In the third and subsequent editions of Principles of Biomedical Ethics, Tom Beauchamp and James Childress articulate a series of ethical norms that they regard as “derived” from, and hence carrying, the “authority” of the common morality. Although Beauchamp and Childress do not claim that biomedical norms they derive from the common morality automatically become constituents of the common morality, or that every detail of their account carries the authority of the common morality, they regard these derived norms as provisionally (...) binding in a way that does not apply to the norms of mere “particular” moralities. Whereas particular moralities “do not bind other persons or communities,” Beauchamp and Childress have designed the norms of Principles of Biomedical Ethics to be “extensions” of the common morality that universally binds other persons and communities. Beauchamp and Childress seem to hold that (1) the norms they articulate in Principles of Biomedical Ethics are derived in an objective way from the common morality, and also that by virtue of being so derived (2) they carry a moral authority that objectively exceeds the authority of norms constituting particular moralities. My thesis in this essay is that both of these claims are false. (shrink)

Thomas Hobbes is one of the most ardent and thoroughgoing opponents of participatory democracy among Western political philosophers. Though Hobbes 's alternative to participatory democracy - assent by subjects to rule by an absolute sovereign - no longer constitutes a viable political alternative for Westerners, his critique of participatory democracy is a potentially valuable source of insight about its liabilities. This essay elaborates five theses from Hobbes that stand as cogent warnings to those who embrace participatory democracy, especially those advocating (...) for deliberative democracy based on a rational consensus model. In light of these warnings, the author suggests an alternative, modus vivendi approach to deliberative democracy that would radically alter the current practice of bioethics. (shrink)

In an attempt to respond effectively to the COVID-19 pandemic, policy makers and scientific experts who advise them have aspired to present a unified front. Leveraging the authority of science, they have at times portrayed politically favored COVID interventions, such as lockdowns, as strongly grounded in scientific evidence—even to the point of claiming that enacting such interventions is simply a matter of “following the science.” Strictly speaking, all such claims are false, since facts alone never yield moral-political conclusions. More importantly, (...) attempts to present a unified front have led to a number of other actions and statements by scientists and policy makers that erode the authority of science. These include actions and statements that: (1) mislead the public about epidemiological matters such as mortality rates, cause of death determinations, and computerized modeling, or fail to correct mainstream media sources that interpret such concepts in misleading ways; (2) incorporate moral-political opinions into ostensible statements of fact; and (3) misrepresent or misuse scientific expertise. The fundamental thesis of the paper is not primarily that such actions and statements have proliferated during the COVID-19 epidemic (though I think they have), but rather that they are unscientific and that presenting them as science undermines the authority of science. In the moral-political realm, the great power of science and the source of its authority derives from its agnosticism about fundamental moral-political claims. Science, for instance, has no built-in presumption that we should respect life, promote freedom, or practice toleration; nor does it tell us which of these values to prioritize when values conflict. Because of this agnosticism, science is recognized across a broad diversity perspectives as morally and politically impartial, and authoritative within its proper sphere. When it is infused with partisan bias, it loses that authority. (shrink)

By articulating a Peircean strain of bioethical inquiry, Elizabeth Cooke admirably attempts to avert the anti-realism, subjectivism and focus on consensus that afflict much so-called “pragmatic” bioethics. Yet, like many of her Deweyan colleagues, she falls prey to the egalitarian conviction that inquiry should be undertaken by huge numbers of like-minded individuals, proceeding in accordance with an authoritative canon of rules of discourse. In this essay, I argue that Cooke's egalitarianism is inconsistent with her apparent commitment to Peirce, and that (...) an alternative, libertarian account of inquiry is better and truer to Peirce. (shrink)

The concept of autonomy as self-sovereignty is developed in this essay through an examination of the thought of American transcendentalist philosophers Emerson and Thoreau. It is conceived as the quality of living in accordance with one’s inner nature or genius. This conception is grounded in a transcendentalist moral anthropology that values independence, self-reliance, spirituality, and the capacity to find beauty in the world. Though still exerting considerable popular and academic influence, both the concept of autonomy as self-sovereignty and the underlying (...) anthropology diverge in important ways from counterparts that are prominent in contemporary bioethics. Autonomy as self-sovereignty calls into question the manifold ways that patients (and citizens) are brought to heel by institutional (and political) values they do not themselves affirm. It also emphasizes the inevitable deep plurality of moral visions of health and appropriate healthcare, rejecting tendencies (strong in mainstream bioethics) to regard “health” as a univocal concept or healthcare as a basic need, to attempt to conform “reasonable” clinical decision-making to a single model, and to appoint government as a guarantor of access to healthcare or a regulator of healthcare standards. Autonomy as self-sovereignty, like its competitors, can justify itself only in question-begging terms. Still, bioethics might do well to recognize it within the mix of moral visions. (shrink)

In an attempt to respond effectively to the COVID-19 pandemic, policy makers and scientific experts who advise them have aspired to present a unified front. Leveraging the authority of science, they have at times portrayed politically favored COVID interventions, such as lockdowns, as strongly grounded in scientific evidence—even to the point of claiming that enacting such interventions is simply a matter of “following the science.” Strictly speaking, all such claims are false, since facts alone never yield moral-political conclusions. More importantly, (...) attempts to present a unified front have led to a number of other actions and statements by scientists and policy makers that erode the authority of science. These include actions and statements that: (1) mislead the public about epidemiological matters such as mortality rates, cause of death determinations, and computerized modeling, or fail to correct mainstream media sources that interpret such concepts in misleading ways; (2) incorporate moral-political opinions into ostensible statements of fact; and (3) misrepresent or misuse scientific expertise. The fundamental thesis of the paper is not primarily that such actions and statements have proliferated during the COVID-19 epidemic (though I think they have), but rather that they are unscientific and that presenting them as science undermines the authority of science. In the moral-political realm, the great power of science and the source of its authority derives from its agnosticism about fundamental moral-political claims. Science, for instance, has no built-in presumption that we should respect life, promote freedom, or practice toleration; nor does it tell us which of these values to prioritize when values conflict. Because of this agnosticism, science is recognized across a broad diversity perspectives as morally and politically impartial, and authoritative within its proper sphere. When it is infused with partisan bias, it loses that authority. (shrink)

The “Father of the United States Constitution,” James Madison, once described justice as “the end” of both government and of civil society. Yet curiously, Madison said little about justice in elaborating the principles of American federalism in The Federalist Papers and elsewhere. His fundamental concerns, to the contrary, were in contriving a system of separated, countervailing powers and in establishing a first federal principle of enumerated powers — in which federal powers “are few, and defined.” This strategy, for Madison, was (...) the most feasible way of checking the innate tendency of political power to accumulate, centralize, and trample on citizens’ liberties. (shrink)

This essay contrasts the notions of charity employed by Traditional Christianity and by liberal cosmopolitan bioethics, arguing that: (1) bioethics attempts to reconstruct the notion of charity in a manner that is caustic to the Traditional Christian moral vision, (2) Christians are, on the whole, more charitable than proponents of bioethics' reconstructed view (even given the standards of the latter), and (3) the theistically oriented conception of charity employed by Traditional Christianity cannot be expressed in bioethics' purportedly neutral public vocabulary. (...) The upshot is that, in the name of neutrality and pluralism, liberal cosmopolitan bioethicists seek to impose an impoverished moral vocabulary that reflects liberal cosmopolitan ideology while excluding input from Traditional Christianity and other non-liberal-humanistic moral visions. (shrink)

The medical profession, challenged by critics and reformers, is hard-pressed to give account of itself. Just what do physicians stand for? What do they revere? Where are they headed? These questions are becoming increasingly important yet increasingly difficult to answer, by established physicians and aspiring medical students alike. The perceived paralysis in the face of such questions and challenges is the central problem around which this book was written. To correct this failure, Dr. Trotter proposes the application of Josiah (...) Royce's "philosophy of loyalty" and the related thought of Alasdair MacIntyre to the practice of medicine. Uniquely qualified as both a professionally trained philosopher and an experienced physician, Trotter is the first to apply systematic philosophical precepts to this fundamentally important professional discipline. (shrink)

Contemporary bioethics begins with the perception that medical values are a matter of public, rather than merely professional, interest. Such was the message of delegates in Helsinki and of the New Jersey court that decided for Quinlan. It is a theme that lurks within almost every major bioethical treatise since the first edition of PrinciplesofBioethics. This perception also undergirds the increasingly popular suggestion that moral authority in the patient-physician relationship resides neither in the medical profession, nor in the singular will (...) of the patient, but in moral communities that link both parties with higher social orders. (shrink)

In speculating on the motives for government, English philosopher Thomas Hobbes identified the pervasive role of fear and the danger of violent death, holding famously that where no government prevails to secure physical safety and property, there can also be no enduring knowledge, art, or civilization—leaving human lives “solitary, poore [sic], nasty, brutish and short.”.

This issue of CQ was conceived in Salt Lake City, at the third annual meeting of the American Society of Bioethics and Humanities (ASBH). There, President-elect Laurie Zoloth delivered a stirring address, emphasizing the role of bioethics in responding to social deprivations and suggesting that ASBH on important issues where members share consensus. Not all the stirrings were pleasant. Debate erupted about the propriety of consensus statements, especially regarding possible deleterious effects on academic discourse, misappropriation of dues, and the proliferation (...) of quasi-political factions. The roots of this controversy extend deeply into the collective psyche of contemporary bioethics. (shrink)

In Holding Health Care Accountable , E. Haavi Morreim differentiates between duties of expertise and resource duties, arguing for tort liability respecting the former and contract liability respecting the latter. Though Morreim's book addresses ordinary clinical medicine, her liability scheme may also be relevant elsewhere. Focusing on disaster medicine, and especially the medical management of violent mass disasters (e.g., where terrorists have deployed weapons of mass destruction), I argue in this essay that Morreim's classification of duties still fits, but that (...) it is difficult to hold government powers accountable for their many resource and expertise duties. This difficulty is compounded by political arrangements that foist under-funded mandates for disaster services on healthcare providers. As a result of such arrangements, hospitals and clinicians are prone to liability for expenditures and clinical interventions that are beyond their scope. This problem can be mitigated, I argue, by examining and clarifying the apparent social compact between society and healthcare. (shrink)

Were terrorists ever to effectively deploy weapons of mass destruction, medical practice would be quickly transformed. Many ordinary clinicians would be asked or required to treat unfamiliar yet serious medical conditions in a setting of overwhelming urgency and impossible odds. Clinical focus would shift from doing good things for a succession of individual patients to considering many patients at once, a change that could beget loss of trust and rapport with patients. Clinicians might also experience restrictions in personal liberties and (...) appropriation of their property. The purpose of this essay is to develop a teleological framework for undertaking this transformation. In ordinary clinical medicine, the elusiveness of the individual telos (i.e., the good for the individual) is acknowledged in procedures (such as social history taking, informed consent and outpatient scheduling) designed to protect patients' (and clinicians') prerogatives to interpret the telos for themselves. In mass casualty scenarios, on the other hand, the telos is standardized and regarded as an Immediate Object (usually as a state of affairs in which survival is maximized and permanent disability is minimized). Clinicians who provide mass casualty care will face a number of ethical challenges that can be negotiated by appealing to the political and ethical rationale, and limits, pertaining to the pursuit of aggregate survival as an Immediate Object. (shrink)

This essay examines the management of ventilatory failure in disaster settings where clinical needs overwhelm available resources. An ethically defensible approach in such settings will adopt a “sufficiency of care” perspective that is: (1) adaptive, (2) resource-driven, and (3) responsive to the values of populations being served. Detailed, generic, antecedently written guidelines for “ventilator triage” or other management issues typically are of limited value, and may even impede ethical disaster response if they result in rescuers’ clumsily interpreting events through the (...) lens of the guideline, rather than customizing tactics to the actual context. Especially concerning is the tendency of some expert planners to mistakenly assume that medical treatment of respiratory failure: (1) always requires full-feature mechanical ventilators, (2) will always occur in hospitals, and (3) can be planned in advance without sophisticated public consultation about likely ethical dilemmas. (shrink)

According to Native American myths, there once roamed an Eye Juggler—a humanoid deity who could detach his eyes and juggle them. His talents were of no special appeal to members of the various tribes, given that it is quite possible to hunt buffalo, prepare meals, or play stickball without tossing around your eyes. However, there was a white man who grew interested in the Eye Juggler. Sensing great utility in detachable eyes—for spying, or looking two ways at once—the white man (...) formulated a deal. He would trade away his wealth in return for the Eye Juggler's gift. To this proposition the Juggler agreed, but also issued a warning. If the eyes stay detached for very long, they rot and cannot be used. (shrink)

In fall 2002, Paul Ellwood's Jackson Hole Group proposed “Heroic Pathways”—a healthcare reform concept that includes a voluntary system of portable, personal electronic medical records owned by patients and a health information pathway that is managed by patients and clinicians. This proposal, like so much of the innovative thinking in healthcare policy, is premised on the conviction that informed patients will drive healthcare changes in the near future.

Old habits die slowly. Hence there is little surprise that attorneys fashioning the Model State Emergency Health Powers Act preserved much of their own standard operating procedure. This model statute was designed for the worst of times—for horrific scenarios in which terrorism, infectious disease, or natural calamity threaten to derail the machinery of civilization while snuffing out thousands or even millions of human lives. Such grave threats seem to justify grave measures aimed at restoring order and maximizing survival. So, the (...) model statute bestows sweeping power on state governors and public health officials, allowing them to seize private property, obtain clinical services through impressment, and enact quarantine and isolation measures without the usual due process. Yet amid all these drastic measures, certain standards persist. (shrink)

As medical students we were not discouraged from introducing ourselves by saying, “Hello, I'm Dr. So-and-so,” as opposed to identifying ourselves as students. If we happened to be doing rounds with an intern or resident, the physician would introduce himself or herself as “Dr. X and over here is Dr. Y”—indicating a student. When I introduced myself as a medical student, I got the feeling that people thought it was silly or unnecessary.

In “Ethics and the Underpinnings of Policy in Biodefense and Emergency Preparedness,” Lisa Eckenwiler advances discussion about emergency preparedness by exploring ethical commitments that shape healthcare and defense policy in an age of terrorism. Eckenwiler rightly discerns that policymakers' assumptions about controlling and containing hostile malefactors and the need for public consent regarding security measures are part of an epistemic framework that orders the current response to terrorism. Again rightly, she suggests that citizens ought to have a say in shaping (...) and interpreting such fundamental assumptions, a reductive medical model that focuses on mitigation and the management of casualties is insufficient for understanding and responding to the complex social, political, and economic factors that precipitate terrorist attacks, and there is in emergency preparedness an ethically problematic disproportion between the demands society places on public health/medical professionals and the resources society provides for them to meet these demands. She is also probably correct in claiming that, properly understood, the ethical underpinnings of public health policy are teleological in nature. (shrink)

In a recent issue of CambridgeQuarterlyofHealthcareEthics, Howard Brody and Lawrence Schneiderman offer contrasting opinions about how to apply the concept of in medicine. Brody holds that are those in which it is reasonably certain that a given intervention when applied for the purpose of attaining a specific clinical goal. To determine which actions are futile, Brody prescribes a division of labor. Patients are charged with choosing the goals of treatment while physicians are charged with determining whether specific treatments will be (...) effective in achieving these goals. Though physicians do not choose specific goals, Brody thinks they have a prerogative to decide whether they can, in good conscience, aid in the achievement of specific patient goals. Let us use to denote choosing between alternative goals and to denote choices about whether one will assist in the pursuit of particular goals. Brody's position is essentially that patients are positive validators and that physicians are negative validators. Brody concludes that treatments that are effective in achieving patients' goals are not futileFutilitypromote a goal that both agree is desirable.”. (shrink)

What is morality? Is “morality” something that admits of technological enhancement? What could it possibly mean for a society to have a moral imperative to morally enhance? We are compelled to take up questions like these as we move into the future of moral bioenhancement. Each article in this issue of the Journal of Medicine and Philosophy attempts to bring some clarity as to what is meant by morality, such that one could be morally obligated to morally enhance. These articles (...) broaden the scope of the question as to the nature of human morality, what might and what might not be permitted in terms of moral bioenhancement, and explore the nature of the kinds of beings humans might become—whether human or post-human—and the moral obligations that may exist toward them. (shrink)

Public health ethics is neither taught widely in medical schools or schools of public health in the US or around the world. It is not surprising that health care professionals are particularly challenged when faced with ethical questions which extend beyond safeguarding the interests of their individual patients to matters that affect overall public good. The perceived threat of terror after September 11 2007, the anthrax attacks and the Katrina debacle are recent circumstances which may result in coercion. These have (...) piqued the interest of medical professionals and the general public on public health ethics. The Ethics of Coercion in Mass Casualty Medicine written by Griffin Trotter MD, PhD attempts to fill a timely void in this area by examining the ethics of coercion in times of public health disasters. (shrink)