edited by Tuija Takala and Matti Häyry, welcomes contributions on the conceptual and theoretical dimensions of bioethics.

ABSTRACT The paper explores the ethical aspects of introducing cultural circumcision of children into the EU public health system. We reject commonplace arguments against circumcision: considerations of good medical practice, justice, bodily integrity, autonomy and the analogy from female genital mutilation. From the unique structure of patient‐medicine interaction, we argue that the incorporation of cultural circumcision into EU public health services is a kind of medicalization, which does not fit the ethos of universal healthcare. However, we support a utilitarian argument (...) that finds hospital‐based circumcision safer than non‐medicalized alternatives. The argument concerning medicalization and the utilitarian argument both rely on preliminary empirical data, which depend on future validation. (shrink)

Following a discussion of some historical roots of conscience, we offer a systematized version of reflective equilibrium. Aiming at a comprehensive methodology for bioethical deliberation, we develop an expanded variant of reflective equilibrium, which we call ‘triangular reflective equilibrium’ and which incorporates insights from hermeneutics, critical theory and narrative ethics.We focus on a few distinctions, mainly between methods of justification in ethics and the social practice of bioethical deliberation, between coherence in ethical reasoning, personal integrity and consensus formation, and between (...) political and moral deliberation.The ideal of deliberation is explicated as a sharing of conscience within a special commitment to sincerity and openness to persuasion. Personal growth in wisdom is an indirect by-product of the continuous practice of moral deliberation. This is explicated in the light of Sternberg's balance theory of wisdom and in the context of medicine as a profession embodying altruistic responsibilities of care in democratic and pluralistic societies. (shrink)

This article isolates ten prepositions, which constitute the undercurrent paradigm of contemporary discourse of health disease and medicine. Discussion of the interrelationship between those prepositions leads to a systematic refutation of this paradigm. An alternative set is being forwarded. The key notions of the existing paradigm are that health is the natural condition of humankind and that disease is a deviance from that nature. Natural things are harmonious and healthy while human made artifacts are coercive interference with natural balance. It (...) is suggested that the current paradigm is influenced by the world of finances and by instrumental reason. The alternative model suggests that human nature cannot be delineated. Humans fashion their own selves and nature by artificial means, medicine among them. The article discusses the implications of the paradigm adapted in various scholarly and popular debates such as the use of sex hormones for contraception, the care of the elderly, holistic medicine and distributive justice in health care. Medicine is not an isolated or a privileged realm. There is no unique entitlement to health care. It is always part of a broader agenda of social values and institutions. A open view of human societies, values and practices as they are situated within concrete material conditions is the platform required for an integrative and creative discourse of health care. (shrink)

The article calls for a departure from the common concept of autonomy in two significant ways: it argues for the supremacy of semantic understanding over procedure, and claims that clinicians are morally obliged to make a strong effort to persuade patients to accept medical advice. We interpret the value of autonomy as derived from the right persons have to respect, as agents who can argue, persuade and be persuaded in matters of utmost personal significance such as decisions about medical care. (...) Hence, autonomy should and could be respected only after such an attempt has been made. Understanding suffering to a significant degree is a prerequisite to sincere efforts of persuasion. It is claimed that a modified and pragmatic form of discourse is the necessary framework for understanding suffering and for compassionately interacting with the frail. (shrink)

This paper aims at explicating a theory of hope that is also suitable for gravely ill people and based on virtue ethics, research in the psychology of “well-being,” and the philosophy of palliative care. The working hypotheses of the theory are that hope is conditioned neither by past events nor by present needs, but is not necessarily oriented toward the future, especially the distant future; that hope is related to personal agency and to freedom; and that hope is deliberative, hence (...) evaluative, motivatory, and rationally critical. Following Higgins’ distinction between “prevention-focus” and “promotion-focus” strategies of coping, and Rawls’ notion of the “Aristotelian principle,” it is argued that hope is the valuation of and personal identification with “promotion-focus” goals with an attitude of nonattachment to any one goal. (shrink)

The article surveys and analyzes the roles in Judaism of the value of imago Dei/human dignity, especially in bioethical contexts. Two main topics are discussed. The first is a comparative analysis of imago Dei as an anthropological and ethical concept in Jewish and Western thought (Christianity and secular European values). The Jewish tradition highlights the human body and especially its procreative function and external appearance as central to imago Dei. The second is the role of imago Dei as a moral (...) value relative to others. In rabbinic Judaism, respect for human dignity is not the primary moral maxim; it is secondary to the value of neighborly love and sometimes to other moral laws and values. (shrink)

ABSTRACT Accepting the claim that the living have some moral duties with regard to dead bodies, this paper explores those duties and how they bear on the popular travelling exhibition Bodyworlds. I argue that the concept of informed consent presupposes substantial duties to the dead, namely duties that reckon with the meaning of the act in question. An attitude of respect and not regarding human remains as mere raw material are non‐alienable substantial duties. I found the ethos of Bodyworlds premature (...) but full of promises such as public attitudes to organ donations. At the practical level I conclude that Bodyworlds should use only willed donations or unclaimed bodies for which dignified funerals are not available. In the case of live donations, Bodyworlds has a duty to participate in the medical care of needy donors. However, secrecy with regard to the sources of cadavers seems to be the most troublesome aspect of Bodyworlds. (shrink)

: This paper examines the main Jewish sources relevant to end-of-life ethics, two Talmudic stories, the early modern code of law (Shulhan Aruch), and contemporary Halakhaic (religious law) responsa. Some Orthodox rabbis object to the use of artificial life support that prolongs the life of a dying patient and permit its active discontinuation when the patient is suffering. Other rabbis believe that every medical measure must be taken in order to prolong life. The context of the discussion is the recent (...) release of the "Steinberg Report," which proposes a law regulating end-of-life issues in Israel. It is argued that the Orthodox rabbis base their views on a strongly positivist concept of the religious law. The rabbis deliberate the law as a manifestation of the will of God and try to stretch the law as much as possible in order to benefit the patient, even when it is good for the patient to die. Direct and active actions that kill are prohibited; certain forms of passive euthanasia and contrivances that terminate life support without needing direct human action are accepted. (shrink)

Western culture has a few traditions of representing the human body – among them mortuary art (gisants), the freak show, the culture of the relics, renaissance art and pre-modern and modern anatomy. A historical analysis in the spirit of Norbert Elias is offered with regard to body – person relationship in anatomy. Modern anatomy is characterized by separating the story of the person from the story of the body, a strategy that is incompatible with the bio-psycho-social paradigm of clinical medicine. (...) The paper discusses different aspects of the above traditions and how they might bear on this conflict and on contemporary bioethics and bedside practice. (shrink)

In its first part, the paper explores the challenge of conceptualizing the Thomist theological virtue of hope in Aristotelian terms that are compatible with non-Thomist and even atheist metaphysics as well. I argue that the key concept in this endeavor is friendship—as an Aristotelian virtue, as relational value in Thomist theology, as a recognized value in supportive care and as a kind of ‘personal hope.’ Then, the paper proceeds to examine the possible differences between hope as a virtue and hope (...) as an experience reported by people, terminal patients in particular. With the clinical problem of hope at the end of life in mind, the paper concludes with two meta-ethical questions—about the overridingness of .. (shrink)

The article questions the assumption that conjoined twins are necessarily two people or persons by employing arguments based on different points of view: non-personal vitalism, the person as a sentient being, the person as an agent, the person as a locus of narrative and valuation, and the person as an embodied mind. Analogies employed from the cases of amputation, multiple personality disorder, abortion, split-brain patients and cloning. The article further questions the assumption that a conjoined twin's natural interest and wish (...) is separation. I first contend that separation is such a radical procedure as to render the post-separation person different from the pre-separation one. Therefore, it is not possible to benefit the pre-separation twin by the act of separation. The article concludes with a critical evaluation of the tendency in bioethics to regard ethical challenges as rivalry between individuals competing for scarce resources. (shrink)

Contrary to the common view, this paper suggests that the Hippocratic oath does not directly refer to the controversial subjects of euthanasia and abortion. We interpret the oath in the context of establishing trust in medicine through departure from Pantagruelism. Pantagruelism is coined after Rabelais' classic novel Gargantua and Pantagruel. His satire about a wonder herb, Pantagruelion, is actually a sophisticated model of anti-medicine in which absence of independent moral values and of properly conducted research fashion a flagrant over-medicalization of (...) human problems. Ultimately this undermines the therapeutic core of medicine itself. We contend that PAS is a case of such over-medicalization and that its institution creates medicophobia. This article does not express an opinion about euthanasia in general. Rather, we claim that physicians should learn from the oath and from Rabelais that they should keep their practice to medical care and not to exploit their expertise and social privileges for the sake of ulterior motives, even when their patients desire those goals. (shrink)

Rabbi HaCohen Kook’s essay on vegetarianism and peace, first published in instalments in 1903–4, and reissued 60 years later, is the only treatise in rabbinic Judaism on the relationship between humans and animals. It is here examined as central to his ethical beliefs. His writings, shaped by his background as rabbi and mystic, illuminate the history of environmental and applied ethics. A century ago, he perceived the main challenge that confronts reform movements: multiculturalism.

Utilitarianism focuses on the optimization of personal well being in ways that seems to make the practice of medicine irrelevant to the well being of the practitioners, unless given external incentives such as money or honor. Care based on indirect incentives is considered inferior to care motivated internally. This leads to the paradox of utilitarian care. Following Nozick's conceptual Pleasure Machine it is argued that in addition to the promotion of personal well being, people care about fulfilling their well being (...) in a world which is real, just, good, and beautiful. Complete mechanization of social and personal life in accordance with a strict utilitarian regime is also incompatible with the kind of world people desire, even if it promises more fulfillments in terms of personal well being. This explains the so-called Taurek-Parfit paradox, according to which sometimes ethics seems “to count the numbers” and sometimes not. The very pursuit of utilitarianism does not contribute to any personal life plan. The helping professions make the world a better place for us to live in, even though they do not necessarily bear directly on the well being of any individual other than the recipients of care. This resolves the paradox of utilitarian care. (shrink)

In refutation of hedonism, Nozick offered a hypothetical thought experiment, known as the Experience Machine. This paper maintains that end-of-life-suffering of the kind that is resistant to state-of-the-art palliation provides a conceptually equal experiment which validates Nozick’s observations and conclusions. The observation that very many terminal patients who suffer terribly do no wish for euthanasia or terminal sedation is incompatible with motivational hedonism. Although irreversible vegetative state and death are equivalently pain-free, very many people loath the former even at the (...) price of the latter. This attitude cannot be accounted for by hedonism. Following these observations, the goals of palliative care are sketched along four circles. The first is mere removal or mitigation of noxious symptoms and suffering. The second targets sufferings that stymie patients’ life-plans and do not allow them to be happy, the third targets sufferings that interfere with their pursuance of other goods (palliation as a primary good). The fourth is the control of sufferings that do not allow the person to benefit from any human good whatsoever (“total pain” or critical suffering). Only in the fourth circle are people hedonists. (shrink)

This paper discusses one of the most famous paintings on medical themes: The Doctor by Sir Luke Fildes (Fig. 1), which exemplifies how an ideal type of doctoring is construed from reality and from the views and expectations of both the public and doctors themselves. A close reading of The Doctor elucidates three fundamental conflicts in medicine: the first is between statistical efficiency in accordance with scales of morbidity and mortality and the personal devotion that every sick child or suffering (...) individual wants to receive; the second is between the doctor-dominated market and the patient-dominated market; and the third is between influential and rich doctors (“consultants”) and practitioners of family medicine (GPs).1 Fig. 1 Sir Luke Fildes, “The Doctor”, oil on canvas, 1891. With permission from The Tate Gallery, London. (shrink)