Bioethics Principles, Issues, and Cases PDF by Lewis Vaughn

 Bioethics Principles, Issues, and Cases Fourth Edition Lewis Vaughn New York Oxford OX F OR D U N I V E R SI T Y PR E S S v...

 Bioethics Principles, Issues, and Cases Fourth Edition Lewis Vaughn New York Oxford OX F OR D U N I V E R SI T Y PR E S S vau03268_fm_i-xii.indd i 05/15/19 12:27 PM Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries. Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America. © 2020, 2017, 2013, 2010 by Oxford University Press For titles covered by Section 112 of the US Higher Education Opportunity Act, please visit www.oup.com/us/he for the latest information about pricing and alternate formats. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above. You must not circulate this work in any other form and you must impose this same condition on any acquirer. Library of Congress Cataloging-in-Publication Data Names: Vaughn, Lewis, author. Title: Bioethics: principles, issues, and cases / Lewis Vaughn. Description: Fourth edition. | New York: Oxford University Press, | Includes bibliographical references and index. Identifiers: LCCN 2019017497 (print) | LCCN 2019015775 (ebook) | ISBN 9780190903268 (paperback: alk. paper) | ISBN 9780190903282 (epub) Subjects: LCSH: Medical ethics. | Bioethics. Classification: LCC R724.V38 2020 (ebook) | LCC R724 (print) | DDC 174.2—dc23 LC record available at https://lccn.loc.gov/2019017497 9 8 7 6 5 4 3 2 1 Printed by LSC Communications, United States of America vau03268_fm_i-xii.indd ii 05/15/19 12:27 PM  B R I E F CO N T E N T S Preface x Part 1. ​Principles and Theories Chapter 1 ​m oral reasoning in bioethics 3 Chapter 2 ​b ioethics and moral theories 34 Part 2. ​Medical Professional and Patient Chapter 3 ​paternalism and patient autonomy 97 Chapter 4 ​t ruth-telling and confidentiality 176 Chapter 5 ​i nformed consent 228 Chapter 6 ​h uman research 271 Part 3. ​Life and Death Chapter 7 ​a bortion 339 Chapter 8 reproductive technology 440 Chapter 9 ​g enetic choices 562 Chapter 10 ​e uthanasia and physician-assisted suicide 648 Part 4. ​Justice and Health Care Chapter 11 ​d ividing up health care resources 743 Appendix 811 Glossary 813 Index 815 iii vau03268_fm_i-xii.indd iii 05/15/19 12:27 PM  CO N T E N T S Preface x Chapter 2 bioethics and moral theories 34 Part 1. ​Principles and Theories The Nature of Moral Theories 34 Chapter 1 Influential Moral Theories 35 Utilitarianism 36 moral reasoning in bioethics 3 In Depth: Utilitarianism and the Golden Rule 38 Ethics and Bioethics 3 Kantian Ethics 38 Ethics and the Moral Life 5 Principlism 40 In Depth: Morality and the Law 7 Natural Law Theory 41 Moral Principles in Bioethics 8 Rawls’ Contract Theory 43 Autonomy 9 Virtue Ethics 44 Nonmaleficence 10 In Depth: Can Virtue Be Taught? 46 Beneficence 10 The Ethics of Care 46 Utility 11 Feminist Ethics 47 Justice 12 Casuistry 48 Ethical Relativism 13 Criteria for Judging Moral Theories 49 In Depth: Anthropology and Moral Review: E valuating Moral Theories: Criteria Diversity 14 of Adequacy 50 Ethics and Religion 17 Applying the Criteria 50 Moral Arguments 19 Utilitarianism 51 Argument Fundamentals 19 Kant’s Theory 52 Patterns of Moral Arguments 22 Key Terms 53 Review: V alid and Invalid Argument Summary 53 Forms ​23 Further Reading 54 In Depth: Fallacies in Moral Reasoning 24 Notes 54 Evaluating Premises 26 readings 55 Assessing Whole Arguments 28 “Utilitarianism,” John Stuart Mill 55 Key Terms 29 “The Moral Law,” Immanuel Kant 58 Summary 29 Nicomachean Ethics, Aristotle 63 Argument Exercises 30 “Caring,” Nel Noddings 74 Further Reading 32 “The Need for More Than Justice,” Annette C. Baier 78 Notes 33 “Moral Saints,” Susan Wolf 86 vau03268_fm_i-xii.indd iv 05/15/19 12:27 PM  Contents v Part 2. ​Medical Professional and Patient “Fundamental Elements of the Patient-Physician Relationship,” AMA Council on Ethical and Chapter 3 Judicial Affairs 165 paternalism and patient “Advocacy or Subservience for the Sake of autonomy 97 Patients?” Helga Kuhse 166 Shades of Autonomy and Paternalism 97 “Paternalism Revisited,” Harriet Hall 174 Refusing Treatment 98 In Depth: The Hippocratic Oath 99 In Depth: Physician Autonomy 100 Chapter 4 Legal Brief: Advance Directives 101 truth-telling and Futile Treatment 102 confidentiality 176 Legal Brief: Refusing Treatment for Children Paternalism and Deception 176 on Religious Grounds 103 In Depth: Do Patients Want the Truth? Do In Depth: CPR and DNR 104 Physicians Tell It? 177 In Depth: Moral Conflicts in Nursing 104 Confidential Truths 179 Classic Case File: Elizabeth Bouvia 105 Legal Brief: Confidentiality and a Duty Applying Major Theories 106 to Warn 180 Key Terms 107 In Depth: Truth-Telling and Cultural Summary 107 Diversity 181 Cases for Evaluation 108 Classic Case File: Carlos R. 182 Further Reading 110 Applying Major Theories 183 Notes 110 Key Terms 183 Summary 183 readings 111 Cases for Evaluation 184 “Paternalism,” Gerald Dworkin 111 Further Reading 186 “The Refutation of Medical Paternalism,” Notes 186 Alan Goldman 121 “Why Doctors Should Intervene,” readings 187 Terrence F. Ackerman 127 “Telling the Truth to Patients: A Clinical Ethics “Autonomy, Futility, and the Limits of Medicine,” Exploration,” David C. Thomasma 187 Robert L. Schwartz 132 “On Telling Patients the Truth,” “Four Models of the Physician-Patient Relationship,” Mack Lipkin 191 Ezekiel J. Emanuel and Linda L. Emanuel 137 “Is It Ever OK to Lie to Patients?,” “Patient Autonomy and Physician Responsibility,” Shelly K. Schwartz 193 Commentaries by Patrick C. Beeman and “Respect for Patients, Physicians, and the Truth,” Ryan C. VanWoerkom 147 Susan Cullen and Margaret Klein 196 “Confronting Death: Who Chooses, Who Controls? “Why Privacy Is Important,” James Rachels 204 A Dialogue Between Dax Cowart and Robert Burt,” “Confidentiality in Medicine—A Decrepit Dax Cowart and Robert Burt 150 Concept,” Mark Siegler 209 Bouvia v. Superior Court, California Court “Ethical Relativism in a Multicultural Society,” of Appeal 160 Ruth Macklin 212 vau03268_fm_i-xii.indd v 05/15/19 12:27 PM vi Contents Tarasoff v. Regents of the University of California, In Depth: Women in Clinical Supreme Court of California 223 Trials 278 Research on the Vulnerable 279 In Depth: Why Enter Chapter 5 a Clinical Trial? 280 informed consent 228 Applying Major Theories 283 Autonomy and Consent 228 Key Terms 284 Conditions of Informed Consent 229 Summary 284 In Depth: Decision-Making Classic Case File: The UCLA Schizophrenia Capacity 231 Study 285 In Depth: Two Views of Informed Consent 233 Cases for Evaluation 286 Legal Brief: Important Informed Consent Further Reading 290 Cases 234 Notes 290 Applying Major Theories 235 Classic Case File: Jerry Canterbury 236 readings 291 Key Terms 237 The Nuremberg Code 291 Summary 237 Declaration of Helsinki: Ethical Principles for Cases for Evaluation 238 Medical Research Involving Human Subjects, Further Reading 240 World Medical Association 292 Notes 240 “The Belmont Report,” The National Commission for the Protection of readings 240 Human Subjects of Biomedical and “The Concept of Informed Consent,” Behavioral Research 295 Ruth R. Faden and Tom L. Beauchamp 240 “Final Report: Human Radiation Experiments,” “Informed Consent—Must It Remain a Fairy Advisory Committee on Human Radiation Tale?” Jay Katz 245 Experiments 298 “Transparency: Informed Consent in Primary “Of Mice but Not Men: Problems of the Care,” Howard Brody 255 Randomized Clinical Trial,” Samuel Hellman “Informed Consent: Some Challenges to the and Deborah S. Hellman 304 Universal Validity of the Western Model,” “A Response to a Purported Ethical Robert J. Levine 261 Difficulty with Randomized Clinical Canterbury v. Spence, United States Court of Trials Involving Cancer Patients,” Appeals 267 Benjamin Freedman 310 “Racism and Research: The Case of the Tuskegee Syphilis Study,” Allan M. Brandt 314 Chapter 6 “Is It Time to Stop Using Race in Medical human research 271 Research?” Angus Chen 326 The Science of Clinical Trials 272 “The Ethics of Clinical Research in the Third In Depth: The Tuskegee Tragedy 273 World,” Marcia Angell 328 Beneficence, Science, and Placebos 274 “Ethical Issues in Clinical Trials in Developing Science and Informed Consent 277 Countries,” Baruch Brody 332 vau03268_fm_i-xii.indd vi 05/15/19 12:27 PM  Contents vii Part 3. ​Life and Death Chapter 8 Chapter 7 reproductive technology 440 abortion 339 In Vitro Fertilization 440 Fact File: Assisted Reproduction 441 Starting Point: The Basics 339 Surrogacy 446 Fact File: U.S. Abortions 340 In Depth: IVF and Children’s Future In Depth: Abortion and Public Children 447 Opinion 2017 343 Cloning 448 The Legal Struggle 344 In Depth: Cloning Time Line 451 In Depth: Late-Term Abortion 345 Applying Major Theories 452 Persons and Rights 345 In Depth: Sherri Shepherd: How Surrogacy In Depth: Does a Fetus Feel Pain? 348 Can Go Wrong 453 Applying Major Theories 350 Key Terms 454 Key Terms 351 Summary 454 Summary 351 Classic Case File: Baby M 455 Classic Case File: Nancy Klein 352 Cases for Evaluation 456 Cases for Evaluation 353 Further Reading 458 Further Reading 355 Notes 459 Notes 356 readings 357 readings 460 “A Defense of Abortion,” Judith Jarvis “IVF: The Simple Case,” Peter Singer 460 Thomson 357 “IVF and Women’s Interests: An Analysis “Why Abortion Is Immoral,” of Feminist Concerns,” Mary Anne Don Marquis 367 Warren 464 “An Almost Absolute Value in History,” “‘Give Me Children or I Shall Die!’ New John T. Noonan, Jr. 379 Reproductive Technologies and Harm to “On the Moral and Legal Status of Abortion,” Children,” Cynthia B. Cohen 476 Mary Anne Warren 383 “Instruction on Respect for Human Life in Its “Virtue Theory and Abortion,” Rosalind Origin and on the Dignity of Procreation,” Hursthouse 394 Congregation for the Doctrine of the “Abortion and the Concept of a Person,” Faith 487 Jane English 408 “The Presumptive Primacy of Procreative “Abortion,” Margaret Olivia Little 414 Liberty,” John A. Robertson 497 “Abortion Through a Feminist Ethics Lens,” “Surrogate Mothering: Exploitation or Susan Sherwin 419 Empowerment?” Laura M. Purdy 504 Roe v. Wade, United States “Is Women’s Labor a Commodity?” Elizabeth S. Supreme Court 428 Anderson 514 Planned Parenthood of Southeastern “Egg Donation and Commodification,” Bonnie Pennsylvania v. Casey, United States Supreme Steinbock 526 Court 433 “The Wisdom of Repugnance,” Leon R. Kass 535 vau03268_fm_i-xii.indd vii 05/15/19 12:27 PM viii Contents “Cloning Human Beings: An Assessment “Genetic Interventions and the Ethics of of the Ethical Issues Pro and Con,” Enhancement of Human Beings,” Julian Dan W. Brock 551 Savulescu 627 “Germ-Line Gene Therapy,” LeRoy Walters and Julie Gage Palmer 636 Chapter 9 “What Does ‘Respect for Embryos’ Mean genetic choices 562 in the Context of Stem Cell Research?” Genes and Genomes 562 Bonnie Steinbock 643 Genetic Testing 563 Declaration on the Production and the Scientific In Depth: Direct-to-Consumer Genetic Tests 566 and Therapeutic Use of Human Embryonic Gene Therapy 570 Stem Cells, Pontifical Academy for Life 646 Fact File: Available Genetic Tests for Cancer Risk 571 Chapter 10 Fact File: Recent Research Breakthroughs in Gene Therapy 574 euthanasia and physician-assisted suicide 648 Stem Cells 575 Applying Major Theories 577 Deciding Life and Death 649 Classic Case File: The Kingsburys 578 Legal Brief: Euthanasia and Assisted Suicide: Major Developments 651 Key Terms 579 In Depth: Assisted Suicide: What Do Doctors Summary 579 Think? 652 Cases for Evaluation 579 Autonomy, Mercy, and Harm 653 Further Reading 582 In Depth: Oregon’s Death With Dignity Act 655 Notes 582 In Depth: End-of-Life Decisions in the Netherlands 657 readings 583 Applying Major Theories 657 “Implications of Prenatal Diagnosis for the In Depth: Physician-Assisted Suicide and Public Human Right to Life,” Leon R. Kass 583 Opinion 658 “Genetics and Reproductive Risk: Can Having Classic Case File: Nancy Cruzan 659 Children Be Immoral?” Laura M. Purdy 587 Key Terms 660 “The Morality of Screening for Disability,” Summary 660 Jeff McMahan 594 Cases for Evaluation 661 “Genetic Dilemmas and the Child’s Right to an Further Reading 664 Open Future,” Dena S. Davis 598 Notes 665 “Disowning Knowledge: Issues in Genetic Testing,” Robert Wachbroit 608 readings 666 “The Non-Identity Problem and Genetic “Death and Dignity: A Case of Individualized Harms—The Case of Wrongful Handicaps,” Decision Making,” Dan W. Brock 612 Timothy E. Quill 666 “Is Gene Therapy a Form of Eugenics?” “Voluntary Active Euthanasia,” Dan W. Brock 670 John Harris 616 “When Self-Determination Runs Amok,” “Genetic Enhancement,” Walter Glannon 622 Daniel Callahan 682 vau03268_fm_i-xii.indd viii 05/15/19 12:27 PM  Contents ix “Physician-Assisted Suicide: A Tragic View,” The Ethics of Rationing 754 John D. Arras 687 Classic Case File: Christine deMeurers 756 “Active and Passive Euthanasia,” James Key Terms 758 Rachels 702 Summary 758 “Dying at the Right Time: Reflections on Cases for Evaluation 759 (Un)Assisted Suicide,” John Hardwig 706 Further Reading 761 “The Philosophers’ Brief,” Ronald Dworkin, Thomas Notes 762 Nagel, Robert Nozick, John Rawls, Thomas Scanlon, and Judith Jarvis Thomson 717 readings 763 “Legalizing Assisted Dying Is Dangerous “Is There a Right to Health Care and, if So, What for Disabled People,” Liz Carr 725 Does It Encompass?,” Norman Daniels 763 “  ‘For Now Have I My Death’: The ‘Duty to Die’ “The Right to a Decent Minimum of Health Versus the Duty to Help the Ill Stay Alive,” Care,” Allen E. Buchanan 770 Felicia Ackerman 727 “Rights to Health Care, Social Justice, and Fairness Vacco v. Quill, United States Supreme Court 738 in Health Care Allocations: Frustrations in the Face of Finitude,” H. Tristram Engelhardt, Jr. 776 Part 4. ​Justice and Health Care “Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better Chapter 11 U.S. Health Care,” Eric C. Schneider, Dana O. dividing up health care Sarnak, David Squires, et al. 784 resources 743 “Public Health Ethics: Mapping the Terrain,” Health Care in Trouble 743 James F. Childress et al. 788 In Depth: Unequal Health Care for “Human Rights Approach to Public Health Minorities 746 Policy,” D. Tarantola and S. Gruskin 799 Fact File: U.S. Health Care 747 Appendix 811 Theories of Justice 748 Glossary 813 In Depth: Comparing Health Care Systems: United States, Canada, and Index 815 Germany 749 Fact File: Poll: The Public’s Views on the ACA (“Obamacare”) 751 A Right to Health Care 752 In Depth: Public Health and Bioethics 753 vau03268_fm_i-xii.indd ix 05/15/19 01:53 PM  P R E FAC E This fourth edition of Bioethics embodies all the features filling out the discussions with background on the that have made it a best-selling textbook and includes all latest medical, legal, and social developments. The the most important changes and improvements that main issues include paternalism and patient auton- dozens of teachers have asked for recently and over the omy, truth-telling, confidentiality, informed consent, years. The book is, therefore, better than ever. And if it research ethics, clinical trials, abortion, assisted re- isn’t, let even more good teachers say so and let the cor- production, surrogacy, cloning, genetic testing, gene rections and enhancements continue. And may the book therapy, stem cells, euthanasia, physician-assisted remain, as so many teachers have said, exactly suitable to suicide, and the just allocation of health care. their teaching approach. Every issues chapter contains five to twelve read- Bioethics provides in-depth discussions of the ings, with each selection prefaced by a brief s­ ummary. philosophical, medical, scientific, social, and legal The a­ rticles—old standards as well as new ones— aspects of controversial bioethical issues and reflect the major arguments and latest thinking in combines this material with a varied collection of each debate. They present a diversity of perspectives thought-provoking readings. But on this foundation on each topic, with pro and con positions well rep- are laid elements that other texts sometimes forgo: resented. In most cases, the relevant court rulings are also included. 1. An extensive introduction to ethics, bioethics, moral principles, critical thinking, and moral reasoning special features 2. Full coverage of influential moral theories, A two-chapter introduction to bioethics, moral including criteria and guidelines for evaluat- reasoning, moral theories, and critical thinking. ing them (the focus is on utilitarianism, These chapters are designed not only to introduce ­Kantian ethics, natural law theory, Rawls’ the subject matter of bioethics but also to add co- contract theory, virtue ethics, the ethics of herence to subsequent chapter material and to care, and feminist ethics) provide the student with a framework for thinking 3. Detailed examinations of the classic cases critically about issues and cases. Chapter 1 is an in­ that have helped shape debate in major issues troduction to basic ethical concepts, the field of 4. Collections of current, news-making cases for bioethics, moral principles and judgments, moral evaluation reasoning and arguments, the challenges of rela- 5. Many pedagogical features to engage students tivism, and the relationship between ethics and and reinforce lessons in the main text both religion and the law. Chapter 2 explores moral 6. Writing that strives hard for clarity and conci- theory, shows how theories relate to moral princi- sion to convey both the excitement and com- ples and judgments, examines influential theories plexity of issues without sacrificing accuracy (including virtue ethics, the ethics of care, and feminist ethics), and demonstrates how they can be topics and readings applied to moral problems. It also explains how to Nine chapters cover many of the most controversial evaluate moral theories using plausible criteria of issues in bioethics, detailing the main arguments and adequacy. vau03268_fm_i-xii.indd x 05/15/19 12:27 PM  Preface xi Helpful chapter elements. Each issues chapter Annette C. Baier, “The Need for More Than contains: Justice” Ezekiel J. Emanuel and Linda L. Emanuel, 1. Analyses of the most important arguments “Four Models of the Physician-Patient offered by the various parties to the debate. Relationship” They reinforce and illustrate the lessons on Dax Cowart and Robert Burt, “Confronting moral reasoning in Chapter 1. Death: Who Chooses, Who Controls? A Di- 2. A section called “Applying Major Theories” alogue Between Dax Cowart and Robert showing how the moral theories can be ­applied Burt” to the issues. It ties the discussions of moral Harriet Hall, “Paternalism Revisited” theories in Chapter 2 to the moral problems and Angus Chen, “Is It Time to Stop Using Race illustrates the theories’ relevance. in Medical Research?” 3. A section labeled “Classic Case File” that Liz Carr, “Legalizing Assisted Dying Is ­examines in detail a famous bioethics case. The Dangerous for Disabled People” stories covered in these sections include those Felicia Ackerman, “‘For Now I Have My of Elizabeth Bouvia, Jerry Canterbury, Nancy Death’: The ‘Duty to Die’ Versus the Duty to Klein, Baby M, Nancy Cruzan, the Kingsburys, Help the Ill Stay Alive” Christine deMeurers, and the UCLA Schizo- Eric C. Schneider, Dana O. Sarnak, David phrenia Study. These are in ­addition to many Squires, et al., “Mirror, Mirror 2017: Interna- other controversial cases covered elsewhere in tional Comparison Reflects Flaws and Op- the book—for example, the Terri Schiavo con- portunities for Better U.S. Health Care” troversy, the Tuskegee tragedy, the Willow- Clarifications and Further Discussions brook experiments, and the U.S. government’s Principlism and prima facie principles human radiation studies. Feminist ethics 4. A bank of “Cases for Evaluation” at the end Abortion and Judaism of each chapter. These are recent news stories Research on euthanasia in Oregon and the followed by discussion questions. They give stu- Netherlands dents the chance to test their moral ­reasoning End-of-life decisions in the Netherlands on challenging new scenarios that range across (statistics) a broad spectrum of current topics. Advance directives A diverse package of pedagogical aids. Each Updates issues chapter contains a chapter summary, sugges- Important informed consent cases tions for further reading, and a variety of text boxes. U.S. abortion (statistics) The boxes are mainly of three types: Abortion and public opinion (survey) Recent breakthroughs in gene therapy 1. “In Depth”—additional information, illustra- Euthanasia and assisted suicide: major tions, or analyses of matters touched on in developments the main text. Assisted suicide: What do doctors think? 2. “Fact File”—statistics on the social, medical, (survey) and scientific aspects of the chapter’s topic. Public opinion: physician-assisted suicide 3. “Legal Brief”—summaries of important court rul- (survey) ings or updates on the status of legislation. Health care: the uninsured, per capita spending, U.S. health care quality new to this edition Comparing health care systems: U.S., Ten New Readings Canada, Germany Aristotle, Nicomachean Ethics, Books I and II Public opinion: views on the ACA Nel Noddings, “Caring” (“Obamacare”) vau03268_fm_i-xii.indd xi 05/16/19 02:47 PM xii Preface ancillaries Leslie P. Francis, University of Utah The Oxford University Press Ancillary Resource Center Devin Frank, University of Missouri–Columbia (ARC) at www.oup-arc.com/vaughn-bioethics-4e Kathryn M. Ganske, Shenandoah University houses an Instructor’s Manual with Test Bank and Martin Gunderson, Macalester College PowerPoint Lecture Outlines for instructor use. Stu- Helen Habermann, University of Arizona dent resources are available on the companion website Stephen Hanson, University of Louisville at www.oup.com/us/vaughn and include self-quizzes, Karey Harwood, North Carolina State flashcards, and helpful web links. University Sheila R. Hollander, University of Memphis Scott James, University of North Carolina, acknowledgments Wilmington This edition of the text is measurably better than James Joiner, Northern Arizona University the first thanks to the good people at Oxford Uni- William P. Kabasenche, Washington State versity Press—especially my editor Robert Miller University and assistant editor Alyssa Palazzo—and many Susan Levin, Smith College reviewers: Margaret Levvis, Central Connecticut State Keith Abney, Polytechnic State University University at San Luis Obispo Burden S. Lundgren, Old Dominion University Kim Amer, DePaul University Joan McGregor, Arizona State University Jami L. Anderson, University of Michigan Tristram McPherson, Virginia Tech Carol Isaacson Barash, Boston University Jonathan K. Miles, Bowling Green State Deb Bennett-Woods, Regis University University Don Berkich, Texas A&M University James Lindemann Nelson, Michigan State Stephan Blatti, University of Memphis University William Bondeson, University of Missouri, Thomas Nenon, University of Memphis Columbia Laura Newhart, Eastern Kentucky University Lori Brown, Eastern Michigan University Steve Odmark, Century College David W. Concepción, Ball State University Assya Pascalev, Howard University Catherine Coverston, Brigham Young Viorel Pâslaru, University of Dayton University David J. Paul, Western Michigan University Russell DiSilvestro, Assistant Professor, Anthony Preus, Binghamton University ­California State University, Sacramento Susan M. Purviance, University of Toledo John Doris, Washington University in St. Louis Sara Schuman, Washtenaw Community College Denise Dudzinski, University of Washington David Schwan, Bowling Green State University School of Medicine Anita Silvers, San Francisco State University Craig Duncan, Ithaca College M. Josephine Snider, University of Florida Anne Edwards, Austin Peay State University Joseph Wellbank, Northeastern University John Elia, University of Georgia Gladys B. White, Georgetown University Christy Flanagan-Feddon, Regis University David Yount, Mesa Community College Jacqueline Fox, University of South Carolina School of Law vau03268_fm_i-xii.indd xii 05/15/19 12:27 PM  Principles and Theories 1 vau03268_ch01_001-033.indd 1 05/02/19 07:36 PM vau03268_ch01_001-033.indd 2 05/02/19 07:36 PM  CHAP TER 1 Moral Reasoning in Bioethics Any serious and rewarding exploration of bio- Second, it would be difficult to imagine moral ethics is bound to be a challenging journey. issues more important—​more closely gathered What makes the trip worthwhile? As you might around the line between life and death, health expect, this entire text is a long answer to that and illness, pain and relief, hope and despair—​ question. You therefore may not fully appreciate than those addressed by bioethics. Whatever the trek until you have already hiked far along our view of these questions, there is little doubt the trail. The short answer comes in three parts. that they matter immensely. Whatever answers First, bioethics—​like ethics, its parent disci- we give will surely have weight, however they fall. pline—​is about morality, and morality is about Third, as a systematic study of such ques- life. Morality is part of the unavoidable, bitter- tions, bioethics holds out the possibility of an- sweet drama of being persons who think and feel swers. The answers may or may not be to our and choose. Morality concerns beliefs regarding liking; they may confirm or confute our precon- morally right and wrong actions and morally ceived notions; they may take us far or not far good and bad persons or character. Whether we enough. But, as the following pages will show, like it or not, we seem confronted continually the trail has more light than shadow—​ and with the necessity to deliberate about right and thinking critically and carefully about the prob- wrong, to judge someone morally good or bad, lems can help us see our way forward. to agree or disagree with the moral pronounce- ments of others, to accept or reject the moral ethics and bioethics outlook of our culture or community, and even to doubt or affirm the existence or nature Morality is about people’s moral judgments, of moral concepts themselves. Moral issues are principles, rules, standards, and theories—​a ll of thus inescapable—​including (or especially) those which help direct conduct, mark out moral prac­ that are the focus of bioethics. In the twenty-first tices, and provide the yardsticks for measuring century, few can remain entirely untouched by moral worth. We use morality to refer gener- the pressing moral questions of fair distribution ally to these aspects of our lives (as in “Morality of health care resources, abortion and infanti- is essential”) or more specifically to the beliefs cide, euthanasia and assisted suicide, exploitative or practices of particular groups or persons (as research on children and populations in devel- in “American morality” or “Kant’s morality”). oping countries, human cloning and genetic en- Moral, of course, pertains to morality as just gineering, assisted reproduction and surrogate ­defined, though it is also sometimes employed parenting, prevention and treatment of HIV/ as a synonym for right or good, just as immoral AIDS, the confidentiality and consent of patients, is often meant to be equivalent to wrong or bad. the refusal of medical treatment on religious Ethics, as used in this text, is not synonymous with grounds, experimentation on human embryos morality. Ethics is the study of morality using the and fetuses, and the just allocation of scarce life- tools and methods of philosophy. Philosophy is saving organs. a discipline that systematically examines life’s 3 vau03268_ch01_001-033.indd 3 05/02/19 07:36 PM 4 PA R T 1: P R I N C I P L E S A N D T H E O R I E S big questions through critical reasoning, logical some or all of these as proper guides for our ac- argument, and careful reflection. Thus ethics—​ tions and judgments. In normative ethics, we also known as moral philosophy—​is a reasoned ask questions like these: What moral principles, way of delving into the meaning and import of if any, should inform our moral judgments? moral concepts and issues and of evaluating the What role should virtues play in our lives? Is the merits of moral judgments and standards. (As principle of autonomy justified? Are there any with morality and moral, we may use ethics to exceptions to the moral principle of “do not say such things as “Kant’s ethics” or may use kill”? How should we resolve conflicts between ethical or unethical to mean right or wrong, moral norms? Is contractarianism a good moral good or bad.) Ethics seeks to know whether an theory? Is utilitarianism a better theory? action is right or wrong, what moral standards A branch that deals with much deeper ethical should guide our conduct, whether moral prin- issues is metaethics. Metaethics is the study of ciples can be justified, what moral virtues are the meaning and justification of basic moral be- worth cultivating and why, what ultimate ends liefs. In normative ethics we might ask whether people should pursue in life, whether there are an action is right or whether a person is good, good reasons for accepting a particular moral but in metaethics we would more likely ask what theory, and what the meaning is of such notions it means for an action to be right or for a person as right, wrong, good, and bad. Whenever we try to be good. For example, does right mean has the to reason carefully about such things, we enter best consequences, or produces the most happi- the realm of ethics: We do ethics. ness, or commanded by God? It is the business of Science offers another way to study morality, metaethics to explore these and other equally and we must carefully distinguish this approach fundamental questions: What, if anything, is from that of moral philosophy. Descriptive the difference between moral and nonmoral be- ethics is the study of morality using the meth- liefs? Are there such things as moral facts? If so, odology of science. Its purpose is to investigate what sort of things are they, and how can they the empirical facts of morality—​the actual be- be known? Can moral statements be true or liefs, behaviors, and practices that constitute false—​or are they just expressions of emotions people’s moral experience. Those who carry out or attitudes without any truth value? Can moral these inquiries (usually anthropologists, sociol- norms be justified or proven? ogists, historians, and psychologists) want to The third main branch is applied ethics, the know, among other things, what moral beliefs a use of moral norms and concepts to resolve person or group has, what caused the subjects to practical moral issues. Here, the usual challenge have them, and how the beliefs influence behav- is to employ moral principles, theories, argu- ior or social interaction. Very generally, the dif- ments, or analyses to try to answer moral ques- ference between ethics and descriptive ethics is tions that confront people every day. Many such this: In ethics we ask, as Socrates did, How ought questions relate to a particular professional field we to live? In descriptive ethics we ask, How do such as law, business, or journalism, so we have we in fact live? specialized subfields of applied ethics like legal Ethics is a big subject, so we should not be ethics, business ethics, and journalistic ethics. surprised that it has three main branches, each Probably the largest and most energetic subfield dealing with more or less separate but related is bioethics. sets of ethical questions. Normative ethics is the Bioethics is applied ethics focused on health search for, and justification of, moral standards, care, medical science, and medical technology. or norms. Most often the standards are moral (Biomedical ethics is often used as a synonym, principles, rules, virtues, and theories, and the and medical ethics is a related but narrower term lofty aim of this branch is to establish rationally used most often to refer to ethical problems in vau03268_ch01_001-033.indd 4 05/02/19 07:36 PM  Chapter 1: Moral Reasoning in Bioethics 5 medical practice.) Ranging far and wide, bio- about art; norms of etiquette about polite social ethics seeks answers to a vast array of tough behavior; grammatical norms about correct use ethical questions: Is abortion ever morally per- of language; prudential norms about what is in missible? Is a woman justified in having an abor- one’s interests; and legal norms about lawful and tion if prenatal genetic testing reveals that her unlawful acts. But moral norms differ from these fetus has a developmental defect? Should people nonmoral kinds. Some of the features they are be allowed to select embryos by the embryos’ sex thought to possess include the following. or other genetic characteristics? Should human embryos be used in medical research? Should Normative Dominance. In our moral practice, human cloning be prohibited? Should physicians, moral norms are presumed to dominate other nurses, physicians’ assistants, and other health kinds of norms, to take precedence over them. care professionals always be truthful with patients Philosophers call this characteristic of moral whatever the consequences? Should severely im- norms overridingness because moral consider- paired newborns be given life-prolonging treat- ations so often seem to override other factors. ment or be allowed to die? Should people in A maxim of prudence, for example, may suggest persistent vegetative states be removed from life that you should steal if you can avoid getting support? Should physicians help terminally ill caught, but a moral prohibition against stealing ­patients commit suicide? Is it morally right to con­ would overrule such a principle. An aesthetic (or duct medical research on patients without their pragmatic) norm implying that homeless people consent if the research would save lives? Should should be thrown in jail for blocking the view of human stem-cell research be banned? How a beautiful public mural would have to yield to should we decide who gets life-saving organ trans­ moral principles demanding more humane treat- plants when usable organs are scarce and many ment of the homeless. A law mandating brutal patients who do not get transplants will die? actions against a minority group would conflict Should animals be used in biomedical research? with moral principles of justice and would there- The ethical and technical scope of bioethics is fore be deemed illegitimate. We usually think wide. Bioethical questions and deliberations that immoral laws are defective, that they need to now fall to nonexpert and expert alike—​to pa- be changed, or that, in rare cases, they should be tients, families, and others as well as to philoso- defied through acts of civil disobedience. phers, health care professionals, lawyers, judges, scientists, clergy, and public policy specialists. Universality. Moral norms (but not exclusively Though the heart of bioethics is moral philoso- moral norms) have universality: Moral princi- phy, fully informed bioethics cannot be done ples or judgments apply in all relevantly similar without a good understanding of the relevant situations. If it is wrong for you to tell a lie in nonmoral facts and issues, especially the medi- a particular circumstance, then it is wrong for cal, scientific, technological, and legal ones. everyone in relevantly similar circumstances to tell a lie. Logic demands this sort of consistency. It makes no sense to say that Maria’s doing ethics and the moral life action A in circumstances C is morally wrong, Morality then is a normative, or evaluative, enter- but John’s doing A in circumstances relevantly prise. It concerns moral norms or standards that similar to C is morally right. Universality, how- help us decide the rightness of actions, judge the ever, is not unique to moral norms; it’s a charac- goodness of persons or character, and prescribe the teristic of all normative spheres. form of moral conduct. There are, of course, other sorts of norms we apply in life—​nonmoral norms. Impartiality. Implicit in moral norms is the Aesthetic norms help us make value judg­ments notion of impartiality—​the idea that everyone vau03268_ch01_001-033.indd 5 05/02/19 07:36 PM 6 PA R T 1: P R I N C I P L E S A N D T H E O R I E S should be considered equal, that everyone’s inter- the moral life—​is to do moral reasoning. If our ests should count the same. From the perspective moral judgments are to have any weight at all, if of morality, no person is any better than any they are to be anything more than mere per- other. Everyone should be treated the same unless sonal taste or knee-jerk emotional response, there is a morally relevant difference between they must be backed by the best of reasons. They persons. We probably would be completely baf- must be the result of careful reflection in which fled if someone seriously said something like we arrive at good reasons for accepting them, “murder is wrong... except when committed by reasons that could be acknowledged as such by myself,” when there was no morally relevant dif- any other reasoning persons. ference between that person and the rest of the Both logic and our commonsense moral ex- world. If we took such a statement seriously at all, perience demand that the thorough sifting of we would likely not only reject it but also would reasons constitutes the main work of our moral not even consider it a bona fide moral statement. deliberations—​regardless of our particular moral The requirement of moral impartiality pro- outlook or theory. We would think it odd, per- hibits discrimination against people merely be- haps even perverse, if someone asserted that cause they are different—​different in ways that physician-assisted suicide is always morally are not morally relevant. Two people can be dif- wrong—​and then said she has no reasons at all for ferent in many ways: skin color, weight, gender, believing such a judgment but just does. What- income, age, occupation, and so forth. But these ever our views on physician-assisted suicide, we are not differences relevant to the way they would be justified in ignoring her judgment, for should be treated as persons. On the other hand, we would have no way to distinguish it from if there are morally relevant differences between personal whim or wishful thinking. Likewise she people, then we may have good reasons to treat herself (if she genuinely had no good reasons for them differently, and this treatment would not her assertion) would be in the same boat, adrift be a violation of impartiality. This is how phi- with a firm opinion moored to nothing solid. losopher James Rachels explains the point: Our feelings, of course, are also part of our moral experience. When we ponder a moral The requirement of impartiality, then, is at issue we care about (abortion, for example), we bottom nothing more than a proscription against may feel anger, sadness, disgust, fear, irritation, arbitrariness in dealing with people. It is a rule or sympathy. Such strong emotions are normal that forbids us from treating one person differ- and often useful, helping us empathize with ently from another when there is no good reason others, deepening our understanding of human to do so. But if this explains what is wrong with suffering, and sharpening our insight into the racism, it also explains why, in some special consequences of our moral decisions. But our kinds of cases, it is not racist to treat people dif- feelings can mislead us by reflecting not moral ferently. Suppose a film director was making a truth but our own psychological needs, our own movie about the life of Martin Luther King, Jr. personal or cultural biases, or our concern for He would have a perfectly good reason for ruling personal advantage. Throughout history, some out Tom Cruise for the starring role. Obviously, people’s feelings led them to conclude that such casting would make no sense. Because there women should be burned for witchcraft, that would be a good reason for it, the director’s “dis- whole races should be exterminated, that black crimination” would not be arbitrary and so men should be lynched, and that adherents of a would not be open to criticism.1 different religion were evil. Critical reasoning can help restrain such terrible impulses. It can Reasonableness. To participate in morality—​to help us put our feelings in proper perspective engage in the essential, unavoidable practices of and achieve a measure of impartiality. Most of vau03268_ch01_001-033.indd 6 05/02/19 07:36 PM  Chapter 1: Moral Reasoning in Bioethics 7 or economic. Thus murder and embezzlement are I N D E P TH both immoral and illegal, backed by social disapproval and severe sanctions imposed by law. Controversy MORALITY AND THE LAW often arises when an action is not obviously or seri- ously harmful but is considered immoral by some who want the practice prohibited by law. The conten- Some people confuse morality with the law, or iden- tious notion at work is that something may be made tify the one with the other, but the two are distinct illegal solely on the grounds that it is immoral, re- though they may often coincide. Laws are norms gardless of any physical or economic harm involved. enacted or enforced by the state to protect or pro- This view of the law is known as legal moralism, and mote the public good. They specify which actions it sometimes underlies debates about the legalization are legally right or wrong. But these same actions of abortion, euthanasia, reproductive technology, can also be judged morally right or wrong, and these con­traception, and other practices. two kinds of judgments will not necessarily agree. Many issues in bioethics have both a moral and Lying to a friend about a personal matter, deliberately legal dimension, and it is important not to confuse trying to destroy yourself through reckless living, or the two. Sometimes the question at hand is a moral failing to save a drowning child (when you easily one (whether, for example, euthanasia is ever morally could have) may be immoral—​but not illegal. Racial permissible); whether a practice should be legal or bias, discrimination based on gender or sexual orien- illegal then is beside the point. Sometimes the ques- tation, slavery, spousal rape, and unequal treatment tion is about legality. And sometimes the discussion of minority groups are immoral—​but, depending on concerns both. A person may consider physician- the society, they may not be illegal. assisted suicide morally acceptable but argue that it Much of the time, however, morality and the law should nevertheless be illegal because allowing the overlap. Often what is immoral also turns out to be practice to become widespread would harm both illegal. This is usually the case when immoral actions patients and the medical profession. cause substantial harm to others, whether physical all, it can guide us to moral judgments that are purports to explain right actions, or make judg- trustworthy because they are supported by the ments about right or wrong actions. best of reasons. Moral values, on the other hand, generally The moral life, then, is about grappling with a concern those things that we judge to be morally distinctive class of norms marked by normative good, bad, praiseworthy, or blameworthy. Nor- dominance, universality, impartiality, and rea- mally we use such words to describe persons (as sonableness. As we saw earlier, these norms can in “He is a good person” or “She is to blame for include moral principles, rules, theories, and hurting them”), their character (“He is virtu- judgments. We should notice that we commonly ous”; “She is honest”), or their motives (“She did apply these norms to two distinct spheres of our wrong but did not mean to”). Note that we also moral experience—​ to both moral obligations attribute nonmoral value to things. If we say that and moral values. a book or bicycle or vacation is good, we mean Moral obligations concern our duty, what we good in a nonmoral sense. Such things in them- are obligated to do. That is, obligations are about selves cannot have moral value. conduct, how we ought or ought not to behave. Strictly speaking, only actions are morally In this sphere, we talk primarily about actions. right or wrong, but persons are morally good or We may look to moral principles or rules to bad (or some degree of goodness or badness). guide our actions, or study a moral theory that With this distinction we can acknowledge a vau03268_ch01_001-033.indd 7 05/02/19 07:36 PM 8 PA R T 1: P R I N C I P L E S A N D T H E O R I E S simple fact of the moral life: A good person can We can see appeals to moral principles in do something wrong, and a bad person can do countless cases. Confronted by a pain-racked, something right. A Gandhi can tell a lie, and a terminally ill patient who demands to have his Hitler can save a drowning man. life ended, his physician refuses to comply, rely- In addition, we may judge an action right or ing on the principle that “it is wrong to inten- wrong depending on the motive behind it. If tionally take a life.” Another physician makes a John knocks a stranger down in the street to pre- different choice in similar circumstances, insist- vent her from being hit by a car, we would deem ing that the relevant principle is “ending the suf- his action right (and might judge him a good fering of a hopelessly ill patient is morally person). But if he knocks her down because he permissible.” An infant is born anencephalic dislikes the color of her skin, we would believe (without a brain); it will never have a conscious his action wrong (and likely think him evil). life and will die in a few days. The parents decide The general meaning of right and wrong seems to donate the infant’s organs to other children clear to just about everyone. But we should be so they might live, which involves taking the careful to differentiate degrees of meaning in organs right away before they deteriorate. A these moral terms. Right can mean either “obliga- critic of the parents’ decision argues that “it is tory” or “permissible.” An obligatory action is one unethical to kill in order to save.” But someone that would be wrong not to perform. We are obli- else appeals to the principle “save as many chil- gated or required to do it. A permissible action is dren as possible.”2 In such ways moral principles one that is permitted. It is not wrong to perform it. help guide our actions and inform our judg- Wrong means “prohibited.” A prohibited action is ments about right and wrong, good and evil. one that would be wrong to perform. We are obli- As discussed in Chapter 2, moral principles gated or required not to do it. A supererogatory are often drawn from a moral theory, which is a action is one that is “above and beyond” our duty. moral standard on the most general level. The It is praiseworthy—​a good thing to do—​but not principles are derived from or supported by the required. Giving all your possessions to the poor theory. Many times we simply appeal directly to is generally considered a supererogatory act. a plausible moral principle without thinking much about its theoretical underpinnings. Philosophers make a distinction between ab- moral principles in bioethics solute and prima facie principles (or duties). An As noted earlier, the main work of bioethics is absolute principle applies without exceptions. trying to solve bioethical problems using the An absolute principle that we should not lie de- potent resources and methods of moral phi- mands that we never lie regardless of the cir- losophy, which include, at a minimum, critical cumstances or the consequences. In contrast, a ­reasoning, logical argument, and conceptual prima facie principle applies in all cases unless analysis. Many, perhaps most, moral philoso- an exception is warranted. Exceptions are justi- phers would be quick to point out that beyond fied when the principle conflicts with other these tools of reason we also have the consider- principles and is thereby overridden. W. D. Ross able help of moral principles. (The same could be is given credit for drawing this distinction in his said about moral theories, which we explore in 1930 book The Right and the Good.3 It is essen- the next chapter.) Certainly to be useful, moral tial to his account of ethics, which has a core of principles must be interpreted, often filled out several moral principles or duties, any of which with specifics, and balanced with other moral might come into conflict. concerns. But both in everyday life and in bio- Physicians have a prima facie duty to be truth­ ethics, moral principles are widely thought to be ful to their patients as well as a prima facie duty indispensable to moral decision-making. to promote their welfare. But if these duties come vau03268_ch01_001-033.indd 8 05/02/19 07:36 PM  Chapter 1: Moral Reasoning in Bioethics 9 in conflict—​if, for example, telling a patient the their consent, treating competent patients against truth about his condition would somehow result their will, physically restraining or confining pa- in his death—​a physician might decide that the tients for no medical reason—​such practices con- duty of truthfulness should yield to the weight- stitute obvious violations of personal autonomy. ier duty to do good for the patient. Not all restrictions on autonomy, however, Moral principles are many and varied, but in are of the physical kind. Autonomy involves the bioethics the following have traditionally been capacity to make personal choices, but choices extremely influential and particularly relevant cannot be considered entirely autonomous unless to the kinds of moral issues that arise in health they are fully informed. When we make decisions care, medical research, and biotechnology. In in ignorance—​without relevant information or fact, many—​perhaps most—​of the thorniest issues blinded by misinformation—​our autonomy is in bioethics arise from conflicts among these diminished just as surely as if someone physi- basic principles. In one formulation or another, cally manipulated us. If this is correct, then we each one has been integral to major moral have a plausible explanation of why lying is theories, providing evidence that the principles generally prohibited: Lying is wrong because it capture something essential in our moral expe- undermines personal autonomy. Enshrined in rience. The principles are (1) autonomy, (2) non­ bioethics and in the law, then, is the precept of maleficence, (3) beneficence, (4) utility, and informed consent, which demands that patients (5) justice.4 be allowed to freely consent to or decline treat- ments and that they receive the information they Autonomy need to make informed judgments about them. Autonomy refers to a person’s rational capacity In many ways, autonomy is a delicate thing, for self-governance or self-determination—​ the easily compromised and readily thwarted. Often ability to direct one’s own life and choose for a person’s autonomy is severely undermined not ­oneself. The principle of autonomy insists on full by other people but by nature, nurture, or his or ­respect for autonomy. One way to express the prin- her own actions. Some drug addicts and alcohol- ciple is: Autonomous persons should be allowed ics, people with serious psychiatric illness, and to exercise their capacity for self-determination. those with severe mental impairment are thought According to one major ethical tradition, autono- to have drastically diminished autonomy (or to mous persons have intrinsic worth precisely be essentially nonautonomous). Bioethical ques- because they have the power to make rational tions then arise about what is permissible to do decisions and moral choices. They therefore must to them and who will represent their interests or be treated with respect, which means not violating make decisions regarding their care. Infants and their autonomy by ignoring or thwarting their children are also not fully autonomous, and the ability to choose their own paths and make their same sorts of questions are forced on parents, own judgments. guardians, and health care workers. The principle of respect for autonomy places Like all the other major principles discussed severe restraints on what can be done to an here, respect for autonomy is thought to be autonomous person. There are exceptions, but in prima facie. It can sometimes be overridden by general we are not permitted to violate people’s considerations that seem more important or autonomy just because we disagree with their compelling—​ considerations that philosophers decisions, or because society might benefit, or and other thinkers have formulated as princi- because the violation is for their own good. We ples of autonomy restriction. The principles are cannot legitimately impair someone’s autonomy articulated in various ways, are applied widely without strong justification for doing so. Con- to all sorts of social and moral issues, and are ducting medical experiments on patients without themselves the subject of debate. Chief among vau03268_ch01_001-033.indd 9 05/02/19 07:36 PM 10 PA R T 1: P R I N C I P L E S A N D T H E O R I E S these is the harm principle: a person’s autonomy A health care professional violates this prin- may be curtailed to prevent harm to others. To ciple if he or she deliberately performs an action prevent people from being victimized by thieves that harms or injures a patient. If a physician and murderers, we have a justice system that intentionally administers a drug that she knows prosecutes and imprisons the perpetrators. To will induce a heart attack in a patient, she obvi- discourage hospitals and health care workers ously violates the principle—she clearly does from hurting patients through carelessness or something that is morally (and legally) wrong. fraud, laws and regulations limit what they can But she also violates it if she injures a patient do to people in their care. To stop someone from through recklessness, negligence, or inexcusable spreading a deadly, contagious disease, health ignorance. She may not intend to hurt anyone, officials may quarantine him against his will. but she is guilty of the violation just the same. Another principle of autonomy restriction is Implicit in the principle of nonmaleficence is paternalism. Paternalism is the overriding of a the notion that health professionals must exer- person’s actions or decision-making for her own cise “due care.” The possibility of causing some good. Some cases of paternalism (sometimes pain, suffering, or injury is inherent in the care called weak paternalism) seem permissible to and treatment of patients, so we cannot realisti- many people—​when, for example, seriously de- cally expect health professionals never to harm pressed or psychotic patients are temporarily anyone. But we do expect them to use due care— restrained to prevent them from injuring or kill- to act reasonably and responsibly to minimize ing themselves. Other cases are more controver- the harm or the chances of causing harm. If a sial. Researchers hoping to develop a life-saving physician must cause patients some harm to treatment give an experimental drug to some- effect a cure, we expect her to try to produce the one without his knowledge or consent. Or a least amount of harm possible to achieve the re- physician tries to spare the feelings of a compe- sults. And even if her treatments cause no actual tent, terminally ill patient by telling her that she pain or injury in a particular instance, we expect will eventually get better, even though she in- her not to use treatments that have a higher sists on being told the truth. The paternalism in chance of causing harm than necessary. By the such scenarios (known as strong paternalism) is lights of the nonmaleficence principle, subjecting usually thought to be morally objectionable. patients to unnecessary risks is wrong even if no Many controversies in bioethics center on the damage is done. morality of strong paternalism. Beneficence Nonmaleficence The principle of beneficence has seemed to many The principle of nonmaleficence asks us not to to constitute the very soul of morality—​or very intentionally or unintentionally inflict harm on close to it. In its most general form, it says that others. In bioethics, nonmaleficence is the most we should do good to others. (Benevolence is dif- widely recognized moral principle. Its aphoris- ferent, referring more to an attitude of goodwill tic expression has been embraced by practitio- toward others than to a principle of right action.) ners of medicine for centuries: “Above all, do no Beneficence enjoins us to advance the welfare of harm.” A more precise formulation of the prin- others and prevent or remove harm to them. ciple is: We should not cause unnecessary injury Beneficence demands that we do more than or harm to those in our care. In whatever form, just avoid inflicting pain and suffering. It says nonmaleficence is the bedrock precept of count- that we should actively promote the well-being of less codes of professional conduct, institutional others and prevent or remove harm to them. In regulations, and governmental rules and laws bioethics, there is little doubt that physicians, designed to protect the welfare of patients. nurses, researchers, and other professionals have vau03268_ch01_001-033.indd 10 05/02/19 07:36 PM  Chapter 1: Moral Reasoning in Bioethics 11 such a duty. After all, helping others, promoting possible benefits of the treatment outweigh its their good, is a large part of what these profes- risks by an acceptable margin. Suppose a man’s sionals are obliged to do. clogged artery can be successfully treated with But not everyone thinks that we all have a open-heart surgery, a procedure that carries a duty of active beneficence. Some argue that considerable risk of injury and death. But imag- though there is a general (applicable to all) duty ine that the artery can also be successfully not to harm others, there is no general duty to opened with a regimen of cholesterol-lowering help others. They say we are not obligated to aid drugs and a low-fat diet, both of which have a the poor, feed the hungry, or tend to the sick. much lower chance of serious complications. Such acts are not required, but are supererogatory, The principle of utility seems to suggest that the beyond the call of duty. Others contend that latter course is best and that the former is mor- though we do not have a general duty of active ally impermissible. beneficence, we are at least sometimes obligated The principle also plays a major role in the to look to the welfare of people we care about creation and evaluation of the health policies of most—​such as our parents, children, spouses, institutions and society. In these large arenas, and friends. In any case, it is clear that in cer- most people aspire to fulfill the requirements of tain professions—​particularly medicine, law, and beneficence and maleficence, but they recognize nursing—​benefiting others is often not just that perfect beneficence or maleficence is im- supererogatory but obligatory and basic. possible: Trade-offs and compromises must be made, scarce resources must be allotted, help and Utility harm must be balanced, life and death must be The principle of utility says that we should pro- weighed—​tasks almost always informed by the duce the most favorable balance of good over bad principle of utility. (or benefit over harm) for all concerned. The prin- Suppose, for example, we want to mandate ciple acknowledges that in the real world, we the immunization of all schoolchildren to pre- cannot always just benefit others or just avoid vent the spread of deadly communicable dis- harming them. Often we cannot do good for eases. The cost in time and money will be great, people without also bringing them some harm, but such a program could save many lives. or we cannot help everyone who needs to be There is a down side, however: A small number helped, or we cannot help some without also of children—​perhaps as many as 2 for every hurting or neglecting others. In such situations, 400,000 immunizations—​w ill die because of a the principle says, we should do what yields the rare allergic reaction to the vaccine. It is impos- best overall outcome—​the maximum good and sible to predict who will have such a reaction minimum evil, everyone considered. The utility (and impossible to prevent it), but it is almost principle, then, is a supplement to, not a substi- certain to occur in a few cases. If our goal is social tute for, the principles of autonomy, beneficence, beneficence, what should we do? Children are and justice. likely to die whether we institute the program In ethics this maxim comes into play in sev- or not. Guided by the principle of utility (as well eral ways. Most famously it is the defining pre- as other principles), we may decide to proceed cept of the moral theory known as utilitarianism with the program since many more lives would (discussed in Chapter 2). But it is also a stand- likely be saved by it than lost because of its alone moral principle applied everywhere in implementation. bio­ethics to help resolve the kind of dilemmas Again, suppose governmental health agencies just mentioned. A physician, for example, must have enough knowledge and resources to de- decide whether a treatment is right for a patient, velop fully a cure for only one disease—​either a and that decision often hinges on whether the rare heart disorder or a common form of skin vau03268_ch01_001-033.indd 11 05/02/19 07:36 PM 12 PA R T 1: P R I N C I P L E S A N D T H E O R I E S cancer. Trying to split resources between these justify the properties, or traits, of just distribu- two is sure to prevent development of any cure tions. A basic precept of most of these theories is at all. The heart disorder kills 200 adults each what may plausibly be regarded as the core of year; the cancer occurs in thousands of people, the principle of justice: Equals should be treated causing them great pain and distress, but is equally. (Recall that this is one of the defining rarely fatal. How best to maximize the good? On elements of ethics itself, impartiality.) The idea which disease should the government spend its is that people should be treated the same unless time and treasure? Answering this question there is a morally relevant reason for treating (and others like it) requires trying to apply the them differently. We would think it unjust for utility principle—​a job often involving complex a physician or nurse to treat his white diabetic calculations of costs and benefits and frequently patients more carefully than he does his black generating controversy. diabetic patients—​and to do so without a sound medical reason. We would think it unfair to Justice award the only available kidney to the trans- In its broadest sense, justice refers to people get- plant candidate who belongs to the “right” po- ting what is fair or what is their due. In practice, litical party or has the best personal relationship most of us seem to have a rough idea of what with hospital administrators. justice entails in many situations, even if we The principle of justice has been at the heart cannot articulate exactly what it is. We know, of debates about just distribution of benefits and for example, that it is unjust for a bus driver to burdens (including health care) for society as a make a woman sit in the back of the bus because whole. The disagreements have generally not been of her religious beliefs, or for a judicial system to about the legitimacy of the principle, but about arbitrarily treat one group of citizens more how it should be interpreted. Different theories harshly than others, or for a doctor to care for of justice try to explain in what respects equals some patients but refuse to treat others just be- should be treated equally. cause he dislikes them. Libertarian theories emphasize personal free- Questions of justice arise in different spheres doms and the right to pursue one’s own social of human endeavor. Retributive justice, for ex- and economic well-being in a free market with- ample, concerns the fair meting out of punish- out interference from others. Ideally the role ment for wrongdoing. On this matter, some of government is limited to night-watchman argue that justice is served only when people are functions—​ the protection of society and free punished for past wrongs, when they get their economic systems from coercion and fraud. All just deserts. Others insist that justice demands other social or economic benefits are the respon- that people be punished not because they de- sibility of individuals. Government should not serve punishment, but because the punishment be in the business of helping the socially or eco- will deter further unacceptable behavior. Dis- nomically disadvantaged, for that would require tributive justice concerns the fair distribution violating people’s liberty by taking resources of society’s advantages and disadvantages—​for from the haves to give to the have-nots. So uni- example, jobs, income, welfare aid, health care, versal health care is out of the question. For the rights, taxes, and public service. Distributive jus- libertarian, then, people have equal intrinsic tice is a major issue in bioethics, where many of worth, but this does not entitle them to an equal the most intensely debated questions are about distribution of economic advantages. Individu- who gets health care, what or how much they als are entitled only to what they can acquire should get, and who should pay for it. through their own hard work and ingenuity. Distributive justice is a vast topic, and many Egalitarian theories maintain that a just dis- theories have been proposed to identify and tribution is an equal distribution. Ideally, social vau03268_ch01_001-033.indd 12 05/02/19 07:36 PM  Chapter 1: Moral Reasoning in Bioethics 13 benefits—​whether jobs, food, health care, or But moral objectivism is directly challenged some­thing else—​should be allotted so that every- by a doctrine that some find extremely appeal- one has an equal share. Treating people equally ing and that, if true, would undermine ethics means making sure everyone has equal access to itself: ethical relativism. According to this view, certain minimal goods and services. To achieve moral standards are not objective but are rela- this level of equality, individual liberties will tive to what individuals or cultures believe. have to be restricted, measures that libertari- There simply are no objective moral truths, only ans would never countenance. In a pure egali- relative ones. An action is morally right if en- tarian society, universal health care would be dorsed by a person or culture and morally wrong guaranteed. if condemned by a person or culture. So eutha- Between strict libertarian and egalitarian views nasia is right for person A if he approves of it but of justice lie some theories that try to achieve a wrong for person B if she disapproves of it, and plausible fusion of both perspectives. With a the same would go for cultures with similarly nod toward libertarianism, these theories may diverging views on the subject. In this way, moral exhibit a healthy respect for individual liberty norms are not discovered but made; the indi- and limit governmental interference in econo­ vidual or culture makes right and wrong. Ethi- mic enterprises. But leaning toward egalitarian- cal relativism pertaining to individuals is known ism, they may also mandate that the basic needs as subjective relativism, more precisely stated as of the least well-off citizens be met. the view that right actions are those sanctioned In bioethics, the principle of justice and the by a person. Ethical relativism regarding cultures theories used to explain it are constantly being is called cultural relativism, the view that right marshaled to support or reject health care poli- actions are those sanctioned by one’s culture. cies of all kinds. They are frequently used—​along In some ways, subjective relativism is a com- with other moral principles—​to evaluate, design, forting position. It relieves individuals of the and challenge a wide range of health care pro- burden of serious critical reasoning about mo- grams and strategies. They are, in other words, rality. After all, determining right and wrong is far from being merely academic. a matter of inventorying one’s beliefs, and any sincerely held beliefs will do. Morality is essen- tially a matter of personal taste, which is an ex- ethical relativism tremely easy thing to establish. Determining The commonsense view of morality and moral what one’s moral views are may indeed involve standards is this: There are moral norms or deliberation and analysis—but neither of these principles that are valid or true for everyone. is a necessary requirement for the job. Subjective This claim is known as moral objectivism, the relativism also helps people short-circuit the un- idea that at least some moral standards are ob- pleasantness of moral debate. The subjective jective. Moral objectivism, however, is distinct relativist’s familiar refrain—“That may be your from moral absolutism, the belief that objective truth, but it’s not my truth”—has a way of stop- moral principles allow no exceptions or must be ping conversations and putting an end to rea- applied the same way in all cases and cultures. A soned arguments. moral objectivist can be absolutist about moral The doctrine, however, is difficult to maintain principles, or she can avoid absolutism by ac- consistently. On issues that the relativist cares cepting that moral principles are prima facie. In little about (the moral rightness of gambling, any case, most people probably assume some say), she may be content to point out that moral form of moral objectivism and would not take norms are relative to each individual and that seriously any claim implying that valid moral “to each his own.” But on more momentous norms can be whatever we want them to be. topics (such as genocide in Africa or the Middle vau03268_ch01_001-033.indd 13 05/02/19 07:36 PM 14 PA R T 1: P R I N C I P L E S A N D T H E O R I E S is a promise to commit a crime.... It has been I N D E P TH customary to hold that diverse evaluations of the same act are automatic evidence for the ANTHROPOLOGY presence of different principles of evaluation. AND MORAL DIVERSITY The preceding examples point to an error in this interpretation. Indeed, an examination of the relational factors points to the operation of Many moral philosophers have been quick to point constant principles in situations that differ in out that differences in moral judgments from culture concrete details.... Anthropological evidence to culture do not in themselves prove a difference in does not furnish proof of relativism. We do not moral standards. Some anthropologists have made know of societies in which bravery is despised the same argument. Solomon Asch, for example, says, and cowardice held up to honor, in which We consider it wrong to take food away from a ­generosity is considered a vice and ingratitude hungry child, but not if he is overeating. We a virtue. It seems rather that the relations consider it right to fulfill a promise, but not if it ­between valuation and meaning are invariant. 5 East), she may slip back into objectivism and of killing millions of Jews during World War II. declare that genocide is morally wrong—​not Suppose American serial killer and cannibal just wrong for her but wrong period. Jeffrey Dahmer approved of his murdering Such inconsistencies hint that there may be 17 men and boys. Then by the lights of subjec- something amiss with subjective relativism, and tive relativism, all these mass killings were mor- indeed there is: It seems to conflict violently with ally right because their perpetrators deemed them commonsense realities of the moral life. For one so. But we would find this conclusion almost thing, the doctrine implies that each person is impossible to swallow. We would think these morally infallible. An action is morally right actions morally wrong whether the killers ap- for someone if he approves of it—​if he sincerely proved of their own actions or not. believes it to be right. His approval makes the Subjective relativism also implies that an- action right, and—​if his approval is genuine—​ other commonplace of the moral life is an illu- he cannot be mistaken. His believing it to be sion: moral disagreement. Consider: Hernando right makes it right, and that’s the end of it. If he tells Sophia that allowing seriously impaired endorses infanticide as a method of population infants to die is morally right. Sophia replies control, then infanticide is morally permissible. that allowing seriously impaired infants to die is His sincere approval settles the issue, and he morally wrong. We may think that Hernando cannot be in error. But our commonsense moral and Sophia are having a straightforward dis- experience suggests that this relativist account is agreement over an important moral issue. But absurd. Our judgments about moral matters—​ according to subjective relativism, no such dis- actions, principles, and people—​are often wide agreement is happening or could ever happen. of the mark. We are morally fallible, and we are In stating his approval of the actions in ques- rightly suspicious of anyone who claims to be tion, Hernando is essentially expressing his per- otherwise. sonal taste on the issue, and Sophia is expressing There is a more disturbing way to frame this her personal taste. He is saying he likes some- point. Suppose former Iraqi leader Saddam thing; she says she does not like it—​and they Hussein approved of slaughtering thousands of could both be correct. Subjective relativism im- Iraqis during his reign. Suppose Hitler approved plies that they are not uttering conflicting claims vau03268_ch01_001-033.indd 14 05/02/19 07:36 PM  Chapter 1: Moral Reason