, "what is bioethics all about?" is also increasingly being asked from a sociological or political perspective. What are the social origins of bioethics? Why has it become so influential as an academic discipline in such a short time? Why is so much governmental funding targeted at bioethics? Why are the professions involving bioethics in their training? An interesting aspect of this larger sociological question, in the United Kingdom at least, is the question of why it is that so much excellent and important bioethics work is being carried out in the academic institutions of the North West of England? The chapters that go to make up the content of this volume are ample evidence of the quality and international nature of this work. Matti Hayry and Tuija Takala are to be congratulated on having assembled such a fine collection of authors, and for asking them collectively and individually to address the question of what bioethics is and ought to be all about. In so doing, they help us to see that we have thus far indeed only just "scratched the surface of bioethics." There is much interesting and important work to be done. No doubt much of the best of it will continue to be carried out in the North West. Dr Michael Parker Reader in Medical Ethics The Ethox Centre Oxford University November 2002

PREFACE The idea of this book was conceived in September 2001 in Massa-Carrara, Italy, where the Board of Directors of the International Association of Bioethics (IAB) met, enjoying the hospitality of Professor Maurizio Mori. During the Board's visit to the marble quarries of Carrara, and the nearby town of Colonnata, Professor S0ren Holm suggested that we should organize an academic meeting in which bioethicists working in the North West of England could exchange views on the conceptual and empirical aspects of the subject. We agreed that S0ren and Matti would plan the meeting, and that Tuija would then join Matti in editing a volume of the best contributions for the Special Series Values in Bioethics (ViB) of the Value Inquiry Book Series (VIBS). It was also decided that the venue of the meeting would be the University of Central Lancashire (UCLAN) in Preston, England. The birth of the book became, in this way, linked with two co-sponsors of ViB, namely the IAB and the Centre for Professional Ethics (CPE) at UCLAN's Faculty of Health. The meeting, the First North West Bioethics Roundtable (NorthWeb 1), was held in Preston on 23 January 2002, secured by the kind financial support of Eileen Martin, Dean of the Faculty of Health at UCLAN. The participants, who made the encounter an academic success, were philosophers and social scientists from the universities of Keele, Lancaster, Liverpool, Manchester, and Central Lancashire in Preston. The sponsors of North Web 1 included Empirical Methods in Bioethics, a project co-ordinated by Professor S0ren Holm and funded by the European Union Quality of Life and Management of Living Resources research program; Genes, Information, and Business, a project co-ordinated by Professor Matti Hayry and funded by the Academy of Finland; What Is Bioethics All About? a project co-ordinated by Dr Tuija Takala and funded by Emil Aaltonen Foundation and Helsingin Sanomain 100 Years Foundation; Values in Bioethics, a Special Series in Rodopi's Value Inquiry Book Series; Centre for Social Ethics and Policy, University of Manchester; Institute of Medicine, Law, and Bioethics, University of Manchester; Centre for Professional Ethics, University of Central Lancashire; and Faculty of Health, University of Central Lancashire. The organizers, and the editors of this book, acknowledge this support with gratitude.

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PREFACE

The editors' thanks are due to the authors, and to Peter Herissone-Kelly (CPE/UCLAN), the Assistant Editor of ViB, who prepared with great skill, speed, and dedication the Index, the "About the Editors and Contributors" section, and the camera-ready version of the book from the authors' contributions. The finishing touches were added to the book on our way home from yet another IAB event, the Sixth World Congress of Bioethics in Brasilia, Brazil, during and after which we were once again confronted with the question: "What is bioethics all about?" Matti Hayry Tuija Takala 5 November 2002 Bar 420, Avenida N. S. de Copacabana, Rio de Janeiro, Brazil

Introduction WHAT IS BIOETHICS ALL ABOUT? A START Matti Hayry and Tuija Takala 1. A Start What is bioethics all about? Is it only about medicine, nursing, and healthcare? No. Is it only about law and regulation? No. Is it only about philosophy and philosophical ethics? No. Is it only about social phenomena and their interpretation? No. Bioethics embraces all these and more. In this book, a preliminary attempt is made to sketch some of the main empirical and conceptual approaches in the field—to "scratch the surface of bioethics."

2. Empirical, Conceptual, or Both? The book opens with three inquiries into the nature of bioethics as a multidisciplinary or inter-disciplinary subject. In chapter one, Rebecca Bennett and Alan Cribb defend the view that bioethics should be seen, or at least it should be allowed to be seen, as an interdisciplinary enterprise in which, in addition to the contributions of health professionals, bioscientists, and moral philosophers, social scientists can also play an important role. This role should not, Bennett and Cribb argue, be limited to "supplying facts" to philosophical ethicists, who can then use them as (minor) premises in their moral arguments. Philosophers who expect social scientists to produce facts, or unequivocal empirical findings, for their own purposes are likened by the authors to legislators who consult moral philosophers only for their normative conclusions. Philosophical bioethicists usually think that much of the value of their own work is in the analysis leading to their conclusions. Similarly, Bennett and Cribb suggest, studies by social scientists should be read as arguments supporting certain claims about social life. While it is the task of moral philosophers to make defensible ethical claims, it is the task of empirical researchers to make defensible claims about the social world and social life. In chapter two, Mairi Levitt joins Bennett and Cribb in defending the view that sociological "facts" are complex theoretical constructions, not simple descriptive glimpses of social life to be taken at face value. She goes on to argue that sociology has three distinct advantages over purely or predominantly

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MATT1HAYRYAND TUIJA TAKALA

philosophical approaches to bioethical issues. Sociologists believe that the attitudes and opinions of lay people are as important to bioethical debates as the views of medical, scientific, and ethical experts. This enables them to take on board a variety of concerns that members of the general public actually have, and to avoid the problematic alliance of bioethics with professional groups in positions of power. Sociologists also have a history of empathetically understanding the viewpoints of the underprivileged, and even the "immoral." By trying to make sense of real-life ethical decision making without passing moral judgments, they can lay the foundation for policies which are more sensitive to the circumstances in which people live than the solutions philosophers offer when they engage in culturally and socially impoverished thought experiments. Finally, sociologists do not believe that normative ethical statements can be unproblematically transformed into behavior changes. They examine critically the implementation as well as the formulation of bioethical regulations. Levitt concludes by stating that philosophers and sociologists should find meaningful ways of co-operation, as this would enable them to make a more lasting contribution to bioethics. In chapter three, Tuija Takala tackles the roles of reason and emotions in bioethics. She holds that since strong feelings of, say, disgust and indignation can rule out other feelings and attitudes prevalent in modern societies, "the only way to take all emotions and convictions equally seriously is to take none of them too seriously." But bioethical decisions cannot really be based on reason, either. There are two main causes for this. When rational calculations clash with some of the most widely shared emotional responses, it does not always seem reasonable to assert that intellect must override people's sensitivities. Furthermore, such calculations can in many cases be based on several different definitions of what is rational. Despite these difficulties, Takala argues, some sort of a balance must be struck between sense and sensibilities, because real-life suffering and evil cannot be ignored even by academic bioethicists. Her own proposal is that we should join forces to create a minimal public morality that leaves maximal room to private moral deliberations. 3. The Role of Reason in Bioethics The first methodological part of the book is followed by three contributions that define the role of reason and philosophical theory in bioethics. In chapter four, Eve Garrard and Stephen Wilkinson defend the role of moral theory in bioethics. People who hold an "anti-theory" approach to bioethics have argued that normative theories of morality are useless in practical decision making, because the prescriptions they yield cannot be told apart in real-life situations. To counter this, Garrard and Wilkinson show how, for

What is Bioethics All About ?

3

instance, consequentialist and deontological doctrines support different views concerning the duties of medical professionals to their patients. While physicians with deontological leanings can concentrate on their own patients at the expense of wider social concerns, consequentialist doctors cannot do this. The former approach is intrinsically "agent-relative," and the latter "agent-neutral." Another anti-theory claim is that metaethics is of no use in bioethics, because it does not lead to normative conclusions, and because the moral views of the general public provide a better framework for moral decision making anyway. Garrard and Wilkinson disagree on both accounts. Convictions regarding realism, relativism, and nihilism do have a direct bearing on our views on substantive ethical issues, and these issues cannot be discussed even by the general public without a prior commitment to one of these metaethical background theories. In chapter five, S0ren Holm considers one way in which theoretical analysis has been used in contemporary bioethics. He discusses "parity of reasoning" arguments, in other words, claims that certain beliefs and actions people hold or perform force them, in the name of consistency, to believe in the validity or legitimacy of certain other beliefs and actions. Holm begins by describing five different ways to argue from the parity of reasoning. He distinguishes cases where the starting point of the investigation is a complete argument; an incomplete argument; a reconstructed argument; an incompletely justified piece of regulation; and a piece of regulation for which a moral justification can be found, although none has been presented by the authorities implementing it. All these can provide good grounds for parity of reasoning objections, but more often than not bioethicists present each other's cases in unnecessarily weak forms. Holm employs James Rachels's justification of active euthanasia to highlight the problems of combining hypothetical examples with rhetorics based on alleged parity of reasoning. He concludes by calling for honesty in argumentation in general, and for the use of the principle of charity in the interpretation of other people's views in particular. In chapter six, Harry Lesser defends the role of philosophers and reason in bioethics against three objections to utilitarian moral theorists presented by Anne Maclean. According to Maclean, the utilitarian philosophers she attacks must regard themselves as moral experts, because they endeavor to find the fundamental principles of ethics. Lesser points out that it is one thing to seek ethical principles, and another to believe that the principles one has unearthed must be valid. Philosophical inquiries are always open to criticism, and this means that philosophers need not have exaggerated ideas about their expertise in the field they study. Maclean also thinks that practices instead of principles should form the basis of moral action. Lesser's rejection of this notion is founded on the observation that not all practices are good, and that it would not do to use them to settle matters "when what we do is nice and not when it is

4

MATTY HA YRYAND TUIJA TAKALA

nasty." Maclean's final objection against utilitarianism as she sees it is that it requires emotional detachment, which is inhuman. We should always think about what is best for the greatest number of people, and never what is good for us or those we hold dear. Lesser notes that this critique is based on an unnecessarily naive understanding of utilitarianism. Our well-being will almost certainly be best promoted if we form close relationships with other people, and prioritize them in our private choices, and forms of utilitarianism which recognize this will be immune to Maclean's criticism.

4. Principles and Their Use The examination of methodological issues is continued in the next three investigations, where the applicability of principles in bioethics is explored. In chapter seven, Peter Herissone-Kelly examines Tom Beauchamp and James Childress's famous claim that the principles of autonomy, beneficence, non-maleficence, and justice are universally valid in bioethics at all times and in every region of the world. Many critics have thought that the claim is empirical, and rejected it by appeals to observable variation in moral views in different cultures. Herissone-Kelly argues, however, that the thesis advanced by Beauchamp and Childress assumes its strongest form when it is interpreted as a conceptual statement. In this form, it asserts that moral judgments cannot be legitimately made unless a set of norms central to morality exists. HerissoneKelly shows that, although this is the best possible formulation of the thesis, it is nonetheless unsound. Members of one culture can justifiably criticize members of other cultures even in the absence of universal norms. And even if a universal set of norms existed, this would not support the idea that the named four principles would belong to this set, or be always applicable to bioethical issues everywhere. In chapter eight, Charles A. Erin expresses his concern regarding the role of Beauchamp and Childress's principles in bioethics teaching and learning. Health professionals, who actually need moral guidance in their work, are attracted to the pragmatism of the four-principles model, enthusiastically advocated in the United Kingdom by Raanan Gillon. But does this, Erin asks, prevent them from gaining a more comprehensive understanding of the philosophical and theoretical underpinnings of ethics? The British Medical Association has noted that the use of the principles as a checklist may cloud the complexity of questions related to end-of-life decisions. Erin argues that it is not always sufficient to consider only those duties and norms that can be accepted by philosophers of different ethical persuasions. The justifications given to moral choices in competing views can be radically different, and there are areas in which disagreement cannot be eliminated by general references to autonomy, beneficence, non-

What is Bioethics AII About ?

5

maleficence, and justice. He concludes that it would be useful for health professionals to learn more about ethics than the four-principles model allows them to learn. In chapter nine, Matti Hayry asks whether bioscientists need professional ethics. Established professional groups like physicians and lawyers have ethical codes, which they use internally as regulative devices and externally as a justification for their independence and self-rule in modern societies. But do bioscientists form a distinct professional group? Hayry suggests that this is a question only bioscientists themselves can answer conclusively. If they think that they have a clear identity as a group, and if they undertake to create an ethical code for their work, they can become a profession. Philosophers can help in the formulation of the ethical code by proposing principles that could be useful in molecular biology, medical technology, and genetics. In the end, however, the choice of the principles, norms, and rules of conduct must be left to the professionals themselves. If the point of professional ethics in the sense delineated by Hayry is self-rule within the group in question, philosophers cannot dictate the content of the rules (to be) assumed by bioscientists.

5. The Limits of Life and Autonomy The remaining contributions deal with specific philosophical doctrines, views, and principles employed in bioethics. In chapter ten, John Harris questions the validity of so-called "pro-life" positions in ethics. He sketches the views presented by David Oderberg, and claims that the doctrines of the "sanctity of life" and "double effect" do not in fact protect life, or human life, in all its forms. Instead, they defend only lives defined as "innocent," and even those only against attacks that can be described as "malevolent." Harris argues that there are several serious inconsistencies in Oderberg's account. In this account it is, for instance, wrong to defend oneself against lethal threats which have not yet materialized, even if the person posing the threat has already formed an intention to kill in the future. On the other hand, however, Oderberg also states that external acts do not add to the wrongness of the internal intention to perform them. Harris points out that if the latter idea is taken seriously, pre-emptive acts of self-defense should be considered as justifiable as self defense after the wrongdoer's intentions have been made visible to others. This and other considerations lead Harris to insist that pro-life approaches to ethics are not only flawed, but defy their alleged claim to protect human lives. In chapter eleven, Simo Vehmas challenges the way in which certain prominent bioethicists, including Helga Kuhse, Peter Singer, Dena S. Davis, John Harris, and Julian Savulescu, have conceptualized the phenomena of

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MA777 HAYRY AND TUIJA TAKALA

impairment and disability. Vehmas starts with the idea that impairments as organic facts do not always lead to disabilities as reduced states of functioning without the intervention of people's attitudes and social arrangements which prioritize "normality." He then goes on to refute the main objections leveled at this model. Some theorists have argued that impairments are a burden to the impaired individuals, and to their families. But people with Down syndrome, for instance, can be happy with their lives, and the problems impaired children cause to their families are often comparable to the problems caused by nonimpaired children. The economic sacrifices societies have to make to take care of impaired individuals can be distinguished from sacrifices made to take care of others only by resorting to unethical ideological assumptions. And rational parents can hold a variety of clashing views concerning the kind of children they would like to have. Vehmas ends up maintaining the view that more attention should be paid to the social and ethical dimensions of disability. In chapter twelve, Mark P. Sheehan defends the view that theories that aim at promoting the good of patients can account for a justifiable range of paternalistic practices as well as the currently more popular theories which are based on the idea of an individual's right to self-determination and autonomy. He outlines several definitions of an individual's good, and shows how every normative view regarding justified paternalism generated by the ethics of autonomy can be equally well explained and supported by an ethics of beneficence. Sheehan argues that since beneficence can be seen as the cornerstone of medical activities, it would be more natural to examine physicians' attempts to promote the well-being of their patients in the unified context of promoting their good rather than in the belligerent model of opposing individual autonomy and medical benefits in the way many rights-based theories do. This would also give room to the reasonable notion that paternalistic choices are called for when people's perceptions of their own good clash with the professional opinion of their carers. In chapter thirteen, Paul Barrow concludes the book by raising a variety of questions not often asked in contemporary bioethics. He begins by contrasting present and past policies on giving blood transfusions to Jehovah's Witnesses against their will. What was standard medical practice thirty years ago can now lead to severe legal consequences. Seen from the viewpoint of autonomy as a right this is all for the good. But Barrow argues that if autonomy is seen, in the way that followers of Immanuel Kant see it, as a duty, the situation is radically different. It would go against the professional duties of physicians to perform bloodless operations that are not as effective as the ones involving transfusions. Patients, according to this view, may freely refuse medical procedures, but they have no right to choose options that are seen as sub-optimal by the professionals caring for them. This is not to say that different views of the world should not be taken into account in medicine and bioethics. Addressing the idea of physical immortality, Barrow asks, "is the likelihood of several hundred years more driv-

What is Bioethics AHA bout ?

1

ing on motorways in drizzle a more attractive prospect than the certainty of a shorter life on earth, and the possibility of Christian heaven?"

6. The Scratches on the Surface In its thirteen chapters, this book makes several scratches on the often excessively polished surface of contemporary bioethics. It suggests new ways of defining the relationship between conceptual and empirical work in ethics. It explores the interplay between reason and emotion in our ethical decision making. It questions the soundness and applicability of allegedly universal principles in biomedical ethics. And it challenges some of our deeply rooted beliefs concerning the moral ideals we have learned to accept. It is a start.

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One THE RELEVANCE OF EMPIRICAL RESEARCH TO BIOETHICS: REVIEWING THE DEBATE Rebecca Bennett and Alan Cribb 1.

Introduction

This paper was written as part of the European Commission funded project "Empirical Methods in Bioethics" (EMPIRE). Increasingly, bodies set up to deal with bioethical issues are becoming involved in empirical research such as public consultations.' The EMPIRE project consisted of a multi-national, multidisciplinary group which, simply put, aimed to analyze if and how data generated by empirical research can be relevant to bioethical debate and public policy in the area of healthcare and biotechnology. While the aim of the project was to explore this relationship between empirical research and bioethics, much of the discussion in the early stages of the project centered on what, we suggest, are best seen as terminological disputes. These disputes are mainly about what is meant by "bioethics," although they also reflect conflicting conceptions of empirical research. This paper aims to describe these terminological differences and some of the concerns lying behind them. Our concern is to help the debate about the role of empirical research in bioethics to move forward, and avoid it getting stuck at the first hurdle, that is, at an impasse concerning the nature of bioethics itself. Only once this ground is cleared can the crucial questions about the potential contribution of empirical research be addressed.

2.

Bioethics

A. Models of Bioethics To date there has been a running discussion of what is meant by the term "Bioethics" and what the methodology of "Bioethics" consists in. Many moral philosophers see the methodologies of moral philosophy as central and essential to bioethics. Those from other disciplines find this difficult as they believe themselves to also be "bioethicists," but with the methodology of their discipline as the focus of their enquiry into ethically problematic issues.

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We believe that this disagreement is easily solved. We suggest that at least a significant part of the dispute arises from a purely terminological issue. We will introduce two possible models of what is meant by the term "bioethics" to illustrate this terminological dispute. B. Model One On model one, bioethics is characterized as the "investigation of ethical issues arising in the life sciences (medicine, healthcare, genetics, biology, research, and so on) by applying the principles of moral philosophy to these issues." There are good reasons why moral philosophers see their methodology as the central tool in problem-solving in bioethics. Most of these reasons have to do with the tradition of applied ethics and medical ethics, and the word "bioethics" itself. There is often much confusion about what the methodology of bioethics is. Bioethics is characterized as a multidisciplinary mode of inquiry. Healthcare professionals, life scientists, philosophers, theologians, lawyers, economists, psychologists, sociologists, anthropologists, and historians are among those who are typically involved in bioethical inquiry. However, according to model one, while a wide range of disciplines are actively involved in bioethics, the central method of bioethics is moral philosophical enquiry. Bioethics, instead of being a multidisciplinary mode of inquiry, is a branch of applied ethics that is characteristically informed by multidisciplinary expertise and findings. As Ronald Green puts it: while ethics and moral philosophy may sometimes represent a relatively small part of the actual work of bioethics, they form in a sense the confluence to which all the larger and smaller tributaries lead, and, more than any other single approach, the methods of ethics and philosophy remain indispensable to this domain of inquiry.2 If bioethics is viewed as a subset of applied ethics in this way, then it is clear why moral philosophers see their own methodology at its center. Applied ethics involves the application of the principles and methods of moral philosophy to practical problems. Bioethics, according to model one, is a branch of applied ethics, and as such applies these principles and methods of moral philosophy to issues arising in the life sciences. C. Model Two Model two characterizes bioethics as the "investigation of ethical issues arising in the life sciences (medicine, healthcare, genetics, biology, research, and so on)

The Relevance of Empirical Research to Bioethics

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through multidisciplinary inquiry." On this second model, bioethics is a truly multidisciplinary area of inquiry where those from all disciplines (including healthcare professionals, life scientists, philosophers, theologians, lawyers, economists, psychologists, sociologists, anthropologists, and historians) use the methodology from their discipline to tackle "ethically" problematic social and public policy consequences of biological advances.3 The multidisciplinary dimension of bioethics on this model allows individuals from different disciplines to work together toward a solution to these problematic consequences of advances in biomedicine and biotechnology. Before continuing, it is important to note that what is meant by "ethical issues" in model two is not necessarily the same as what is meant in model one. In model one, bioethics is the name of an academic domain (a branch of ethics) albeit one in which the subject matter lies in some significant way outside the academy (compare phrases such as "medical ethics" and "nursing ethics"). To recognize something as an "ethical issue" on model one is principally to see it as falling within the disciplinary framework of academic ethics. But given that there exists a "real world" field of "bioethical issues"—for example social and policy conundrums about what ought to be done with cloning technologies and so on—then we potentially can bring any sort of disciplinary perspective to bear upon this field. On either model one or model two, academic work can be more or less "discipline-centered" or more or less "practice-centered." In model one all of the work—however far down the applied spectrum—"borrows" the name "bioethics" from the name of the academic discipline. In model two the work in the different disciplines "borrows" the name "bioethics" from the substantive field under investigation.

3. Skepticism about Model One Bioethics The debates about the relevance of empirical research to bioethics partly reflect a confusion, and a shifting back and forth, between these two models. Moral philosophers, relying upon model one, tend to downplay the role of empirical work. On model one, bioethical problems cannot be solved by appeal to or use of empirical evidence. Empirical research may inform an argument but it will not provide a solution. Moral problems can only be solved by the use of reason and argument. Empirical research work, such as public consultation, may be interesting, but cannot provide the answers as to the morality of the problem in hand. Those interested in empirical research, in turn, often treat this model one perspective dismissively. The Wellcome Trust in the United Kingdom has caricatured this approach to bioethics as "an abstract exercise carried on over sherry in the tutorial rooms of academic ivory towers."4 There also exists

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skepticism as to whether it is possible to resolve moral problems in this way. It might be argued that ultimately morality is a personal, subjective, and culturally determined matter, and as such one person's beliefs are as good as another's, and it is impossible to choose between them. Those who adhere to model one bioethics counter this skepticism by arguing that morality cannot be subjective in the same way as personal taste is, as if this were so it would not make sense to rationally defend moral beliefs, in the same way that it does not make sense to rationally defend tastes. For model one bioethicists, then, it is the role of reason that distinguishes personal tastes from moral judgments. James Rachels makes this point, saying: In this way moral judgments are different from mere expressions of personal taste—if someone says "I like coffee" he does not need to have a reason— he is merely making a statement about himself, and nothing more. There is no such thing as "rationally defending" one's like or dislike of coffee, and so there is no arguing about it. So long as he is accurately reporting his tastes, what he says must be true. Moreover, there is no implication that anyone else should feel the same way; if everyone else in the world hates coffee, it doesn't matter. On the other hand, if someone says that something is morally wrong, he does need reasons, and if his reasons are sound, other people must acknowledge their force. But if he has no good reason for what he says, he is just making noise and we need pay him no attention.5 Another related argument against the usefulness of model one bioethics stems from the theory of cultural relativism. However, those who hold to model one bioethics dismiss this theory of cultural relativism, arguing that truth claims in ethics have universal relevance, and that ethics (including bioethics) is thus an attempt to discover universal truths. The claim is that there are independent ethical standards by which cultural differences can be judged. Here we see the problem with the "sherry sipping" notion of bioethics and its relationship to, and detachment from, empirical research. Sherry sippers are not much interested in the cultural codes of different societies, as they believe that true morality is not necessarily to be found in these codes. The good news is that in practice moral philosophers engaged in bioethics (even those who sign up to model one) are not sherry sippers in this sense. While they may believe that what is morally right and wrong cannot be determined by empirical research, their role is not simply to determine what is morally right or wrong but to help determine what society's response to such dilemmas should be. Thus, while moral philosophers may, through much reasoning and argument, establish a strong case that something is morally wrong or right it may be that it is not this factor that determines policy. For instance, many moral philosophers hold that the human fetus has no interests and no moral status—

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that it is a non-person. However, few moral philosophers would suggest this provides sufficient grounds to make it permissible to use human fetuses for any purposes (for example to make soup or earrings), as to do so would in many cases cause distress to many for no great gain. Similarly, while recklessly transmitting Human Immunodeficiency Virus to another through sex may be morally wrong, to criminalize this action may not be the appropriate thing to do if it is shown that legislation of this kind is likely to prove counterproductive in terms of reducing HIV infection. The evidence about the distress caused by fetus "misuse," or the evidence that criminalization of HIV is counterproductive, will come from empirical research. Without it these judgments are just unsubstantiated intuitions from the philosophers. Some may see the examples summarized here differently. It is possible to see the evidence as not simply an extra consideration which gets "added" to the ethical analysis for policy making purposes, but instead that the evidence of distress or counterproductiveness changes the ethical analysis and the appropriate ethical judgment. Evidence, on this alternative account, is not an add-on but an intrinsic part of ethical analysis. However, this way of putting things makes no real difference to the model one position. The central point is that the rightness or wrongness of the policy is determined by a process of philosophical reasoning (which can incorporate empirical evidence), and not by the evidence itself. So, while empirical research may not provide the answer about what is morally wrong or right, empirical research is important when moral philosophers apply their analysis of morality to the more practical and immediate problem of policy making. If a study existed which showed that criminalization made those who suspected they were HIV positive avoid testing and treatment, then this would be a relevant factor even for bioethicists who hold to model one. What makes model one distinctive is that it uses the methods of moral philosophy to aim at rigorous and defensible ethical judgments and solutions; and moral philosophy is the only discipline which even aspires to play this role.

4. Empirical Research Before a concluding discussion of the relationships between empirical research and bioethics, it is crucial to acknowledge a lack of clarity about what exactly is meant by "empirical research." In disputes regarding the nature of bioethics, empirical research has often been portrayed as either a would-be "substitute" for moral philosophy or as servant of it—as the means of uncovering the "facts" for the philosopher's mill. We want to suggest that neither of these conceptions of the relationship is very helpful; but these rival conceptions cannot be assessed without some account of the nature of empirical research. We will assume that

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the scope of concern here is the social sciences and will leave aside discussion of the physical and biological sciences (although all of these might properly be included as empirical inquiries). There are at least three different pictures of empirical research in play: (1) All social science—that is, all of the social science disciplines, all of the forms of inquiry they deploy, and all of their products. This covers a vast range of epistemological styles and approaches, including what would typically be described as "theoretical" as well as "empirical" work, and work which springs from quite different concerns and interests—explanation, prediction and control, understanding, critique and soon. (2) A circumscribed set of approaches to quantitative and qualitative data collection and analysis—the kinds of "methods" which are discussed in social science research methods texts (surveys, quasi-experiments, case study, ethnography and so on). There exists no definitive way of drawing this boundary; it could, for example, reasonably include historical methods. What these approaches share is that they involve systematic attempts to sample a "piece" or a "slice" of the social world and "find out about" and "make sense of it. (3) Any research which includes an "empirical component" (as defined in 2)—this would be one way of compromising between model one and model two. It would exclude social science work that is essentially theoretical or argumentative in nature, and which does not include any systematic use of empirical data and data analysis. The way the scope of (social) empirical research is conceptualized depends on what is being contrasted with what. Some philosophers apply the term very generally to include any work that makes claims about social reality as opposed to purely philosophical work. Social scientists tend to use it more narrowly to distinguish their empirical methods—to some extent at least—from their more theoretical methods. But even if we define empirical research fairly narrowly— along the lines of 2 above—it would be a mistake to abstract empirical research from the disciplinary and theoretical contexts of social science. The same textbooks that describe empirical research methods see their use as dependent upon diverse theoretical frameworks from a range of disciplinary traditions (within, for example, anthropology, social psychology, economics, or political science). Empirical methods are best understood as a "surface" feature of the traditions of disciplinary inquiry in which they are deployed. It is widely understood that data collection and analysis cannot be a simple accumulation of "theoryfree facts," but depend upon theoretical frameworks and models (theories and

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models that, in turn, embody ontological and normative assumptions— recognizing this highlights the continuities between philosophical and empirical questions instead of their separation). For bioethicists to look to empirical research studies simply to provide "empirical findings"—facts about the social world—to inform philosophical debate would be strange. It would be the equivalent of policy makers looking to moral philosophers simply for their "ethical conclusions", as if these conclusions carried weight independently of the quality of the theorizing and argumentation that underpinned them; and this theorizing, argumentation, and the other properties of philosophical discourse were not part of what moral philosophers have to offer to others. In the same way, empirical research "findings" need to be understood and evaluated in their methodological and disciplinary contexts; and it may be that these methodological and disciplinary excursions are as (or more) valuable to moral philosophers than any particular set of results or analysis. (For example, a study which looks at "communication, class, and consent" in doctor-patient encounters may not happen to yield particularly interesting, important, or robust data, but the way in which the study explores the shifting notions and embodiments of class and social hierarchy in healthcare may provide valuable theoretical material.) We suggest that the role of empirical research should be seen as analogous to that of moral philosophy. Whereas moral philosophy is the disciplinary project of making defensible ethical claims, the disciplines of empirical research combine into the project of making defensible claims about (describing, understanding, explaining) the social world and social life. Given this general notion of empirical research it would be bizarre to see it as either a potential substitute for moral philosophy, or as playing a mere service role to it—instead, it has its distinctive orientation and purpose.

5. Skepticism about Empirical Research There exist many possible reasons for skepticism about empirical research. Some of these reasons are relatively trivial: we may wonder what exactly the technical-sounding apparatus of empirical research adds to common sense; we may note that empirical research is often done badly in one way or another; we may be frustrated by the extraordinary variety of, and the contestation between, the numerous styles and approaches which make it up. However, all of these reactions are equally likely to be found when people first come to moral philosophy, or view it "from the outside." Just because an academic domain is diverse, contested, of mixed quality, and sometimes over technical does not mean it does not contain good quality or worthwhile work.

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But there also exist several less trivial reasons to be skeptical about the potential of empirical social research. There are inherent difficulties in making knowledge claims about the social world (as debated within the philosophy of social science)—the social world is made up of complex and open systems; there are philosophical problems in specifying the relationships between the "elements" of the social world (between structures, cultures, meanings, and agency); social forms are to some degree historically and culturally specific and in flux. In practical terms, this means that the ambitions of empirical research studies to "point beyond themselves"—to say something which has relevance beyond the particular settings in which data is collected—are hard to realize. (It is well known that quantitative methods normally aim for some level of "generalizability," but even qualitative methods will often seek to build analyses and models of more general relevance—what is sometimes called theoretical instead of statistical generalizability). No one is more exercised by these methodological challenges than empirical social researchers themselves, and the traditions of empirical research amount to a range of strategies designed to overcome or minimize these difficulties. The techniques of rigor and the argumentative and theoretical traditions of empirical social research are the most considered resources available for making defensible claims about the social world. It would be perverse to conclude from such knowledge's being hard to attain that we should abandon these resources and rely entirely upon common sense (although, to be fair, this is the same reaction that many social scientists have to moral philosophy). Instead, given that there are inevitably empirical claims and assumptions built into bioethics, it is better to consider the rigor on which they are built, and to be critically reflective about the theoretical frameworks of social description they rest upon, than to leave them unexamined.

6. The Role of Empirical Research and the Two Models of Bioethics As we have seen, empirical research has relevance on either model of bioethics. There exist many potential meeting points between bioethics and empirical research.6 According to model two, bioethics is multi-disciplinary and hence empirical research is relevant by definition. Some of this research might intersect, but not overlap, with model one bioethics—it might, for example, look at the history of codes of ethics within a particular profession, or involve a comparative study of medical ethics curricula in different countries. The important questions we referred to at the beginning of this paper relate to the relationships between empirical research and model one bioethics or applied moral philosophy. The example of the criminalization of HIV, used above, is sufficient to indicate the relevance of empirical research at the "app-

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lied end" of applied moral philosophy. Here it should be obvious that empirical research has relevance. If we consider bioethical issues from the point of view of the policy making or practice agents who confront them, it is plain that an understanding of such things as cultural and institutional norms, or policy and legal climates, is of importance. There are, however, interesting practical and methodological questions about how best to conduct (and to develop) interdisciplinary work of this kind. These questions about inter-disciplinary working become even more testing if we ask whether empirical research has any relevance to applied moral philosophy at a more foundational level. It is at least arguable that it does—that ethical theory can only be framed against some empirically informed understanding of the possibilities and limits of social action. It is on these sorts of epistemological questions, as well as the practical and "professional" questions about inter-disciplinary collaboration, that we suggest future effort should be concentrated. Above all we should seek to avoid continually revisiting the same terminological disputes. To this end we suggest that—for the purposes of asking these important questions about the relevance of empirical research to bioethics—we should adopt model two bioethics (or at least accept it as a legitimate way of talking); we should work with a broad conception of empirical research, seeing empirical methods in their proper contexts; and we should refine and recast the question that faced the EMPIRE project. We should ask: What is the relationship between applied moral philosophy and empirical research in the field of bioethics? How and where are these traditions complementary? How and where can they be successfully combined in inter-disciplinary work? These questions have both practical and philosophical importance. If we want to address the immense practical and ethical challenges of healthcare and biotechnological change, we cannot afford to neglect the potential contribution of empirically oriented disciplines. More parochially, if we want to consider these issues in institutions, or at meetings, under the label of "bioethics," we will have to decide whether there are "insiders" and "outsiders" in these considerations, and on the grounds for potential inclusion or exclusion. However, at base, these questions are philosophical ones. How far is it possible to insulate the assessment of ethical judgments from the assessment of judgments about the nature of social reality?

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REBECCA BENNETT AND ALAN CRIBB Acknowledgment

This paper was written as part of the project "Empirical Methods in Bioethics" funded by the European Union Quality of Life and Management of Living Resources research program. The authors thank the European Commission, Directorate-General Research and other participants in the project for stimulus and support.

NOTES 1. E.g. The Human Fertilisation and Embryology Authority and Advisory Committee on Genetic Testing Report: Consultation Document on P re implantation Genetic Diagnosis, November 1999; Tom Wilkie, "Navigating the Moral Maze: The Bioethics Programme," an article adapted from Wellcome News, Issue 14,1998 and published on the web at http://www.wellcome.ac.Uk/en/l/mismisethmaz.html. 2. Ronald M. Green, "Method in Bioethics," The Journal of Medicine and Philosophy, 15:2 (1990), p. 182. 3. Wilkie, "Navigating the Moral Maze: The Bioethics Programme." 4. Ibid. 5. James Rachels, The Elements of Moral Philosophy (New York: McGraw Hill, 2nded., 1993), pp. 10-11. 6. S0ren Holm, Ethical Problems in Clinical Practice: The Ethical Reasoning of Healthcare Professionals (Manchester: Manchester University Press, 1997), pp. 23-39.

Two BETTER TOGETHER? SOCIOLOGICAL AND PHILOSOPHICAL PERSPECTIVES ON BIOETHICS Main Levitt 1. The Limited Role of Sociologists in Bioethics Although different disciplines work in the field of bioethics, it is the theories and methods of moral philosophy that have predominated.1 As a sociologist working with philosophical bioethicists, I want to defend a vision of bioethics that involves co-operation between social scientists and philosophers who are "better together" in the sense of having something different but complementary to bring to research into bioethical issues. In the traditional view of bioethics as moral philosophy, sociologists are junior technicians in the bioethical enterprise rather than equal partners. Where bioethics is concerned with normative ethics, setting out what ought to be done, if sociologists are required at all they will only be useful to provide background data. The philosopher may select from these data, but any empirical research will always be subordinate to moral reasoning, taking into account Hume's distinction between an "is" and an "ought," between fact and value.2 "The fact/value distinction precludes moral inference from brute facts."3 For some bioethicists then, social scientists have technical expertise, a knowledge of statistics, and methods that may be useful for empirically investigating questions raised by ethicists. However, the relevant theoretical frameworks and questions are ethical, and there is no place for the questions or theories of social science. The problems that philosophical bioethics has with sociological empirical bioethics can be summarized as follows: Finding out what people think or do does not further ethical research because it does not necessitate normative conclusions. Ethicists have always recognized that descriptive ethics, which asks how people actually behave, may have a use, but the key purpose of bioethics is to ask normative questions.4 Bioethics should be giving a lead to public opinion, not following it. If x% of the public oppose genetically modified food, so what? The stated views of a sample of people in response to a question at one

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MAIRI LEVITT particular time tells you nothing about whether GM technology should or should not be used in food production. For empirical research in bioethics to be useful to ethicists, there needs to be a philosophical input into the design of the research. In this way ethicists will have the information they see as relevant. For example, the costs of different treatments and evidence of the outcomes would be relevant to constructing a normative framework for priorities in healthcare treatment. Bioethicists who employ philosophical techniques bring clarity and reason to ethical problems, whereas ethnographers produce detailed descriptions and muddy the issues.5 For example, using thought experiments ethicists strip a case of superfluous detail in order to highlight the core ethical issues. In this way, they are able to apply reason to the problem and come to a clear conclusion. In contrast, social scientists seem increasingly fond of qualitative techniques of data collection, providing masses of information for no clear purpose and then claiming that theories emerge from the data.6 The aim of bioethics is to argue for what ought to be done, "what really is best."7 Sociologists are relativistic. They cannot say what ought to be done. Sociologists "at their worst [allege that] all perspectives on morality are ... of equal value or none ... ."8

2. The Limits of Philosophical Bioethics Sociologists in their turn have problems with philosophical bioethics. Philosophical bioethics is deferential to medical doctors and scientists and to medical science and science. The process by which medical and scientific "facts" are produced is not generally a subject for study by ethicists. Philosophical bioethicists see empirical research as possibly useful to supply "facts," which again leaves the production of these "facts" unexamined. Philosophical bioethicists lack interest in "ordinary people" who are not recognized experts in science, medicine, or ethics. Philosophical bioethics is asocial and acultural, which limits its application to real life, where ethical dilemmas arise in a social and cultural context. Philosophical bioethicists work to agendas set by others, for example the health professionals or scientists, and so may fail to question the

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process by which a case or policy is labeled as ethically problematic or to seek additional background information to that selected by others as relevant. Philosophical bioethicists use a "stripped down" form of reality that again makes their conclusions less applicable to real life. Philosophical bioethics does not pay enough attention to the practicalities of policy implementation. A. The Construction of Facts Ethicists accept areas of medical and scientific expertise and claim their own area of ethical expertise, whereas sociologists want to look at the way medical decisions are made and scientific "facts" constructed and so encroach on both these spheres. If the stated policy of a health system is that the allocation of transplant organs is on the basis of who has the greatest chance of survival instead of giving priority to the sickest patient, it might be assumed that chance of survival is a medical matter and so a no-go area for the bioethicist who comes in to comment on the policy.9 The sociologist would be interested in how chance of survival is measured. What tests are done, what social factors taken into account, what taken-for-granted knowledge invoked? It may be that for a child transplant some families are seen as better able to cope than others, as more able to comply with the drug regime that the child will need. What about a young person who needs a liver transplant because of her action in a suicide attempt or a middle aged person who has damaged her liver through heavy drinking? All sorts of social and moral judgments may be included and dressed up as medical ones. Are they evidence based? Are less educated or poorer families disproportionately assessed as less able to cope? Is this justified? Is the heavy drinker likely to waste the organ by refusing to give up alcohol or the young person to attempt suicide again? These are empirical questions that the bioethicists quoted by Raymond DeVries and Peter Conrad did not ask.10 Instead they accepted "chance of survival" as a medical fact and commented only on the ethics of this change to the previous policy. In contrast, sociologists tend to be skeptical about medical and scientific positions. The way scientific and medical facts are constructed and medical decisions are made can be unpacked. When bioethicists concentrate their work on particular cases that are controversial or present dilemmas, it is easy to overlook the broader socio-economic context. Considering this context leads to questions about why some cases are seen as ethically difficult while other ethical decisions are made without reflection; how clinical judgments are in fact made and what areas are blocked off from ethical challenge; issues of funding and access to healthcare. To give ethical advice in a particular case is to work within

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the agenda set by other professionals, whereas Daniel Callahan pleads for bioethicists to "cause trouble now and then."11 Sociologists are not just suffering from injured pride if they object to their role being reduced to that of suppliers of useful "facts" generated by empirical research. Any basic introduction to sociology suggests to students that the "facts" that are uncovered by empirical research will be related to the chosen perspective, the theoretical framework, research questions, and methods used. Facts do not speak for themselves, and theory "is everywhere... intimately connected to issues of problem, method, and substance."12 Instead of taking "facts" at face value it is therefore important to examine where they came from, who produced them, what methods they used, and so on. The danger of using facts out of context is that the ethicist will select those that suit his or her particular argument and ignore the rest. B. Public Expertise The philosophical bioethicists' lack of interest in the general public rests on the view that bioethicists are the experts in saying what ought to be done and input from the public will not help them in this task. When ethicists need other information they go to other experts, for example scientists or lawyers. They hold to a deficit model of public understanding of ethical issues like the traditional deficit model of public understanding of science, in which the public are seen as ignorant of scientific facts and therefore not equipped to contribute to debate on scientific applications. However, sociological research indicates that lay publics discussing the ethical and social implications of science and technology raise difficult issues that may be glossed over by health professionals. For example, the difficulty of deciding where to "draw the line" between acceptable and unacceptable applications of genetics and the problems of reifying individual autonomy when in practice medical, structural, and cultural factors shape client's decisions.13 In relation to genetics, Anne Kerr and others concluded from their focus group research that the lay public's "views and experiences of genetics ought to provide both the topic and resource for more sophisticated and accountable policy making... that challenges privilege, inequality, and discrimination."14 The value of a wide range of views is that the publics have different and relevant experiences. Deaf people who identify with deaf culture and pregnant women who have undergone prenatal testing, are two examples where people who have neither ethical nor medical expertise do have an alternative perspective that is relevant to health policy.15 Deaf people themselves may not view deafness as undesirable, which has implications for genetic counseling for hereditary deafness. While, from their experience, pregnant women may question the view that prenatal testing offers women

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choice, provides useful information, and, where test results are negative, reassurance. C. Social and Cultural Context Sociology has a history of interest in the "underdog," the relatively powerless, and social outcasts. Among the classic studies in sociology in the United States and Britain are those that focus on street corner society, drug users, the professional thief, mental hospital inmates, and student doctors.16 Much of this research involved studying people in their natural settings and attempting to present their view of what is going on. Sociologists doing ethnographic studies attempt to understand other people's cultures, and these studies are generally not judgmental about individual activities. The relativism of which sociologists are accused by philosophers is a necessary procedural stance, regardless of the researchers' values, where the aim is empathetic understanding.17 If the aim is to attempt to change behavior, then empathetic understanding may be a necessary starting point. For example, smoking is expensive in terms of cost to health and income, yet high rates of smoking are found—at least in the United Kingdom— among young women with low socio-economic status, not among those with high incomes and better access to healthcare.18 In a qualitative study Lorraine Greaves looked at how women feel about smoking and the benefits that it brings them in the context of their lives, providing some understanding of their behavior where a rational and objective assessment could not.19 Changing behavior would seem to depend on these women having alternative ways of obtaining these benefits; ways already available to those whose income and status allow them more control over their lives. Philosophers often use hypothetical cases to illustrate their points, but the problem is that they are not usually plausible since they are stripped of their social and cultural context. These cases are a type of empirical data but have the advantage of being totally within the control of the writer. People can be given a few selected attributes and put in situations where only one can be rescued; mothers can choose to conceive a child who will definitely be mentally handicapped or wait and have the chance of having a normal child; parents can demand to select a baby with an unusual attribute because of their convictions. An ethical decision is then made using an example that is decontextualized, with complexity reduced and the number of morally relevant factors limited.20 When you actually go out and collect empirical data you find that the situation is more complicated and messy. Philosophical ethicists isolate one factor in order to clarify the issues and say "all other things being equal" this is what ought to be done. But other things are not equal in real life. In making a decision about whether to terminate a pregnancy people take into account factors like the social and economic situation of the parents, the health resources they will have

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available, the ages of their other children, as well as the state of the fetus. How can there be an overall right or wrong thing to do, except in ridiculously extreme cases, such as termination of a child only for having a particular eye or hair color? Medical "facts" are not necessarily clear-cut either. For example, patients may not be unambiguously terminal and incompetent so that an advance directive can be applied.21 There exist fuzzy and gray areas, and focusing on the extremes is not helpful. Ethicists may strip down a case to clarify the ethical issue but then exclude elements that people in fact use (and need) to make decisions. In the areas covered by bioethics, sociologists use a wide range of empirical methods including the study of cases as they are: ambiguous and complicated. D. Knowledge and Behavior; Policy and Practice Ethicists do not seem concerned with the process by which policies are implemented. They seem to assume that once the situation is clarified and principles or theories applied, ethical behavior will follow. However, there is no simple line from values to behavior or knowledge to behavior. In a review of research into people's responses to the identification of genetic risk, Theresa Marteau and Caryn Lerman concluded that changing behavior is difficult and that "providing people with DNA derived information about risks to their health does not increase motivation to change behavior beyond that achieved with nongenetic information."22 Philosophers who do not pay attention to the implementation of policy may share the assumption of some medical writers that people will behave rationally: that is, in the way medical science suggests will optimize their health. In reality, specific behavior does not necessarily follow from specific values (there is a difference between what we do and what we say we are doing).23 A sociological approach would suggest both less certainty about the right policy and the need for more focus on the barriers to implementation.

3. Philosophical Ethics Answers Back! Philosophical ethicists will, no doubt, have answers and counter arguments to all these criticisms. Here some possible ripostes are outlined. They might start by pointing out that the task of normative ethics is to seek to answer questions about what ought to be done. Whether philosophers apply ethical theory, ethical principles, or case based approaches, they will use critical reasoning to evaluate options and arguments. Sociologists are wary of making explicit "ought" statements, but their work is riddled with "ought" assumptions (for example that the reduction of child poverty is a good thing, or increasing income inequality is a bad thing). These assumptions are implicit but rarely supported by reasoned

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argument. Sociologists are not always independent, explicit about their agenda, or critical.24 In contrast, philosophers expose their reasoning for others to see, and perhaps try to improve on, which is why they often disagree with one other. It is in debate that better arguments are formulated. As John Harris puts it, "I have always tried ... where this is possible, to argue for definite conclusions about what should be done and what should be permitted to be done. Of course I do not think that the conclusions are unassailable ... I believe however, that I have produced arguments with which others can engage."25 Being critical entails reasoned argument, not the automatic anti-medical stance adopted by many sociologists who are overly suspicious of the medical profession.

4. Better Together in Bioethics? Together philosophical and sociological bioethics can widen the bioethical perspective by setting an issue or problem in its historical, social, cultural, and political context. Together they can give a voice to stakeholders who would not otherwise be heard, namely the less powerful and the non-expert, as well as consider the ethical concerns presented by health professionals, scientists, and policy makers. The two approaches can complement each other by asking different questions and using different methods derived from their respective theoretical cores.26 Sociologists will remain wary of making "ought" statements and be more interested in what is presently the case, with a skeptical eye on official accounts of procedures and policies. Philosophers will be unable to resist the simplification of dilemmas to clarify the issues and make an ethical judgment. The two disciplinary approaches can retain their differences while respecting each other's expertise and becoming "better together."

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NOTES 1. Donald W. Light and Glenn McGee, "On the Social Embeddedness of Bioethics," Bioethics and Society: Constructing the Ethical Enterprise, ed. Raymond DeVries and J. Subedi (Englewood Cliffs, NJ: Prentice Hall, 1998), pp. 1-15. 2. David Hume, Treatise of Human Nature (London: Dent, 1911), Book III, Part 1, pp. 177-8. 3. D. P. Sulsamy and J. Sugarman, "The many methods of medical ethics," Methods in Medical Ethics, ed. J. Sugarman and D. P. Sulmasy (Washington, DC: Georgetown University Press, 2001), pp. 3-18. 4. Ibid., p. 4. 5. Charles L. Bosk, "Professional Ethicist Available: Logical, Secular, Friendly," Daedalus, 128:4 (1999), pp. 47-68. 6. B. G. Glaser and A. Strauss, Discovery of Grounded Theory: Strategies for Qualitative Research (Chicago, IL: Aldine de Gruyter, 1967). 7. James Rachels, "Ethical Theory and Bioethics," A Companion to Bioethics, ed. Helga Kuhse and Peter Singer (Oxford: Blackwell, 1998), p. 15. 8. Raanan Gillon, "Bioethics, Overview," Encyclopedia of Applied Ethics, ed. Ruth Chadwick (San Diego, CA: Academic Press, 1998), p. 312. 9. Raymond DeVries and Peter Conrad "Why Bioethics Needs Sociology," Bioethics and Society: Constructing the Ethical Enterprise, ed. DeVries and Subedi, p. 238. 10. Ibid. 11. Quoted in DeVries and Conrad, "Why Bioethics Needs Sociology," p. 245. 12. T. May, Social Research: Issues, Methods, and Process (Milton Keynes: Open University Press, 1993), p. 22. 13. A. Kerr, S. Cunningham-Burley, and A. Amos, "Drawing the Line: An Analysis of Lay People's Discussions about the New Genetics," Public Understanding of Science, 7:1 (1998), p. 131. 14. Ibid., p. 132. 15. K. Grundfast and J. Rosen, "Ethical and Cultural Considerations in Research on Hereditary Deafness," Otolaryngologic Clinics of North America, 25:5 (1992), pp. 973978; Women and Prenatal Testing: Facing the Challenges of Genetic Technology, ed. K. H. Rothenberg and E. J. Thomson, (Columbus, OH: Ohio State University Press, 1994); Ruth Chadwick and Mairi Levitt, "Genetic Technology: A Threat to Deafness," Medicine, Healthcare, and Philosophy, 1:3 (1998), pp. 209-215. 16. W. F. Whyte, Street Corner Society (Chicago, IL: University of Chicago Press, 1973); C. Conwell and E. H. Sutherland, The Professional Thief (Chicago, IL: University of Chicago Press, 1989); J. Young, The Drugtaker: the Social Meaning of Drug Use (London: Paladin, 1971); E. Goffman, Asylums: Essays on the Social Situation of Mental Patients and Other Inmates (New York: Anchor Books, 1961); B. Geer, E. C. Hughes. A. Strauss, and H. S. Becker, Boys in White: Student Culture in Medical School (Brunswick, NJ: Transaction Publishers, 1991). 17. M. Weber, Economy and Society: Vol.1 (New York: Bedminster Press, 1968). 18. J. Townsend, P. Roderick, and J. Cooper, "Cigarette Smoking by SocioEconomic Group, Sex, and Age: Effects of Price, Income and Health Publicity," British Medical Journal, 309:6959 (1994), pp. 923-927.

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19. L. Greaves, Smoke Screen: Women's Smoking and Social Control (London: Scarlet Press, 1996). 20. Fox and Swazey, quoted in Light and McGee, "On the Social Embeddedness of Bioethics," p. 5. 21. Ibid. p. 3 22. T. Marteau and C. Lerman, "Genetic Risk and Behavioural Change," British Medical Journal, 322:7293 (2001), pp. 1056-1059. 23. Bosk, "Professional Ethicist Available," p. 66. 24. James Lindemann Nelson, "Moral Teachings from Unexpected Quarters: Lessons for Bioethics from the Social Sciences and Managed Care," Hastings Center Report, 30:1 (2000), pp. 12-17. 25. John Harris, Clones, Genes, and Immortality (Oxford: Oxford University Press, 1998), p. 3. 26. Ruth Chadwick and Mairi Levitt, "Complementarity: Multidisciplinary Research in Bioethics," Bioethics Research: Policy, Methods and Strategies, ed. S. Gindro, R. Bracalenti, and E. Mordini (Rome: European Commission Directorate General XII Science, Research, and Development, 1997).

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Three THE ROLE OF SENSE AND SENSIBILITY IN BIOETHICS TuijaTakala

1. The Ambiguity in Bioethics Involvement in bioethics is seldom a merit among philosophers. Philosophers with an analytic training are often treated with suspicion among bioethicists. The willingness and ability to analyze rationally the core of ethical issues is regarded as proof of one's inhumane and insensitive nature—and of one's inability to understand ethical matters. One of the main problems in bioethics is, indeed, how to strike a balance between sense and sensibility. What is the role of reason, and to what degree, and how, should feelings be taken into account in bioethical decision making? How do we know what is right? Do we take the route suggested, for instance by James Rachels, that ethics is about reason, or should we resort to the feeling-based ideas of Anne Maclean and others?1 Both these extreme approaches, and almost every possible middle-way solution, have been utilized in contemporary bioethics. The 2,400 years of moral philosophy offer a vast selection of standpoints to choose from. In this paper, I will tackle the shortcomings of the polar positions, scrutinize some of the problems of taking the middle path, and propose a few ground rules for an approach that would take sense and sensibility equally into account. In an academic field of study, it would be quite odd to disregard reason altogether. If the general rules of scientific reasoning are not applied, no conclusions could be argued for—or falsified, for that matter. Conceptual clarity and sound arguments are also needed because bioethical problems are complicated enough as they are—there is no call to aggravate the situation by vague terms and insubstantial arguments. Most ethicists, however, also hold that ethics is somehow concerned with human well being and happiness, and this brings emotions into the picture. It is also possible, as some theorists hold, that a better way to know what is right and what is wrong is to use feelings or intuitions, instead of reason, as our guide.

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For different reasons, people seem to think that feelings are of the utmost importance to ethics. Not many hold, like some British philosophers of the eighteenth century did, that our moral sense tells us what is right and what is wrong, but emotion-based approaches do not always fall far short of the mark. Maclean, for instance, thinks that we know how to treat small children ethically, "simply because they are our babies." According to her, rational discussion only trivializes the matter.2 They are our babies, and therefore we just know how to treat them. The classical example of an emotion-based approach to applied ethics can be found in the work of Lord Devlin, although Mary Warnock's ideas could be used in this context as well.3 In The Enforcement of Morals (1965), Devlin writes about the intolerability of homosexuality. In his contribution, he argues that moral wrongs invoke in us deep feelings of disgust. If these feelings pass the test of a calm and dispassionate analysis, we can be sure that we have encountered something truly intolerable, something which can be legally banned.4 And if homosexual practices invoke these feelings, they can, according to him, be considered immoral and kept illegal. These feelings of repulsion reflect, so the argument goes, the essence of British morality, and their dismissal would signal the end of British society as it is (or was). The problem with this line of argument is that while disgust may reflect the values of a society, we cannot say whether the values of that society are "moral." And it should be noted that Devlin's model can also be interpreted as not being interested in feelings as such at all, but only as a means to preserve established structures. This interpretation is backed up by the fact that Devlin was not, after all, that interested in the feelings of those he was so ready to condemn. A common problem with the emotion-based models is that they take into account some feelings but not others, without, however, giving reasons or "overriding feelings" for this. Let me take this discussion to a more personal level. Abortion does not invoke strong feelings in me. If I were forced to witness one, I would probably not feel all that great, but this is true of most medical procedures—and there exist many that, for me, would be more disgusting than abortion. I have no problem with voluntary euthanasia, nor do I see any problem in cloning cells for therapeutic reasons. On the other hand, I do feel deeply disgusted by the thought that people who wish to die are condemned to live on because others think they should. I am appalled by people who force young girls to go through pregnancies, and by the fact that unwanted babies and terribly suffering children are being born. People have different feelings about different bioethical problems. That is why they are problems in the first place. Things would be easy if we lived in a communitarian Utopia, where everyone shared the same morality, but we do not.

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If bioethical theories are to take emotions truly into account, they should take all emotions into account equally. Some people are horrified by the thought of, say, cloning, but others can be horrified by the thought of missed opportunities to reduce suffering by research that involves cloning. Emotions and convictions are not truly considered in models that include some feelings and reject others, or argue for some convictions at the expense of others. If this is done, truly sensitive measures for acceptability are not used. Therefore, the only way to take all emotions and convictions equally seriously is to take none of them too seriously.

3. Rule of Reason Because of these and other problems, many philosophers think that resorting to reason alone can solve moral dilemmas. But this approach neglects the fact that if ethics has something to do with human well-being and happiness, these cannot be properly accounted for if only reason is consulted. Another difficulty is that there exists no one universal reason to be consulted to begin with. John Harris's "Survival Lottery" (1975) is an oft-quoted example of the unacceptability of utilitarianism, and of the over-emphasis of reason in ethical argumentation. To sum up the contents of this influential article, Harris starts from the empirical observation that the number of donated vital organs is too small to meet the demand, and suggests that a "survival lottery" could solve the problem. The (voluntary) lottery would be arranged so that, for all those participating, when sacrificing one individual as an organ donor can save two or more lives, that person is called up when the proper authorities draw her lottery ticket.5 It would be rational for everyone to take part in the lottery—simple calculations show that, statistically speaking, everyone has a better chance of living long in a society where the lottery is operated than in societies where it is not. Since Harris's model has been regarded as repugnant and emotionally unacceptable, it has also been thought that utilitarianism, and other reason-based theories, must be rejected. This is not, I think, the right conclusion. What can be learned from the "survival lottery" and from the reactions it has raised, however, is that in many cases the mere use of rational arguments is emotionally unacceptable. Even more importantly, the reason behind this particular model can be contested. It would be rational to take part in the lottery, if people indeed held that the maximal length of life is our ultimate goal. But not everyone shares this conviction. This is why there may be good reasons for holding that a society where the lottery is operated would be a worse place to live than a society where it is not. The problem of believing in the rule of one reason can be further demonstrated by different appeals to the choices of the "reasonable person" often used

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in bioethical arguments. On the one hand, for instance, it can be argued that reasonable persons should seek, and be happy to receive, whatever genetic information concerning themselves is available. It would be rational for them to maximize the benefits offered by modern medicine and medical knowledge, or, at least, to make their life plans more realistically.6 On the other hand, the standards of reasonableness used here can be challenged. Medical knowledge does not convey truths in any absolute sense. People can decide the course of their lives based on other information. Some may think that every child (whatever the genetic composition) has a right to be born, information may cause more misery than good, and, additionally, there are the questions of social justice and discrimination. The list is endless—reason, too, can work in contrary directions.7 Even in models where emotions are entirely discarded, agreement cannot always be reached, as opinions on what is rational, or ultimately desirable, vary.

4. Bioethics Revisited Many of the approaches sketched here are mixtures of moral and legal thinking. But that is characteristic of modem bioethics. The new technologies need to be regulated, and it is felt that ethicists can help in this task. Within the European Union, there are constant attempts at "bioethical legislation," and all the different ethical committees around the world frequently deal with borderline cases of the law. In bioethics, it is often difficult to distinguish the moral and the legal spheres. The fact that bioethicists sit on ethics committees and act as advisors to legislators lays an extra burden on the profession. This is an aspect that philosophers should not forget when they enter the intellectually stimulating world of academic bioethics. There really are moral problems and related suffering (or whatever is considered to be the particular "evil") out there, and whatever is done in academic bioethics will have an impact on the real world. Many philosophers try to downplay the more drastic conclusions of their arguments by saying that they would not like to see their ideas turned into legal regulations—that these are only their private moral views. I find statements like this disturbing. Bioethics as a field of study is closely connected to the real world. If we advise legislators, sit on ethics committees, help medical and research staff to make ethical decisions on behalf of others—and maybe even make these decisions ourselves as clinical ethicists—what do we base our expertise on, if not on the work we have done in our academic studies? In the academic world our ideas are tested and evaluated by our peers, and this can give them some credibility, even if it does not elevate them to the sphere of "truth."

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Furthermore, if the views philosophers have formulated in their academic work only represent their private views, then what is the point of presenting them publicly? In our roles as ethical experts we are supposed to add an impartial element to the discussion, and this cannot be done by indulging in the glorification of the values we learned at home, and that are not, to any great degree, shared by all.

5. Baby Steps Bioethics should somehow take into account both reason and emotions, as has been suggested (for practical ethics in general) by Jonathan Glover, and specified by others.8 When we cannot agree on whose reasons and which emotions bioethics should be based on, we need to work on compromises. How this should be done in practice, I am not sure. Two of the most promising candidates I have found so far are H. Tristram Engelhardt's "morality of moral strangers," and its predecessor, John Stuart Mill's idea of separating the spheres of "the private" and "the public."9 The idea in both these frameworks is that consensus in moral questions is impossible to come by, and that questions belonging to the sphere of ethics should be regulated only insofar as absolutely necessary. What I see as the philosophical bioethicist's main task is to try to formulate minimal regulations that would take everyone's senses and sensibilities equally into account, thus leaving as much room as possible for private moral deliberations. This is why we should join forces to develop a minimal morality instead of ego-tripping in our own little moral landscapes. This is the only way in which, by ongoing academic discussion, we can contribute to the development of at least minimal rules that could be accepted by all in our pluralistic societies. Both in scientific and in moral issues we should acknowledge that the New World created by modern biotechnologies and other developments is a complicated one. It is highly unlikely that an all-purpose moral theory that could solve all the problems will appear. In matters of emotion, no agreement will ever be reached, and attempts to find such an agreement can only lead us to ignore the feelings of many. Reason cannot do much better. Even if we could agree on what is reasonable, which is not probable, the dangers involved are so manifold that their acceptability cannot be judged by reason alone. Therefore, what I think bioethics should do is to engage in a continuous discussion where, piece by piece, argument by argument, concept by concept, and contribution by contribution, we seek ethically acceptable solutions.

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1. James Rachels, The Elements of Moral Philosophy (New York: McGraw Hill, 2nd ed., 1993); Anne Maclean, The Elimination of Morality: Reflections on Utilitarianism andBioethics (London: Routledge, 1993). 2. Maclean, The Elimination of Morality. 3. See Mary Warnock, A Question of Life: The Warnock Report on Human Fertilization and Embryology (New York: Basil Blackwell, 1985). 4. Patrick Devlin, The Enforcement of Morals (Oxford: Oxford University Press, 1965), p. 17. 5. John Harris, Violence and Responsibility (London: Routledge and Kegan Paul, 1980), ch. 6. 6. See e.g. Rosamond Rhodes, "Genetic Links, Family Ties, and Social Bonds: Rights and Responsibilities in the Face of Genetic Knowledge," Journal of Medicine and Philosophy, 23:1 (1998), pp. 10-30. 7. E.g. Tuija Takala, "Genetic Information and Reasonable Paternalism," Theoretical Medicine and Bioethics 22:5 (2001), pp. 485^91. 8. Jonathan Glover, Causing Death and Saving Lives (Harmondsworth: Penguin Books, 1977); Matti Hayry, Liberal Utilitarianism and Applied Ethics (London and New York: Routledge, 1994), pp. 153-8; Norman Daniels, Justice and Justification: Reflective Equilibrium in Theory and Practice (Cambridge: Cambridge University Press, 1996). 9. H. Tristram Engelhardt, Jr., The Foundations of Bioethics (Oxford: Oxford University Press, 2nd ed., 1996); John Stuart Mill, On Liberty and Subjection of Women (Hertfordshire: Wordworth Classics of World Literature, 1996).

Four DOES BIOETHICS NEED MORAL THEORY? Eve Garrard and Stephen Wilkinson 1. Introduction In this paper we address the title question—"does bioethics need moral theory?"—by looking first at normative ethical theory (section two) and then at metaethical theory (section three). In each case, we outline the "anti-theory" arguments, those which purport to show that theory is unnecessary or of little use to bioethics, and then critically assess such arguments, concluding that they are (for the most part) unsuccessful. After critiquing the anti-theory arguments we also (in section four) suggest some pro-theory arguments and some practical ways in which moral theory does, and should, influence bioethics.

2. Normative Ethical Theory At the level of normative moral theory, the anti-theory view raises two main objections. The first is that theories such as consequentialism and deontology are insufficiently action-guiding: they do not in fact tell us what to do (it is argued) and so how can they be of use in solving the substantive moral problems which constitute bioethics? Consequentialism by itself does not tell us whether abortion is right or wrong, for example—all it can say is that we ought to maximize good outcomes. Until we feed in an account of what constitutes good outcomes in this context, which in turn will require us to draw on a wide range of empirical data, we will be no nearer a determinate account of what it is that we ought to do. Deontology is in no better shape in this respect; it too requires a range of supplementary assumptions and data before it can produce a clear action-guiding outcome. The second objection is that theories such as consequentialism and deontology are not as a matter of fact incompatible at the level of bioethics. It is true that on the face of it, these two families of theories are quite different, and admittedly the simplest forms of each, act-consequentialism and absolutist deontology, can deliver quite different prescriptions for action. For any moral problem, the act-consequentialist will tell us that the right action is the one that maximizes value, which produces the best outcomes. So as long as we have a plausible theory of value in hand, and a grasp of the relevant empirical data, we

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can read off the right action directly from the account of the maximum good available in the situation. But absolutist deontology, which claims that there is a range of different, mutually irreducible, moral principles, each one of which has no exceptions, will flatly deny that the right action is always the one that maximizes the good. In fact, all forms of deontology will share this view—for according to deontologists, other considerations (such as the duty to keep our promises, or to pay our debts) may sometimes take priority even if doing our duty does not produce the best consequences. So, if we confine ourselves to the most basic forms of these theories, they do appear to deliver different outputs at the level of bioethics (and applied ethics more generally). However, as soon as the theories become at all sophisticated (so the anti-theorist's argument goes) they become remarkably similar in the guidance they offer. Rule-consequentialism, or indirect act-consequentialism,1 prescribes actions very similar to those prescribed by some forms of deontology.2 And this is no accident—these more complex forms of consequentialism have been developed precisely to try to capture the moral intuitions which drive deontology.3 In response to this, there is quite a lot that the pro-theorist—the person who thinks that bioethics does need moral theory—would want to say. First, she would want to point out that the two anti-theory objections do not appear to form a coherent pair: the claim that theory is not action-guiding is not really consistent with the claim that different theories guide action in the same direction. But putting that point to one side, the pro-theorist will, for both of these objections, want to accept the truth of much of their content, while denying that the anti-theory conclusions follow. With respect to the first objection, the pro-theorist will happily agree that moral theories do need to be conjoined with other information to generate prescriptions. Specifying a theory-type is never going to be sufficient to determine the solution to a moral dilemma—"I'm a deontologist so abortion is wrong" just will not do. But then whoever thought that it would? Certainly no pro-theorist need be committed to the absurd view that the empirical data are irrelevant to the moral state-of-play, as if the medical or psychological facts made no difference to what it is right for us to do. In the case of consequentialism, the relevance is obvious: we need to know the facts about the outcomes of the different actions available to us if we are to perform the consequentialist calculation. But the empirical facts are also relevant for absolutist deontology. This normally involves the presence of subsidiary doctrines such as the acts and omissions doctrine, which claims that acts are morally more significant than omissions, or the doctrine of double effect (roughly, the view that an act with both a good and a bad outcome may be morally permissible so long as only the good outcome is intended, and the bad one unintended but merely foreseen). But this ensures that empirical facts, such as those concerning the intentional structure of the proposed acts, are relevant to the moral verdict.4 However the fact

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that P is action-guiding only in conjunction with Q does not entail that P is not action-guiding at all. So, for example, the (non-moral) injunction to eat five portions of fruit and vegetables a day to maintain good health is only actionguiding in conjunction with information about what foods count as fruit and vegetables. But it still is genuinely action-guiding, as the large amount of money spent by the Department of Health in promulgating it attests. On the basis of this argument, the pro-theorist can accept the truth of the first objection's content, whilst rejecting its anti-theory conclusion. With respect to the second objection, again the pro-theorist can accept the truth of at least part of its content. It is perfectly true that as soon as we move to more sophisticated versions of consequentialism and deontology the difference in output begins to disappear, and so the move to the theoretical level does not, in many cases, help establish which substantive moral judgments we should endorse. However, it is by no means true that there is no difference at all between these theories in terms of their output of moral prescriptions. There is a deep structural difference between the two theories, and this does show up in a set of cases that are handled differently by each of them. For all forms of consequentialism, the right is ultimately derived from the good: value is basic, and what we ought to do is a function of what it is good to have in the world. For deontology, the right action is not necessarily the one which produces the most value in the world: value matters, morally speaking, but so do other things, and not all our duties are based on the production of value. We stand in a variety of different relations to others, and these different relationships (for example of parent to child, of promiser to promisee, of healthcarer to patient) can generate duties independently of value considerations.5 As a result of this structural difference between the two theories, the kind of moral rules that they recognize differ. Deontology includes agent-relative moral principles, that is, rules which contain an ineliminable reference to the agent herself, whereas all forms of consequentialism recognize only principles which are ultimately agent-neutral. The nature of the principles will not always be obvious from their surface structure: a principle that claims that every parent has a duty to look after her own children has both an agent-relative and an agentneutral construal. On the agent-relative construal, the principle tells each one of us to look after her own children, independently of any duty we may or may not have to ensure that children get looked after. On an agent-neutral construal, however, the principle tells each of us to ensure that children get looked after by their own parents. These two construals come apart in a certain sort of situation, namely where the agent can only ensure that the maximum number of children get looked after by their own parents, by herself neglecting to look after her own children. On an agent-neutral understanding of the rule, that is what she should do. On an agent-relative understanding, that is prohibited—the rule says to each one of us: look after your own children! It does not tell us to maximize the

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number of children who get looked after by their own parents—that is the agentneutral understanding of the rule. Why do the two theories recognize different kinds of rules? The difference derives from the central role which value plays in consequentialism, and the more peripheral role it has in deontology. For any given value, such as the value of having children looked after by their own parents, consequentialism tells us to maximize it. Hence, it must take the agent-neutral construal of the relevant moral principle. But for deontology, the right thing to do is not a matter of maximizing value at all, so it is free to recognize the existence of agent-relative rules.6 The anti-theorist might at this point complain that such rules, and the difference between the two construals, play no part in bioethics. But consider how we might think about a doctor's duty, say, to look after her own patients. This moral requirement can be construed agent-neutrally, as a principle which enjoins us to maximize the extent to which doctors look after their own patients, or agentrelatively, as a rule which says to each doctor: you must look after your own patients. These rules look quite similar, and in many situations they prescribe exactly the same behavior, since normally the easiest way for any doctor to maximize the extent to which doctors look after their own patients is to look after her own patients herself. But in some situations the two rules will come apart. Suppose our doctor is in a situation where she can maximize the extent to which doctors look after their own patients only by, herself, neglecting her patients—perhaps she has to choose between looking after her own patients or training ten other doctors to look after their own patients. The agent-neutral version of the rule will tell her to go ahead and train the other doctors. The agent-relative version of the rule will say: that is only morally permissible if you can go on looking after your own patients. So the two rules in this case will prescribe different actions. Consequentialism must construe the rule as an agentneutral one, since it must construe it as deriving from the value attributed to doctors looking after their own patients. Deontology, on the other hand, is at liberty to construe the rule as an agent-relative one, since as we have seen, for the deontologist the right is not derived from the good. It can be conceded to the anti-theorist that many, perhaps even most, bioethics issues do not have this structure, although some do. However, there are two further reasons for thinking that normative theory is important in bioethics. Firstly, consequentialism and deontology are not the only contenders in the theoretical arena. There are also virtue ethics, feminist ethics, and a range of other theoretical possibilities. It is most unlikely that they would all give the same readings on the bioethical issues that trouble us. So the choice of theory will certainly guide us in dealing with those problems. Secondly (and perhaps this point applies especially to the teaching of bioethics), the different theories involve quite different styles of moral thinking. So, in discovering which one is

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most acceptable to us, which one is most convincing, we are finding out something about different ways of "doing" ethics, including bioethics.

3. Metaethics We turn now to metaethics, to theories that concern themselves with the meaning and status of moral utterances, and with the existence and nature of moral properties and facts. Given metaethics' inescapably theoretical subject matter, it is perhaps not surprising that it should be accused of uselessness when it comes to issues in applied ethics. For, at first glance, the view that metaethical differences have no substantive moral implications—that metaethics leaves everything just as it is—is attractive, as is the related view that metaethics (therefore) cannot "do anything" for bioethics. One reason for this is that metaethics is abstract, whereas (a good deal of) bioethics is concrete, concerning itself with real cases, laws, practices, and policies. Another is that metaethics is essentially external to the practice of "doing ethics." It analyses the whole practice from an external perspective, looking not at the Tightness or wrongness of specific actions or beliefs, but at the nature of the whole discourse or enterprise. Thus, one might argue, metaethical views (which are supposed, after all, to be philosophical analyses of ethical discourse) cannot, or should not, conflict with or entail particular substantive moral prescriptions. A useful analogy here might be philosophies of science which, one might argue, ought not to (or cannot) conflict with particular scientific theories. However, this argument for the "uselessness" of metaethics will not work because it ignores the fact that several well-known metaethical views have obvious practical implications. The most famous and popular of these is moral relativism: more specifically, metaethical relativism, which says (roughly) that there is no single true or most justified morality and that moral propositions are true (insofar as they are true at all) just in virtue of their conforming to the relevant society's attitudes or conventions. (This view should be carefully distinguished—and is not entailed by—descriptive relativism, the view that there is, as a matter of fact, extensive cross-cultural and inter-personal diversity in moral attitudes and opinions.) So according to relativism, a particular practice—say, sex between adults and children—may be "wrong-for-us" (for example the population of England) because we generally have negative attitudes to such relationships, but at the same time "right-for-them" (some other society) because, in "their" society, sexual relationships between adults and children are generally approved of. Relativism of this sort has two direct implications for bioethics. The first is methodological. For if (as relativism tells us) what makes propositions such as "X is wrong" true (or "true for S," where S is a relevant social group) is that the

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fact that "X is wrong" is endorsed by most members of the relevant community, then we can find out the answer to most, if not all bioethical questions just by surveying people and finding out what they think. So, if relativism is true, then bioethics should be little more than a branch of sociology. This is because sociologists could (at least in principle) give us the answer to bioethics questions such as "is sex selection wrong?" just by surveying people and finding out what they thought about sex selection. If people generally like sex selection, then it is permissible or good. If they do not, then it is wrong. Criticizing relativism is not our aim here, but it is nonetheless worth pointing out that this implication exposes a major flaw in the theory—the uncritical identification of "might" (majority opinion or social convention) with "right" (what people really ought to do). For while public opinion should be taken into account when framing policy, there is no necessary connection between what "society thinks" about any given issue and the moral truth of the matter. In other words, it is possible for "society to think" that sex selection is immoral even if, in fact, there is nothing wrong with it. Or, to employ more telling (if rather cliched) examples, it is possible for a "society to think" that sexual relationships between adults and children, genocide, and torturing kittens "for fun" are all morally permissible, even though—really—such practices are wrong. As we have said, relativism of this sort has two direct implications for bioethics. The second (which is closely related to the first) is that it appears to commit us, as bioethicists, to being deeply conservative, or at least conservative with respect to the present conventions and practices of our own society. This is because we can "read off' the answers to moral questions from public opinion and because (since, on this view, "might is right") there appears not to be a perspective from which to criticize prevailing views on moral matters. Let us turn now to look briefly at another metaethical theory with bioethical implications: moral nihilism.7 Nihilism is sometimes confused with metaethical relativism, but really the two are quite different. For while relativism gives an (albeit implausible) account of what makes moral propositions true (social attitudes or conventions), nihilism says that there are no true moral propositions—that they are all false. According to nihilists, morality is all a big mistake, there are no moral facts, properties or truths, and those of us who believe in such things are in the grip of an illusion. Clearly, this view is not useful to bioethics if by "useful" we mean something like "able to underpin particular bioethical arguments or views." For it is too negative, rejecting all positive ethical views as false and all positive moral arguments as unsound. Similarly, it is too general to be "useful," treating all ethical views and arguments with equal disdain. However, the existence of nihilism as a theoretical possibility does (like the existence of relativism) serve to refute the view that metaethical differences have no substantive moral implications—that metaethics leaves everything just as it is. Indeed, nihilism serves to illustrate a more general fact about metaethics,

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a fact which is the main reason why the anti-theory arguments considered so far will not work. This is that while (admittedly) some metaethical theories do attempt to do nothing more than analyze our ordinary moral discourse ("leaving everything just as it is"), other theories (including egoism and nihilism) are revisionary, asserting that some or all of our moral beliefs are false and should be modified or abandoned. The anti-theorist then appears bound to concede that some metaethical theories have implications at the substantive level and that these implications often impact on bioethics. How might she respond to these points? One response is to claim that only "exotic" or "extreme" metaethical theories (like nihilism and relativism) have implications at the substantive level and that such theories can be ignored for the purposes of getting on with practical work in bioethics. A parallel here might be natural scientists, who normally manage perfectly well without engaging with relativistic or skeptical theories in the philosophy of science—even though such philosophical views (if true) would have profound implications for science. The anti-theorist may argue then that bioethicists (rather like natural scientists) can get on with "doing bioethics" without worrying about nihilistic and relativistic theories in the philosophy of ethics (metaethics). A second (related) anti-theory response is to suggest that when doing bioethics we can and should act as if "folk" ethics (the moral attitudes and beliefs of "ordinary" people) is broadly true, engaging critically with such attitudes only when they are internally incoherent. In other words, we should ignore meta-level critique of ethics-in-general and engage only in "practice-internal" critique. We would certainly agree that the bioethicist should be principally concerned with issues in applied ethics rather than with ones in moral theory. Otherwise, what is the point in calling oneself a bioethicist instead of a philosopher? However, the stronger view that one can get on with "doing bioethics" without worrying about metaethics at all, and that one can do bioethics by acting as if "folk" ethics is broadly true, appears to us to be problematic on at least two counts. The first problem is that much of "folk" ethics is itself theory-laden. In other words, ordinary people's thoughts about morality are often driven by metaethical assumptions and so, in order to engage with these first-order views, it is necessary to engage with the metaethical assumptions lying behind them. Again, relativism provides a good example. Many people think that commitment to metaethical relativism implies a commitment to the ethical claim that we ought to tolerate a wide diversity of different moral views. Not many philosophers endorse the view that relativism will take us straight through to tolerance—at least not since Bernard Williams gave it such a hammering back in 1973.8 But many non-philosophers do think this—after all, if the truth or legitimacy of a moral claim is relative to an individual's or society's opinions on the

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matter, then what grounds can we possibly have for criticizing other people's moral judgments? For reasons that cannot be spelled out in any detail here, our view is that if we want to find a secure place in morality for tolerance, we will do better to ground it in some form of moral realism. But the point we are wanting to make here is that this metaethical debate is found in folk morality, and very often in the healthcare context. And the very widespread debates about multi-culturalism, for example, also take place well outside the walls of academe, and they are clearly affected by background views about relativism. A rather different example of "folk" ethics being theory-driven is religious ethics. For example, many people still believe that what makes moral propositions true is that God endorses them or that they can be derived from The Bible (or from some other supposedly authoritative religious book such as The Koran). This is a metaethical theory of a sort and one that is extremely influential, especially in countries less secular than our own. Hence, bioethicists will need, from time to time, to engage critically with this theory (which incidentally appears to us to be pretty implausible, even for those with religious beliefs). For example, in debates about abortion, euthanasia, and sex, we sometimes come across religious people whose main argument is that such-and-such a thing is wrong because it is condemned in The Bible. In such situations, challenging their metaethical view may be required. The second problem with trying to take "folk" morality at face value when doing bioethics is that "folk" morality is incoherent (or perhaps non-existent). For people—even people with quite similar backgrounds and cultures—often disagree, not only about superficial things, but about quite deep matters. For example, some people take the "sanctity of life" doctrine seriously and some do not—and some people believe that embryos are morally significant while others do not. So either "folk" morality, understood as the conjunction of different individuals' views, is self-contradictory, or (more plausibly) we should say that there is no such thing as the "folk" morality, but instead that there are many different "folk" moralities. But either way—whether there is one self-contradictory morality or several competing ones—it is just impossible to accept "folk" morality uncritically and to act as if it were true. For the different "folk" moralities will involve different, often incompatible, prescriptions. 4. Theory and Intuition: A Symbiotic Relationship? We turn now to some more general thoughts about the relationship between metaethical theory and the substantive moral questions that constitute bioethics. Firstly, we will argue that our grasp of the moral problems themselves may involve hidden theoretical commitments, such that we cannot even discuss, let alone settle, the moral problems independently of these assumptions. Secondly,

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our theoretical and substantive moral views may be inextricably interdependent, such that neither can be established without an appeal to the other. Taking the first of these points, let us consider how we might go about trying to establish whether (say) euthanasia is morally permissible. Part of the argument is bound to include some reference to the putative wrongness of killing innocent human beings, to a principle claiming that killing the innocent is wrong. But one of the disputants is likely to claim that though it is often wrong to do this, it is not always prohibited—that is, if such a principle exists, it is not absolute. Moral principles play a very well-known role in bioethics, especially in medical ethics. But the legitimacy (or otherwise) of absolute moral principles, or of any moral principles at all, is a theoretical issue, which cannot be settled entirely at the substantive level. The possible positions here range from a commitment to absolute moral principles, from which particular moral judgments such as the one about euthanasia can be read off, through to the belief that there are moral principles, but they are not exceptionless and they have to be weighed against each other in specific cases, all the way to the view that there are no legitimate moral principles at all—each moral situation must be judged entirely on its merits.9 The difference between principlism (or generalism) and particularism in ethics, is partly an issue in normative ethics (to the question "what principles should we adopt?" the particularist replies "none"), and partly an issue in metaethics, making claims about the nature of moral judgments (they are not derived from moral principles). If the argument about euthanasia is to be adequately settled, then somewhere along the line this theoretical issue will have to be addressed. Far from being redundant, theory appears to be underpinning many of the moral positions on this topic. And it is hard even to make sense of, let alone engage with, such positions without a solid understanding of their theoretical foundations. Turning now to the possibility that our theoretical and substantive moral views may be inextricably interdependent, we note (not for the first time in this paper) that a notorious feature of all substantive moral discourse is the extent to which there is disagreement in moral matters. Some quite widespread moral intuitions are incompatible with others; since rationality requires that there be no contradictions in our views, we know that we must either show that the appearance of incompatibility is mistaken, or we must dump at least one of the moral intuitions. Indeed, much of the argument in bioethical issues involves pointing out inconsistencies in different positions. But though the charge of inconsistency (if made successfully) is a very powerful one, it does not by itself solve the problems facing us: it does not tell us which intuition has to be abandoned. For this we generally turn to theory—we say that our duty as healthcare professionals to our individual patients overrides the demands of the general good; or alternatively we say that it must be right to do as much good as we can with our limited resources, and so the needs of one particular patient must be weighed

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against those of others. But these are theoretical claims (of very familiar kinds). Furthermore, when we are trying to construct our theories, one of the principal constraints on them is that they should capture as many of our moral intuitions as possible. We know that no adequate theory will capture all of them, since some of them contradict others, but it is a strike against a moral theory if it fails to accommodate a fair number of our most dearly held moral intuitions. All this is just to say that there is a symbiotic relationship between moral theory and moral intuitions: we constantly adjust one in the light of the other, in a process of reflective equilibrium. So again we see moral theory playing a crucial role in the construction of our moral judgments.

5. Conclusion So does bioethics need moral theory? Our view is that it does, or at least bioethics is better off with moral theory than without it (if the latter is a real possibility). In the preceding sections, we have tried to show that the anti-theory arguments, those which purport to show that theory is unnecessary or of little use to bioethics, are generally weak and unconvincing. For not only normative ethical theory, but even metaethics, can have implications at the substantive level. We have also suggested that theoretical and practical moral views are inextricably interdependent, in which case bioethics without theory may well be impossible—unless "bioethics without theory" just means ignoring the fact of the interdependence of substantive and theoretical issues. And surely the antitheory view is not just a call to ignore the genuine complexities which are present in the field of bioethics? If it is, we should dismiss it—substantive morality, in bioethics as elsewhere, is never going to be simple.

NOTES 1. See D. McNaughton, "Consequentialism," Routledge Encyclopaedia of Philosophy Online, ed. Edward Craig, http://www.rep.routledge.com/. 2. See W. D. Ross, The Right and the Good (Oxford: Clarendon Press, 1930). 3. See Peter Railton, "Alienation, Consequentialism, and the Demands of Morality," Consequentialism and Its Critics, ed. Samuel Scheffler (Oxford: Oxford University Press, 1988). 4. See Nancy Davis, "Contemporary Deontology," Companion to Ethics, ed. Peter Singer (Oxford: Blackwell, 1991). 5. See Ross, The Right and the Good.

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6. See David McNaughton and Piers Rawling, "On Defending Deontology," Ratio, 11:1 (1998). 7. See J. L. Mackie, Ethics: Inventing Right and Wrong (Harmondsworth: Penguin Books, 1977),ch. 1. 8. See Bernard Williams, Morality (Harmondsworth: Penguin Books, 1973). 9. See Jonathan Dancy, Moral Reasons (Oxford: Blackwell, 1993), ch. 4.

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Five "PARITY OF REASONING" ARGUMENTS IN BIOETHICS—SOME METHODOLOGICAL CONSIDERATIONS S0ren Holm 1. The Role of Parity of Reasoning Arguments Many writers in bioethics explicitly reject a foundationalist metaethics and its normative corollary in the form of the so-called "engineering model" of applied ethics, and others write as if they had no foundational theory although they actually have one. The writings therefore display a form of reasoning that is congruent with a coherentist metaethics of the kind that Matti Hayry has called rational intuitionism, and defined in the following way: All moral choices and principles should be justified by rational arguments. These arguments, in their turn, must ultimately be based either on the normal usage of language, on the cool consideration of rational preferences, or on thought experiments involving hypothetical, and often exceedingly fanciful, examples.1 One very commonly used argumentative strategy is the employment of "parity of reasoning" arguments (PRAs), with or without the use of hypothetical examples. In this paper I will identify some ways in which parity of reasoning arguments may fail, and argue that this form of argument is often used in bioethics in circumstances where its validity is questionable.

2. Some Different Forms of Parity of Reasoning Arguments and their Problems The simplest form a PRA may take is the following: (1) X puts forward an argument A leading to conclusion B. (2) Argument A will (perhaps with the addition of some further premises that X accepts) also support conclusion C.

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S0RENHOLM (3) X is therefore by parity of reasoning committed to accept conclusion C.

The only way this manner of using the PRA may fail is if additional premises are needed in step 2, and if the additional premises introduced are not premises that X is willing to accept. A slightly more complex situation arises if the argument Al that X puts forward is not complete, that is if it has enthymematic premises. This is a situation that often occurs in real life since even arguments in academic papers are often not complete. In this case we must therefore introduce one further step in our PRA:

(1) X puts forward an incomplete argument Aj leading to conclusion B. (2) Aj can be made complete by the addition of premises PrPn (3) The complete argument A1Com will (perhaps with the addition of some further premises that X accepts) also support conclusion C. (4) X is therefore by parity of reasoning committed to accept conclusion C. This version of the PRA may fail for the same reasons as the simple PRA, but it may also fail if X rejects the way in which AI is made complete. In many cases a valid complete argument can be produced from an incomplete argument in several different ways, with additional premises of varying strengths, and unless X him— or herself has completed the argument—and thereby brought us back to the simple PRA—he or she is not necessarily bound to accept the completion. In some situations we may be able to find support for the specific completion of the argument in X's other writings or statements, but if that is not the case, our PRA may be severely weakened, unless we can show that our completion is one that X ought to accept, for instance because it uses the minimum number of controversial new premises. These considerations entail that a PRA based on an incomplete argument is often much weaker than a PRA based on a complete argument, because we cannot conclusively show that X is (or should be) committed by our completion of his or her argument. In bioethics the PRA is, however, not only used when somebody has put forward an argument leading to a conclusion, but also in situations where the basis for the PRA is an action that X has performed and an argument implied as the justification for this action. In such situations the PRA takes the following form:

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(1) X has performed act Y (or in some cases: X has performed acts Y r Y n , but not acts Zj-ZJ. (2) The justification for Y can be reconstructed as argument A*. (3) Argument A* will (perhaps with the addition of some further premises that X accepts) also support conclusion C. (4) X is therefore by parity of reasoning committed to accept conclusion C. In this case the PRA is only uncontrovertibly valid if our reconstructed argument A* is either accepted by X, or the only possible argument justifying X's act Y, otherwise the inference from 3 to 4 fails. If there are alternative justifications available to X, as will often be the case, the conclusion of our PRA may still be true, but only if step 3 is sound for all of these alternative arguments. A final form of the PRA sometimes seen in bioethical discourse combines features of the two last types of PRA discussed above. This is the PRA proceeding from official regulation or legislation. This type of PRA occurs in two subtypes parallel to the two types of PRA discussed above. The first sub-type is: (1) (2) (3) (4)

Authority X promulgates regulation R. X puts forward an incomplete argument A1R supporting R. A1R can be made complete by the addition of premises Pi-Pn. The complete argument A1RCom will (perhaps with the addition of some further premises that X accepts) also support regulation C. (5) X is therefore by parity of reasoning committed to accept regulation C. The second sub-type is: (1) Authority X promulgates regulation R. (2) The justification for R can be reconstructed as argument AR*. (3) Argument AR* will (perhaps with the addition of some further premises that X accepts) also support regulation C. (4) X is therefore by parity of reasoning committed to accept regulation C. These "official policy" based PRAs may fail for the reasons already discussed above. But a further possible mode of failure occurs if regulation R has been promulgated in a situation where R is a result of a compromise, either because X has openly engaged in a compromise with some other group, or because X has taken the views of some other group into account already when drafting the regulation (for instance in order to ensure a smooth passage through the political process). If a regulation is based on a political compromise it may well be the case that no-one wants to defend or justify the position reached in the regulation, except as a legitimate result of a legitimate political process.

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An example could be the abortion legislation in countries allowing abortion on demand until a certain gestational age. It is unlikely that many people would actually claim to have an argument that can justify the exact limit legislated in a specific country, but many more might be willing to accept it as a legitimate political compromise between those wanting a higher limit and those wanting a lower limit. Such laws therefore do not necessarily imply that something radical is thought to happen to the moral status of the fetus or the moral rights of the mother when the gestational age in question is reached. A PRA based on official policy also needs to take into account that there are limits to the precision with which we can draft regulation, and that ethically extraneous factors play a role. As Tom Beauchamp and James Childress write: Public policy is often formulated in contexts that are marked by profound social disagreements, uncertainties, and different interpretations of history. No body of abstract moral principles and rules can determine policy in such circumstances, because it cannot contain enough specific information or provide direct and discerning guidance. The specification and implementation of moral principles and rules must take account of problems of feasibility, efficiency, cultural pluralism, political procedures, uncertainty about risk, noncompliance by patients, and the like.2 In evaluating official policy it is also crucial not to forget that the ideal policy has to be both locally and globally coherent and consistent, and that maximal coherence in a body of regulations may be achieved by allowing some local inconsistencies. In many legal systems it is for instance accepted that a major change in legal status occurs at birth. This principle permeates many areas of law, also outside of the laws strictly dealing with reproductive matters, and it is at least arguable that global consistency is better served by upholding it in all cases, even if there are a few cases where it might seem to be locally inconsistent.

3. Parity of Reasoning and the Use of Examples A close relative of the PRA often employed in bioethics is the use of a hypothetical example, followed by recourse to the PRA or a more general injunction of consistency when the interlocutor has responded to the example. A classical example of this kind of argumentative strategy can be found in James Rachels's famous article "Active and Passive Euthanasia," where he presents us with the case of two uncles, Smith and Jones, in order to convince us that there is no morally relevant difference between killing and letting die. Rachels writes:

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So, let us consider this pair of cases: In the first, Smith stands to gain a large inheritance if anything should happen to his six-year-old cousin. One evening while the child is taking his bath, Smith sneaks into the bathroom and drowns the child, and then arranges things so that it will look like an accident. In the second, Jones also stands to gain if anything should happen to his six-year-old cousin. Like Smith, Jones sneaks in planning to drown the child in his bath. However, just as he enters the bathroom Jones sees the child slip and hit his head, and fall face down in the water. Jones is delighted; he stands by, ready to push the child's head back under if it is necessary, but it is not necessary. With only a little thrashing about, the child drowns all by himself, "accidentally," as Jones watches and does nothing. Now Smith killed the child, whereas Jones "merely" left the child to die. That is the only difference between them. Did either man behave better, from a moral point of view? If the difference between killing and letting die were in itself a morally important matter, one should say that Jones's behavior was less reprehensible than Smith's. But does one really want to say that? I think not.3 As soon as we have assented to Rachels' s "I think not" we are—at least as far as Rachels is concerned—on the parity of reasoning hook and can be forced to admit that there is no difference between killing and letting die in a range of other circumstances, including the case that Rachels is really interested in: the case of euthanasia by a medical doctor. Rachels's hypothetical case, and his interpretation of it, is problematic in several ways, as has been pointed out by many critics over the years.4 There is some amount of overdetermination at play, and there is an unargued elision of the moral evaluation of an act and the moral evaluation of the agent performing the act. It could be the case that although Smith's and Jones's acts are not morally equivalent, the two men are equally reprehensible. However, what is important in the current context is not the possible deficiencies of Rachels's case, but the light it can shed on the use of the PR A based on hypothetical examples. What Rachels wants to argue is something like the following: (1) In this pair of cases "killing" and "letting die" are morally equivalent because both cases involve the death of the cousin as a result of an action by the uncle. (2) Anyone who accepts (1) must accept that in other situations where cases differ only in being either "killing" or "letting die," there is by parity of reasoning no moral difference between the cases.

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If we are unconvinced of the moral equivalence at this stage, it would be possible to devise other hypothetical examples to deal with the objections raised, and we would get a chain of examples leading inexorably to the conclusion that there is no difference between "killing" and "letting die." Such use of examples can be found in many papers and books on euthanasia, and the conclusion argued for is almost invariably that what matters is not the nature or description of the act, but its consequences. It is, however, important to see that we could just as well have moved through a quite different chain of hypothetical examples to a quite different conclusion. This chain would start with an only slightly different PRA: (1) In this pair of cases "killing" and "letting die" are morally equivalent because both cases involve the intended, and directly aimed at, death of the cousin. (2) Anyone who accepts (1) must accept that in other situations where cases differ only in being either "killing" or "letting die," there is by parity of reasoning no moral difference between the cases. The endpoint of this chain of hypothetical would be that what matters is not the description of the act, but its underlying (objective?) intention. The more general point is that most hypothetical cases are not selfinterpreting or straightforwardly interpretable in only one way. When a person concurs with a judgment about a specific case, there are often several different possible justifications for that judgment, and we cannot necessarily decide from the judgment which of the justifying arguments the person will assent to (it may even be the case that he or she will assent to more than one). The situation we are in can be illustrated as in Figure 1. As the author of a paper using the strategy for argumentation, it is up to me to decide which of the possible underlying distinctions to emphasize in my choice of further positive or negative hypothetical examples. And by choosing wisely I can try to lead my reader to believe in the relevance or truth of any of the distinctions and arguments that are a possible justification for his or her initial judgment. A real life example of this can be found in the way that both proponents and opponents of the doctrine of double effect use versions of the so-called "Trolley example."5

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Figure 1

This argumentative strategy contains a potential problem because the repeated application of PR As to minutely different hypothetical examples potentially involves an exploitation of either the vagueness of natural language or serial judgments involving imperceptible differences. There is no reason to believe that our moral predicates are less vague than other predicates, and no reason to believe that our moral perception is more fine-grained than our perception of heaps of grain. We may therefore involve ourselves, and our readers, in problems equivalent to the classical problems of the sorites paradox where the question is when we can say that a heap appears in a process of adding individual grains of sand.6 This means that although our opponent may have assented to each step in the chain of arguments, he or she may still be able to deny the conclusion. He or she may not even have to state exactly at what step we have applied the sleight of hand of exploiting vagueness or imperceptible differences, if he or she can just make the case that a sorites has occurred.

4. The Principle of Charity—a Forgotten Principle in Bioethics? As we have seen above, most applications of the PRA and the use of hypothetical examples combined with the PRA involve the analysis and interpretation of arguments put forward by others and their completion or reconstruction.

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It is generally accepted in the field of logic and the analysis of informal arguments, that in this process we should apply the Principle of Charity, even in those cases where we disagree with our interlocutors. The Principle can be stated in the following way: This principle requires that we try to make the best possible interpretation of the discourse being evaluated, whether we are trying to decide if an argument occurs in a passage, looking for the main point of an argument, attempting to clarify the meaning of questionable words or phrases, or formulating missing premises. The aim is to give the benefit of the doubt to the speaker or author. Rather than ridiculing someone for a remark that doesn't follow from what was said earlier or that isn't strictly true, it is more reasonable and responsible to try to reinterpret the passage so that it will make more sense. [...] The Principle of Charity is a reminder to attend to the main thrust of an argument and deal with it fairly. The Principle of Charity also offers sound practical advice by telling us to avoid setting up a "straw man," a weak imitation of the argument we are considering. It may be easy to break down a "straw man," but it will also be easy for an adversary to rebut an attack by reformulating the argument slightly to meet your objections. The arguer will simply claim, correctly, that you have misinterpreted the argument by making it seem weaker than it really is.7 This principle has both an ethical and a pragmatic justification. The ethical justification is that if we do not apply the Principle of Charity we deliberately disrespect our partners in discussion and treat them unfairly. The pragmatic justification is, as mentioned in the quotation, that we have only shown our opponent to be conclusively wrong, if we have shown the strongest possible version of his or her argument to be wrong. Refuting a weak or misleading version of someone's argument does not amount to refuting the argument. If the Principle of Charity was always applied in the development of a PRA, many of the problems identified above would not occur, since the completions and reconstructions of our opponents' arguments would always be done in order to give them the best and strongest possible form. But, as is made evident by even a cursory reading of the bioethics literature, the Principle of Charity is often forgotten, and the opponent's view is put in a weak form or in a form that allows us to score easy rhetorical points. One reason for this is probably that written bioethics is far removed from the kind of dialogue that is conducive to collaborative discourse instead of to competitive discourse. Bioethics is often not a Socratic dialogue between equals, all searching for the truth. I do not have my interlocutors personally present when I write

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my critique of their views, or use them as a foil to expound my views. I am therefore unable to ask them to fill in the missing premises in their incomplete arguments, and I may be tempted to fill them in in a way that benefits my argumentative strategy without being fair to their position. The situation is not much better in public debates where each discussant is often supposed to defend a particular view, and where rhetoric may often be a better strategy than reasoned and balanced argument if we want to influence the public.

5. Conclusion This paper began with an analysis of the problems in the application of one particular type of argument in the field of bioethics, but has gradually moved to a more general critique of the argumentative style employed by some writers in the field (including in moments of weakness the writer of this paper). But why do some bioethical arguments stray across the fine line between argument and rhetoric? The first reason, which is in essence a positive reason, is that many bioethicists have something they want to say. They are convinced that there are things that are right and things that are wrong, arguments that are sound and arguments that are flawed, and they want to persuade the reader to share these convictions, because they think that ethics matters. The conclusions of ethical arguments have real implications for how we ought to live. In many cases it may be easier to move people by effective rhetoric than by complicated argument and counter-argument. If it is the result that matters, the change of position of our partners in conversation, then there is a strong temptation to use the most effective means. The second, and perhaps more negative, reason is that most theoretical positions in bioethics have embarrassing consequences in a range of real life situations. We all have theoretical "patches" that we believe solve these embarrassments, but these patches are often either unconvincing to people not sharing our theoretical convictions, or difficult to explicate. It is therefore often easier, and less fraught with problems, to hide our theoretical commitments and pretend to argue purely on the basis of consistency and coherence. But the problem is that we are in many situations only pretending. When we seem to be trying to reach a set of consistent judgments in a localized field of inquiry, we hide the fact that we already know the outcome because it follows from our hidden commitment to a much larger global network of consistency. Let me therefore end with a plea for truthful labeling of writings and public utterances in bioethics. Let us admit when we are mainly in rhetorical mode, let us not begin our papers with "In this paper I want to explore..." if we really mean "In this paper I want to convince you that...," let us not write "By parity

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of reasoning X is committed to accept..." unless we have looked at X's arguments in the light of the Principle of Charity, and let us not hide the embarrassing consequences that follow from applying PRAs to our views.

NOTES 1. Matti Hayry, Playing God—Essays on Bioethics (Helsinki: Helsinki University Press, 2001), p. 70. 2. Tom Beauchamp and James Childress, Principles ofBiomedical Ethics (Oxford: Oxford University Press, 5th ed., 2001), pp. 8-9. 3. James Rachels, "Active and Passive Euthanasia," Applied Ethics, ed. Peter Singer (Oxford: Oxford University Press, 1986), p. 32. 4. David Oderberg, Moral Theory-—a Non-Consequentialist Approach (Oxford: Blackwell Publishers, 2000). 5. J. J. Thomson, Rights, Restitution, and Risk (Cambridge, MA: Harvard University Press, 1986); F. M. Kamm, "The Doctrine of Triple Effect and Why a Rational Agent Need Not Intend the Means to His End," Proceedings of the Aristotelian Society, supp. 74 (London: The Aristotelian Society, 2000), pp. 21-39; John Harris, "The Moral Difference Between Throwing a Trolley at a Person and Throwing a Person at a Trolley," Proceedings of the Aristotelian Society supp. 71 (London: The Aristotelian Society, 2000), pp. 40-57. 6. Kamm, "The Doctrine of Triple Effect"; Timothy Williamson, Vagueness (London: Routledge, 1994); Vagueness: A Reader, ed. R. Keefe and P. Smith (Cambridge, MA: MIT Press, 1997). 7. R. P. Churchill, Becoming Logical—An Introduction to Logic (New York: St. Martin's Press, 1986), p. 58.

Six ANNE MACLEAN'S CRITICISM OF BIOETHICS Harry Lesser 1. Maclean's Criticisms of "Reason" in Ethics Maclean's The Elimination of Morality: Reflections on Utilitarianism and Bioethics is, as its subtitle indicates, an attack on the utilitarian approach to bioethics, in particular in its contemporary versions; her targets are John Harris, Peter Singer, James Rachels, and Michael Tooley, roughly in that order. It is also an attack on a particular form of rationalism in ethics, to which she claims these writers subscribe, and it is this attack that will be discussed in this paper. I will argue that the attack is unsound for several reasons, but is worth studying, because an examination of why it fails helps us to understand more about the role in ethics of reasoning and of general theories. So the aim of the paper is, via a discussion of some arguments used against one theory of "ethical rationalism," to consider the general question of what uses of reason are appropriate in ethical discussion. This is an old problem, but still very much with us. Maclean characterizes the view that she is attacking as follows. To discover what we ought to do morally, in bioethics or any other area, we need to discover through rational investigation the ultimate basic principles of morality; and then, by working out what logically follows from them and combining this with the relevant facts, we can discover what ought to be done in particular types of situation. This enterprise needs to be undertaken by philosophers, because only a philosopher ... is trained in a discipline that takes nothing for granted ... Philosophy is concerned with the isolation and justification of assumptions, including fundamental assumptions, and it is for those educated in tha^ discipline ... to identify the principles on which rational moral judgments and decisions must be based.1 This is in fact not a fair characterization of the view of rationality held by the particular authors Maclean is attacking. But it is unfair mainly in what it leaves out; and it will be most convenient to deal with this in the course of considering the objections she brings against it. There are three objections, the first being that this involves the claim that those philosophers who, in their own opinion,

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have carried this exercise out correctly, must then regard themselves as moral experts, uniquely equipped to inform others what they should do. Maclean compares her point here with Socrates' objection to the Sophists, but there is an important difference. Socrates thought that there could be such a thing as moral expertise, but that the claim of the Sophists to possess it and be able to teach it was false, since no one yet possessed the required knowledge; Maclean thinks that there can be no such thing. This is important; but first we should consider the question whether anyone who believes that an investigation into the basis of ethics is worthwhile and possible, and that philosophical techniques can contribute to this investigation, must also believe that philosophers who have done this correctly, such as themselves, if they are philosophical ethicists, are moral experts, equipped to teach others what is right and wrong. It should be pointed out that even utilitarian bioethicists, with the possible exception of Peter Singer, do not in fact believe this; but we do have here a plausible argument that logically they should: if you believe that it is possible to discover the basis of ethics by the correct use of reason, and also that you are using reason correctly in order to discover this basis, surely you must then draw the conclusion that you are now a moral expert! 2. Replies to Maclean's First Criticism There are three reasons why the above argument, though plausible, is unsound: and the reasons are both interesting and important. The first is that anyone who has tried to discover the philosophical basis of ethics, even though they may come to believe that they have reached the truly rational conclusion, must, in the light of the immense difficulties in this area and the obvious lack of success, over many centuries, of many great minds, also believe that it is highly likely— close to certain—that they are partly wrong, and more likely than not that they are seriously wrong. Thus John Harris in the preface to The Value of Life comments, in effect, that, while it would be very gratifying if he was right, the subject of bioethics will benefit just as much if someone proves him to be wrong.2 Similarly, there is a well known paradox that anyone who writes a nonfiction book, comprising the statements a, b, c ... and so on, will, if they are honest, believe of a, that it is true, of b, that it is true, and so on, but also believe that some of the propositions a, b, c... are false. So we can believe that we have reached the proper rational conclusion, and also recognize that this itself must be subjected to philosophical scrutiny. This is perhaps the crucial point: the criticism ignores the fact that the exercise is unending, and has to scrutinize its conclusions as well as those of other people. Hence there are no moral experts, not because this is in principle impossible, but because there is no point at which we can claim immunity from further philosophical scrutiny: the practical aim is

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to work toward what is best supported rationally and may at the moment be taken as what is most likely to be true. Secondly, though this exercise is philosophical, there is no reason to suppose that only trained philosophers can undertake it with success. It is to be hoped that a philosophical training can be of help, and probably one motive for doing bioethics at all is the wish to put one's training to some practical use. But an academic course is not the only way of obtaining the necessary skills, and indeed it is neither necessary nor sufficient. On the one hand, Socrates and Plato had no academic training; on the other, Frege, though a brilliant logician, remained a rabid anti-semite. The point can be generalized: there are many skills that are most easily learned by an academic training, some of which it is very difficult to acquire in any other way, but this does not mean either that everyone who has been through the training has the skill at any high level or that no one who has not been trained in the orthodox way can possess the skill. Thirdly, it is certainly useful to try to have a clear grasp of the fundamental principles of ethics in order to reach the right practical conclusions, but it is neither necessary nor sufficient. It is not sufficient, because we can still make mistakes in applying the principles, and also because we may be deflected from working things out rationally by all kinds of temptations and self-deceptions. It is not necessary, because in practice the more precise subsidiary principles, which are sometimes more obvious, may serve as a better guide to action. C. S. Lewis once asked rhetorically whether we would rather play cards with someone who knew the philosophical arguments against cheating, or with someone who had learnt from childhood that a decent person does not cheat. The conclusion of this is that we can hold that the search for fundamental principles is practically as well as theoretically worthwhile, and even that it can be logically established that a rational theory of ethics must be of a certain sort, without believing that being a philosophical ethicist makes a person any kind of moral expert. Moreover, I have already pointed out that hardly any philosophers seem to believe anything like this: if anything, bioethicists have been too reluctant to stick their necks out and say what they think on practical issues.

3. The Second Criticism and Replies to It Maclean's second objection is that "moral bedrock" (my metaphor, not hers) is provided not by principles but by our practices themselves. This means two things. One is that arguments over what should be done, and statements justifying what is to be done, take place in a certain context, and require no reference to anything outside that context. For example, suppose a doctor

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HARRY LESSER agrees to terminate the pregnancy of a frightened fourteen-year-old who lacks the support of the child's father and of her own family... what is held to justify the abortion is the inability to cope; the child's entitlement to life, or lack of it, does not enter into the matter.3

The other is that, though our practices act as justifications, it is neither necessary nor possible to justify the practices themselves: We treat babies in some ways and not in others; not, for example, as if their lives were at our disposal. Bioethicists demand for what reason we do so, but there is no reason—or, to put the same point differently, their being babies is the reason, all the reason in the world.4 Earlier on the same page she says, "We are not of the opinion that it is generally wrong to kill babies. Our thinking this is a matter of what we do, as a matter of course and without question." The consequences of this are, first, that there are no fundamental moral principles from which we can deduce specific moral duties, but only moral practices that we learn to operate. Secondly, though some people clearly operate these practices better than others, this is because of more serious moral commitment and the possession of different moral qualities, such as honesty and sympathy, and not because they have acquired any knowledge not possessed by other people already. Hence even in principle there cannot be moral experts. Although this final conclusion is, as we have seen, probably correct, though in practice instead of in principle, there are two things wrong with the argument. First, practices have varied in different communities in different times and places: no society has held that the lives of babies are at anyone's mercy, but some have held that parents may legitimately decide whether their children live. The argument, if accepted, must lead to cultural relativism: it appears to leave us with no way of challenging, if they are in context, racism, sexism, imprisoning homosexuals and blasphemers, slavery, torture, female circumcision, footbinding, and burning witches. There appears to be no way of saying that "that is what we do" settles the matter when what we do is nice and not when it is nasty. Secondly, it is not true that reasons cannot be given for practices. Indeed, the reverse is true: practices imply certain assumptions, both factual and evaluative. In the example of abortion, given above, the child's entitlement to life, whether mentioned or not, does very much enter into the matter. To consider abortion at all is to presuppose, rightly or wrongly, that the entitlement to life is not absolute: a convinced Catholic would refuse to begin the discussion or to put it on the agenda. That it is often—though not always—unnecessary to refer to these assumptions does not mean that they are not there. The problem is that Maclean makes the Wittgensteinian mistake of supposing that because a statement is not

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one that would normally be made it is therefore unintelligible. "It is generally wrong to kill babies" has a weird sound, but it is both true and intelligible, though admittedly weak, since killing babies is not just generally wrong but almost always abominably wrong. Moreover, there are contexts in which a person may need to make some statement of this sort—for example in war, distinguishing combatants and non-combatants, given that extreme callousness toward the children of the enemy is by no means unknown, even among those whose cause is just. Hence, we can always intelligibly ask what justifies a practice, and given how many practices are undesirable or worse, we must.

4. The Third Criticism and the Reply Maclean's third argument is that rationality in this sense demands an inappropriate emotional detachment, requiring people to regard their families and friends as no more important than anyone else, and favoring them only when this has good social consequences. This is because the aim of morality must be, for this kind of rationalist, to bring about the best possible consequences. So we must consider how many people are affected by our actions, whether for good or bad, and how intensely. But who these people are is morally irrelevant—the only ground for favoring one person over another could be the social usefulness of doing so. And such "rationality," it could be said, is inhuman. This argument applies, as set out here, to a consequentialist rationalism, such as is indeed held by Maclean's main targets, who are committed to the view that what is right is what has the best consequences. It sounds plausible, but it fails against any subtle form of consequentialism. For if the promotion of human happiness and the reduction of suffering are at least among the aims of morality, as consequentialists claim, then it is perfectly reasonable to maintain that, in the interests of long-term welfare, we should cultivate family affection, friendship and mutual help among families and friends, even if on particular occasions this fails to produce the best short-term results. The point here is to recognize that emotions are not inherently irrational. Morally the rational thing to do is not to try to be emotionally detached, but to cultivate those emotions that on the whole motivate morally desirable behavior, such as family affection and loyalty to one's friends, and even love of humanity, if we can manage it, and to suppress or eliminate only the undesirable emotions, such as racism or general misanthropy. As has been recognized since Aristotle, rational ethics requires both appropriate emotional responses and the recognition of special duties, such as those to one's family and friends. However, ethics also requires, under some circumstances, a properly detached and unbiased approach. Hume—not a philosopher who underrated human emotions—pointed out correctly in the Enquiry Concerning the Principles of

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Morals that "limited benevolence," that is being concerned only with one's family and friends, did as much harm, or more, to a society as did pure selfishness. (The Cosa Nostra would be an obvious modern example of great generosity within the family and organization being combined with total unscrupulousness outside it.) The truth is that there are areas of moral and political life, such as the operation of the law and the Civil Service, that require the setting aside of private feelings and obligations, in the name not only of the common good but also of justice. There are other areas of life where it is right and proper to favor one's family and friends. It has sometimes been thought, not only by Maclean, that this poses a problem for the consequentialist, because it means that we should not always do what has the best consequences—for example, if resources are limited, a person should help his or her family, instead of trying to work out who is most socially useful and giving it to them. But, as we have seen, a proper consequentialist view will support favoring one's family in these situations, as being the type of behavior that will be best for humanity in the long-term, given the vital need for family support. So the answer to this third criticism is first, that sometimes emotional detachment is morally required, and secondly, that when it is not, it is not required by the demands of rationality. To meet the requirements of a rational ethic does not entail being rational in the sense of being detached or unemotional. Both inappropriate emotion and inappropriate lack of emotion can interfere with good ethical reasoning. 5. Consequences of the Above From all this I think we should conclude, in opposition to Maclean, that existing moral practices and moral feelings do need to be examined and challenged. It follows that the rational search for basic moral principles is proper and necessary, though probably destined always to only partial success, and can be carried out without either unnatural detachment or the arrogant assumption that philosophy will make us moral experts. But a key question remains: if practices and feelings must be challenged by reason, why should not reason be challenged by appeals to feelings and to established practice? Such a challenge might make a weak or a strong claim. The weak claim, which is not a problem for the rationalist, is that the existence of the practice, or the feeling, should make anyone whose moral theory is incompatible with it examine their position carefully, to make sure that the opposing position does not have merits that they have overlooked. The strong claim is that feelings or practices stand to moral theories as facts stand to scientific theories, and their existence can serve to refute theories that are incompatible with them. It is often argued, for example, that utilitarianism must be wrong because it leads to the conclusion that sometimes we should punish the innocent or torture suspects, and utilitarians have to decide whether

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to argue that the conclusion can be avoided or that it is morally acceptable. The problem is that the strong claim is sometimes quite unconvincing, as when people have argued that interracial marriage is wrong because it makes them feel sick, and sometimes quite convincing: we may feel more sure that neonates have a right to life than of the correctness of any argument concluding that they do not. It appears to me, therefore, that we cannot rely only on reason or only on feelings and practices, and that those who talk about "reflective equilibrium" are right. But this is not an answer, only the recognition of a problem, which I suspect requires a lot more work. Nevertheless, if the argument of this paper is correct, the problem is unavoidable, because the two alternative positions, that of Maclean herself, that we have to rely on our practices and our feelings because nothing else is possible, and that of her imaginary opponent, that we should rely on reason alone and ignore any conflicting feelings, are both in the end untenable.

NOTES 1. Anne Maclean, The Elimination of Morality: Reflections on Utilitarianism and Bioethics (London: Routledge, 1993), p. 4. 2. John Harris, The Value of Life: An Introduction to Medical Ethics (London: Routledge, 1985). 3. Maclean, The Elimination of Morality, p. 30. 4. Ibid., p. 36.

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Seven THE PRINCIPLIST APPROACH TO BIOETHICS, AND ITS STORMY JOURNEY OVERSEAS Peter Herissone-Kelly ic? 1. The Global Applicability of Principlism—an Empirical Thesis?

The principlist approach to bioethics, pioneered by Tom Beauchamp and James Childress in their hugely influential book Principles of Biomedical Ethics, can usefully be characterized as consisting of two central theses. The first is that of the non-absolute nature of moral principles. The claim is that the institution of morality includes a plurality of principles, and there is no "determinate order of precedence" amongst those principles. That is, each moral principle is prima facie only, and can, depending on context, be overridden by any other. The prima facie principles that Beauchamp and Childress consider to be most relevant to the sphere of bioethics are four in number: respect for autonomy, beneficence, non-maleficence, and justice. The second central claim might be labeled the global applicability of the four principles thesis ("the global applicability thesis" for short). Its contention is that the four principles are derived from a core set of norms—the "common morality"—to which all "morally serious persons" supposedly subscribe, regardless of their culture, or of the time in which they live.1 The suggestion is that, with the common morality as its foundation, principlism cannot fail to be universally applicable. The bioethical community in the United States, principlism's country of origin, tended on the whole to extend a hearty welcome to the approach when first it appeared. This is perhaps not surprising. Principlism seemed to straddle the divide between ethical theory and ethical anti-theory, and to combine a commitment to the centrality of principles in moral reasoning, with a respect for the exigencies of circumstance and a liberating pluralism. Here was a framework that seemed sensitive to everyday moral beliefs, respectful of the complexities of actual moral problems, and distrustful of the mechanical application of inflexible theory. And these are, undoubtedly, not insignificant advantages. However, two potentially devastating lines of criticism have been leveled at principlism. First, the prima facie nature of the principles has been thought to render the approach inadequate as a guide to action. If no principle invariably

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overrides any other, when two or more conflict (so the criticism runs), there will be no decision procedure available to determine which ought to be followed. Second, especially when the principlist's credo reached European shores, dissenting voices started to maintain that the principles, far from offering a globally acceptable framework for bioethical inquiry, instead at least included some emphatically American values. Even where the four principles were accepted as universal, it was still maintained that Beauchamp and Childress's analyses of them carried a distinctly American flavor, and, further, that such analyses were bound to vary across cultures. I do not intend to address the question of whether principlism contains an adequate decision procedure, or whether it matters if it does not. Others— including Beauchamp and Childress themselves—have addressed these issues.2 Instead, I will concern myself exclusively with the global applicability thesis. I will argue that principlism's stormy journey overseas—its hostile reception in the countries for which it has been an import instead of a home-grown bioethical product—has largely been due to Beauchamp and Childress's common morality theory being presented as an empirical or sociological thesis. When regarded as such, the global applicability thesis is very easy to overturn: one can just say, "what Beauchamp and Childress consider to be a universally shared morality is nothing of the sort; we can produce sociological data to prove that we think differently about moral matters, and subscribe to different principles (or to different analyses of the same principles)." If the data we produce are compelling, the global applicability thesis has been defeated. One example of this sort of response to principlism is that of S0ren Holm's paper "Not Just Autonomy—the Principles of American Biomedical Ethics,"3 in which it is argued that Beauchamp and Childress's analyses of the four principles, especially of justice and beneficence, are distinctively American in character, and fail to capture a more European conception of those principles. A claim that the supposedly universal principle of respect for autonomy is not to be found in Buddhist cultures at all (and a fortiori not in Buddhist bioethics), due to that religion's metaphysic of co-conditioned causality, is encountered inR. E. Florida's "Buddhism and the Four Principles."4 And H. TristramEngelhardt, Jr. and Kevin William Wildes argue that the "sociological and cultural fact"5 of the post-modern condition renders the common morality theory untenable, and necessitates a libertarian "recasting" of the principles. Other responses to the common morality theory as an empirical claim abound, showing that, when so construed, the theory has little or no credibility. My claim will be that responses of this sort are not appropriate, and are indeed bound to miss their mark, since the common morality theory—and with it the global applicability thesis—is in fact a collection of conceptual, rather than empirical, claims. Consequently, the deployment of empirical data in counterexamples (saying, "but this group of people do not think of morality in that way")

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will fail to make a serious dent in this aspect of principlism. A non-empirical thesis of this sort cannot be undermined by empirical means. Of course, Beauchamp and Childress explicitly maintain that their common morality theory is empirical in nature, but I shall argue that they are straightforwardly wrong on that count. That done, I will evaluate the specifically conceptual support that I find for the global applicability thesis in the text of Principles of Biomedical Ethics. My conclusion will be that that support fails to prove the thesis.

2. The Common Morality and the Favored Subset Model First, however, we should take time to get a little clearer about Beauchamp and Childress's account of the common morality, and its relationship with the four principles. Let us start with a definition: (CM) The common morality =def. a set of norms shared by all morally serious persons. Some expressions in (CM)'s defmiens need further explanation. First, the term "norms" picks out a genus of which there are different species, including principles, rules, moral ideals, rights, and virtues.6 Rules, it appears, are concrete guides to action, such as "do not lie," "do not kill," "do not steal," and so on. They are, in Beauchamp and Childress's parlance, specifications (a term also used to mean something like "analyses") of principles, which in turn are characterized as very general values that are, we might say, "wrapped up in" rules: A set of principles in a moral account should function as an analytical framework that expresses the general values underlying rules in the common morality.7 So, the set of the common morality's norms has several subsets, one of which is the set of the common morality's principles. Let us call this latter set F. We know from Beauchamp and Childress that F has at least four members. Does it have any more than four? The suggestion appears to be that it does, since on first introducing their four principles (on which occasion they refer to them, confusingly, as clusters of principles), Beauchamp and Childress state that, four clusters of moral "principles" are central to biomedical ethics* and that,

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PETER HERISSONE-KELLY The selection of these four principles, rather than some other cluster of principles, does not receive an argued defense in Chapters 1 and 2. However, we will, in Chapters 3 through 6, defend the vital role of each principle in biomedical ethics?

That just the principles of respect for autonomy, beneficence, nonmaleficence and justice have been selected, rather than any others, because of their "vital role in," and centrality to, biomedical ethics, strongly suggests the following model. F is made up of 4+n members, where n > 0, and is potentially quite a high number. A subset of four principles (call it F*) is selected from F on the basis of its members' relevance to biomedical ethics—we can imagine that another set of principles (potentially with some of the same members as F, though perhaps with a different cardinality) might have been selected for business ethics, another for the ethics of social work, another for research ethics, and so on. Raanan Gillon, the foremost European apologist for principlism, offers further support for this reading of Beauchamp and Childress—a reading that I shall call the favored subset model. Gillon reports an increasing propensity on his part to think that the members off* are sufficient to deal with all moral issues, and not just those that typically arise in the area of healthcare.10 His claim shows that he supports the favored subset model as a reading of Beauchamp and Childress, even as it expresses his doubt that it accurately captures the truth about the cardinality and constituents of F. That is, his possession of an increasing inclination to find F identical to F* suggests that he thinks the official line is that F and F* are not identical: that the members of F* are specifically appropriate to biomedical ethics. I shall return shortly to the favored subset model, as I wish to argue that, if it is an accurate reading, it drastically undermines Beauchamp and Childress's apparent belief in the universality of principlism. First, however, I want to take a closer look at the second part of (CM)'s defmiens—at the expression "all morally serious persons," and the work that that expression does in the account of the common morality. I think that by doing so, we will be able to discern the true, non-empirical nature of the common morality theory.

3. The Morally Serious Person As I mentioned earlier, Beauchamp and Childress are convinced that their claims about the existence of a common morality are based on empirical considerations. They draw a distinction between normative claims about the common morality ("claims about what should be universal in moral belief,"11 claims that "the common morality actually has normative force"12) and "nonnormative (that

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is, empirical) claims about what is universal in moral belief." The nonnormative, supposedly empirical, claims, then, would seem to encompass beliefs about the existence of a universally shared set of values, and beliefs about precisely what values make up that set. However, when it comes to what effectively amount to sociological claims of this latter sort, they concede that they may appear to be on shaky ground. They acknowledge, that is, that there is no unique set of values adhered to by everyone. Nonetheless, it is left open to them to insist that there is such a set acknowledged by all people who are "serious about morality," and this—as (CM) shows—is just what they do. And it appears that, following this last maneuver, they retain their confidence in the empirical nature of their claims. But that confidence is misplaced. If we are to continue to regard the common morality theory as based on empirical considerations, and if we want to determine that a shared set of norms exists, and what that set's members are, we need empirical criteria for identifying morally serious persons. What could such criteria look like? Well, at least pre-theoretically, we would expect the predicate "morally serious" to attach to people who are earnestly concerned to discover what is morally right, and to do what is morally right once they have discovered it. The morally serious person could also be expected to think carefully about moral matters, and to see them as having greater importance than matters of personal pleasure, achievement, and so on. So perhaps by assessing people's behavior and avowals against these criteria, we could find some people who are morally serious. Then, the set of norms shared by those people would, by definition, be that which constitutes the common morality. There is a problem here, however. There appears to be no inconsistency in supposing both that a person could meet the criteria for moral seriousness set out above, and that she could be mistaken in her moral judgments. For instance, Aristotle believed in the acceptability of slavery and the natural inferiority of women. He was wrong on both counts. And yet, there appears to be something odd about the claim that the author of the Nicomachean Ethics was not serious about morality. Evidently, Beauchamp and Childress's notion of moral seriousness must differ from that expressed in our criteria. What criteria, then, ought we to employ? Well, one alternative might be stipulatively to define "morally serious person" by reference to a list of norms. So, we might declare that a morally serious person is someone who accepts and adheres to the set {norm!, norm2, ..., norm,,}. The thought would be that, once such a stipulative definition had been made, we would have clear empirical criteria that we could then utilize to identify those who are morally serious. It should be clear this last move would be question begging, and consequently illegitimate. That it might appear to be a move that Beauchamp and

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Childress make is something that they themselves acknowledge. However, they deny that they do genuinely make it: Our formulation may seem to simply pack our conception of morality into the notion of morally serious persons, while failing to take seriously the empirical claims of multiculturalists. This criticism misunderstands our position.13 In precisely what way does the criticism misunderstand Beauchamp and Childress's position? Their answer to this question is, I submit, the key to the true— conceptual—nature of the common morality theory. Immediately after the passage quoted above, they declare that, We accept the thesis that morality in the community-specific sense reflects significant cultural differences; but we think it is an institutional fact about morality, not merely our view of it, that it contains fundamental precepts.14 What sort of fact is an "institutional fact?" It could, I suppose be a contingent fact about a given institution; something that just happens to be true of that institution. But I would urge that Beauchamp and Childress are attempting to indicate a deeper fact about the institution of morality here. I think that by "institutional fact" they may well mean a non-contingent, essential fact about a given institution; something that is necessarily true of that institution, and so something that is "not merely our view of it." If this is what they mean, then they would appear to be claiming that there is a privileged set of norms that are, collectively, in some sense constitutive of morality, in that we would not be disposed to count any institution that lacked them as a morality at all. And perhaps it is this privileged set that is shared by all those who take morality seriously. One way of making sense of this—and for all I know it may well be Beauchamp and Childress's way—is to propose the following principle of moral seriousness: (MS) To take morality seriously just is to recognize the sorts of norms that are internal, or essential, to the very concept of morality, and presumably to be disposed to let those norms guide one's action. So, since the norms that are necessarily shared by all morally serious people are those that are internal to the concept of morality, (CM) is equivalent to the following statement: (CM*) The common morality =def a set of norms that are internal to, or constitutive of, or essential to the concept of morality.

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To talk of some norms as being "internal to," or "constitutive of," or "essential to" the concept of morality is not to make an empirical claim at all; instead, it is to make a claim about what is involved in the concept of morality. It is to adhere to the sort of view put forward by Philippa Foot in "Morality and Art": [T]here are ... starting points fixed by the concept of morality. We might call them "definitional criteria" of moral good and evil, so long as it is clear that they belong to the concept of morality—to the definition and not to some definition which a man can choose for himself. What we say about such definitional criteria will be objectively true or false.15 There is an important point to be made here. Let us suppose that Beauchamp and Childress (as I am interpreting them, at any rate) are right, and that there exists a set of core values internal to the notion of morality. I take it that nothing about precisely which of our norms are members of that core set, and which are more parochial, follows from this claim. In order to determine the members of that set, it will do no good just to discount those norms that occur in relatively few cultures, as their rarity may just be a sign that fewer people are serious about morality than we might have imagined. Nor will it help to conduct an empirical survey to identify those norms that occur most widely; that a norm resurfaces often in studies of different cultures is not a sufficient condition of its being somehow partially constitutive of the concept of morality. Nor, crucially, can we first identify some morally serious persons, and then find out what values they share. Before we can tell who is morally serious, we need to know what the norms that determine moral seriousness are. So we cannot find out what those norms are by inspecting some independently identified morally serious persons: there is no independent method of identification. What is needed instead is a rigorous analysis of the concept of morality, something that Principles of Biomedical Ethics does not provide. Incidentally, while I admit that a belief in a core set of norms internal to the very concept of morality is at least reasonable, I think that it is far from obviously true. It might turn out that what is essential to morality—what makes a system qualify as a morality at all—is not its inclusion of any one core set of norms, but the function that it fulfils, or the role that it takes, in a society. On the other hand, it is I suppose possible that any system S fulfilling a particular function F will necessarily include a particular set of norms A. I leave this question open.

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Let me briefly summarize my position so far. I think it not at all unreasonable to suggest that there exists a privileged set of norms that are essential to any institution on which the name "morality" can correctly be bestowed. But to say this is to say nothing about what those norms are. What is more, the notion of moral seriousness is powerless to help us to identify them; only a careful analysis of the concept of morality can do that. Crucially, in the absence of such an analysis, we cannot be sure that the four members of F*, which according to the favored subset model are selected from F (the set of the common morality's principles), are actually to be found in F at all. And if they are not members of F, they are not partially constitutive of the concept of morality, and so cannot lay claim to any universal applicability. This last point may be viewed as a rather unrealistic, and even disingenuous, quibble. "Look," an objector might say, "you have agreed that there may well be a privileged set of norms internal to the very concept of morality, and that the norms that make up that set must consequently hold wherever the institution of morality occurs. And I am prepared to agree that the only way to identify all the members of the privileged set is through a more or less detailed conceptual analysis of morality. But that does not mean that we cannot, in advance of carrying out that fairly major piece of conceptual analysis, readily identify several norms that will feature in the privileged set. We can, for instance, be confident that it will contain a norm forbidding the torture of other people for fun. It is just obvious that any institution lacking such a norm could never be worthy of the title 'morality.' Similarly, it appears little short of perverse to doubt that the privileged set will contain the principles of respect for autonomy, beneficence, non-maleficence, and justice. And as they quite plainly form part of the common morality, their being selected for inclusion in F* is entirely justified." How ought we to respond to this objection? The most powerful response, I think, involves granting, for the sake of argument, the point it makes, and then going on to show that even if that point is correct, the universal applicability of principlism does not follow. Doing this will involve exposing a crucial flaw at the heart of the favored subset model. Let us briefly remind ourselves of what the favored subset model involves. There is a set, F, of all the principles from the privileged set of norms that make up the common morality. From this set, a favored subset, F*, is constructed, consisting of just those principles that are deemed to be especially applicable to the sphere of bioethics. Beauchamp and Childress, as we well know by now, contend that the members of the favored subset are respect for autonomy, beneficence, non-maleficence, and justice. It is clear that the members of F, being partially constitutive of the very concept of morality, will be universally

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applicable; any institution that can correctly be counted as a morality will include them. But what a believer in the global applicability of principlismmust hold is that this universality will extend from F to F*. In other words, she will urge that because the four principles hold universally (in so far as they are included in F), and because they are especially applicable to the sphere of biomedical ethics, they will universally be especially applicable to the sphere of biomedical ethics. My suggestion, however, is that it is at just this point that the favored subset model shows a fatal weakness. That is, there seems no reason to suppose that the extension of universality from F to F* is legitimate. After all, aspects of the practice of medicine will vary across communities—healthcare may, for instance, be privately purchased in one society, and state-funded in another—as will the wider cultural conditions that serve as a backdrop to the medical practice. Different cultures, for example, may have differing attitudes to death and illness, as well as differing levels of disease. These cultural variables will, one would have thought, be partial determinants of the sorts of moral issues to which the practice of healthcare gives rise, and so to the sorts of norms most appropriately exercised in addressing those issues. The upshot is that a norm's being universally applicable in the field of morality in general does not entail its universal applicability in any one particular area of ethical concern. So, to summarize, the mere fact of the existence of a privileged set of norms constitutive of morality does not entail that respect for autonomy, beneficence, non-maleficence, or justice are members of that set. And even if they are members of that set, their special applicability to biomedical ethics is not thereby guaranteed, most obviously because of local variations in the practice of medicine, and the way in which that practice is embedded in wider social contexts. What is more, even if we were to accept (as I think we should not) that universal applicability could legitimately be extended from F to F*, still nothing is entailed about the universality of any particular analysis, or specification, of F*'s members. Even though the "conceptual," as opposed to the "empirical," interpretation of the common morality theory may supply several norms that are internal to the concept of morality, it appears reasonable to suppose that those norms would be restricted to the moderately general. In other words, it is doubtful that detailed analyses of, say, respect for autonomy, or justice, are likely to result just from an analysis of the concept of morality. What such analysis would deliver would presumably be little more than fairly skeletal accounts of a small number of norms, each of which would then require significant "fleshing out" through its own analysis. And, as Tuija Takala has pointed out, the very general norms in question are such thick concepts that multiple analyses of them will inevitably be possible.16 What is more, it is always possible that no one analysis, or "specification," will be the uniquely right one—the concepts may be by their nature thoroughly indeterminate. Another alternative here would be to say that, although a concept

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of, for example, respect for autonomy is thoroughly determinate, there are many different (determinate) concepts picked out by the expression "respect for autonomy." This would be of no help to Beauchamp and Childress, however, as it will still remain to be determined which concept of respect for autonomy is conceptually tied to the institution of morality.

5. A Transcendental Argument for the Common Morality I have said that it is not unreasonable to suppose that some norms are constitutive of, or essential to, the concept of morality. However, I do think it unreasonable to accept a second non-empirical argument that Beauchamp and Childress appear to offer in support of this conclusion. The argument is transcendental in nature, and has as far as I know been entirely neglected in the literature on principlism. Starting with the claim that there exist some "fundamental precepts" that make up the common morality, Beauchamp and Childress state that, These fundamental precepts alone make it possible for persons to make cross-temporal and cross-cultural judgments and to assert firmly that not all practices in all cultural groups are morally acceptable.17 If I understand this passage correctly, it would seem that we could, without doing violence to its content, recast its claims as follows: (1) We are able to make cross-temporal and cross-cultural moral judgments. (2) A necessary condition of our being able to make such judgments is the existence of a set of fundamental norms making up a common morality. (3) Therefore, there is a set of fundamental norms making up a common morality. Whilst this argument is valid, it is not sound, since its second premise is false. It holds that we would not be able to judge the activities of other cultures (cultures separated from ours either geographically or temporally), unless there were some norms essential or internal to the very institution of morality. This is not the case, as a number of people have pointed out.18 To see why, imagine for a moment that the following situation holds:

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Situation S The world contains just two cultures, culture x and culture y. Culture x holds that torturing children is morally impermissible. Culture y holds that torturing children is morally required. All moral values are entirely culture-bound. So, when culture x attributes some moral property F to an action-type (p, this entails nothing more than that cp-ing is considered F in x. Similarly, when culture y attributes some moral property G to the action-type cp, this entails nothing more than that cp-ing is considered G in y. If both the second premise of Beauchamp and Childress's transcendental argument and all the claims that make up Situation S were true, it would follow that culture x would not be able to judge that culture y's practice of torturing children is wrong. But what is the force of the expression "would not be able to" here? Does it mean that it would be literally impossible for anyone from culture x even to formulate that judgment? It is hard to see why anyone would believe that: those who belong to culture x would be able to formulate the judgment about the sort of act in question when it was carried out by one of their own number, and there would appear to be no reason why they could not retain this opinion of the act regardless of who performs it. Indeed, it would be odd if they did not. Perhaps we are to conclude that "would not be able to" means something like "would not justifiably be able to." The thought here would be that although someone who belongs to culture x could formulate the thought "Culture y's practice of torturing children is wrong," that thought could have no moral justification. This is a familiar enough belief about the implications of relativism: that if all moral values are culture-bound, we can have no moral justification for making judgments about the practices of cultures other than our own. A familiar belief it may be, but it is nonetheless mistaken. To explain: if all moral values really are culture bound, then we have a castiron moral justification for judging other cultures' practicesyw.rt in case our own culture's set of norms allows such a judgment. There seems no reason at all to rule judgments about culture y out of the set of norms that have their sole justification within culture x. To think otherwise is to fall into the trap of relying on the very notion that relativism rejects—that of a moral viewpoint that is divorced from, and external to, all cultures, and from which we can declare a lack of justification for any judgment about "moral strangers."

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PETER HERISSONE-KELLY 6. Summary

The line of thought I have followed in this paper has taken several twists and turns, and it may be helpful now to attempt a reasonably neat summary, and in the process to re-emphasize some of the points I have made. The contention with which I started was that empirical counterexamples to the principlist's claims on behalf of the common morality theory, and the global applicability of the four principles thesis that it is taken to entail, will not work. This is because, despite what Beauchamp and Childress say, the common morality theory is not based on empirical considerations. This, in turn, is due to the theory having no credibility prior to the qualification that its norms are shared only by those who are morally serious, and to its having no genuine empirical content following that qualification. However, Beauchamp and Childress do, perhaps unwittingly, offer two non-empirical considerations on which common morality theory may be based. The first is the possibility that there is a privileged set of norms internal to the very concept of morality. But even if this possibility is actual, the mere existence of such a set entails nothing about what its members are. That being the case, we cannot know, at least not in advance of a detailed analysis of the concept of morality, whether the privileged set includes the principles of respect for autonomy, beneficence, non-maleficence, and justice. And if those principles are not in the common morality, they are not globally applicable. What is more, even if they were shown to be in the common morality, that would entail nothing about their universal applicability to the field of biomedical ethics. Finally, even if they were shown to be universally applicable to that sphere, it is likely that a mere analysis of the concept of morality will not be so far reaching as to provide an analysis of the principles, and that any further analysis of the principles will result in wildly different—and perhaps culturally determined—interpretations of them. Beauchamp and Childress's second non-empirical consideration takes the form of a transcendental argument that moves from the existence of our ability to make cross-cultural judgments, to the conclusion that there exists a common morality. Though valid, this argument is unsound, since one of its premises apparently relies on an incoherent view of the implications of relativism. Our conclusion can only be that, while principlism fails when it takes the common morality theory as empirically based, it just as implacably runs aground when it takes that theory as conceptually based.

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NOTES 1. Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, Fifth Edition (New York: Oxford University Press, 5th ed., 2001), pp. 2-5, and passim. 2. See Beauchamp and Childress, Principles of Biomedical Ethics, pp. 19-21; Tom Tomlinson, "Balancing Principles in Beauchamp and Childress," Twentieth World Congress of Philosophy, Boston, Massachusetts, USA 10-15 August 1998 (published on the World Wide Web at http://www.bu.edu/wcp/Papers/Bioe/BioeToml.htm); Rosalind Hursthouse, On Virtue Ethics (New York: Oxford University Press), pp. 52-62. 3. S0ren Holm, "Not Just Autonomy—the Principles of American Biomedical Ethics," Journal of Medical Ethics, 21:6 (1995), pp. 332-338. 4. R. E. Florida, "Buddhism and the Four Principles," Principles of Healthcare Ethics, ed. Raanan Gillon (Chichester: John Wiley and Sons, 1996), pp. 105-116. 5. H. Tristram Engelhardt, Jr. and Kevin William Wildes, "The Four Principles of Healthcare Ethics and Post-Modernity: Why a Libertarian Interpretation is Unavoidable," Principles of Healthcare Ethics, ed. Raanan Gillon, p. 136. 6. Beauchamp and Childress, Principles of Biomedical Ethics, p. 13. 7. Ibid., p. 12. 8. Ibid., p. 12, my emphasis. 9. Ibid., p. 13, my emphases. 10. Raanan Gillon, "Preface: Medical Ethics and the Four Principles," Principles of Healthcare Ethics, ed. Raanan Gillon. 11. Beauchamp and Childress, Principles of Biomedical Ethics, p. 3. 12. Ibid., p. 4. 13. Ibid., p. 4. 14. Ibid., p. 4. My emphasis. 15. Philippa Foot, "Morality and Art," Philosophy As It Is, ed. Ted Honderich and Myles Burnyeat (London: Pelican Books, 1979), p. 14. 16. Tuija Takala, "What is Wrong with Global Bioethics? On the Limitations of the Four Principles Approach," Cambridge Quarterly of Healthcare Ethics, 10:1 (2001), pp. 72-77. 17. Beauchamp and Childress, Principles of Biomedical Ethics, pp. 4-5. 18. See e.g. Bernard Williams, Morality (Harmondsworth: Penguin Books, 1973).

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Eight WHO NEEDS "THE FOUR PRINCIPLES?' Charles A. Erin 1. Who, if Anyone, Needs the Four Principles Approach to Biomedical Ethics? It is almost impossible for those with even a passing interest in the subject to avoid "the four principles approach to biomedical ethics."1 This approach, often ("contemptuously")2 referred to as the "Georgetown mantra," identifies four prima facie principles of healthcare ethics. Developed by TomL. Beauchamp and James F. Childress (both of Georgetown University in Washington DC at the time), the approach first saw the light of day in 1979 with the publication of their book Principles of Biomedical Ethics,3 and has met with widespread acceptance—Principles of Biomedical Ethics is now in its fifth edition. It appears to me that the approach is especially popular among healthcare professionals. I have little by way of hard evidence for this, other than a decade's experience of lecturing in biomedical ethics to a Master's Program that invariably includes a high percentage of healthcare professionals. It is my contention, however, that if anyone needs the four principles approach, it is likely to be the hard pressed healthcare professional. My reasons for this intuition may become apparent by the end of this short piece. Among those who have lent their fervent support to this approach is Raanan Gillon who, in his own words, "used and enthusiastically promoted"4 the four principles in his book Philosophical Medical Ethics5 of 1985—indeed, Gillon has been described as the "most vigorous European proponent"6 of this "ethical system." I will, in the main, focus on the work in support of the four principles approach that has been done by Gillon. There is an informal sense in which Gillon opens himself to my observations, as he is a physician; he is also, of course, a philosopher. (While I have never come under Gillon's knife in the medical context, I have, on several occasions, had the good fortune to experience the sharpness of his philosophical scalpel.) Moreover, his Philosophical Medical Ethics originated in a series of articles for the British Medical Journal and it is clear that the book was primarily intended for the same audience as those articles.

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CHARLES A. ERIN 2. Legion: For We Are Many;7 First Among Equals?8

There is more than one "principle-based approach in bioethics,"9 more than one version of what Robert Veatch terms "the theory of principles of right action."10 The distinctions are to be found among the "small set of principles that describe the right-making characteristics of actions and rules."11 The four principles identified by Beauchamp and Childress are the following: the principle of Respect for autonomy; the principle of Non-maleficence; the principle of Beneficence; and the principle of Justice. However, as Veatch notes: There is no rule that there must be four principles. Various principlists point to beneficence and nonmaleficence, respect for persons through respect for autonomy, fidelity, veracity, avoidance of killing, and justice.12 Interestingly, a major European Commission funded research project, "Basic Ethical Principles In Bioethics And Biolaw (1995-1998)," yielded a different set of four principles: autonomy, dignity, integrity, and vulnerability.13 Even so, it is Beauchamp and Childress's version that has attracted most attention in the field of biomedical ethics, and a brief survey of the literature reveals that where the term "principlism" is used, it more often than not refers to Beauchamp and Childress's four principles approach. (It is worth noting that Beauchamp and Childress consider the term "principlism" disparaging,14 at least as used by Dan Clouser and Bernard Gert15 in regard of the four principles approach.) As will be underscored below, the question of prioritization of these principles, or "clusters of principles"16 is problematic. Even so, Gillon would seem to give priority to the principle of beneficence. In essence, beneficence means "doing good for others," and Gillon identifies this as a duty—indeed, he identifies all four principles as duties. Whether beneficence is a moral obligation on all persons is a moot point, as Gillon admits, but he does assert that "it is undoubtedly true that members of the medical profession undertake to place the interests of their patients before their own in many circumstances."17 The remaining principles Gillon sees as constraints on this duty of beneficence. Thus, Gillon argues in general autonomy, when it exists, ought to be respected in so far as such respect is compatible with respect for the autonomy of others ... In most cases,... of a doctor's dealings with patients (or clients ...) not only is there

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an independent moral presumption that he must respect their autonomy but, even if he is interested only in doing them good, he must generally respect their autonomy in order to do so.{ Whilst admitting that [d]octors ... are too ready to assume that they can tell what the patient wants, or even what is best for the patient, without asking,19 Gillon asserts that there are some circumstances in which The doctor is not obliged by the (prima facie) duty of beneficence always to do what the patient after ... discussion wants.20 The principle of non-maleficence, "the duty to do no harm,"21 again Gillon views as tempering the duty of beneficence. Interestingly, Gillon sees respect for patient autonomy as sometimes being a component of the principle of nonmaleficence—"for people's conception of what they would find harmful is, like their conception of what they would find beneficial, intensely personal."22 And finally, for Gillon, as for many others, the principle of justice is something like fairness. He writes: It seems clear and virtually beyond dispute that if all the available medical resources were used to provide care for only a favored section of the sick population (say, the rich or members of a particular party or race or just those whom the doctors fancied) no matter how beneficent and nonmaleficent that care was, no matter how excellent, it would be unjustly, be9^ cause unfairly, provided. Clearly, each of these four principles has been the subject of much debate. However, that is not the point. What is of concern to me is the implications of the belief that by taking these four principles together we might account for any dilemmas the healthcare professional will encounter.

3. What Can I Get for £250 (€392; US$365)? It is apparent that Gillon's enthusiasm for the four principles has not waned with the passing of time, and we have seen published in 1994 his edited volume Principles of Healthcare Ethics. This mighty tome weighs in at 2.26kg, and, within its 1,152 pages, contains chapters from more than 100 authors; some of the most recognized names in moral philosophy are there, including such lumi-

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naries as Tom Beauchamp, Alastair Campbell, H. TristramEngelhardt, Jr., John Finnis, Gillon himself, Richard Hare, John Harris, Robert Veatch—the list is not endless, but it is long. Gillon asked all his authors to refer to the four principles, either critically or in support of them, and thus the book takes the four principles as an "underlying theme."24 In fact, the first 28 chapters, which come under the section headed "Approaches to Applied Healthcare Ethics," all focus on the four principles, from quite diverse standpoints. Among the chapter titles in this section, we have, for example: "An Anglican View of the Four Principles"; "A Jewish Perspective on the Four Principles"; "Islam and the Four Principles"; "Buddhism and the Four Principles," and so on. Writing in Chapter 28, Gillon admits to "being very reassured by the remarkably positive response manifested in this first section of the book."25 There are, to be sure, critical voices to be found in Principles of Healthcare Ethics, and in this short piece I wish to add mine to them. Why? Much has been written in regard of the philosophical shortcomings of principlism,26 and the theoretical problems associated with its claim to provide a common moral language.27 However, here, in the spirit of scratching the surface of biomedical ethics, I wish merely to highlight one particular concern that I and others, especially in Europe, have in regard of the four principles approach. The concern has been neatly summed up in Harris's introduction to his chapter28 in Gillon's edited work: This volume is dedicated to the idea that all problems of bioethics can be fruitfully elucidated by reference to a set of moral principles that have sometimes been characterized as the "Georgetown mantra" .... There is no doubt that respect for autonomy, the idea that we should help others and that we should not harm them, and finally that we must be just in our dealings with them, are important parts of any morality. However, seeing all ethical problems in terms even of so prominent a set of principles has its dangers. For one thing there is a tendency to use them as a checklist, and the tendency to put ticks in boxes is inimical to thought, let alone to reasoning. We may be tempted to think that if we have considered a problem from the perspective of these four principles we have done all that may reasonably be required of us as moral beings, whether or not we have resolved the problem or come to a decision as to what to do. However, since these principles can conflict, we may have a further duty to try to prioritize them, to see which are more important. If we fail to do this we may find that the four principles yield no obvious solution or course of action, and there may then be a tendency to think that, having rehearsed the principles, we are now free to decide on our intuitions or feelings. Or we may need to attempt to see whether all or some of the principles are in fact expressions or dimensions of some prior and more fundamental

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principle, and to try to discover what this principle is. Moreover, the Georgetown mantra may incline us to feel that resolving conflicts of principle is beyond our terms of reference; that it is enough if we simply note 9Q what each has to say about a particular dilemma. Before expanding on this, let me briefly lay out what I would not want to say. First, in line with Harris, I am not saying that these four principles, taken individually, are not important tools to moral philosophy. They certainly are. Indeed, and for example, the choice theory of rights to which I am committed takes the principle of respect for autonomy as central and, we might say, overarching.30 That there is no reason why this should not be the case is recognized by Veatch when he states: "Similar norms with similar content arise among rights theorists and those who talk about the moral rules."31 Second, I am not saying that the four principles approach does not constitute as good a place as many to begin an investigation of biomedical ethics—both Beauchamp and Childress' s Principles of Biomedical Ethics and Gillon's Philosophical Medical Ethics are useful tools in teaching (and learning). And, finally, I am not saying that application of the four principles to a particular problem in healthcare ethics will not sometimes yield a result, and perhaps the same result as other approaches to biomedical ethics might yield. What I take exception to is the apparent belief of so many in the formulaic infallibility of the four principles approach. Empirical evidence suggests that, on introduction to the four principles approach, many students of biomedical ethics are instantly beguiled by them; almost effortlessly, they seem to fall into the belief that the approach exhausts our capability for ethical analysis; it is almost as if the four principles approach becomes a substitute for their powers of discernment and critical reflection. It is not an exaggeration to say that several students, when answering an assignment—especially, in my experience, a casebased assignment—feel that they have done all that is required of them when they submit an essay that contains a brief introduction, an even briefer conclusion, and four intervening sections that, if they are titled, bear the heads "autonomy," "beneficence," "non-maleficence," and "justice."

4. Not the Four Principles Approach I would not wish to chance giving an unfair picture of the four principles approach, so let me outline briefly, again using Gillon's work, what apparently it is not. According to Gillon: The four principles approach has never purported to provide a decision mechanism or procedure for application when the principles conflict in a

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Those who find the four principles approach attractive would be well advised to bear these points in mind. What of Harris's point about prioritizing these principles? As S0ren Holm notes, Beauchamp and Childress "go to great lengths to emphasize that this listing of the principles does not imply a ranking."34 He points, however, to the common charge that autonomy and, perhaps, non-maleficence, are assigned greater significance, at least in the American context.35 In the United Kingdom, the British Medical Association (BMA) is at pains to point up "the difficulties inherent in any effort to rank these moral values in order of priority."36 They further observe that "[t]he potential for conflict between them is particularly illustrated when they are applied to life or death decisions."37 But, surely, it is just here, in life or death decision-making, where we might hope that a common morality approach, even a checklist, would prove most helpful, especially to the healthcare professional facing such decisions. Where the BMA expands upon the grounding of its ethics advice, it is quite clear as to the place of the four principles approach: The four principles, while offering a helpful encapsulation of what are widely held to be the important elements of medical decision-making, often clash and cannot be ranked in order of priority ... We share the reservations, which many people have expressed, about the application of abstract or formulaic responses to the untidy dilemmas of real life. Few dilemmas are likely to be resolved wisely or satisfactorily by a blinkered adherence to abstract principles alone.38 Let us recap. The four principles approach does not provide a decision-making mechanism in cases of conflict, and it is not a moral theory. It is a "checklist" as Harris and others charge, and as Gillon admits, but this Gillon sees as "of outstanding moral significance."39 He writes: Just like any other "checklist" this one too points to a prior commitment; but rather more importantly than most "checklists" this one points to the existence of four substantive, though admittedly only prima facie, moral concerns that everyone can accept as of common and mutual moral relevance. 40 Beauchamp and Childress have also responded to the checklist criticism, in particular as it has been leveled by Clouser and Gert:41

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Regarding their criticism that our principles are checklists or headings without deep moral substance, we agree that principles order, classify, and group moral norms that need additional content and specificity. Until we analyze and interpret the principles ... and then specify and connect them to other norms ... it is unreasonable to expect much more than a classification scheme that organizes the normative content and gives very general moral guidance.42

5. Whose Common Morality? The point is that Gillon, Beauchamp and Childress, and others in that camp, see commitment to the four principles as transcending "barriers of religion, culture, politics, nationality, philosophical stance, even gender,"43 and as providing the "elements of a common moral language."44 This all seems quite fair comment, as long as the four principles are viewed in this context and the limitations of the approach, as admitted and identified by the original authors, are fully comprehended. The alleged compatibility of the four principles with a wide variety of moral and religious theories is, I am sure, of some significance, but it would be a tragic mistake to think of this compatibility as a common ground on which to negotiate a truce between such theories. Take, as an example, what are two of the most widely divergent moral theories, utilitarianism and Kantianism. In this context, Gillon claims: The elegance of the four principles approach is that it need say nothing about the deep, and some claim untraversable, philosophical chasm separating these two types of philosophical theory—instead it offers each a meeting place in practical ethics.45 Well, perhaps so. But, so what? Neo-Kantians such as myself are generally quite happy to meet utilitarians like, perhaps, Harris, but I really do not see much point in a polite discourse on the fact that both utilitarian and deontological theories can tolerate, and even find a useful role for these four principles. And this raises a more important question. Harris and I have definite, distinct views, theories of choice, our own philosophical worldviews, if you will, which have been developed over many years of study, analysis, and reflection. But I fear that for those who have yet to fully develop their own considered view, enthusiasm for the four principles approach will not facilitate that development. Instead, it is more likely to incline the student of biomedical ethics to take a seat on the fence between theories. Is it this fence-sitting that is intended by "common morality" or "global ethics?"

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The purported universalizability of the four principles approach appears to be the chief attraction of it to its proponents and adherents. It has been argued, however, that the claim that the four principles approach is a "common morality theory" is a false claim.46 As Holm reminds us, we must not forget whence it originates: The fact that common-morality theory necessarily uses the shared morality in a specific society as its basic premises, is often overlooked by both proponents and opponents of the four principles. These basic premises derived from common-morality are further analyzed and re-arranged in order to reach a coherent moral theory, but it should come as no surprise that the content of this theory will be influenced by its basic premises, and therefore influenced by the morality and culture of the society from which it originates. Because the theory of PBE4 [4th edition of Principles of Biomedical Ethics] is developed from American common morality (and in reality only from a subset of this morality) it will mirror certain aspects of American society, and may, for this reason alone, be untransferable to other contexts and other societies.47 Whether the four principles approach does provide a useful "meeting place in practical ethics," whether it is or is not a common morality theory, and whether it can be "routed 'from above' by advocates of 'theory'"48 or "ambushed 'from below' by contextualists ... and their allies, the casuists"49 are, I am sure, important questions. But none of this addresses my concern regarding those who need biomedical ethics, but do not have the opportunity to dig any deeper than the four principles approach. My worry is engendered by the approach appearing to have rapidly become not only the first port of call for these people, but the only one, and it is clear from my experience that the inherent limitations of the approach are often missed. 6. Wasting Much Time ... Notl Let me end by looking at the role that Gillon originally envisaged for the four principles approach: As I began to teach using this framework I was impressed by the readiness with which doctors could agree that the four principles were indeed consistent with their own perspective on medico-moral issues. When I lectured more widely I found similar reactions from nurses, other healthcare workers, medical students, and more recently members of the general public.50

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Further in, he expands on this general theme: [U]nlike philosophy, the work of healthcare workers requires moral decisions in the real world, and the only real purpose of introducing philosophy to healthcare is to help healthcare workers individually and collectively to make their decisions better.51 Later still, we have this: Nor, I believe, do all healthcare workers themselves need to try to acquire sufficient philosophical skills to come to a soundly based, well defended philosophical decision about which moral theory they accept as grounding those principles and why they reject all the others. If life long philosophers cannot succeed in this enterprise to the satisfaction of their philosophical opponents it would surely be ludicrous even to suggest that it is appropriate for healthcare workers spending a small part of their student and professional lives on the study of healthcare ethics to attempt it. Instead let us accept those (relatively few) moral claims that these competing philosophical theorists can agree on and use them as mutually acceptable premises in our moral reasoning and argument. Instead of wasting much time in healthcare ethics on fruitless argument about the underlying moral theories underpinning those moral claims, let us concentrate on learning to use the important philosophical techniques of clear unambiguous, logical reasoning and argument in the light of the strongest counter-arguments, so as to help us make our moral decisions better.52 I am certain that Gillon's motivation for such paternalism is benevolent, beneficent even, but paternalism it remains. In this regard, it is instructive to recall Gillon's background—he qualified in medicine, and then some time later completed a bachelor's degree in philosophy whilst practicing as a part-time General Practicioner. Now consider this: Philosophy is singularly unhelpful if it tries to turn healthcare workers into philosophers (there will always be a few exceptions who will become fascinated by philosophy for its own sake—I was one such—but that is not the function of philosophy in healthcare ethics).53 If a healthcare worker is to view biomedical ethics as just one of many subdisciplines of which they need to be aware to make their practice of medicine more informed, perhaps limiting that knowledge to the four principles does at least offer some basis for making ethical medical decisions. However, the

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growing interest of the general public, and the media, in biomedical ethical issues, and the growing number of healthcare professionals who make the effort and bear the financial burden of focused study in biomedical ethics, suggests to me that, for many at least, the "checklist" approach is insufficient. I believe that many healthcare professionals, lawyers, and other professionals do wish "to come to a soundly based, well-defended philosophical decision about which moral theory they accept," just as much as everybody wants to develop their own moral worldview. Perhaps I am naive in this, but it is difficult to accept that those who make the effort are "wasting much time in healthcare ethics on fruitless argument about the underlying moral theories."

Notes 1. Principles of Healthcare Ethics, ed. Raanan Gillon (Chichester: John Wiley and Sons, 1994), passim. 2. Norman Daniels, Justice and Justification - Reflective Equilibrium in Theory and Practice (Cambridge: Cambridge University Press, 1996), p. 335. 3. Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics (New York: Oxford University Press, 1979). 4. Raanan Gillon, "Preface: Medical Ethics and the Four Principles," Principles of Healthcare Ethics, ed. Gillon, p. xxi. 5. Raanan Gillon, Philosophical Medical Ethics (Chichester: John Wiley and Sons, 1985). 6. S0ren Holm, "Not Just Autonomy—the Principles of American Biomedical Ethics," Bioethics, ed. John Harris (Oxford: Oxford University Press, 2001), p. 495. 7. St Mark, 5:9. 8. Cf. Jeffrey Archer, First Among Equals (London: Harper Collins, 1993). 9. Tom L. Beauchamp, "Principlism and its Alleged Competitors," Bioethics, ed. Harris, p. 479. 10. Robert M. Veatch, "The Foundations of Bioethics," Bioethics, \3:3>-4 (1999), p. 215. \\.lbid. 12. Ibid., p. 216. 13. Jacob Dahl Rendtorff and Peter Kemp, Basic Ethical Principles in European Bioethics and Biolaw—Vol. I: Autonomy, Dignity, Integrity, and Vulnerability (Copenhagen and Barcelona: Center for Ethics and Law, and Institut Borja De Bioetica, 2000). 14. Beauchamp and Childress, Principles of Biomedical Ethics, p. 37. 15. K. Danner Clouser and Bernard Gert, "A Critique of Principlism," Journal of Medicine and Philosophy, 15:2 (1990), p. 232. 16. Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics (New York: Oxford University Press, 5th ed., 2001), p. 12 and passim. 17. Gillon, Philosophical Medical Ethics, p. 73.

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18. Ibid., p. 75. My emphasis. 19. Ibid. 20. Ibid. 21. Ibid., p. 76. 22. Ibid., pp. 76-77. 23. Ibid., p. 77. 24. Principles of Healthcare Ethics, ed. Gillon, p. xxi. 25. Raanan Gillon, "The Four Principles Revisited—a Reappraisal," Principles of Healthcare Ethics, ed. Gillon, p. 319. 26. See, e.g., Daniels, Justice and Justification, ch. 16. 27. See, e.g., Tuija Takala, "What is Wrong with Global Bioethics? On the Limitations of the Four Principles Approach," Cambridge Quarterly of Healthcare Ethics 10:1 (2001), pp. 72-77. 28. John Harris, "Not all Babies Should be Kept Alive as Long as Possible," Principles of Healthcare Ethics, ed. Gillon, pp. 643-655. 29. Ibid., p. 643. 30. See, e.g., L. W. Sumner, The Moral Foundation of Rights (Oxford: Clarendon Press, 1987), pp. 46-47 and passim. 31. Veatch, "The Foundations of Bioethics," p. 216. 32. Gillon, "The Four Principles Revisited—a Reappraisal," p. 320. 33. Ibid., p. 321. 34. Holm, "Not Just Autonomy—the Principles of American Biomedical Ethics." 35. Ibid., pp. 495-496. 36. BMA's Ethics, Science and Information Division, Medical Ethics Today: Its Practice and Philosophy (London: BMJ Publishing Group, 1993), p. 151. 37. Ibid. 38. Ibid., p. 318. 39. Gillon, "The Four Principles Revisited—a Reappraisal," p. 321. 40. Ibid. 41. Clouser and Gert, "A Critique of Principlism." 42. Beauchamp and Childress, Principles of Biomedical Ethics, p. 389. 43. Gillon, "The Four Principles Revisited—a Reappraisal." 44. Ibid. 45. Ibid., p. 325. 46. Holm, "Not Just Autonomy—the Principles of American Biomedical Ethics." 47. Ibid., p. 496. 48. Daniels, Justice and Justification, p. 333. 49. Ibid. 50. Gillon, "The Four Principles Revisited—a Reappraisal," p. 319. 51. Ibid., p. 326. 52. Ibid., pp. 326-327. 53. Ibid., p. 326. My emphasis.

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Nine DO BIOSCIENTISTS NEED PROFESSIONAL ETHICS? Matti Hayry 1. The Questions What is the role of ethics in scientific development with regard to advances in molecular biology, medical technology, and genetics? Do bioscientists need ethics? More specifically, do they need professional ethics? And if they do, can philosophical bioethicists help them in the formulation of their professional codes? I believe they do and can. But it is not easy to demonstrate this, for various reasons. For one thing, it is not clear that those working in biosciences form a profession. I will begin by saying a few words about this: what is a profession, who are professionals, and what it means to be a member of a professional group. And for another thing, it is not clear what "ethics" means in this context. I will try to clarify this, once the first issue has been settled.

2. Professionals and Nonprofessionals First, then, are bioscientists professionals, or something completely different? In modern Western societies, individuals are normally expected to make a living, more or less independently, and to take care of the well-being of their immediate family members, especially their children. The independent ways of making a living include being a professional, in business, or in the service of others, within the private or the public sector. These categories do not rule each other out. Some professionals are self-employed business people, others serve as employers for commercial enterprises or public institutions. On the other hand, of course, people can make an independent living without being professionals. Plumbers and television repair persons, if they are selfemployed, have a trade, but not, properly speaking, a profession. Their assistants, in their turn, have a job, and, it is to be hoped, some skills for the job, but they, too, are nonprofessionals. The same applies to the owner-manufacturers of the piping and the electronic appliances that plumbers and television repairers use in their work. These individuals are involved in an industry, but they do not

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need to be professionals (although they may, periodically, require professional services).

3. Professionals and Their Codes Who, then, does belong to the class of professionals, and how can they be identified? The following criteria have been suggested for true professionals:1 • • • • • • •

specialized knowledge; long and intensive academic studies; permanent careers; organization and self-rule within the group; as a group, a decisive role in the arrangement of the relevant studies, and in the recruitment of new members to the group; a distinctive professional ethos, or morality within the work; and positions of considerable responsibility in communities and societies.

When all these criteria are fulfilled, the group in question can unproblematically call itself a profession. If some of them are not fulfilled, the situation is more complicated. The most traditional professions, medicine and the law, have a long time ago formulated their own ethical standards and codes, and tried to ensure that their members do not violate these. There are usually some high moral grounds for the existence of such codes, but they also serve a practical purpose. By making their ethical codes known to others, professionals send out a message saying that they can be trusted with responsible positions—the positions their members normally seek in social life. Plumbers do not, as a rule, have an ethical code. Their clients do not necessarily expect them to do the job they are hired for without constant supervision. The contractual rules of business apply, of course, but that is about it. In medicine and healthcare, and in other more professional fields, requirements are normally higher. The jobs people expect these professionals to perform are supposed to be independent. If something goes wrong, the clients of the medical profession will in most cases consider ways of seeking for compensation. This is especially true if people suspect that the professional's conduct has been "unethical."

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4. Ethics in Practice What makes the conduct of individuals, or professionals, ethical or unethical? Ethics has to do with right conduct, and perhaps it is related to ways in which people can live and fare well in their societies and communities. Professionals are normally expected to know the laws pertaining to their profession, and to act in accordance with them; and to know what the ethical codes of their profession require of them, and to behave accordingly. Other aspects of being ethical may also require individuals to know themselves and follow their conscience, to respect the traditions and customs of the society, community, and establishment they work in, to respect the moral views of their clients, and (perhaps) to live by the general moral principles ethicists and philosophers often talk about.

5. Is Bioscience a Profession? My first question here, however, was, do bioscientists form a unified profession? This is really a question for me, as a philosopher, to ask, and for others to answer. It seems clear that people working in the field of biosciences do have specialized knowledge, long and intensive academic studies, (often) permanent careers, and (sometimes) positions of considerable responsibility in communities and societies. But do they have organization and self-rule within the group? Do they have, as a group, a decisive role in the arrangement of the relevant studies, and in the recruitment of new members to the group? And do they have a distinctive professional ethos, or morality within their work? There are two main questions here, and philosophers or ethicists can answer only one of them. A question only people working in the field, and perhaps social scientists, can answer is, do bioscientists form a unified group, or at least several distinct groups with their own identity (which would work equally well)? People within the medical profession seem to think that they should be the model, or the paradigmatic core group, and that the ethics of the biosciences should be shaped after their codes. But where does this leave others, those who do not identify themselves with physicians, or medical researchers? The second question can be answered only after the first has been settled to everybody's satisfaction. It is, what kinds of ethical considerations are important to bioscientists as a group (or as several-distinct groups)?

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At this point, the scientists I am talking about are liable to challenge my efforts. As long as they are doing their jobs, why would questions of professional identity have any importance? It is quite possible that they do not, but the following points are still valid. If bioscience is not a profession, then it is exclusively a trade, a job with skills, or an industry. This is not automatically a bad thing, but it would make bioscientists more vulnerable to outside pressures than they would probably like to be. Professions, like the guilds of craftsmen and merchants in the past, provide some degree of self-rule to their members. So unless bioscientists want to be regulated exclusively in terms of popular moral concerns and the benefit of the society as a whole, it would be a clever move to claim professional status. For this, however, the two conditions I have outlined must be met. A profession must be a unified group. And this group must have an ethos, if not for other reasons, then as a shield, or protective armor, against the claims of others.

7. Ethics and Moral Concerns It is now time to move on to the second question I promised to answer at the outset, namely the meaning of the term "ethics" in this context. I have already said that ethics, more generally, has to do with some rules of right conduct, and with the well-being of (at least) human beings in societies and communities. I also said that professionals, in order to be ethical, or moral, are normally expected to obey the laws regulating their work, and to respect the moral views they themselves or other people hold. Since I am not an expert in legal matters, I will leave their clarification to others. But I do believe that laws, although they encapsulate and give expression to some ethical concerns, are not by themselves enough when codes of professional conduct are formulated. Legal regulations are expressions of political power, and they can be assessed critically in the light of moral considerations. In other words, laws can be unjustified. And even when they are not, they do not address all the legitimate moral concerns that (some groups of) people may have. For instance, it would presumably have been a good idea, from the moral point of view, if all German doctors had in the 1930s followed the Hippocratic Oath instead of the prevailing laws of their nation. So what sorts of moral concerns should be taken into account in the professional codes of bioscientists? At least two alternatives readily present themselves. (There are undoubtedly others.) One is to take the route favored by American bioethicists, the other is to follow their (mostly) European critics. Both approaches are based on the idea that the many, and different, moral concerns people have can be summarized in the form of ethical principles. It has been

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argued that such "principles of bioethics" are too far removed from practical concerns to be of any real use to scientists. This may be true. But let me briefly present these models, which seem to be popular in public discussions, and then say a few words about their implications on bioscience.

8. The American Approach The first model is the four principles approach, mainly advocated by American bioethicists.2 It states that an ethically good choice, or course of action, fulfils the following criteria: It respects the autonomy of individuals. It does not inflict unnecessary harm on anybody. It does some good to somebody. It does not violate any rules of justice. How can this be read in the context of biosciences? A simple way to respect the autonomy of individuals is to let them do what they want to do, provided that they do not violate the other principles. If a research group wants to study, for instance, the mechanism of cloning human beings, then they should be allowed to do so, if they do not harm anybody in the process, if what they do can be beneficial to somebody, and if they do not commit violations of justice. A straightforward way to calculate the harms of scientific work is risk assessment. Since today's risk assessment shows that cloning could easily harm individuals created by the method, reproductive cloning can be ruled out. But the study of cloning for other purposes can still be a good idea, if it is useful and just. Would research on cloning do good to somebody? Some argue that it would contribute considerably to the development of medicine. Others have noted that research of this kind is expensive, and that the money could be used more beneficially elsewhere. What about justice? If research on cloning can lead only to modest successes in medicine, and if the money could be allocated to more useful purposes, it could perhaps be restricted by appeals to justice. But on the other hand, if it is just that individuals and business enterprises can invest their money in activities they regard as good and interesting, then this objection is not a very good one. This brief countdown is not meant to prove either that cloning human beings is justifiable, or that it is unjustifiable. The point is, instead, to show that the "four principles" can be used in many ways, depending on the preferred definitions of "autonomy," "harm," "good," and "justice." The four concepts

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serve as a shopping list, with which people can give some structure to their ethical thinking on particular issues.

9. A European Alternative The open-endedness of the four principles model has, however, been criticized from many different angles.3 Some liberal ethicists have seen it as too conservative, or restrictive. By giving the terms convenient definitions, people who are irrationally afraid of new inventions can argue against them, and claim that their fears are somehow respectable. Many conservative ethicists, in their turn, have argued that the model is too liberal. The second group includes many European ethicists, who have tried to find fundamental moral principles elsewhere.4 Their favorite criteria for a sound ethical decision seem to be: • •

It does not violate the dignity of human beings. It is precautionary: that is, it takes into account all conceivable consequences, along with those that are currently unforeseeable.

The application of these principles to biosciences yields primarily restrictive results. The principle of human dignity appears to outlaw, almost automatically, all research on cloning human beings, or research on human embryos in general. This is an ambiguous principle, open to many interpretations, but the majority of those who use it seem to connect it with religious thinking, and the concept of "the sanctity of human life."5 It is, nevertheless, quickly becoming one of the most popular principles in international declarations and legislation, including UNESCO's Universal Declaration on the Human Genome and Human Rights.6 What cannot be prohibited by appeals to human dignity, can be opposed by appeals to the "precautionary principle." It says, essentially, that we should not engage in activities, which may have harmful consequences, although we do not, as yet, know about them.7 A consistent application of the principle would show that we can never do anything, as all our actions may have harmful consequences we do not know about. But for some reason, the use of this principle is normally restricted to new forms of science and technology.8

10. Ethics for Bioscientists? In conclusion, then, do bioscientists need professional ethics? I do not know, because I am not sure that a unified professional group of bioscientists exists.

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But if there is such a group, then my message is this. Professional groups need ethical codes. Ethical codes can be partly, but not exclusively, informed by the prevailing national and international laws. In addition, people's moral concerns should be taken into account. One way of doing this is to follow some simplified moral rules, or ethical principles. The choice of these principles depends on the nature of the work the professional group performs, and on their views on morality. So what the right principles for the professional ethics of bioscientists are is up to them, or up to who "they" are, as a group.

NOTES 1. See, e.g., Ethics and the Professions, ed. Ruth F. Chadwick (Aldershot: Avebury, 1994). 2. Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics (New York and Oxford: Oxford University Press, 1979); Principles of Healthcare Ethics, ed. Raanan Gillon (Chichester: John Wiley and Sons, 1994). 3. E.g., S0ren Holm, "Not Just Autonomy—the Principles of American Biomedical Ethics," Journal of Medical Ethics, 21:6 (1995), pp. 332-338; Tuija Takala, "What Is Wrong With Global Bioethics? On the Limitations of the Four Principles Approach," Cambridge Quarterly of Healthcare Ethics, 10:1 (2001), pp. 72-77. 4. Bioethics and Biolaw Vol. II: Four Ethical Principles, ed. Peter Kemp, Jacob Rendtorff, and Niels Mattson Johansen (Copenhagen: Rhodes International Science and Art Publishers and Centre for Ethics and Law, 2000). 5. Matti Hayry, "Another Look at Dignity," Cambridge Quarterly of Healthcare Ethics, forthcoming. 6. Universal Declaration on the Human Genome and Human Rights, adopted by the General Conference of UNESCO at its 29th session on 11 November 1997. 7. Matti Hayry, "Precaution and Solidarity," The Foundations of Healthcare, ed. David Thomasma, David Novak, and David Weisstub (Dordrecht: Kluwer Academic Publishers, forthcoming). 8. The Precautionary Principle and Its Implications for Science, ed. Matthias Kaiser, Foundations of Science, 2 (1997), pp. 201-341.

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Ten PRO-LIFE IS ANTI-LIFE: THE PROBLEMATIC CLAIMS OF PRO-LIFE POSITIONS IN ETHICS John Harris 1. Why Pro-Life? So-called "pro-life" positions in bioethics are as ubiquitous as they are tendentious. They claim the moral high ground in two principal and unprincipled ways. In the first by their self proclaimed "pro-life" stance they imply that those with whom they differ are in some sense anti-life, hostile to living creatures and perhaps to life itself. While this may simply be a natural and even a forgivable tendency to rhetoric in arguments that, while philosophical, are never only that but also highly political, it is of course irritating if not offensive to those who, like myself, they single out as anti-life and who not unnaturally perhaps, regard their own approach to bioethics as both life-affirming and also respectful of the value of life. I should declare here a strong personal interest and involvement in the debate that readers will wish to note. The second way in which pro-life positions claim the moral high ground is by purporting to take a principled, uncompromising, and universal stand in favor of protecting human life and the value that human life represents. Classically such positions identify killing as something "absolutely forbidden," wrong "whatever the consequences." They use phrases like "the sanctity of life," and talk of life as "sacred" or "sacrosanct"; those who reject the particular pro-life interpretation of life's moral importance or value are often castigated as wicked or depraved. The saintliness of the pro-life position is emphasized while again by implication, the profanity and sinfulness of those who disagree is highlighted. David Oderberg1 is one of the most recent defenders of an extreme pro-life position and his defense is disarmingly open about the ways in which a pro-life stance amounts in effect to the articulation of a set of justifications for killing people. He presents a view of the sanctity of life and of personhood that he contrasts with consequentialism in general and my own views in particular. His general stance is that consequentialism is wicked—as Oderberg reminds us, Elizabeth Anscombe once memorably characterized consequentialism as the product of a "depraved mind." Oderberg and other so-called "pro-life" commentators by contrast often rather tendentiously call their own take on these issues "the common tradition," which they identify as originating with Aristotle. This is not Oderberg's term but that of another contemporary Catholic commentator who has

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also made much of the common tradition and of the allegedly opportunistic character of philosophies that reject that tradition. John Finnis's three essays on euthanasia (which are paired with three essays of mine on the same subject) are the source of this particular choice of terminology.2 While "common" may refer to the "common era" in the Christian tradition, in common parlance it refers inevitably to ideas that are common in the sense not only of being universal (hence "common") but also somehow folksy and friendly and accepted (hence "traditional"), the theoretical equivalent of motherhood and apple pie. Oderberg has dedicated himself to defend traditional approaches to morality against the wicked and "inhuman"3 consequentialism that he rather naively describes as "the overwhelmingly pre-eminent theory used in applied ethics in Britain, the USA, Australia, and elsewhere in the West."4 Obviously Oderberg has never been to, or even heard about, such Western countries as Italy, Spain, Portugal, Germany, France, Greece, Eire, Poland, Malta, or almost any other country of Western Europe let alone most of the United States and South America. The truth is that so far from being the dominant ideology, consequentialism is a minority approach to ethics in the world at large, and in some of the countries I have listed consequentialists are discriminated against in employment and systematically marginalized. Oderberg so far from being, as he represents himself to be, a spokesman for a lonely and beleaguered minority in fact speaks for an overwhelmingly dominant and dominating philosophy. So that when he says, rather pathetically, I console myself with the following thought: that every single one of the major positions I defend was believed by the vast majority of human beings in Western society for thousands of years, right up until some time in the 1960s.5 he is not only being disingenuous but also appealing to popular prejudice in a highly tendentious fashion. The vast majority of people right up until exactly the time he identifies as signaling a decline in morality believed, among many other similar idiocies and false and "traditional" beliefs that were also "time honored," that women were inferior to men, that rape within marriage was impossible, and that sex outside marriage was wicked. 2. The Hollowness of Pro-Life Positions The hollowness of pro-life positions has been demonstrated in many ways and it will not be my purpose in this short paper to attempt a catalogue of the ways in which such positions are so often wantonly destructive of human lives and of the value that "life" represents. However we should note for the record that by drawing a rigid distinction between acts and omissions or between what is

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sometimes called "direct" and "indirect" killing, pro-life advocates are prepared to countenance the destruction of countless innocent lives. This happens, as we will see, because only those lives that are candidates for direct or intentional killing are maximally protected in pro-life approaches to ethics. Other lives, innocent or not, can be sacrificed; and this is why pro-life positions often cost more lives, and pro-life advocates are often willing to countenance the deaths of more innocent people, than those whom they castigate for failing to treat life as sacrosanct. Consequentialists, for example, classically (though not always) believe in maximizing lives saved and will countenance killing only where the result is that more lives are saved than would be the case if some people were not killed. Consequentialists take the value of life and the value that life represents so seriously that they ensure that it is maximally protected. Not so pro-lifers. One classic example would be shooting an aircraft hijacker and her innocent shield dead to pre-empt a hijack that would cause the deaths of all the passengers. Another is the separation of conjoined twins where both will die unless the operation is performed but one must be killed to save the life of the other. Such a separation was recently performed in the United Kingdom (the so called "Manchester Conjoined Twins" case6) and the operation was strongly opposed by pro-life organizations and the Catholic Church. Another, but rather different, example of the anti-life nature or pro-life positions is the misery and needless sacrifice of innocents occasioned by absolute opposition to abortion. This has been well catalogued and must be a constant reminder of the evil done and endlessly attempted by those who hold extreme pro-life positions.7 As Laurence H. Tribe has commented on the effects of the Roe v Wade case in the supreme court of the United States that established a right to terminate pregnancy: Within only a few years of Roe the death rate for women undergoing legal abortions was ten times lower than that for women who had illegal abortions and five times lower than for women who went through childbirth.8 The pro-life position on the policeman's dilemma illustrates a further dimension of its unacceptable face. A lorry driver is trapped in the blazing cab of her vehicle following an accident. A policeman is on the scene and sees that the driver cannot be extracted before the flames get to her and she is burned alive. The policeman can let her be burned alive or can give her a quick and relatively painless end by shooting her in the head. The driver says "please shoot me, don't let me be burned alive!"9 Those who, like Oderberg, regard killing innocent people as absolutely forbidden must let the driver burn to death. Of course if the driver was lucky enough to have been guilty of murder she could be spared this terrible fate—but the innocent must suffer.

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Pro-life positions presuppose a world10 in which there are no abortions even to save the life of the mother or in the case of child rape, a world in which conjoined twins are both left to die when one could be saved by an operation that must kill the other, a world in which those dying in agony cannot be prematurely released by a swift death that they desperately seek but are forced to linger on in suffering and in desperation, a world without contraception, without the Intra Uterine Device or the morning after pill, without Assisted Reproduction Technologies (which have brought hundreds of thousands of happy children into the world, children who without it would never have been born). Not all will regard such a world as undesirable of course. Ultimately we will have to choose the sort of world we want and justify that choice. A further dimension of the pro-life position that has not received the critical attention its hypocrisy merits is the way in which a pro-life position does not in fact embody an uncompromising and principled stand against killing, but instead is the articulation and defense of a particular set of justifications for killing normal human beings. I will look briefly at two principles or arguments deployed by Oderberg, which he uses to contrast the so-called "common tradition" with ways of thinking that are by implication upstart, opportunistic (not Oderberg's term), and depraved. 3. The Principle of the Sanctity of Life11 A first and important thing to note about Oderberg's discussion is that the principle of the sanctity of life is qualified in three important ways: (1) By the types of creatures whose lives qualify. (2) By their moral state—namely "innocence." (3) By the intentions of those who have it in mind to kill them. Oderberg's approach makes transparent something that is quite often concealed or obfuscated. As we have noted, Catholic philosophers commonly represent themselves as "pro-life." The great attraction of the so-called "common tradition" has been that it appears to stand for something important and highly principled. It has represented itself as upholding the value of life in a supreme and unqualified form. The whole "pro-life" movement has nailed its colors to this mast and has relied on this appeal for its attraction when contrasted with those who have regarded the value of life or of some lives as qualified in any way. But what Oderberg has made startlingly clear is that, if he interprets Catholic theology and the common tradition from Aristotle correctly, Catholics cannot claim to be "prolife" at all. They, just like those with whom they disagree and with whom they

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contrast their approach, are not pro-life, they are "pro" only those lives that qualify for approbation or which are not protected in some way (in the case of pro-life positions, by the malevolence of their would-be assailants). It may seem odd to talk of malevolence as a protection but it is a classic paradox of Catholic theology or any philosophy that employs the doctrine of double effect that since no one may intend to kill a protected individual those that do not intend to kill protected individuals are in fact permitted to do so. So the malevolent may not kill but those who do not wish our deaths may be our executioners. Moreover, the types of creatures that have valuable lives are, for Oderberg, innocent human beings. So that what pro-lifers are "pro" is not just any human life but human life that has been evaluated and found to be innocent. Not then human life warts and all, but human life that has qualified itself for Catholic approbation or rather has not disqualified itself. We should also note that the insistence on innocence as a qualification for moral importance does not pick out an intrinsic or existential state: no lives are intrinsically valuable—valuable because they are lives of a particular sort of creature, the lives of human beings instead of animals, as it is sometimes put, of a special "natural kind." We find that pro-life philosophy does not identify a class of beings whose lives are intrinsically important; instead it refers to certain "well founded categories" of justification for killing. What we are offered is not a theory about the sanctity, the moral value, and importance of lives of a particular sort—human lives. Instead, Oderberg and others seek to extrapolate from, instead of arguing for, certain allegedly "well-founded" categories of creatures that may be killed. What we find then is a catalogue of exceptions to a common tradition of valuing life, something that might be better described as a common tradition of disvaluing lives. We should be clear that Oderberg and other pro-lifers are not taking an absolutist stance against killing or violating the sanctity of life—Oderberg in particular is appealing to categories (not really even theories or arguments) that justify killing people in particular cases. Here his position is morally distinguishable from that of consequentialists only in the quality of the justificatory arguments produced to explain the distinctions he is making. Instead of arguments, Oderberg usually appeals simply to the fact that some people fall into well-founded categories that make them fair game for killing, but the good foundation for these categorical exceptions is not well explored or even well-founded. The question that immediately arises and that must be pressed home is: are the justifications for killing offered by Oderberg "better," or "more moral," than those offered by consequentialism?

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The theories or arguments to which Oderberg appeals are based on "self defense"; either in war, or personal self defense. In the case of war, Oderberg states that killing is justified "in defense of [a state's] integrity or [of] its citizens."12 Oderberg treats the truth of these statements as self-evident or "well-founded." Certainly there is a long tradition of treating these sorts of considerations as adequate justifications for killing, although they are by no means unproblematic. States differ wildly in their moral respectability and before the integrity of the state may be considered a justification for killing we might want to ask whether the particular state is justified in existing at all or whether its existence is worth the cost of maintaining it. These are just the sorts of consequentialist calculations that Oderberg affects to dislike, but on which as a matter of fact his position depends. While national integrity or saving the lives of citizens are undoubtedly plausible candidates as justifications for killing (if appropriately subjected to analysis and perhaps also only where there are no alternatives to killing), they are not qualitatively different from consequentialist reasons—indeed they are consequentialist reasons. The whole point and certainly the whole tenor of Oderberg's approach is to set out the common traditional alternative to consequentialism. Catholic, prolife, commonly traditional approaches to ethics castigate the grubby practicality of consequentialism that goes in for cost-benefit analysis or that compromises ethical purity with considerations of expediency, or necessity, or common decency. And they contrast this with the moral purity of universal principles that supposedly value life "whatever the consequences" and will stick to principles "should the heavens fall." These quotation marks do not indicate that Oderberg has said this, they are instead the terms often used in a pro-life context. However, through Oderberg's slippery fingers the heavens fall wondrously; and if not with a bang, certainly with a resounding whimper. Oderberg's preferred justification for self defense (although he offers two), is the Doctrine of Double Effect (DDE). DDE expresses the claim that we may do lethal things to stop people, so long as we do not intend or aim at, killing. For Oderberg, DDE rules out a pre-emptive strike both in war and in more personal violence, although if this is the only way of achieving the legitimate aims it is hard to see why it might be ruled out. Oderberg believes that ... even if you knew for certain that someone was going to kill you tomorrow, you would not be allowed to carry out a 'pre-emptive strike' by going over and shooting them dead today.13 The reason why you cannot do this is that you may not shoot with the intention of killing but only of preventing an attack, and today you are not being attacked.

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However Oderberg is, confusingly, also committed to the view that a person who is resolved to perform a good act is still praiseworthy even though the act is prevented by circumstance.... Similarly, a person who intends a bad act, say the burglary of another's house, has still acted badly even though he cannot find a way to break in.14 So the person who intends a bad act is relevantly guilty even if the act is not completed. Given this, and that the person who has resolved to kill me tomorrow is, like the burglar, already as blameworthy as if she had done the act, it is unclear why a pre-emptive strike is ruled out (particularly since Oderberg is also in favor of capital punishment)! It is important to note here that the idea of sanctity of life deployed by Oderberg has subtly changed. "Sanctity," which qualifies "life" in the original idea of sanctity of life, no longer performs this function, although it pretends to. Oderberg has moved from using "sanctity" to qualify "life" to using "sanctity" to qualify the state of mind of the person taking the life. It is not the lives of human beings nor yet of innocent human beings that are sanctified but the state of mind of the killer. It is virtuous state of mind or virtuous intention that is important, not preserving the value that life represents. And of course this cannot be defended in a classically rule utilitarian way (at least not by Oderberg or pro-lifers) by claiming that fostering these virtuous states of mind is the best way to ensure that the maximum number of protected lives are preserved. We now have a sanctity of life doctrine with two essential elements. By that I mean that lives are only protected from being killed if two different sets of conditions are met. (1) The first is that the lives in question must be in a state of grace or innocence. It is not enough that the lives in question are human, or even those of persons or members of a natural kind the value of whose members has been independently established. (2) The second condition is that the mind of the killer must be free of a particular intention. The killer can sometimes kill the guilty so long as she believes they are guilty, but she can also kill the innocent so long as she does not directly intend their deaths, so long as their deaths are only a so-called "second effect" of her actions. So pro-lifers are only: (1) pro-innocent life; and

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JOHN HARRIS (2) pro only lives that they must kill directly. It is open season on indirect killing.

5. Guilt and Innocence We must now ask what precisely makes subjects "guilty," that is, vulnerable to lethal force and what makes them lose protection of the Doctrine of Sanctity of Life? According to Oderberg, lives can lose sanctity by waiver or by forfeiture.15 Oderberg appears to think that the same reason underlies both waiver (voluntary) and forfeiture (involuntary) loss of protection. So protection is lost where "[the aggressor has offended against] the very right they claim for themselves."16 Oderberg is clearly onto something important here. The idea is that those who threaten life or who kill have forfeited the respect owed to their own lives by demonstrating that this value—the value of life—is not a value they hold, and therefore not a value that they can invoke to claim protection. Moreover, as we have seen, Oderberg is committed to the view that "the external act (that is actually achieving what you intend) adds nothing qualitative to the inner act of the will."17 While the idea that people lose their rights to life by forfeiture or waiver is attractive, it is not clear that it applies in the absence of a special argument. If I steal from you it does not follow that someone else may ethically or even legally steal from me. It may be that I cannot with a straight face, so to speak, claim that I am against theft; but that is not the same thing as giving anyone and everyone a legal and moral license to steal from me. So it is one thing to claim, plausibly, that those who have killed or would kill can hardly complain if others do not respect their claim to life. But to say that such people are not valuable or morally important beings requires at least some additional argument. It is perhaps also important here to note that "innocence," based as it is on a state of mind, is both a relatively weak and possibly an ephemeral state. Is innocence lost once and for all? Can it be regained? It is surely doubtful that such a "thing" could make the whole difference between a life being protected and it being vulnerable to killing. It is perhaps worth remembering here that on one of the views with which Oderberg contrasts his own, namely views of the value of life that place personhood at their center, all persons have valuable lives—even guilty persons.

6. When May We Kill in Self Defense? Now since self defense would in many cases be impossible or at any rate worth-

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less as a right if it could not be pre-emptive in some sense (if I have to wait to be actually murdered before I can defend myself, self defense would be a nugatory entitlement) people must be able to defend themselves from threats to their life either at the attempt or at the formation of intent stage. Since, as we have seen, Oderberg believes that "nothing qualitative" is added to the inner act of the will by actually succeeding in what we intend, it looks as though the intent should be enough. Indeed this is an inconsistency in almost all double effect approaches to responsibility.18 So the right of self defense, if it is to exist at all, must be triggered by either: • •

an attempt to harm; or the intent to harm.

We should note that in real life, the operative concept, by which I mean the idea that we often accept (which common sense morality accepts) as excusing killing, is more usually that of "posing a credible and unjustifiable threat" than either actually attempting the attack or forming the intent (a fact that because it is "all in the mind" is often not available to potential victims). If we had to have reliable evidence of the requisite intent before defending ourselves, self defense would hardly ever be an available option. We should end by considering one case that most people regard as involving both self defense and justified killing of the innocent. On 11 September 2001, passengers are believed to have overcome hijackers and forced a hijacked plane into a field in Pennsylvania, so forestalling the attempt to target the twin towers of the World Trade Center, New York, or some other target. Such an act, while defending the victims in the "target of choice," did involve killing the innocent passengers and crew. They were killed before they otherwise would, and although they would have died anyway their deaths must have offended against the sanctity of life doctrine as defended by Oderberg, for on his view, killing the innocent who are posing no threat is not legitimate however noble the justification. So this widely praised act, which probably saved many innocent lives, must for Oderberg be one of pure wickedness on the part of the passengers who resisted the hijack if their intent was to crash the plane and not exclusively to overpower the hijackers.

7. Personhood We have examined Oderberg's defense of the sanctity of life doctrine, which we noted has three elements: •

the types of creatures whose lives qualify;

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JOHN HARRIS their moral state—namely "innocence"; and the intentions of those who have it in mind to kill them.

We saw that the first element is an empty category, since creatures only qualify either because of their state of innocence or guilt, or because they are protected by the intentions or lack of intentions of those who would harm them. Finally, we should note that Oderberg absolutely rejects personhood as a moral category. That is, he rejects the idea that valuable lives are possessed only by beings with a particular range of capacities. He says unequivocally: all humans participate in that moral protection (that is, have valuable or sacred lives) by virtue of being what they are essentially, irrespective of the contingent circumstances in which they find themselves. Some of us might only be potential persons but we are all actual persons because we are human beings.19 It is on this view membership of a natural kind—human being—that confers value. This is the official position, but Oderberg has made it quite clear that he does not actually believe it for a moment. As we have seen, it is only innocent persons or persons who others wish to kill that he really is interested in protecting. And guilt or innocence is of course contingent; it depends on whether we are involved in a war or pose a credible threat. Moreover, on this question as on so many others, Oderberg is radically inconsistent. At the start of his book, so far from treating persons as equivalent to all human beings, valuable simply in virtue of their belonging to a natural kind, he waxes lyrical about the very things that those who operate with a concept of the person most value. This is Oderberg in Chapter 2,20 where he tries to distinguish human beings from animals: The point here is that man has an intellect unlike any other kind of creature on earth. He is capable of reasoning about how he should live his life. He spends much of his time ordering things so that he lives a certain kind of life. He reflects on how he wants to live and proposes certain things to himself as worthy or not worthy ... he ... thinks about how he should arrange those ingredients that go to make up what he believes will be a good life for him.21 This could have come straight out of Singer, or me, or any of Oderberg's other stalking horses. And there is much more besides. Oderberg here appears really to believe not that "we are all actual persons because we are human beings" but instead that we are all morally important beings because we have intellect, reasoning, ordering, reflection, a conception of the good life, and so on. But of

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course he does not believe this either. Even this impressive list does not make the lives of the guilty morally significant, nor will it protect those who are not lucky enough to be the targets of malevolence.

Acknowledgments I am grateful to Rebecca Bennett, Ellie Lee and David Paintin for valuable assistance.

NOTES 1. David Oderberg, Moral Theory (Oxford: Blackwell Publishers, 2000). 2. Euthanasia Examined: Ethical Clinical and Legal Perspectives, ed. John Keown (Cambridge: Cambridge University Press, 1995). 3. Ibid., p. x. 4. Ibid., p.vii. 5. Ibid., p.viii. 6. See John Harris, "Conjoined Twin Non-Persons," Medical Law Review 9:3 (2000), pp. 221-236. 7. See John Harris, Violence and Responsibility (London: Routledge and Kegan Paul, 1980); John Harris, The Value of Life: An Introduction to Medical Ethics (London: Routledge, 1985). 8. Laurence H. Tribe, Abortion, The Clash of Absolutes (New York and London: W. W. Norton and Company, 1990), p. 140. 9. SeeH. L. A. Hart, "Intention and Punishment," in his Punishment and Responsibility (Oxford: Oxford University Press, 1968). 10. Julian Savulescu has argued something like this in a personal communication. 11. See Oderberg, Moral Theory, p. 147. 12. Ibid., p. 148. 13. Ibid., p. 149 (but cf. p. 88). 14. Ibid., p. 88. 15. Ibid., p. 149. 16. Ibid., p. 150. 17. Ibid., p. 88. 18. See Harris, Violence and Responsibility. 19. Ibid., p. 183. 20. Ibid. 21. Ibid., p. 36.

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Eleven THE GROUNDS FOR PREVENTING IMPAIRMENTS: A CRITIQUE Simo Vehmas 1.

Different Ways of Preventing Impairments

No sensible person wants to be impaired. Impairments imply unfortunate outcomes to individuals, their families, and their social environment. This is why preventing impairments is a priori regarded as a justified and desirable project. Many prominent bioethicists have aimed at providing sound reasons for this common intuition. It is my task in this article to investigate critically the arguments offered to support the notion that impairments should be prevented. It should be noted at this point, that in this article the terms "impairment" and "disability" or "disablement" carry different meanings. By "impairment" I refer to a condition that is medically defined as an organic deviation (for example, missing or defective limb, organism or mechanism of the body). Disability and disablement, on the other hand, refer to an individual's state of functioning that conflicts with or jeopardizes the fulfillment of her civic, commercial, and personal flourishing, or to a state of social and environmental factors that cause the disablement of some individuals. The prevention of impairments can be carried out by medical, social, behavioral, and educational means. These measures may take place in three different ways. Primary prevention refers to actions that occur before the onset of the ailment, and that stop the ailment from occurring in the first place. This can mean vaccination against some disorders (medical interventions), advising prospective parents that have habits—for example, alcohol abuse—that may harm their future child (behavioral or educational interventions), and creating general welfare programs that aim to create a social environment in which parents could provide themselves, and their future children, with a satisfactory life (social interventions). Secondary prevention refers to actions that shorten the duration of existing ailments, or reverse their effects. This can mean, for example, the newborn screening of PKU (phenylketonuria, a condition that usually, without a special diet, results in profound and irreversible cognitive impairments in children) and early educational intervention programs with highrisk infants. Tertiary intervention aims at limiting the adverse effects of an ailment and improving the individual's level of functioning. This may include optimized medical care and various educational programs.1

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The most serious ethical problems occur in relation to procedures that aim at the prevention of the existence of individuals with impairments. It has been argued, for example, that impairments can provide a proper reason for withdrawing life-saving medical treatment, terminating pregnancies, avoiding conception, and acquiring genetic information in order to prevent the birth of impaired children.2 In what follows, I will explore the reasons offered for the moral justification of preventing the existence of individuals with impairments.

2. Impairments as Threats to Well-Being From an individual's perspective, impairments are seen as harmful to her wellbeing. Physical and mental impairments may imply suffering or the kind of dependence on other people that compromises a person's pursuit of a happy life. Selective terminations are often justified by appealing to the principle that it is wrong to bring avoidable suffering into the world.3 It is true that some impairments imply a (short) life filled with enduring pain and continual, uncomfortable medical procedures. Yet, this argument is rarely appropriate with selective abortions. The most common reason for selective abortion is Down syndrome, which, although in some cases it does involve medical problems, usually does not imply in itself any suffering whatsoever. Quite the contrary: individuals with Down syndrome are known to be on the whole joyful and content human beings. What is it then about the quality of life of people with impairments that is seen to justify the prevention of their existence? Helga Kuhse and Peter Singer's well-known and controversial book Should the Baby Live? exemplifies premises and arguments common in bioethics regarding the quality of life of individuals with impairments. Kuhse and Singer argue that life-saving medical treatment should be more available to infants without impairments than to infants with impairments. One crucial element in their argument is the notion that impairments imply poor quality of life. They discuss a case in which a baby with Down syndrome named Brian West was born without an esophagus. They point out, quite correctly, that the Down syndrome was medically a relevant factor in this case. The operation to reconstruct Brian's esophagus was, in fact, more or less experimental due to the characteristic physical features related to Down syndrome: it is associated with poor muscle tone, which may make swallowing with the reconstructed esophagus more difficult. Also, there is an increased susceptibility to upper respiratory tract infections in individuals with Down syndrome, which may cause additional complications. Therefore, Brian West had poor prospects for a successful outcome. From a medical viewpoint, it appears reasonable to question the decision to perform such a risky operation. Kuhse and Singer, however, appeal to other than medical factors as well:

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... quite apart from these medical factors, Down's syndrome is surely relevant to the decision to operate because it means a reduced potential for a life with the unique features that are commonly and reasonably regarded as giving special value to human lives. Even allowing for the more optimistic assessments of the potential of Down's syndrome children, this potential cannot be said to be equal to that of a normal child. The possible benefits of successful surgery in the case of a Down's syndrome child are, therefore, in terms of these widely accepted values, less than the possible benefits of similar surgery in a normal child. It might be justifiable to run some risk of the kind of misery Brian experienced, if there were a fair chance of a reasonably normal life; the same risk might not be justifiable if the best that could be hoped for was the reduced potential of the life of someone with Down's syndrome.4 One curious thing in Kuhse and Singer's account is that it is based on vague normative concepts such as "normal life" and "full human existence."5 These utterances express ideas of what kind of beings human beings ought to be and what kind of lives they ought to live. However, in their position the concepts of normal or full human life remain quite unclear, and the chances of children with impairments reaching different aspects of human existence are left without explication. If we do not know what is actually meant by "full human existence" and to what extent impairments compromise an individual's chances of living such a life, what are we to derive from an account as ambiguous as this? Kuhse and Singer6 assume that the life of an infant with Down syndrome can be merely "reasonably satisfactory"—assuming there are no other complications. The only possible reason for this claim, and for the corresponding claim that the life of an infant with Down syndrome can be reasonably satisfactory but the life of a typically healthy infant can be satisfactory or even very satisfactory, is the fact that people with Down syndrome are usually intellectually less competent than typically healthy people without apparent intellectual limitations. Assuming that there are objective criteria for a good human life and well-being (criteria requiring some amount of intelligence), we could argue on the basis of those criteria that the life of an infant with Down syndrome will be less satisfactory than the life of an infant without cognitive impairments. Despite the numerous problems related to the possible objective account of human well-being, the obvious point in Kuhse and Singer's case is.the fact that such criteria would clash with their utilitarian premises. In Kuhse and Singer's preference utilitarian position, the wrongness of an action is related to the extent to which the action prevents some interests, desires, or preferences from being fulfilled. This means that the good of individuals is to be determined by their own values, instead of by an impersonal

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evaluation of the quantity and quality of their pleasures and pains.7 Yet, Kuhse and Singer have a tendency to stress abstract ideals of a proper human life and consequently ignore the experiences of individuals with cognitive impairments. If a person with such conditions enjoys her life, her experiences, interests, desires and preferences ought to count in the utilitarian calculus as much as the ones of so-called "normal" people. This is not the case in the theory of Kuhse and Singer, whose conclusions therefore conflict with their normative premises. From a utilitarian viewpoint, stressing ideals that do not contribute to an individual's well-being appears quite pointless, especially because well-being appears to be a subjective concept by its very nature; well-being concerns inevitably "what is good or bad for the subject in question."* The obvious contradiction in Kuhse and Singer's account is connected to their difficulty in fully identifying themselves with either the utilitarian position presented by Jeremy Bentham, or that of J. S. Mill. Bentham9 represents a moral theory based strictly on the desires, preferences, or interests of a being: "The question is not, Can they reason! Nor Can they talk! but, Can they suffer!"10 This is what Peter Singer11 in particular emphasizes when discussing the moral status of animals. In the case of euthanasia and infanticide, however, Kuhse and Singer seem to identify themselves with the ideal utilitarian position presented by Mill: "It is better to be a human being dissatisfied than a pig satisfied; better to be Socrates dissatisfied than a fool satisfied."12 When seeing the life of an intelligent human being as more valuable than the life of an individual with cognitive impairments, Kuhse and Singer have created a more or less unresolved contradiction within their utilitarian position.13 To conclude, impairments in themselves do not necessarily cause a significant threat to a person's subjective well-being. The environment and relationships with others may count a great deal more than intellectual competence when assessing a person's chances for a happy life; I have a better chance of being happy if I am the kind of a person that the surrounding community expects me to be, or if it takes me for what I am.14 3. Individuals with Impairments as a Burden Impairments are often regarded as undesirable, not just from an individual's perspective, but from the viewpoint of her family and society as a whole too. As for the topic of family functioning, many bioethicists have argued that children with impairments may paralyze their families both emotionally and financially, to the extent that it would be unreasonable to impose on parents the duty to have such children.15 However, the basic finding of various empirical studies is that the experiences of the families of children with impairments are more similar to than they are different from the experiences of families with children without

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impairments. People seem to assume that children with impairments automatically cause excessive burdens to their parents and, at the same time, forget that every child is more or less a burden to her parents. Children without impairments may cause stress to their parents due to problems (for example, drug or alcohol abuse and eating disorders) in which children with, for example, cognitive impairments usually do not get involved. Families of children with impairments do not necessarily experience any more difficulties than families with "normal" children—their problems are just different.16 Sometimes children with impairments do, however, cause considerable hardships to their families. This may be connected to the child's individual characteristics, such as the degree of impairments. Often, however, social and cultural factors contribute more to the well-being or ill-being of families than the child's impairment in itself. Families that receive support from their communities are, despite the child's impairments, likely to cope better than families that are emotionally and financially on their own. Also, the beliefs, attitudes, and values of parents regarding disability and raising children in general, have a great effect on the way in which having a child with impairments affects their well-being. One reason why parents view a child with impairments as a problem is often related to their generally tending to anticipate "the birth of a usual perfect baby."17 If parents hoped, instead, to have a baby with prospects of a happy life despite her individual characteristics, their reaction to having a child with impairments would not be, to them, as severe as it is when they set strict requirements of "normality" for their offspring.18 The economic interests of society may also be thought to provide a reason to prevent the existence of individuals with impairments. Kuhse and Singer19 point out that since we live in a world with finite resources, we cannot make infinite provision for every life. The increased number of infants surviving with severe impairments is one reason, according to them, that economic issues have become more urgent. In other words, more money for infants with severe impairments will mean less money for others in need: "Do those who talk of 'discrimination' against severely handicapped infants even consider the way in which we 'discriminate' against those who happen not to live in our own fortunate country?"20 To confront in this manner the interests of people living in poor conditions in developing countries and infants with impairments in our own fortunate countries is, of course, arbitrary. With a similar logic we could choose anything from our state budget and claim that this part of the budget in particular takes money away from starving people in poor countries. Which part of the budget we choose reveals what we value as unimportant. This kind of remark, combined with pessimistic rhetoric in which Kuhse and Singer question the meaningfulness of the lives of people with impairments and especially with cognitive impairments, is ultimately based on the view that individuals with impairments are "unwanted people."21

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It appears that the economic burden argument is not, after all, actually just concerned with the economic interests of society. It is hardly convincing to claim that people with impairments constitute the minority that makes a significant difference in the nation's economy—at least not in the Western countries. Instead, the point appears to be the assumed undesirable nature of impairments and even the existence of people with them that bothers so many. To appeal to the economic interests of society as a reason to prevent impairments, appears more or less an excuse for the basic desire to avoid the alleged inconvenience associated with impairments and the existence of people with impairments. 4. Impairments and Limited Opportunities One reason offered for the justification, or obligation, to prevent the existence of children with impairments is the appeal to the child's right not to have her future options irrevocably foreclosed. This means, for example, that deliberately producing a deaf child is wrong because it "narrows the scope of her choices when she grows up; in other words, it violates her right to an 'open future.'"22 Dena S. Davis, the author of these words,23 also concludes that If deafness is considered a disability, one that substantially narrows a child's career, marriage, and cultural options in the future, then deliberately creating a deaf child counts as a moral harm. If Deafness is considered a culture, as Deaf activists would have us agree, then deliberately creating a Deaf child who will have only very limited options to move outside that culture, also counts as a moral harm. As for Deafness being a culture that provides its individuals with only very limited options, one crucial consideration has to be observed. All people are born, and belong, to some culture and community that sets limits to their possibilities. Middle class, white, straight men like myself are not able to explore the possibilities that working class, black, or gay culture may provide. And yet, it would seem absurd to accuse my parents for having violated my right to an open future. What is the issue here is Davis's value judgment of Deaf culture: we cannot say that an individual's future options are limited simply because she belongs to one culture instead of another, unless we are prepared to say that some cultures are better or worse than others.24 So, what is it about Deafness that makes it a harmful condition that implies disablement and a worse culture than a hearing culture? What amounts to a disability and disablement? According to John Harris,25 disabilities are the kind of harmed conditions that someone has a strong rational preference not to be in. A harmed condition is relative both to a person's rational preferences and to possible alternatives. In

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other words, a condition is a disability if it implies the deprivation of worthwhile experiences and of the possibility of exploring them: "The intellectually disabled do miss out on some dimensions of experience which are closed to them in the way that music is closed to the deaf. And this is a disability."26 Although Harris's definition is not very enlightening and leaves many questions open, his intuition appears acceptable. Causing deafness to a child, even if the parents themselves are deaf, seems like causing a harm to the child. Yet, is this intuition a morally valid guideline? The obvious question arising from Harris's position is: what kind of possibilities are relevant in the sense that the lack of them amounts to a disability? What is it about, for example, hearing that makes us think that it is an invaluable faculty; why are people disabled if they cannot enjoy "Mozart, and Beethoven, and dance music, and the sound of the wind in the trees, and the waves on the shore... ?"27 Because listening to music or the sound of waves on the shore is of vital importance to us, to so-called normal people. Some functions are regarded as species-typical and crucial for human well-being because they are "sources of shared experience and social interaction," and also because "our social life and culture are built around some of those functions."28 This is why people do not feel themselves disabled in lacking a sixth sense or the acoustic range or olfactory sensitivity of a typical dog. Also, what is at stake here is not limited opportunities in themselves, but the quality of them. Gender "disables" individuals regarding career; women cannot become fire fighters as easily as men. This is rarely considered as a limitation serious enough to justify selection of children on the basis of gender. Why is it, then, that the limited opportunities related to deafness or cognitive impairments, for example, are considered significant enough to entitle or even oblige parents to prevent the birth of children with such conditions? Why does Harris think that deafness is a disability if deaf people themselves do not feel disabled by their loss of hearing? Human reality is, in any case, restricted for all people, and the possibilities it offers for individuals are inevitably limited. This being the case, limited opportunities cannot be in themselves the basis for defining disability. If the quality of the limited opportunities is the point, then we should be able to provide an objective theory of what counts as a relevant restriction regarding human life, and which a "rational" person would wish to be without. Without such a theory, a more plausible alternative for defining a satisfactory life in terms of opportunities, would be the following: pursuing successfully some possibilities that are good or the best that the restricted human reality offers for this individual, is enough for her to achieve a good life. In this case her individual characteristics would be irrelevant as regards disablement. In other words, it cannot be automatically concluded that deafness or cognitive impairments always imply disablement—we should first evaluate carefully an individual's

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experience of her condition, which is shaped in a complex interaction with her social environment. Defining disability should thus be sensitive to the particularities of individuals' lives. 5. Impairment, Disability, and Discrimination The common views on disability presented in modern bioethical literature are based on a discourse in which the burden of proof is imposed on those who approach having impairments non-judgmentally, whereas those who think that being deaf or having cognitive impairments is intrinsically bad do not have to convince others thoroughly, because their notion reflects the common rhetoric on disability.29 In this rhetoric, individuals are seen to suffer from, for example, Down syndrome, and the chance of having such a child is seen as a risk—the kind of risk that prospective parents ought not to take. Julian Savulescu30 has recently defended a principle that he calls Procreative Beneficence as a reason for preventing the birth of children with undesirable characteristics: "couples (or single reproducers) should select the child, of the possible children they could have, who is expected to have the best life, or at least as good a life as the others, based on the relevant, available information."31 What is "the best life" depends highly on a person's social environment; in India men are likely to have better lives than women. According to Savulescu's principle, Indian parents should aim at producing boys instead of girls even if their choice would maintain or increase social inequality. This seems a repugnant position. Since environment plays a major role in the way in which individual characteristics affect a person's well-being, why would we content ourselves with a social reality that promotes the discrimination of some of its members when we could abolish such discrimination and, at the same time, give birth to children with a variety of characteristics, all capable of having a good life? Besides, the idea of "the best life" is not, without proper elaboration (which Savulescu does not provide) a very helpful moral guideline: instead, it is merely silly. Despite Harris's, for example, recognizing the significance of social reality on disabled people's lives, his contribution primarily individualizes disability, seeing it as an individual's problem. Viewing disability exclusively as a problem, instead of an issue, an idea, a metaphor, a phenomenon, a culture, or a construction, is based on the absence of subjectivity of disabled people, as well as the objectification of them in scholarship.32 If disability is defined primarily from an individualistic perspective, the interventions aimed at abolishing people's disablement will inevitably be directed to individuals in the first place, not communities. This way we are leveling players instead of playing fields,33 and

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so not acting according to Harris's own proclamation that people with impairments are full, free and equal human beings and citizens with all the rights, entitlements and protections that implies. They must be free from discrimination of whatsoever kind and individuals and societies must take whatever steps are required to ensure that this free and equal status can be enjoyed with equal facility as any other person.34 It is hard to see how this could take place if we ignore and nullify the subjective experiences and voices of individuals with impairments. And that is actually what we do when we refuse to accept their own voice and, instead, appeal to some objective standard that implies that they are in a harmed condition that any "rational" person would avoid.

6. Conclusion I have aimed at questioning in this article the view that disability is an individual's unfortunate condition, and have argued that disabilities are largely created and constructed by social values, expectations, and arrangements. Also, impairments in themselves are not necessarily significant threats to well-being and do not automatically provide a reason to prevent the birth of children with such conditions. In the light of my discussion, there are at least three different ways to define and conceptualize disability. These three ways can be reduced to the following terms: Deviance: disability is an undesirable or bad divergence from the normal, desirable or good way of functioning or being. Difference: disability is not necessarily bad or undesirable, merely a different way of functioning. This term also proportions disability to normality and prevalent ways of functioning. It questions neither the dichotomy between disabled and non-disabled people, nor the otherness of the disabled. Human variety: seeing disability primarily as a matter of human variety suggests that the starting point to the conceptualizing of impairments and disability should not be based on a previously agreed upon, fixed notion, which sees impairments in themselves as undesirable conditions and sees disablement as the inevitable result of impairments. Instead, disability and impairment should first be seen as neutral indicators of human variety, not as automatically undesirable individual conditions. After this, we could start exploring whether impairments are desirable or undesirable conditions as such. This approach would, hopefully, enable a many sided scrutiny of disability and its moral significance. Such an orientation requires that non-disabled researchers should respect and genuinely consider disabled people's experiences. They (including myself) have a special responsibility "to pay particular attention

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to issues of their own identity, their own privilege as non-disabled people, and the relationship of these factors to their scholarship," as Simi Linton has put the matter.35 It appears, however, that a social approach to disability can lead into an over-idealistic and glorifying picture of impairments if consistently applied. It would be dishonest and wrong to deny that sometimes impairments cause the kind of suffering, limitations, and inconvenience (minor or major) that cannot be removed by material or social arrangements. Yet, the experience of people with impairments concerning limitations and inconveniences does not necessarily differ decisively from the experiences of people without such conditions. All people face at times, or rather, continually, some sort of limitations and practical inconveniences. There is often a difference of degree in this experience due to the nature of impairment, but the difference between the inconveniences faced by people with impairments and without them is a matter of qualitative difference, not necessarily quantitative. That is, impairments do not inevitably imply greater suffering and limitations; instead, they imply different kinds of suffering and limitations. As for the question of what kind of limitation or inconvenience is decisive enough for us to conclude that it in itself results in the kind of disablement that justifies the prevention of individuals with certain conditions, that is a topic that merits further examination.

NOTES 1. American Association on Mental Retardation, Mental Retardation: Definition, Classification, and Systems of Supports (Washington, DC: American Association on Mental Retardation, 9th ed., 1992). 2. Allen Buchanan, Dan W. Brock, Norman Daniels, and Daniel Wilder, From Chance to Choice: Genetics and Justice (Cambridge: Cambridge University Press, 2000); Dena S. Davis, "Genetic Dilemmas and the Child's Right to an Open Future," Hastings Center Report, 27:2 (1997), pp. 7-15; Jonathan Glover, Causing Death and Saving Lives (Harmondsworth: Penguin Books, 1977); John Harris, "Is There a Coherent Social Conception of Disability?," Journal of Medical Ethics, 26:2 (2000), pp. 95100; James Hudson, "What Kinds of People Should We Create?," Journal of Applied Philosophy, 17 (2000), pp. 131-143; Helga Kuhse and Peter Singer, Should the Baby Live? The Problem of Handicapped Infants (Oxford: Oxford University Press, 1985). 3. See e.g., John Harris, Clones, Genes, and Immortality: Ethics and the Genetic Revolution (Oxford: Oxford University Press, 1998), p. 111. 4. Kuhse and Singer, Should the Baby Live?, p. 143. 5. Ibid., pp. 136, 143. 6. Ibid., p. 141.

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7. Mary A. Warren, Moral Status: Obligations to Persons and Other Living Things (Oxford: Clarendon Press, 1997), p. 65. 8. L. Wayne Sumner, "The Subjectivity of Welfare," Ethics, 105:4 (1995), p. 767. 9. Jeremy Bentham, An Introduction to the Principles of Morals and Legislation (London: Athlone Press, 1970). 10. Ibid., chap. 17,4, 2b. 11. Peter Singer, Animal Liberation (New York: Avon Books, 2nd ed., 1990). 12. John Stuart Mill, "Utilitarianism," On Liberty and Other Essays, ed. John Gray (Oxford: Oxford University Press, 1991), p. 140. 13. Simo Vehmas, "Discriminative Assumptions of Utilitarian Bioethics Regarding Individuals with Intellectual Disabilities," Disability and Society, 14:1 (1999), pp. 3752. 14. Simo Vehmas, "Newborn Infants and the Moral Significance of Intellectual Disabilities," Journal of the Association for Persons with Severe Handicaps, 24:2 (1999), pp. 111-121. 15. E.g., Kuhse and Singer, Should the Baby Live?; Rosamond Rhodes, "Abortion and Assent," Cambridge Quarterly of Healthcare Ethics, 8:4 (1999), pp. 416-427. 16. Erik Parens and Adrienne Asch, "The Disability Rights Critique of Prenatal Testing: Reflections and Recommendations," Hastings Center Report, 29:5 (1999), pp. 1-22; Vehmas, "Newborn Infants and the Moral Significance of Intellectual Disabilities." 17. Kuhse and Singer, Should the Baby Live?, p. 184. 18. Simo Vehmas, "Parental Responsibility and the Morality of Selective Abortion," Ethical Theory and Moral Practice, 5 (2002), pp. 463-484. 19. Kuhse and Singer, Should the Baby Live?, pp. 165-166, 168. 2Q.Ibid.,p. 171. 21. Peter Singer, Rethinking Life and Death: The Collapse of our Traditional Ethics (Oxford: Oxford University Press, 1995), p. 129. 22. Davis, "Genetic Dilemmas and the Child's Right to an Open Future," p. 9. 23. Ibid., p. 14. 24. Tuija Takala, "The Child's Right to an Open Future and Modern Genetics," Ethical Issues in the New Genetics: Are Genes Us?, ed. Brenda Almond and Michael Parker (Aldershot: Ashgate, forthcoming). 25. Harris, Clones, Genes, and Immortality: Ethics and the Genetic Revolution; Harris, "Is There a Coherent Social Conception of Disability?"; John Harris, "One Principle and Three Fallacies of Disability Studies," Journal of Medical Ethics, 27:6 (2001), pp. 383-387. 26. Harris, "One Principle and Three Fallacies of Disability Studies," p. 384. 27. Harris, "Is There a Coherent Social Conception of Disability?," p. 97. 28. David Wasserman, "Some Moral Issues.in the Correction of Impairments," Journal of Social Philosophy, 27 (1996), pp. 128-145. 29. Anita Silvers, "Formal Justice," Disability, Difference, Discrimination: Perspectives on Justice in Bioethics and Public Policy, ed. Anita Silvers, David Wasserman and Mary B. Mahowald (Lanham: Rowman and Littlefield, 1998), pp. 86-89. 30. Julian Savulescu, "Procreative Beneficence: Why We Should Select the Best Children," Bioethics, 15:5-6 (2001), pp. 413-426.

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31. Ibid., p. 413. 32. Simi Linton, Claiming Disability: Knowledge and Identity (New York: New York University Press, 1998), ch. 6. 33. Silvers, "Formal Justice," p. 70. 34. Harris, "One Principle and Three Fallacies of Disability Studies," p. 384. 35. Linton, Claiming Disability, pp. 152-153.

Twelve DEFLATING AUTONOMY Mark P. Sheehan 1. Two Claims A central issue in the contemporary practice of medicine, and in current debates within bioethics, concerns the relative roles of physicians and patients in deciding treatment paths. The physician is the trained expert, but it is the patient's health and future that is at stake. The prevailing contemporary approach is to deal with these issues in terms of patient autonomy.1 In short, physicians need to curtail the urge to paternalism that naturally arises from their superior expertise, and to respect (in varying ways and to varying degrees, according to different authors) the autonomy of their patients. This paper questions the prevailing approach by defending two main claims that, I think, amount to a deflation of the concept of autonomy in bioethics. First, what we might call, "the conflict problem" is often depicted, from the physician's perspective, as a choice between acting beneficently and respecting patient autonomy. This, I claim, misrepresents the problem. Second, and more importantly, I will claim that "good-promoting" theories, that do not need to use the concept of autonomy, are capable of delivering as broad a range of positions on justified paternalism as what we might call "autonomy-trumping" theories. Being exclusively a "goodpromoter" does not exclude a person from holding any positions concerning those cases of paternalism that are morally justified. It is important to notice here that both of the central claims of this paper are non-normative. I am not concerned with which, or whether any cases of paternalism are justified, but with whether the concept of autonomy is required in order to understand the bioethical issues involved. Before we proceed, a few definitions and clarifications are in order. These are intended to be uncontroversial and general enough to cover more specific disputes. First, a beneficent act, let us say, is one that is done for the benefit or good of another. So the principle of beneficence asserts an obligation to act for the benefit or good of others. Second, there are many versions of what constitutes autonomy but most involve ideas like self-governance, self-direction, or personal sovereignty. The principle of autonomy then, asserts an obligation to refrain from interfering with those actions that are the products of autonomous choice (that is, the products of self-governance and so on). Third, there seem to be two key elements involved in acts of paternalism. The first is that such acts

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must be done from a concern for another's good (that is they must be benevolent). The second is that they must knowingly be undertaken irrespective of what the other person takes (or would take) to be his or her good.

2. The Conflict Problem One way to characterize the problem with which we are concerned is as follows. Sometimes two views, those of the physician and the patient, come into conflict in the practice of medicine. These two views conflict when the choices or decisions that a patient makes regarding healthcare are not, in the view of the physician, in his or her best medical interests. The physician must choose between respecting the decision and so failing to act in (what he or she views as) the patient's best medical interests, or ignoring the decision and doing what is (medically) best for the patient. Let us call this "the conflict problem." This conflict problem is sometimes depicted as pitting beneficence against autonomy—that is, where the obligation to respect autonomy comes into conflict with the physician's obligation to act for the good of the patient.2 Here, two values are in conflict: the concern to allow a person to make and determine the course of his or her own life (respecting autonomy) and the concern to do what is in the best interest of another (beneficence). But this way of depicting the conflict problem is inadequate. It fails to acknowledge an ambiguity in the definition of beneficence. This ambiguity involves what is to count as "the good of the patient." It is assumed, on this view, that the patient's good takes a certain form, namely, the patient's good from the physician's perspective: that is, from a medical perspective. Our ordinary concept of beneficence does not include any definitive position on this matter, and the patient may have a different conception of his own good. Moreover, it is clearly the case that acts done for the patient's good, beneficent acts, can be such as to respect that patient's autonomy. So, it is not beneficence in general that conflicts with autonomy in cases of paternalism, but acts done in the name of beneficence that do not respect the patient's choices or are performed irrespective of the patient's own view of what is to his or her benefit. The main consequence of this is that the conflict problem is better represented as a conflict between respecting autonomy and acting paternalistically. What is in conflict is not the patient's autonomy and the patient's good, but two views of the patient's good. The question then is when should the physician respect autonomy, so that the patient's view of his or her own good prevails, and when ought the physician to act paternalistically, so that the medical view of the patient's good prevails. In many cases, the autonomy-beneficence view of the conflict problem will be quite wrong, for it obscures the central fact that there are two competing views of the patient's good at issue.

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Most people would agree that there are some cases of paternalism that are justified. The physician is sometimes justified in acting for the good of the patient irrespective of the patient's wishes. Most would agree that restraining a patient in a wheelchair (against her wishes) is justified if it is done to prevent her from trying to stand and, as a result, falling or re-injuring herself.3 So, the real problem is when acts of paternalism are justified and when they are not. Any solution to this problem will need to provide both a set of criteria for determining when an act of paternalism is justified and when it is not, as well as a justification for this set of criteria.

3. "Autonomy-Trumping" and "Good-Promoting" Versions of a Solution It is often thought that, if we want respect for persons and the like to play a significant role in bioethics, then we must allow autonomy to be the central concept. Moreover, we must allow a particular conception of autonomy, one that is in some way rights based, to play this role. So we might think that the requirement of respect for persons dictates that theories of bioethics should have, as their foundational or justificatory base, some kind of conception of the rights of patients. Dan Brock writes that "it is commonly thought that paternalism is an important example both of the necessity of a rights-based moral theory positing some right to individual self-determination or autonomy and of the inadequacy of consequentialist moral reasoning in terms of promoting the good."4 The structure of these suppositions is as follows. It is assumed that the form of the solution to problems like that of justified paternalism must begin with a respect for individuals, and that this respect is naturally couched in terms of a capacity—autonomy—which individuals possess. From there a particular kind of justification of the principle of autonomy is mounted. If it can be shown that solutions to the problem of justified paternalism can be couched in terms other than those of autonomy, then these suppositions break down and we are not forced into defenses of the principle of autonomy in terms of rights and related concepts. In line with this strategy, there are, I maintain, two ways of representing the same solution to the problem of distinguishing justified from unjustified paternalism. These two ways are represented by what Brock has called "autonomy-trumping" and "good-promoting" theories of justified paternalism.5 It should be noted that what I have to say here applies (though differently) to theories that attempt to "balance" the principle of beneficence and the principle of autonomy. Such theories might suggest conditions under which the principle of autonomy is outweighed by the principle of beneficence.61 am only concerned to show that the balancing need not be between beneficence and

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respect for autonomy. Indeed, as I have suggested in the previous section, depicting the issue of justified paternalism as a conflict between beneficence and autonomy is to risk misrepresenting the problem. An "autonomy-trumping" theory is one that says that a person's autonomous choices should always be respected. So paternalism is only justified in cases where the capability for autonomous choice is either lacking or has not been exercised in a particular case. This kind of theory then goes on to give the details of what constitutes an autonomous choice, and the conditions under which a patient has made a non-autonomous choice. Quite clearly there are a host of positions that may be adopted regarding the most relevant features of autonomous choice; each will have consequences for the kinds of choices and contexts under which paternalism will be justified and unjustified. This position would justify what Joel Feinberg has called soft (weak) paternalism.7 However it should be noticed that there is no settled limit to what counts as a nonautonomous choice (indeed there is much dispute8), so the number of cases of justified paternalism could still be large. Further, given the definitions of soft (weak) and hard (strong) paternalism, an autonomy-trumping theorist cannot recommend hard paternalism. So hard paternalism is only available to goodpromoting theorists or to those who attempt to balance the two principles. A good-promoting theory is, not surprisingly, one that says that the person's good should always be promoted. Obviously, the nature of the person's good is the crucial issue. It is often assumed that the account given by a good-promoting theory will be one in which the nature of a person's good is given by a set of criteria that are, at least partially, independent of the person and their view of their good. We can easily develop such a version of the good-promoting view by adopting, as the minimum criteria for a person's good, the standards that are provided by medicine. So, a person's primary goods are those provided by medicine, and their secondary goods would be whatever they wanted—that is, once they were free of significant pain, illness, disability, etc. An account such as this would lead to a very large number of instances of justified paternalism. Since physicians are the authority on medical goods, they are always in a better position to know the patient's good than is the patient. However, we might think that this account of the nature of a person's good is suspect. It is not obviously true, nor is it the only alternative. Another version of the good-promoting view might hold that the nature of a person's good is entirely tied to what they value or desire. Borrowing a metaphor from Simon Blackburn, we might think of a person's values and desires as being organized on a staircase of practical and emotional ascent.9 At the lowest level of the staircase we find preferences and other short term desires. At the higher levels we find a person's deepest commitments, life plans, and values. The idea is that, in general, things at the higher levels override things at the lower levels. That is, we tend to feel more strongly or are more willing to act on those values and

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desires that are at the higher levels of our staircase (hence, both the practical and emotional components). On this kind of story a particular person's good would be tied directly to this staircase of practical and emotional ascent. Quite clearly those values and commitments at the higher levels, those with which the person identifies, for instance, will occupy a central place in what that person counts as their good. Other lower level values or desires would count, not as central to the person's good but, perhaps, as important. At the lowest level we encounter whims and preferences that, for the most part, an individual is unlikely to see as integral to their well-being. So an individual's good is given entirely by what they count as their good. This does not preclude discussion with others about our good, nor does it preclude an individual from finding out or deciding in a given situation what is best for them—creating their good "on the spot." An individual's good is consequently dynamic: evolving with experience, reflection, interaction with others, and so on. In short, the view insists that the good for an individual is a "subjective" or personal matter, determined by the way in which each person views their life and the best way to live that life. In dealing with the problem of justified paternalism, the challenge for this kind of view is to provide criteria for distinguishing a choice that reflects a person's "genuine" good from one that does not. The idea would be that a physician is justified in disregarding a patient's choice or decision only when that choice does not reflect the patient's genuine good. The idea of a genuine good here is to be contrasted with, in at least some cases, the good that the patient appears to have chosen. There exists a range of such criteria, each of which results in a different set of cases that are counted as justified paternalism. My main concern here is to illustrate that this range of criteria—that is, the range of ways of distinguishing which choices are in line with a person's genuine good—matches the range of positions on justified paternalism that are available to the "autonomy theorist." At one end of this range of positions is the view that no acts of paternalism are justified. This would be the product of a view that denied that there are criteria for isolating a person's genuine good. With no criteria, each of the patient's decisions straightforwardly reflects his or her good and so the physician's obligation is to act for that good. This is an extreme and implausible position but it does correspond to a possible autonomytrumping position that simply equates autonomy with any kind of choosing. On these positions paternalism is never justified. As we move along the continuum of positions on justified paternalism, we increase, from zero, the number of cases that are to count as acts of justified paternalism. By introducing criteria to distinguish choices that reflect the genuine good of a patient from those that do not, the good-promoting theorist can match the positions available to the autonomy theorist.

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Presumably the best account of justified paternalism will lie somewhere between the extremes—allowing neither too many nor too few cases to count as justified. The autonomy theorist must say in what autonomy consists and provide a way of distinguishing autonomous from non-autonomous choice. The good-promoting theorist, again, must provide criteria that will isolate choices that reflect the patient's genuine good. One way of achieving this might be to suggest that a patient's choice reflects her genuine good when that choice is made in a context that satisfies certain pre-determined cognitive standards. We might, for instance, suggest that in order for a particular choice to count as a choice reflecting the genuine good of the patient, the patient must understand the alternatives before her and recognize the consequences of these alternatives—where the criteria for determining understanding and recognition have been given. Similarly, we might place some minimal standards on reasoning— say, requiring the patient to demonstrate, in some way, the reasoning process behind a given choice. So we might claim that in order for a patient to be said to be choosing in line with her genuine good, some kind of reason or explanation is required, perhaps demonstrating that the choice is in line with her conception of her own good. Both of these alternatives give us a way of determining whether the patient's choices reflect her genuine good by giving the preconditions that such choices must satisfy. Brock makes a point in the spirit of these remarks. He notices that "the essential feature of this alternative view is that it accepts people's ultimate aims and values as they are and corrects only for preferences or desires people have as a result of failures of rationality."10 This point makes reference to only one kind of good-promoting theory. As Brock appears to suggest later in his paper,11 we may not be entirely comfortable with the idea that the failures for which the theory corrects are adequately captured by "failures of rationality." What is most important for these good-promoting views is that paternalism is only justified when the person's genuine good is being promoted, where "the genuine good" is one that has been corrected or adjusted in the suggested manner. It is unjustified when the basis of the action is the promotion of another's conception of what is good for that person. There are two kinds of cases that will help to show the breadth of positions that are available to good-promoting theories. The first, discussed by Brock,12 utilizes an example from Donald Van de Veer's book Paternalistic Intervention.13 Brother Francis strongly believes that it is wrong to use animals in drug testing experiments. As a result he volunteers to replace the animals in the testing of a new drug and, so, to put his life at risk. It is easy to see how, on an autonomy-trumping account, preventing Brother Francis from participating in place of the animals would be considered unjustified paternalism. Brother Francis's decision ought to be respected since he has full knowledge and under-

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standing of the situation and of the consequences of his choice. His choice is an autonomous one. But, as Brock suggests, freely and knowingly chosen self-sacrifice in order to forward a goal the subject considers of great importance, such as ending harmful experimentation on animals in this example, does not warrant paternalistic interference and is not subject to the subject's overall interests or good on this good-promotion alternative.14 Whether we agree that this is a case in which paternalism is unjustified or not, there is nothing about the case that prevents a good-promotion account from achieving the results that can be achieved by an autonomy-trumping account. The second kind of case that is important to consider here is one where the patient values her own deciding higher than the goods that are threatened in a given situation. These are cases in which the patient knowingly jeopardizes what she takes to be her own good. So it is not that the physician knows the patient's genuine good but the patient has a corrupted view. Here both the patient and the physician know and understand the patient's good and yet the patient still chooses another (or the opposite) course of action. Choices made out of weakness, stubbornness, and rashness might be such instances. It may be thought that a good-promotion view would be forced into paternalism in cases like this, but again I believe this would be a little hasty. It may well be that the patient simply values deciding for herself. This is part of her conception of her own good. It may be that the trait of stubbornness is an accepted and valued characteristic—"this is just the way I am." Alternatively, the patient may think that in matters of such seriousness the process of coming (let us say, slowly and methodically) to a decision for herself is more valuable than reaching the "right" result. Finally, I may ask my wife if I can cook the dinner tonight, not because I want to guarantee that I get dinner or because I want to ensure that I get the dinner I desire but because I value the activity. Of course it may be that by cooking dinner I seriously jeopardize my chances of getting dinner (or at least an edible dinner). I may know this and wish to do the cooking all the same. Here, although the process is result oriented, it is possible and reasonable to allow the desire to participate in the process to outweigh the desire for a particular result. In both of these examples the good-promoting view can be construed so as to allow only a very limited number of acts of justified paternalism. An account of the nature of a person's genuine good together with the criteria that are given for determining whether a particular decision reflects a patient's genuine good can be used to determine the same range of positions on the kinds of acts that are counted as justified paternalism.

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Now we might ask why this matters. After all it does turn out that either way it is stated the same set of actions is classified as justified paternalism. Both versions can allow that a physician's paternalistic intervention is justified under the same conditions. Tom Beauchamp and James Childress are critical of Edmund Pellegrino and David Thomasma15 in a way that appears to apply here: They argue that the "best interests of the patients are intimately linked with their preferences," from which "are derived our primary duties toward them." This formulation of the beneficence model appears to be little more than a dressed-up defense of the autonomy model. If the content of the physician's obligation to be beneficent is set exclusively by the patient's preferences, respect for autonomy rather than beneficence has triumphed.16 Beauchamp and Childress seem not to mind the description of the problem in terms of beneficence. They are quite happy to redescribe the claim as one concerning respect for autonomy (the reverse of what I have suggested). What they miss, however, are the differences in the kinds of justification for the physician's obligations described in the respective ways. What makes the formulations distinct and so not merely a triumph for autonomy is the way in which each is justified. In the autonomy-trumping theories, the fundamental moral principle is the patient's right to, say, self-governance. Given that persons have this right to self-governance, physicians have an obligation to respect patient's decisions about their treatment, subject to a particular patient's satisfaction of the criteria laid down regarding the conditions for autonomous decision-making. So, the primary justification for the account of justified paternalism will most usually involve person's rights or an appeal in some way to the nature of persons as being essentially decision-makers of a certain kind. Given the lesson of the previous section we can look to the justification of the foundational principles of the good-promoting theory without fear of sacrificing certain kinds of accounts of justified paternalism. Using a goodpromoting theory might also have the advantage of recognizing that, in many important cases, two competing conceptions of the patient's good are at work. Clearly the basic principle for these kinds of theories is the principle of beneficence. The principle of beneficence, as we have seen, asserts an obligation to act for the good of others. In the case of physicians, the others are patients. Now whilst there may be justifications of the principle of beneficence that involve an appeal to broader normative theories, we do not need to look any further than the practice of medicine to find a candidate. To act beneficently, to act for the good of the patient, is, we might say, part of what it means to be a physician. A

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concern to help people, to promote their good, might be why people become physicians. A need of help is why patients go to physicians. A concern that all people receive adequate help might prompt a government to reform a healthcare system. And a concern that the right kind of help is given might prompt the call for medical ethicists. Acting for the good of the patient, I would suggest, is part of the point of the practice of medicine. In short, the justification for the principle of beneficence comes from what we do, and the point of what we do, when we participate in the practice of medicine. The key question that remains in all this is why we should think that the conception of the patient's good, which the physician is committed to promote, is anything other than the patient's good as it is defined by the science of medicine. After all, the physician is not trained in promoting all goods, whatever they may be, but is specifically skilled and knowledgeable in promoting the goods of medicine. It is important to notice, however, that the goods that are provided by medicine are instrumental goods. They are goods that enable us to achieve other goods. Being healthy, or at least being free of illness, pain, or physical incapacity enables us to live our lives in the way that we wish. It enables us to pursue our goals even though it might do so in different ways and to different degrees, depending on the goals. All people need health, some to varying degrees, and all people value health to some degree but not all people value health to the same degree. So we might say that physicians, as "purveyors of the goods of medicine," provide a service. Instead of promoting the goals of medicine in particular physical systems, it is a service that essentially enables individuals to pursue their own goods. My suggestion, then, is that by investigating the general nature of a person's good, especially in relation to choice and decision, we can isolate general criteria for deciding when a particular choice genuinely reflects the chooser's good. These criteria would enable us to determine when paternalism is justified and when it is not. Such an account would make what counts as right conduct for physicians and the justification of this as right conduct, continuous with the ideals, the point, and the practice of medicine. For my purposes here it would provide the beginnings of a theory that is independent of appeals to the concept of patient autonomy.

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1. See, among many others, Tom L. Beauchamp and James F. Childress, Principles ofBiomedical Ethics (New York: Oxford University Press, 5th ed., 2001), p. 57 ff., p. 176 ff. 2. See, again among others, ibid., p. 176. 3. B. Gert, C. M. Culver, and K. D. Clouser, Bioethics: A Return to Fundamentals (New York: Oxford University Press, 1997), p. 197. 4. Dan Brock, "Paternalism and Autonomy," Ethics 98:3 (1988), p. 551. 5. Ibid., p. 555. 6. Beauchamp and Childress, Principles ofBiomedical Ethics, pp. 182-187. 7. Joel Feinberg, Harm to Self (Oxford: Oxford University Press, 1986), p. 12 ff. 8. See Gert et.al., Bioethics: A Return to Fundamentals, pp. 81-82. 9. Simon Blackburn, Ruling Passions (Oxford: Clarendon Press, 1998), p. 9. 10. Brock, "Paternalism and Autonomy," p. 556. 11. Ibid., pp. 562-564. 12. Ibid., pp. 554-556. 13. Donald Van DeVeer, Paternalistic Intervention (Princeton, NJ: Princeton University Press, 1986). 14. Brock, "Paternalism and Autonomy," p. 555. 15. Edmund Pellegrino and David C. Thomasma, For the Patient's Good: The Restoration of Beneficence in Healthcare (New York: Oxford University Press, 1988). 16. Beauchamp and Childress, Principles ofBiomedical Ethics, p. 176.

Thirteen AUTONOMY: OVERWORKED AND UNDER-VALUED Paul Barrow 1. Scope of the Enterprise The original aim of this paper was to produce a tightly argued defense of Kantian autonomy in offering a different approach to the relationship between the Jehovah's Witness patient and the health professional. Further reflection on the generic title suggested that this was altogether too focused and constructive an approach in response to an invitation to do something essentially destructive— to scratch a smooth surface. An analogy might be throwing a brick into a still pond. Beyond the ever widening concentric ripples, no other consequence is predictable, as unrelated phenomena manifest themselves: a heron hitherto unseen flies away, an old bicycle tire floats to the surface, along with the mud stirred up, algae appears, and so on. The paper proceeds in the spirit. The point of entry is indeed speculation about the impact of a particular approach to autonomy on the question of Jehovah's Witnesses and blood transfusion. The point of exit is a consideration of the general questions raised. Where is bioethics rooted? From where does it derive its authority on the assumption that it claims that progress is possible in this (as in every other) branch of philosophy? If bioethics is an "applied" discipline, then is it not important to widen the vocabulary to encompass questions that it is legitimate to raise in a plural society inhabited by devout Muslims as well as by post-enlightenment liberals? The overwhelming number of bed-days in caring institutions are filled mainly by elderly residents with chronic needs. They may face 40 or more years of monotony and unutterable grayness. Is this not a concern of bioethics, and can bioethicists who want to act in some way upon the world afford to give the impression (however undeserved) that they are preoccupied with acute crises now, and the manipulation of life in the future? No apology is given for this outsider's (health manager's) eclectic choice of subjects that are connected allusively and suggestively, not causally. The opportunity to scratch bioethics' smooth (dare we say complacent) features at the start of the third millennium is taken up as a broad and shallow rather than deep and narrow challenge. Above all, it is a plea for bioethics to take more of an interest in areas that are in danger of neglect. Whatever else it is, an act of vandalism is

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a cry for recognition. So no apology is given for describing what is a "perceived" position. It is done with the best of intentions. If, as a former National Health Service Trust Chief Executive, the writer believes that public UK healthcare's last chance of redemption lies with bioethics, then how bioethics is perceived is crucial to its having influence. The Institute of Medicine, Law and Bioethics (IMLAB), which is the collaborative agency from which these articles spring, seeks, in its Mission Statement, "to enhance the quality and effectiveness of healthcare delivery." If that is to have any hope of fulfillment, bioethicists do need to be confident that the subject areas themselves are common ground, even if the message is not always what the National Health Service wants to hear.

2. Jehovah's Witnesses—Then and Now The experience of the writer in the 1960s and early 1970s was that the attitude of many health professionals to the Jehovah's Witness situation was diffuse. But if a general consensus, so far as it went, could be put into words, it would run something like this: Jehovah's Witnesses hold an egregious set of beliefs about blood transfusion. If not actually certifiable, they do need to be protected from selfdestruction. Ignoring their objections to the receipt of life-saving transfusion is a bit illiberal, but is probably defensible (although kindness would suggest that it is probably best to keep quiet about it to them). But even if contravention is subsequently discovered, they are unlikely to succeed in an action for having their lives saved. Thirty years later, the response would be altogether different in content, and reflexive not reflective in tone: "Non-consensual administration of blood to a Jehovah's Witness is a battery in law." The interesting question is: "What has changed over this period, and why?" It is certainly not the law. Common law was then as it is now. But it is unlikely that a Judge in the 60s and early 70s would have opined, as did the Court of Appeal in 1992 in Re T,1 that doctors who act in the spirit of the earlier quotation above "do so at their own peril." That attitudes have changed is undeniable. To the liberal-minded third millennium bioethicist this change is wholly good. Whether driven by consumerism, or the right to respect of privatized belief that goes hand in hand with economic privatization and the right to choose that that entails, individual preference is exalted on the altar labeled "autonomy." In any given ethical scenario, it appears, the search is on for the pearl above price: the autonomously

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expressed wishes of the individual, which will win out against everything, save narrowly defined damage to another. To observe this change in attitude is not to decry it, but to prompt the question as to where bioethics is rooted and from whence it claims its authority. Nobody in her right mind would want a return to the middle ages that made rightfulness of belief the single most important test of a person's value, and that rigorously interrogated those beliefs as a matter, literally, of life and death. But bioethics does operate in the milieu of lived experience, formed from an amalgam of reason, knowledge, intuition, and belief. In answering the challenge of the clinician who would question the Jehovah's Witness position, the bioethicist must do more than rail at this liberal impedence to the onward march of liberal rights as being enough to settle the issue. Bioethics must not fall prey to Chesterton' s aphorism that cessation of belief in something is the guarantor of belief in anything. But if it wishes to avoid it, it must answer the perception that bioethics intuits what is fashionable, and lays claim to it in high-sounding language. This is not necessarily a complaint against the conclusion reached, but against what is excluded from consideration in the process. Sometimes this is expressed as an inability to agonize with a heart that matches the force of its mind. At a human level, the Jehovah's Witness position on blood transfusion probably evokes three reactions: (1) that the beliefs upon which the position is based, are at best egregious, and at worst (especially where the influencing of children is concerned) malign; (2) sadness at the prospect of avoidable loss of life if those beliefs are put into effect; (3) acceptance that health professionals are bound to respect those autonomously expressed beliefs in practice. In the same way as the strongest argument against the death sentence is the experiencing of life in a prison in the days leading up to an execution, and on the day of the execution itself, so the effect of a Jehovah's Witness dilemma on this occasion in this accident unit amongst this group of staff, focuses consideration on all three of the above, and not simply the last one. If bioethics wants to be taken seriously by health professionals, it must live alongside them in their dilemmas just as the Chaplain on death row supports the executioner as well as the condemned. Setting aside the almost impossible-to-answer question of whether someone confronting the prospect of "disfellowship," disgrace, and pariah status can be said to be autonomous in making a choice, where one of the decisions would lead to just those awful consequences, a more interesting set of questions arises

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when the "autonomy" question is examined in a more rounded way than many bioethicists give the impression that they are prepared to do. Again, the issue is not the conclusion reached, but the rich tradition ignored in the process. 3. Autonomy Revisited In many discussions about "autonomy," the word appears to be taken to mean either a "right" to something, or a state of affairs on which that right is predicated. The first meaning would be used in a statement such as: "To give a transfusion to a Jehovah's Witness contrary to expressed wishes is a denial of the autonomous rights of the patient." The second usage is evident in the sentence: "The patient is of sound mind, and therefore autonomous (capable of selfgovernment); the conditions are therefore right for the exercise of that mind to be respected on that account." In the first usage, autonomy appears to attach to the right. In the second it describes a state of being that allows for the exercise of more unfettered rights than would be the case if the subject was not autonomous (for example, if a mental illness impaired judgment in the issue under consideration). These usages, it is submitted, constrain the meaning of autonomy by denying it a context and set of connections that the Kantian usage would restore. If there is no sphere beyond the determinism of the natural sciences, then there is no boundary to unfreedom, and morality is impossible. Autonomy is the guarantor of the possibility of morality. But its significance lies in some end beyond the proclamation of its existence. To say "I am free to do something with my freedom" merely begs the question. To Kant, the freedom is the prerequisite to willing the doing of my duty, which is to fulfil the moral law. The freedom in question and the obligation to use it in this way are universally applicable, and therefore to the health professional as well as the patient. This status of autonomy as being "prior to" and not a completion in itself (its connectedness to the exercise of duty), together with its universal claim, allow the Jehovah's Witness question to be considered from an altered perspective. It avoids the consideration of the legitimacy of one belief as against another, an exercise fraught with difficulty in a multi-faith, multi-cultural context. On this account of autonomy the surgeon too is autonomous. She is therefore free, and must use that freedom to will the performance of duty. This will include the exercise of professional integrity. This is not at all a roundabout way of justifying beneficence trumping autonomy. The volitional patient suffering from breast cancer, who could be cured by radical mastectomy, but only palliated by non-surgical intervention, is entitled to regard early death as preferable to a much longer life with what for her is intolerable disfigurement. But the Jehovah's Witness position is not comparable. The breast cancer patient is not

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constraining the Consultant in the way the operation is performed. She understands what the exercise of that professional course of action will entail in its totality, and rejects it in its totality, in preference to an alternative therapy in its totality, albeit objectively judged "inferior" by everyone, possibly, but her. The Jehovah's Witness position is analogous to that of a rich recluse living in isolation on a desert island that she owns, and who asks a builder, with no risk to anyone but the recluse herself, to erect a house without foundations, with instructions that it be demolished on her death, so that it is a risk only to her. On the account of autonomy given above, the builder has an obligation to decline to accept the invitation, on the grounds that it violates professional integrity. The surgeon, confronted by the uncompromising Jehovah's Witness, is being asked to deviate from what has evolved into the most efficacious way of proceeding. Like the violinist or the painter, the surgeon has through hard toil, and not a little angst and making of mistakes, honed the requisite skills to meet the demands of different procedures professionally determined as the best. The patient is free to reject what the surgeon has on offer, just as the recluse is free to reject the builder or the concertmaster the violinist. The patient, however, has no more right to demand that the surgeon's skills be deviated from than does the recluse to a foundationless house, or the impresario that the violinist will substitute a Beatles tune for the original cadenza in Beethoven's violin concerto. To submit to any of the client's wishes in this way is to allow a non-universalizable consequence of the exercise of autonomy to hold sway over one that is universalizable. To allow the duty to professional integrity to be deviated from would, in the Kantian schema, amount to the same thing as willing untruth telling as a categorical imperative. This position is reinforced where the modus operandi would amount to negligence if followed in the case of a non Jehovah's Witness (for example, undertaking three operations to avoid blood loss, where one operation with safe transfusion would be the norm). On this account, when confronted by a Jehovah's Witness (whether an elective, emergency, or unconscious patient) the surgeon's duty to integrity would require him or her to decline to perform surgery except in accordance with what that integrity dictates. This would be in preference to committing the tort of trespass to the person (battery) by operating contrary to the Witness's objections, on the one hand, or to compromising that integrity on the other. It might be argued that this reasoning could be used to justify a doctor whose "professional integrity" was offended at a cost-limiting decision taken by his employer that proscribed the use of a drug that the doctor favored. This position would not hold for several reasons. Reconciliation of the interests of individual patients with the need for maximum outreach to other current, and to future patients is a rightful preoccupation of the service in general, and those who are stewards of its funds in particular. The introduction

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of cost into the effectiveness equation will produce results (such as limits on prescribing) with which not all practitioners will agree all of the time. But the acknowledgment by dissentients of the binding force of policies arrived at in an ethical way to serve an ethical end, is part of civilized life. The difference between the clinician who defies a professionally accepted ban on prescribing, and the clinician who refuses to countenance deviation from a normal clinical protocol to treat a Jehovah's Witness, is the difference between acting supererogatorily and fulfilling an obligation. The first may be overlooked. The second must be demanded.

4. Cost Consciousness and Conscience On the question of cost, it is of course often true that satisfaction of the Jehovah's Witness's position will increase the cost of doing the procedure. Why not register the point straight away—relying on distributive justice—rather than make the argument more difficult? To succumb to the cost argument would establish a precedent that all conscientious objection that incurs additional treatment cost is thereby unjustifiable. But what of the devout Roman Catholic couple in the "conjoined twins" case? Did not their soul-searching, in terms of keeping both Mary and Jodie in care whilst they were in the throes of conscience, not incur a cost that would have been circumvented had the eventual decision been made at the beginning? There is, at least, a slippery slope looming in the form of curtailment of the working out of an agonized conscience in deference to the dictates of cost-founded utilitarianism. And if not religious belief, why not questions of preference? Would the patient who prefers cataract surgery under general anaesthetic, with its higher attendant costs, be denied that option on the grounds that "squeamish preference" is no argument against the equally effective and lower cost local anaesthetic? The choice is still given on the basis that both techniques accord with what professional integrity allows. In any event, the cost objection could be overturned simply by the Jehovah's Witness agreeing to fund the difference. It is crucial that the central issue of applying autonomy to professional judgment is not fudged. The strength of the conclusion is in its reliance on this argument alone, and its refusal to enter the viper's den of adjudicating on religious beliefs, or agonizing over whether Jehovah's Witnesses are brainwashed and therefore non-volitional on this account, or on account of how they will be treated by their community should they relent on a central tenet. For if professional integrity must deny itself in the face of a religious belief that demands just that, then what reason can there be for not deferring to the dictates of any sect that may be formed: say, a group that taught the wrongfulness of general anesthesia under any circumstances? Must research effort be expended

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on finding ways of doing heart bypass surgery without anaesthetic? If the Jehovah's Witness issue is answered on Jehovah's Witnesses' current terms, then such a prospect cannot be discounted. Recognizing the obligation to duty based on the above notion of autonomy is an essential defense against a descent into absurdity.

5. More Than is Dreamed of If "all is grist to the Philosopher's mill"2 this must be true of ethics, and even more of applied bioethics. But the "all" that is involved in reflecting upon the unfolding experience of humanity embraces more than is dreamed of in and after enlightenment. The charge here is that bioethics is perceived to offer rather thin gruel, as the attempt to enrich the nutrient value of autonomy above sought to demonstrate. One example would be the perceived tendency to overlook the insights from the Faith traditions in mainstream bioethics. This could be on the grounds that belief in God is absurd, or that Nietzsche declared God dead, or that we live in a post religious age, or all three. But just as to say that all subsequent Philosophy is a footnote to Plato does not confer sacred cow status on Plato, so the acknowledgment of the fact of religious belief and the connection, for its adherents, between doctrine and praxis, is not to enthrone it. That there are bodies of people whose frame of reference is a revelatory principle that transcends reason without necessarily for them confuting it is, of itself, justification for their deliberations at least being weighed. This is to validate religious belief as sociological fact, not as divine truth. This is not an attempt to argue for a change in a particular bioethical position, say in the status of the fetus. It is an attempt to enrich the range of material open to consideration, and maybe influence: to thicken the gruel. An illustration of this point would be to set something else alongside a set of deductions based upon the question "what is the value of life?" Might a different set of answers emerge from an intuition that human life was bounded by obligations to an alleged creator compared with those flowing from a rights-based ethic? How might this influence the consideration of immortality, which at a scientific level appears to focus on "more of the same to infinity?" But given that the consummation of this account of immortality could never be experienced, just as a Christian account could not be demonstrated, is the likelihood of several hundred years more driving on motorways in drizzle a more attractive prospect than the certainty of a shorter life on earth, and the possibility of a Christian heaven? Should not the implications of this belief feature in the deliberations of policy analysis, on the ground not that the Theistic eternal life is true, but that belief in it is part of the collective human experience?

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One perceived characteristic of bioethics to the "outsider" is its focus on event crises. These tend to be acute problems confronting patients and practitioners often (but not exclusively) in acute hospital settings. "Should this father give his one indubitably good kidney to save his daughter's life?" "Should that brain dead mother be kept alive for the sake of bringing her fetus of six months' gestation to term?" This is not to say that these, and like problems, are unimportant. But the tendency of the acute sector in healthcare to hog the lion's share of attention (and money) should not infect bioethics. Many patients' experiences are in nursing and social care homes, and there are far more problems for the ethicist than end of life dilemmas (that tend to be resolved in hospital anyway). This nursing home has a policy of banning pets, but her pet dachshund is this woman's reason for living. How can her need be reconciled with the interests of other residents? What if other residents want to keep exotic pets, including poisonous snakes? With a prospect of fifty or sixty more years in retirement— many in old age—should not ethicists be concerned with quality issues beyond cheering on the search for yet more longevity? One issue might be a search for the virtues that should characterise professionals who care for them in future. And what has bioethics to say about "education for the marketplace" as opposed to an "education for leisure" policy, when maybe two-thirds of life in the future will be spent in "leisure?" If bioethicists do not debate these issues, who will? The process of vandalism, of putting a scratch on a few more cars in the street, so to speak, or throwing more bricks into the pond, might incense a few more residents to argument, or excite consideration of added phenomena. But the very self-indulgent and quirky nature of the invitation to "scratch the surface" of bioethics must allow for a peremptory end once the surface scratcher or brick thrower has had his fill. If a few people have been aroused to fury, incredulity, questioning, or puzzlement, then some small good may come from this paper. Arousal is all that has been invited, and it is all that this vandal intends. On this his case must rest.

NOTES l.Re:T[1992]4AllER649. 2. C. E. M. load, Teach Yourself Philosophy (London: The English Universities Press Ltd., 1964), p. 21.

ABOUT THE EDITORS AND CONTRIBUTORS Paul Barrow. After graduating in Law from Liverpool University, Paul worked as a National Health Service Manager, concluding as Chief Executive of an Acute Hospital Trust. In 1997 he left to become Development Executive of the Institute of Medicine, Law, and Bioethics (IMLAB), where he has been involved in several research studies, run courses and conferences, and lectured to healthcare professionals on Law and Ethics in healthcare. He is a Fellow of IMLAB, and has an M.A. degree in Healthcare Law and Ethics from Manchester University. He has recently left IMLAB to train as a non-stipendiary Anglican priest at St Stephen's House, Oxford. Rebecca Bennett is Lecturer in Bioethics at the Centre for Social Ethics and Policy in the School of Law at the University of Manchester. She is Programme Director for the M.A./Postgraduate Diploma in Healthcare Ethics and Law by Distance Learning and a Fellow of the Institute of Medicine, Law, and Bioethics. She has published widely on diverse issues in bioethics and her current research interests include assisted reproductive technologies, testing and screening in pregnancy, HIV/AIDS, cloning, stem cell research, ectogenesis, and selective treatment of infants. Alan Cribb is Director of the Centre for Public Policy Research, King's College London and Editor of Healthcare Analysis: An International Journal of Healthcare Philosophy and Policy. He has published on a range of themes in healthcare ethics and professional education, and has a particular interest in the relationship between health policy and professional ethics. Charles A. Erin holds a B.Sc. (Hons) in Physics (Wales), an M.Sc. in Nuclear and Elementary Particle Physics (London), an M.Sc. in Technical Change and Industrial Strategy (Manchester), and a Ph.D. in Applied Philosophy (Manchester), and is Senior Lecturer in Applied Philosophy at the Centre for Social Ethics and Policy in the School of Law at the University of Manchester. He is Program Director of the M.A. in Healthcare Ethics and Law, and has written on diverse issues in Biomedical Ethics. His current research interests focus on property issues related to the human body. Eve Garrard is Lecturer in Ethics and Philosophy in the Centre for Professional Ethics at Keele University. Before moving to Keele, she worked for several years for the Open University, and has a strong interest in teaching philosophy to adult beginning students. Much of her teaching is now to healthcare (and other) professionals. Her research interests are in moral theory and applied

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ethics, including bioethics, and also philosophical issues arising out of the Holocaust. She has recently published papers on the nature of evil and forgiveness. John Harris is Sir David Alliance Professor of Bioethics and Academic Director of the Institute for Medicine, Law, and Bioethics at the University of Manchester. In 2001, he was elected a Fellow of the United Kingdom Academy of Medical Sciences (FMedSci), the first philosopher to have been elected to Fellowship of this new National Academy, established to serve "the medical sciences in the same way as the Royal Society serves the natural sciences (and) the British Academy serves the humanities." He is a member of the United Kingdom Human Genetics Commission and of the Ethics Committee of the British Medical Association. He was one of the Founder Directors of the International Association of Bioethics and a founder member of the Board of the Journal Bioethics and a member of the Editorial Board of the Journal of Medical Ethics and many other journals. He frequently appears on radio and television both in the United Kingdom and overseas to discuss Biomedical Ethics and related issues. In the last five years he has directed four major projects for the European Commission under their Biomedical and Health Research Programme (DG XII). A new major project for the European Commission (EUROSTEM) began in February 2002. Under his direction, it will investigate and monitor ethics and policy issues surrounding the progress of human stem cell research. Matti Hdyry is Head of the Centre for Professional Ethics and Professor of Moral Philosophy at the University of Central Lancashire. He has taught philosophy and bioethics in various Finnish Universities since 1985, and coordinated research projects in bioethics at the University of Helsinki. He has been a permanent adviser on bioethics to the Finnish National Research and Development Center for Welfare and Health since 1991, and has participated in the work of legislative committees at the Finnish Ministries of Justice and Health. His publications include Critical Studies in Philosophical Medical Ethics (1990), Liberal Utilitarianism and Applied Ethics (1994), Playing God: Essays on Bioethics (2001), and many articles on bioethics and general philosophy in academic journals and edited collections. Peter Herissone-Kelly is a Research Assistant in the Centre for Professional Ethics at the University of Central Lancashire. He has a B.A. in Philosophy from Bolton Institute, a B.Phil, in Philosophy from the University of Oxford, and a background in philosophical logic and metaphysics. He is currently working on a Ph.D. thesis to be entitled Kant on Rational Agency.

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S0ren Holm is Professor of Clinical Bioethics at the University of Manchester, and Professor of Medical Ethics at the University of Oslo. He holds degrees in medicine, philosophy and healthcare ethics, and two doctoral degrees. He is a former member of the Danish Council of Ethics, which advises the Danish Government and Parliament on bioethical issues. Harry Lesser is a Senior Lecturer in Philosophy at the University of Manchester. He is author of several articles in the field of Medical Ethics, some being in journals and some being contributions to books, and editor of the collection Ageing, Autonomy, and Resources (Ashgate, 1999). He has particular interests, in both teaching and research, in the philosophy of psychiatry, and in issues concerning ageing and the elderly. He is currently working on papers on personal identity and dementia, and on research on the quality of life in old age. Mairi Levitt is Principal Lecturer in Social Ethics at the Centre for Professional Ethics, University of Central Lancashire. Her research focuses on ethical and social issues arising from the new genetics, including public attitudes and understanding and empirical methods of investigating ethics. She recently organised a "Gene Week" as a public consultation exercise with a local newspaper, funded by the Wellcome Trust, and is a partner in a three year multidisciplinary European Union project on empirical methods in bioethics. Recent publications include articles in New Genetics and Society, Journal of Medical Ethics, Journal of Medicine, Healthcare and Philosophy, Journal of Beliefs and Values, and the British Medical Journal. Mark P. Sheehan is a Lecturer in Philosophy in the Centre for Professional Ethics at Keele University. His research interests are in metaethics, "metabioethics," and research ethics. His most recent publications include a pair of articles on practical reasoning in primary care for the British Journal of General Practice. Tuija Takala is Decent in Practical Philosophy at the University of Helsinki, Finland and Visiting Academic at the University of Manchester. She has taught philosophy at the Universities of Helsinki and Kuopio in Finland. Her research interests include political philosophy and applied ethics, particularly bioethics. Her publications include Genes, Sense, and Sensibility: Philosophical Studies on the Ethics of Modern Biotechnologies (2000), and articles in Bioethics, Cambridge Quarterly of Healthcare Ethics, Journal of Medical Ethics, and The Journal of Medicine and Philosophy. Simo Vehmas works as a Research Fellow of Special Education at the University of Turku, Finland. He has written about the moral significance of disability in

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the light of various bioethical topics such as infanticide, abortion, and genetic information. He has published in several international journals in the fields of applied ethics and disability studies. Stephen Wilkinson is Senior Lecturer in Ethics and Philosophy in the Centre for Professional Ethics at Keele University. His research papers have addressed topics including the allocation of health service resources, selective abortion, separating conjoined twins, and the nature of mental illness. A paper on this last topic won the Philosophical Quarterly International Essay Prize in 1999. He has recently completed a book on the ethics of commercializing the human body (Bodies for Sale, Routledge, 2003) and is Program Director of Keele's new professional doctorate in Medical Ethics, the D.Med.Eth, as well as of its longstanding M.A. in Medical Ethics and Law.

INDEX abortion, 30, 35-36, 42, 50, 60, 101-102 selective a., 112 agent-relative principles, 3, 3738 agent-neutral principles, 3, 3738 Anscombe, Elizabeth, 99 anti-life, 99-109 anti-theory, 2-3, 35-37, 41, 44, 65 applied ethics, 10,30, 36, 39, 41,47, 100 Aristotle, 61, 69, 99, 102 Assisted Reproduction Technologies (ART), 102 autonomy, 4-6, 22, 65-66, 68, 72-74, 76, 80-84, 95, 123131, 133-140 a.-trumping theories, 123, 125-130 Barrow, Paul, 6 Basic Ethical Principles in Bioethics and Biolaw, 80 Beatles, The, 137 Beauchamp, Tom L., 4, 50, 6576, 79-88, 130 Beethoven, Ludwig Van, 117, 137 beneficence, 4, 6, 65-66, 68, 72-73,76,80-81,83, 123126, 130-131, 136 procreativeb., 118 Bennett, Rebecca, 1 Bentham, Jeremy, 114 bioethical decision making, 29 bioethical legislation, 32 bioscien(tists)(ce), 1, 5, 91-97 Blackburn, Simon, 126 British Medical Association (BMA), 4, 84 British Medical Journal, 79 Brock, Dan, 125, 128-129 Buddhis(m)(t), 66, 82

Callahan, Daniel, 22 Campbell, Alastair, 82 Catholic(ism), 60, 99, 101104, 138 Chesterton, G. K., 135 Childress, James, 4, 50, 65-76, 79-88, 130 Clouser, Dan, 80, 84 common morality, the, 65-76, 84-86 common tradition, the, 99-100, 102-104 conflict problem, the, 123-124 Conrad, Peter, 21 consequentialism, 35-38, 61, 99-100, 103-104 Cribb, Alan, 1 Davis, Dena S., 5, 116 deafness, 22, 116-117 deontolog(ical)(y), 3, 35-38, 85 Devlin, Lord Patrick, 30 DeVries, Raymond, 21 dignity, 80, 96 disability, 6, 111, 115-120, 126 discrimination, 22, 32, 115, 118-119 double effect, doctrine of, 5, 36, 52, 103-104, 107 Down Syndrome, 6, 112-113, 118 Elimination of Morality: Reflections on Utilitarianism and Bioethics, The (Maclean), 57 emotions, 2, 29-33, 61 Empirical Methods in Bioethics (EMPIRE), 9, 17 empirical research(ers), 1, 9, 11-17, 19,20,22 Enforcement of Morals, The (Devlin), 30

146 Engelhardt, H. Tristram, Jr., 33, 66,82 Enquiry Concerning the Principles of Morals (Hume), 60-61 Erin, Charles, 4 ethical argument, 31, 55 European Commission, 9, 18, 80 euthanasia, 3, 42^3, 50-52, 100,114 voluntary e., 30 experts, 22 ethical e., 2, 20, 33 medical e., 2, 20 moral e., 3, 58, 60, 62 scientific e., 2, 20 facts, 13-15, 19-22,24, 36, 39^0, 57, 62 fairness, 81 family, 60-62, 91,114 favored subset model, 67-68, 72-73 Feinberg, Joel, 126 Finnis, John, 82, 100 Florida, R. E., 66 folk ethics (folk morality), 4142 Foot, Philippa, 71 four principles, 65-76, 79-88, 95-96 Frege, Gottlob, 59 Garrard, Eve, 2-3 Georgetown mantra, 79, 82-83 Gert, Bernard, 80, 84 Gillon, Raanan, 4, 68, 79-87 global applicability thesis, 6567 Glover, Jonathan, 33 Greaves, Lorraine, 23 Green, Ronald, 10 God, 42, 139 Hare, Richard, 82 harm, 82, 95, 108, 111, 117 harm(ed condition), 116, 119

INDEX Harris, John, 5, 25, 31, 57-58, 82-85, 116-119 Ha'yry, Matti, 5, 47 Herissone-Kelly, Peter, 4 Hippocratic Oath, Holm, S0ren, 3, 66, 84, 86 Human Immunodeficieny Virus (HIV), 13, 16 Hume, David, 19, 61 hypothetical examples, 3, 47, 50-53 impairment, 6, 111-119 Institute for Medicine, Law, and Bioethics (IMLAB), 134 innocen(ce)(t), 5, 43, 62, 101103, 105-108 Jehovah's Witness(es), 6, 133140 justice, 4-5, 32, 62, 65-66, 68, 72-73,76,80-81,83,95, 138 Kant(ianism)(ian), 6, 85, 133, 136-137 Kerr, Anne, 22 Kuhse, Helga, 5, 112-115 Lerman, Caryn, 24 Lesser, Harry, 3 Levitt, Mairi, 1-2 Lewis, C. S., 59 limited opportunities, 116-117 Linton, Simi, 120 Manchester conjoined twins case, 101, 138 Marteua, Theresa, 24 Maclean, Anne, 3-4, 29-30, 57-63 metaethic(al)(s), 3, 35, 39-44, 47 Mill, John Stuart, 33, 114 moral philosophical enquiryXy), 1,9-13, 1517, 19,29,81,83

INDEX moral theory, 2, 33, 35^4, 62, 84,86-88, 114, 125 morally serious person(s), 65, 67-71,76 Mozart, Wolfgang Amadeus, 117 National Health Service (NHS), 134 Nietzsche, Friedrich, 139 nihilism, 3, 40-41 Oderberg, David, 5, 99-109 parity of reasoning, 3, 47-56 particularism, 43 paternalism, 6, 87, 123-131 hard (strong) p., 126 soft (weak) p., 126 Paternalistic Intervention (Van de Veer), 128 Pellegrino, Edmund, 130 personhood, 99, 106-108 Phenylketonuria (PKU), 111 philosophical bioethics, 19-21 Philosophical Medical Ethics (Gillon), 79, 83 Plato, 59, 139 policy, 9, 11-13, 15, 17,2122, 24-25, 40, 49-50, 139140 precaution, 96 principle of charity, 3, 53-54, 56 Principles of Biomedical Ethics (Beauchamp and Childress), 65, 67, 71,79, 83,86 Principles of Healthcare Ethics (Gillon), 81-82 principlis(m)(t), 43, 65-76, 7988 professional(s), 91-94 p. codes, 91, 94 p. ethics, 5, 91-97 healthcare p., 10-11, 43, 79, 81,84,88 pro-life, 5, 99-109

147

public, the, 2-3, 19, 22, 33, 55 Rachels, James, 3, 12, 29, 5051,57 reason, 2-3, 7, 11-12, 20, 29, 31-33,57-59,62-63,135, 139 reasonable person, 31-31 reasoning, 12, 25, 47, 57, 82, 108, 128, 137 critical r., 24 ethical r., 62 logical r., 87 moral r., 19, 65, 87, 125 philosophical r., 13 scientific r., 29 relativis(tic)(m), 3, 12, 20, 23, 39-42, 60, 75-76 Roe v Wade, 101 sanctity of life, 5, 42, 99, 102103, 105-107 Savulescu, Julian, 5, 118 self defense, 5, 104-107 sense, 2, 29, 33 sensibility, 29 Sheehan, Mark P., 6 "sherry sipping", 12 Should the Baby Live? (Kuhse and Singer), 112 Singer, Peter, 5, 57-58, 108, 112-115 social scien(tists)(ce), 1, 14, 16, 19-20, 93 sociolog(ical bioethics) (ical)(ist)(y), 1-2, 10-11, 19-25, 40, 66, 69, 139 Socrates, 58-59, 114 sorites paradox, 53 supererogat(orily)(ion)(ory), 138 survival lottery, 31 Takala, Tuija, 2, 73 Thomasma, David, 130 Tooley, Michael, 57 transcendental argument, 7476

148 Tribe, Laurence H., 101 trolley example, 52 utilitarianism, 3-4, 31, 57-58, 62,85,105, 113-114,138 Van De Veer, Donald, 128 Veatch, Robert, 80, 82-83 Vehmas, Simo, 5-6 Warnock, Mary, 30 well-being, 4, 6, 31,91,94, 112-115, 117-119, 127 Wellcome Trust, 11 West, Brian, 112 Wildes, Kevin William, 66 Wilkinson, Stephen, 2-3 Williams, Bernard, 41 Wittgenstein(ian), 60

INDEX

VIBS The Value Inquiry Book Series is co-sponsored by: Adler School of Professional Psychology American Indian Philosophy Association American Maritain Association American Society for Value Inquiry Association for Process Philosophy of Education Canadian Society for Philosophical Practice Center for Bioethics, University of Turku Center for Professional and Applied Ethics, University of North Carolina at Charlotte Center for Research in Cognitive Science, Autonomous University of Barcelona Centre for Applied Ethics, Hong Kong Baptist University Centre for Cultural Research, Aarhus University Centre for Professional Ethics, University of Central Lancashire Centre for the Study of Philosophy and Religion, University College of Cape Breton Centre de Estudos em Filosofia Americana College of Education and Allied Professions, Bowling Green State University College of Liberal Arts, Rochester Institute of Technology Concerned Philosophers for Peace Conference of Philosophical Societies Department of Moral and Social Philosophy, University of Helsinki Gannon University Gilson Society The Haitian Studies Association Ikeda University Institute of Philosophy of the High Council of Scientific Research, Spain International Academy of Philosophy of the Principality of Liechtenstein International Association of Bioethics International Center for the Arts, Humanities, and Value Inquiry International Society for Universal Dialogue Natural Law Society Personalist Discussion Group Philosophical Society of Finland Philosophy Born of Struggle Association Philosophy Seminar, University of Mainz Pragmatism Archive R.S. Hartman Institute for Formal and Applied Axiology Research Institute, Lakeridge Health Corporation Russian Philosophical Society Society for Iberian and Latin-American Thought Society for the Philosophic Study of Genocide and the Holocaust Yves R. Simon Institute

Titles Published 1.

Noel Balzer, The Human Being as a Logical Thinker

2.

Archie J. Bahm, Axiology: The Science of Values

3.

H. P. P. (Hennie) Letter, Justice for an Unjust Society

4. H. G. Callaway, Context for Meaning and Analysis: A Critical Study in the Philosophy of Language 5.

Benjamin S. Llamzon, A Humane Case for Moral Intuition

6. James R. Watson, Between Auschwitz and Tradition: Postmodern Reflections on the Task of Thinking. A volume in Holocaust and Genocide Studies 7. Robert S. Hartman, Freedom to Live: The Robert Hartman Story, edited by Arthur R. Ellis. A volume in Hartman Institute Axiology Studies 8.

Archie J. Bahm, Ethics: The Science ofOughtness

9.

George David Miller, An Idiosyncratic Ethics; Or, the Lauramachean Ethics

10.

Joseph P. DeMarco, A Coherence Theory in Ethics

11. Frank G. Forrest, Valuemetrics: The Science of Personal and Professional Ethics. A volume in Hartman Institute Axiology Studies 12. William Gerber, The Meaning of Life: Insights of the World's Great Thinkers 13. Richard T. Hull, Editor, A Quarter Century of Value Inquiry: Presidential Addresses of the American Society for Value Inquiry. A volume in Histories and Addresses of Philosophical Societies 14. William Gerber, Nuggets of Wisdom from Great Jewish Thinkers: From Biblical Times to the Present 15.

Sidney Axinn, The Logic of Hope: Extensions of Kant's View of Religion

16.

Messay Kebede, Meaning and Development

17.

Amihud Gilead, The Platonic Odyssey: A Philosophical-Literary Inquiry

into the Phaedo 18. Necip Fikri Alican, Mill's Principle of Utility: A Defense of John Stuart Mill's Notorious Proof. A volume in Universal Justice 19.

Michael H. Mitias, Editor, Philosophy and Architecture.

20. Roger T. Simonds, Rational Individualism: The Perennial Philosophy of Legal Interpretation. A volume in Natural Law Studies 21.

William Pencak, The Conflict of Law and Justice in the Icelandic Sagas

22. Samuel M. Natale and Brian M. Rothschild, Editors, Values, Work, Education: The Meanings of Work 23. N. Georgopoulos and Michael Heim, Editors, Being Human in the Ultimate: Studies in the Thought of John M. Anderson 24. Robert Wesson and Patricia A. Williams, Editors, Evolution and Human Values 25. Wim J. van der Steen, Facts, Values, and Methodology: A New Approach to Ethics 26.

Avi Sagi and Daniel Statman, Religion and Morality

27. Albert William Levi, The High Road of Humanity: The Seven Ethical Ages of Western Man, Edited by Donald Phillip Verene and Molly Black Verene 28. Samuel M. Natale and Brian M. Rothschild, Editors, Work Values: Education, Organization, and Religious Concerns 29. Laurence F. Bove and Laura Duhan Kaplan, Editors, From the Eye of the Storm: Regional Conflicts and the Philosophy of Peace. A volume in Philosophy of Peace 30.

Robin Attfield, Value, Obligation, and Meta-Ethics

31. William Gerber, The Deepest Questions You Can Ask About God: As Answered by the World's Great Thinkers

32.

Daniel Statman, Moral Dilemmas

33. Rem B. Edwards, Editor, Formal Axiology and Its Critics. A volume in Hartman Institute Axiology Studies 34. George David Miller and Conrad P. Pritscher, On Education and Values: In Praise of Pariahs and Nomads. A volume in Philosophy of Education 35.

Paul S. Penner, Altruistic Behavior: An Inquiry into Motivation

36.

Corbin Fowler, Morality for Moderns

37. Giambattista Vico, The Art of Rhetoric (Institutiones Oratoriae, 1711-1741), from the definitive Latin text and notes, Italian commentary and introduction by Giuliano Crifo. Translated and Edited by Giorgio A. Pinton and Arthur W. Shippee. A volume in Values in Italian Philosophy 38. W. H. Werkmeister, Martin Heidegger on the Way. Edited by Richard T. Hull. A volume in Werkmeister Studies 39.

Phillip Stambovsky, Myth and the Limits of Reason

40. Samantha Brennan, Tracy Isaacs, and Michael Milde, Editors, A Question of Values: New Canadian Perspectives in Ethics and Political Philosophy 41. Peter A. Redpath, Cartesian Nightmare: An Introduction to Transcendental Sophistry. A volume in Studies in the History of Western Philosophy 42. Clark Butler, History as the Story of Freedom: Philosophy in Intercultural Context, with responses by sixteen scholars 43.

Dennis Rohatyn, Philosophy History Sophistry

44. Leon Shaskolsky Sheleff, Social Cohesion and Legal Coercion: A Critique of Weber, Durkheim, and Marx. Afterword by Virginia Black 45. Alan Soble, Editor, Sex, Love, and Friendship: Studies of the Society for the Philosophy of Sex and Love, 1977-1992. A volume in Histories and Addresses of Philosophical Societies

46. Peter A. Redpath, Wisdom's Odyssey: From Philosophy to Transcendental Sophistry. A volume in Studies in the History of Western Philosophy 47. Albert A. Anderson, UniversalJustice: A Dialectical Approach. A volume in Universal Justice 48. Pio Colonnello, The Philosophy of Jose Gaos. Translated from Italian by Peter Cocozzella. Edited by Myra Moss. Introduction by Giovanni Gullace. A volume in Values in Italian Philosophy 49. Laura Duhan Kaplan and Laurence F. Bove, Editors, Philosophical Perspectives on Power and Domination: Theories and Practices. A volume in Philosophy of Peace 50.

Gregory F. Mellema, Collective Responsibility

51. Josef Seifert, What Is Life? The Originality, Irreducibility, and Value of Life. A volume in Central-European Value Studies 52.

William Gerber, Anatomy of What We Value Most

53. Armando Molina, Our Ways: Values and Character, Edited by Rem B. Edwards. A volume in Hartman Institute Axiology Studies 54. Kathleen J. Wininger, Nietzsche s Reclamation of Philosophy. A volume in Central-European Value Studies 55.

Thomas Magnell, Editor, Explorations of Value

56. HPP (Hennie) Letter, Injustice, Violence, and Peace: The Case of South Africa. A volume in Philosophy of Peace 57. Lennart Nordenfelt, Talking About Health: A Philosophical Dialogue. A volume in Nordic Value Studies 58. Jon Mills and Janusz A. Polanowski, The Ontology of Prejudice. A volume in Philosophy and Psychology 59.

Leena Vilkka, The Intrinsic Value of Nature

60. Palmer Talbutt, Jr., Rough Dialectics: Sorokin s Philosophy of Value, with contributions by Lawrence T. Nichols and Pitirim A. Sorokin 61.

C. L. Sheng, A Utilitarian General Theory of Value

62. George David Miller, Negotiating Toward Truth: The Extinction of Teachers and Students. Epilogue by Mark Roelof Eleveld. A volume in Philosophy of Education 63. William Gerber, Love, Poetry, and Immortality: Luminous Insights of the World's Great Thinkers 64. Dane R. Gordon, Editor, Philosophy in Post-Communist Europe. A volume in Post-Communist European Thought 65. Dane R. Gordon and Jozef Niznik, Editors, Criticism and Defense of Rationality in Contemporary Philosophy. A volume in Post-Communist European Thought 66. John R. Shook, Pragmatism: An Annotated Bibliography, 1898-1940. With contributions by E. Paul Colella, Lesley Friedman, Frank X. Ryan, and Ignas K. Skrupskelis 67.

Lansana Keita, The Human Project and the Temptations of Science

68. Michael M. Kazanjian, Phenomenology and Education: Cosmology, Co-Being, and Core Curriculum. A volume in Philosophy of Education 69. James W. Vice, The Reopening of the American Mind: On Skepticism and Constitutionalism 70. Sarah Bishop Merrill, Defining Personhood: Toward the Ethics of Quality in Clinical Care 11.

Dane R. Gordon, Philosophy and Vision

72. Alan Milchman and Alan Rosenberg, Editors, Postmodernism and the Holocaust. A volume in Holocaust and Genocide Studies 73. Peter A. Redpath, Masquerade of the Dream Walkers: Prophetic Theology from the Cartesians to Hegel. A volume in Studies in the History of Western

Philosophy 74. Malcolm D. Evans, Whitehead and Philosophy of Education: The Seamless Coat of Learning. A volume in Philosophy of Education 75. Warren E. Steinkraus, Taking Religious Claims Seriously: A Philosophy of Religion, edited by Michael H. Mitias. A volume in Universal Justice 76.

Thomas Magnell, Editor, Values and Education

77. Kenneth A. Bryson, Persons and Immortality. A volume in Natural Law Studies 78. Steven V. Hicks, International Law and the Possibility of a Just World Order: An Essay on Hegel's Universalism. A volume in Universal Justice 79. E. F. Kaelin, Texts on Texts and Textuality: A Phenomenology of Literary Art, Edited by Ellen J. Burns 80. Amihud Gilead, Saving Possibilities: A Study in Philosophical Psychology. A volume in Philosophy and Psychology 81. Andre Mineau, The Making of the Holocaust: Ideology and Ethics in the Systems Perspective. A volume in Holocaust and Genocide Studies 82. Howard P. Kainz, Politically Incorrect Dialogues: Topics Not Discussed in Polite Circles 83. Veikko Launis, Juhani Pietarinen, and Juha Raikka, Editors, Genes and Morality: New Essays. A volume in Nordic Value Studies 84.

Steven Schroeder, The Metaphysics of Cooperation: A Study ofF. D. Maurice

85. Caroline Joan ("Kay") S. Picart, Thomas Mann and Friedrich Nietzsche: Eroticism, Death, Music, and Laughter. A volume in Central-European Value Studies 86. G. John M. Abbarno, Editor, The Ethics ofHomelessness: Philosophical Perspectives

87. James Giles, Editor, French Existentialism: Consciousness, Ethics, and Relations with Others. A volume in Nordic Value Studies 88. Deane Curtin and Robert Litke, Editors, Institutional Violence. A volume in Philosophy of Peace 89.

Yuval Lurie, Cultural Beings: Reading the Philosophers of Genesis

90. Sandra A. Wawrytko, Editor, The Problem of Evil: An Intercultural Exploration. A volume in Philosophy and Psychology 91. Gary J. Acquaviva, Values, Violence, and Our Future. volume in Hartman Institute Axiology Studies 92.

Michael R. Rhodes, Coercion: A Nonevaluative Approach

93.

Jacques Kriel, Matter, Mind, and Medicine: Transforming the Clinical Method

94. Haim Gordon, Dwelling Poetically: Educational Challenges in Heidegger's Thinking on Poetry. A volume in Philosophy of Education 95. Ludwig Griinberg, The Mystery of Values: Studies in Axiology, edited by Cornelia Grunberg and Laura Griinberg 96. Gerhold K. Becker, Editor, The Moral Status of Persons: Perspectives on Bioethics. A volume in Studies in Applied Ethics 97. Roxanne Claire Farrar, Sartrean Dialectics: A Method for Critical Discourse on Aesthetic Experience 98. Ugo Spirito, Memoirs of the Twentieth Century. Translated from Italian and edited by Anthony G. Costantini. A volume in Values in Italian Philosophy 99. Steven Schroeder, Between Freedom and Necessity: An Essay on the Place of Value 100. Foster N. Walker, Enjoyment and the Activity of Mind: Dialogues on Whitehead and Education. A volume in Philosophy of Education 101. Avi Sagi, Kierkegaard, Religion, and Existence: The Voyage of the Self. Translated from Hebrew by Batya Stein

102. Berime R. Crockett, Jr., Editor, Addresses of the Mississippi Philosophical Association. A volume in Histories and Addresses of Philosophical Societies 103. Paul van Dijk, Anthropology in the Age of Technology: The Philosophical Contribution of Gunther Anders 104. Giambattista Vico, Universal Right. Translated from Latin and Edited by Giorgio Pinton and Margaret Diehl. A volume in Values in Italian Philosophy 105. Judith Presler and Sally J. Scholz, Editors, Peacemaking: Lessons from the Past, Visions for the Future. A volume in Philosophy of Peace 106. Dennis Bonnette, Origin of the Human Species. A volume in Studies in the History of Western Philosophy 107. Phyllis Chiasson, Peirce's Pragmatism: The Design for Thinking. A volume in Studies in Pragmatism and Values 108. Dan Stone, Editor, Theoretical Interpretations of the Holocaust. A volume in Holocaust and Genocide Studies 109. Raymond Angelo Belliotti, What Is the Meaning of Human Life? 110. Lennart Nordenfelt, Health, Science, and Ordinary Language, with Contributions by George Khushf and K. W. M. Fulford 111. Daryl Koehn, Local Insights, Global Ethics for Business. A volume in Studies in Applied Ethics 112. Matti Ha'yry and Tuija Takala, Editors, The Future of Value Inquiry. A volume in Nordic Value Studies 113.

Conrad P. Pritscher, Quantum Learning: Beyond Duality

114. Thomas M. Dicken and Rem B. Edwards, Dialogues on Values and Centers of Value: Old Friends, New Thoughts. A volume in Hartman Institute Axiology Studies 115. Rem B. Edwards, What Caused the Big Bang? A volume in Philosophy and Religion

116. Jon Mills, Editor, A Pedagogy of Becoming. A volume in Philosophy of Education 117. Robert T. Radford, Cicero: A Study in the Origins of Republican Philosophy. A volume in Studies in the History of Western Philosophy 118. Arleen L. F. Salles and Maria Julia Bertomeu, Editors, Bioethics: Latin American Perspectives. A volume in Philosophy in Latin America 119. Nicola Abbagnano, The Human Project: The Year 2000, with an Interview by Guiseppe Grieco. Translated from Italian by Bruno Martini and Nino Langiulli. Edited with an introduction by Nino Langiulli. A volume in Studies in the History of Western Philosophy 120. Daniel M. Haybron, Editor, Earth s Abominations: Philosophical Studies of Evil. A volume in Personalist Studies 121. Anna T. Challenger, Philosophy and Art in Gurdjieff's Beelzebub: A Modern Sufi Odyssey 122. George David Miller, Peace, Value, and Wisdom: The Educational Philosophy ofDaisaku Ikeda. A volume in Daisaku Ikeda Studies 123.

Haim Gordon and Rivca Gordon, Sophistry and Twentieth-Century Art

124. Thomas O Buford and Harold H. Oliver, Editors Personalism Revisited: Its Proponents and Critics. A volume in Histories and Addresses of Philosophical Societies 125. Avi Sagi, Albert Camus and the Philosophy of the Absurd. Translated from Hebrew by Batya Stein 126. Robert S. Hartman, The Knowledge of Good: Critique ofAxiologic I Reason. Expanded translation from the Spanish by Robert S. Hartman. Edited by Arthur R. Ellis and Rem B. Edwards. A volume in Hartman Institute Axiology Studies 127. Alison Bailey and Paula J. Smithka, Editors. Community, Diversity, and Difference: Implications for Peace. A volume in Philosophy of Peace

128. Oscar Vilarroya, The Dissolution of Mind: A Fable of How Experience Gives Rise to Cognition. A volume in Cognitive Science 129. Paul Bube and Jefferey Geller, Editors, Conversations with Pragmatism. A volume in Studies in Pragmatism and Values 130. Richard Rumana, Richard Rorty: An Annotated Bibliography of Secondary Literature, A volume in Studies in Pragmatism and Values 131. Stephen Schneck, Max Scheler 's Acting Persons: New Perspectives. A volume in Personalist Studies 132. Michael Kazanjian, Learning Values Lifelong: From Inert Ideas to Wholes. A volume in Philosophy of Education 133. Rudolph Alexander Kofi Cain: Alain Leroy Locke: Race, Culture, and the Education of African American Adults. A Volume in African American Philosophy 134. Werner J. Krieglstein, Compassion: A New Philosophy of the Other. 135. Robert N. Fisher, Daniel T. Primozic, Peter A. Day, and Joel A. Thompson, Editors, Suffering, Death, and Identity. A volume in Personalist Studies 136. Steven Schroeder, Touching Philosophy, Sounding Religion, Placing Education. A volume in Philosophy of Education 137. Guy Debrock, Process Pragmatism: Essays on a Quiet Philosophical Revolution. A volume in Studies in Pragmatism and Values 138. Lennart Nordenfelt and Per-Erik Liss, Editors, Dimensions of Health and Health Promotion. 139. Amihud Gilead, Singularity and Other Possibilities: Panenmentalist Novelties. 140. Samantha Mei-che Pang, Nursing Ethics in Modern China: Conflicting Values and Competing Role Requirements. A volume in Studies in Applied Ethics 141. Christine M. Koggel, Allannah Furlong, and Charles Levin, Editors, Confidential Relationships: Psychoanalytic, Ethical, and Legal Contexts. A volume in Philosophy and Psychology

142. Peter A. Redpath, Editor, A Thomistic Tapestry: Essays in Memory of Etienne Gilson. A volume in Gilson Studies 143. Deane-Peter Baker and Patrick Maxwell, Editors, Explorations in Contemporary Continental Philosophy of Religion. A volume in Philosophy and Religion 144. Matti Hayry and Tuija Takala, Editors, Scratching the Surface A volume in Values in Bioethics

ofBioethics.