Drawing on philosophy, law and political science, and on a wealth of practical experience delivering emergency medical services in conflict-ridden settings, Lepora and Goodin untangle the complexities surrounding compromise and complicity.

Medical complicity in torture is prohibited by international law and codes of professional ethics. But in the many countries in which torture is common, doctors frequently are expected to assist unethical acts that they are unable to prevent. Sometimes these doctors face a dilemma: they are asked to provide diagnoses or treatments that respond to genuine health needs but that also make further torture more likely or more effective. The duty to avoid complicity in torture then comes into conflict with (...) the doctor’s duty to care for patients. Sometimes the right thing for a doctor to do requires complicity in torture. Whether this is the case depends on: the expected consequences of the doctor’s actions; the wishes of the patient; and the extent of the doctor’s complicity with wrongdoing. Medical associations can support physicians who face this dilemma while maintaining a commitment to clear principles denouncing torture. (shrink)

Compromise arises in contexts where irreconcilable claims must nonetheless somehow be resolved. Ordinary people in everyday life, politicians and artists, doctors engaging in research, humanitarian workers providing aid in the midst of war – all of them will have faced situations where compromise appeared to be the only reasonable option, and yet will have felt that there was nevertheless something deeply wrong with it. The aim of this paper is to help make sense of that sentiment. The focus of this (...) paper will be on some aspects of the morality of compromise. Its lynchpin will be to construe compromise as a joint action, in particular, a joint wrongdoing – taking part in, and sharing responsibility for, the doing of things that are wrong from the point of view of those who are the parties to the compromise. The question of ‘what is wrong with compromise?’ is thus recast as a question of ‘what is my part in the wrongs being done as part of the compromise?’ It is tempting to suppose that a compromise serves to dilute personal responsibility, parsing it out among parties to the compromise. Viewing a compromise as a joint action, in contrast, will help us to see how a compromise actually increases responsibility among parties to it. They are now jointly collaborating in some action that each of them sees as wrong, at least in part (albeit in differing parts). Discussions of compromise traditionally prioritize the inter-personal aspect – compromise, in the transitive form of ‘compromising with’ someone. But I argue that the intransitive form – ‘compromise of’ – deserves pride of place. The reason for prioritizing the intransitive ‘compromise of’ is simple: that is what is involved in the intra-personal calculation that must, of necessity, go on inside one's own head in the process of deciding whether or not to agree to a 'compromise with' someone else. In this paper I shall concentrate specifically on compromises of principles, or (more precisely) on ‘matters of principled concern to the compromising parties’. Not only is that the most troubling and morally problematic sort of compromise, it is also logically the most central case. I demonstrate that that is so by shifting the focus from inter-personal compromise to the more fundamental intra-personal process underlying it – the compromise we are involved in when adjudicating among our own conflicting values, to decide whether or not to agree to a compromise of the inter-personal sort. This is the subject of the first section of the paper below. Compromise involves resolving conflicts of principles through mutual concessions that are accepted and undertaken by all parties. Doing so may be on-balance desirable, not only from some larger perspective (of social peace, or whatever) but also from each party's own perspective. Nevertheless, from each party's perspective, compromise necessarily involves interacting with, and sometimes contributing to, wrongdoing. Morally, something is lost, even if more is gained on balance. (shrink)

Torture is unethical and usually counterproductive. It is prohibited by international and national laws. Yet it persists: according to Amnesty International, torture is widespread in more than a third of countries. Physicians and other medical professionals are frequently asked to assist with torture. -/- Medical complicity in torture, like other forms of involvement, is prohibited both by international law and by codes of professional ethics. However, when the victims of torture are also patients in need of treatment, doctors can find (...) themselves torn. To accede to the requests of the torturers may entail assisting or condoning terrible acts. But to refuse care to someone in medical need may seem like abandoning a patient and thereby fail to exhibit the beneficence expected of physicians. -/- In this paper, we argue that this dilemma is real and that sometimes the right thing for a doctor to do, overall, is to be complicit in torture. Though complicity in a wrongful act is itself prima facie wrongful, this judgment may be outweighed by other factors. We propose three criteria for analyzing how those factors apply to particular cases of medical complicity in torture. (shrink)

Complicity consists in one person contributing to someone else's wrongdoing. But there is a diverse cluster ways of being involved in another’s wrongdoing. For a ‘diagnosis by exclusion’, we first fix the meaning of complicity in contrast to that with which it is often wrongly conflated. Literally cooperating in wrongdoing with others, for instance, is more than complicity. Each and every cooperator is actually a co-principal in the wrong jointly committed; and each bears the full responsibility, shared with all co-principals, (...) for the outcomes of that wrongdoing. Other sorts of involvement with wrongs committed by others amount to less than complicity because the involvement there is causally inert and hence does not actually contribute to the other’s wrongdoing at all. Pardoning wrongs wholly in the past may be like that. So too may be some cases of wilfully overlooking wrongs that others commit under one's very nose. Complicity is a very precise way of being involved in wrongdoing. Complicity consists in a secondary contribution of a causal (or potentially causal) sort to a wrong committed by someone else. That ‘contribution factor’ can be graded on many axes, in terms of how proximate, reversible or frequent the contribution was. Other things being equal, one is more complicit the …. (shrink)

Peter French’s and Steven Ratner’s thoughtful comments are helpful in advancing the analysis we offered in our book On Complicity and Compromise. Inevitably, there are areas of disagreement and bones to pick. However, our primary concern in this reply will be to press, with their assistance, the more positive agenda.

Complicity with wrongdoing comes in many forms and many degrees. We distinguish subcategories cooperation, collaboration and collusion from connivance and condoning, identifying their defining features and assessing their characteristic moral valences. We illustrate the use of these distinctions by reference to events in refugee camps in and around Rwanda after the 1994 genocide, and the extent to which international organizations and nongovernment organizations were wrongfully complicit with the misuse of refugees as human shields by the perpetrators of the genocide who (...) were allowed to run those camps. (shrink)

The cautions of our commentators are all well taken, and we are grateful for them. When we say that physicians should respect the wishes of their patients for medical treatment, even if that would make them complicit in torture being inflicted on their patients, Henry Shue reminds us that that assumes that the patients undergoing torture retain minimally adequate decision-making capacity. Insofar as the torture aims at, and succeeds in, producing ‘regression to an infantile state’, patients who are victims of (...) such torture would likely fail standard tests of that. True though that observation may be, it leaves us with no solution to our initial problem. Were we to assume that the victim does not have decision-making capacity, and reject his request for treatment on that basis, we would victimise him further by abandoning him to his fate leaving him with no alternatives and no support whatsoever. Furthermore, in regimes of psychologically sophisticated torture of the sort Shue discusses, there may be an even stronger reason for a physician to comply with a victim-patient's request for her to treat him. For a physician to refuse a would-be patient's request for treatment, on grounds he lacks adequate decision-making capacity, might further reinforce the infantilising message of the torturers. If so, that would amount to complicity in his torture, insofar as it furthers the wrong done by perpetrators. In the absence of victim's consent, doctors typically use criteria like family's advice, patient's best interest or heuristics identifying what most patients would prefer in similar situations. None of these options is available to doctors caring for torture survivors during the course of their torture, however. The first is obviously not. The second is not because the physician cannot be altogether sure what is in her victim-patient's best interests, given that treating him will …. (shrink)

Gesundheit and colleagues offer dramatic examples of the medical treatment of terrorists but then pose the suggestion that those who engage in terrorism forfeit their right to medical care, and, consequently, that physicians have no obligation to treat them. Their argument presupposes that a physician’s obligation to provide medical care depends on the patients’ right to health care. Therefore, someone who commits heinous and abhorrent acts thereby waives the right to health care and the physicians’ duty to provide health care (...) might consequently be absolved. This view may appeal to physicians who have experienced the complexity and discomfort of treating someone whose morality or even humanity they question, such as a rapist, a serial killer, or a perpetrator of genocide. However we have grounds to believe that the duty of physicians to treat is not based on the moral worth of patients, but rather on the duties that physicians have, and this notion renders any concern about the unacceptability of any person’s behavior irrelevant in determining whether to provide treatment. We will first argue that not all duties are directly derived from rights, and then illustrate how deontological views, along with common views on the role morality of physicians, provide a basis for offering indiscriminate medical care. Second, we will discuss the physician’s role in the context of war, and offer one compelling moral reason on the basis of which warfare norms do indeed obligate physicians to extend their duty to care toward enemies, terrorists included, independently of whatever right they maintain. (shrink)

Bioethics: 50 Puzzles, Problems, and Thought Experiments collects 50 cases—both real and imaginary—that have been, or should be, of special interest and importance to philosophical bioethics. Cases are collected together under topical headings in a natural order for an introductory course in bioethics. Each case is described in a few pages, which includes bioethical context, a concise narrative of the case itself, and a discussion of its importance, both for broader philosophical issues and for practical problems in clinical ethics and (...) health policy. Each entry also contains a brief, annotated, list of suggested readings. In addition to the classic cases in bioethics, the book contains discussion of cases that involve several emerging bioethical issues: especially, issues around disability, social justice, and the practice of medicine in a diverse and globalized world. (shrink)