The book challenges the values of much of contemporary bioethics and health care policy by confronting their failure to secure the moral norms they seek to apply.

This review essay examines H. Tristram Engelhardt, Jr.'s The Foundations of Bioethics, a contemporary nonfeminist text in mainstream biomedical ethics. It focuses upon a central concept, Engelhardt's idea of the moral community and argues that the most serious problem in the book is its failure to take account of the political and social structures of moral communities, structures which deeply affect issues in biomedical ethics.

The American Society for Bioethics and the Humanities (ASBH) issued its Core Competencies for Health Care Ethics Consultation just as it is becoming ever clearer that secular ethics is intractably plural and without foundations in any reality that is not a social–historical construction (ASBH Core Competencies for Health Care Ethics Consultation , 2nd edn. American Society for Bioethics and Humanities, Glenview, IL, 2011 ). Core Competencies fails to recognize that the ethics of health care ethics consultants is not ethics in (...) the usual sense of a morally canonical ethics. Its ethics is the ethics established at law and in enforceable health care public policy in a particular jurisdiction. Its normativity is a legal normativity, so that the wrongness of violating this ethics is simply the legal penalties involved and the likelihood of their being imposed. That the ethics of ethics consultation is that ethics legally established accounts for the circumstance that the major role of hospital ethics consultants is as quasi-lawyers giving legal advice, aiding in risk management, and engaging in mediation. It also indicates why this collage of roles has succeeded so well. This article shows how moral philosophy as it was reborn in the 13th century West led to the ethics of modernity and then finally to the ethics of hospital ethics consultation. It provides a brief history of the emergence of an ethics that is after morality. Against this background, the significance of Core Competencies must be critically reconsidered. (shrink)

Proceedings of the first trans-disciplinary symposium on philosophy and medicin held at Galveston, Texas, May 9-11,1974.

This collection of essays examines the ways in which disputes and controversies about the application of scientific knowledge are resolved. Four concrete examples of public controversy are considered in detail: the efficacy of Laetrile, the classification of homosexuality as a disease, the setting of safety standards in the workplace, and the utility of nuclear energy as a source of power. The essays in this volume show that debates about these cases are not confined to matters of empirical fact. Rather, as (...) is seen with most scientific and technical controversies, they focus on and are structured by complex ethical, economic, and political interests. Drs. Engelhardt and Caplan have brought together a distinguished group of scholars from the sciences and humanities, who sketch a theory of scientific controversy and attempt to provide recommendations about the ways in which both scientists and the public ought to seek more informed resolutions of highly contentious issues in science and technology. Scientific Controversies is offered as a contribution to the better understanding of the roles of both science and nonscientific interests in disputes and controversies pertaining to science and technology. (shrink)

In the face of the moral pluralism that results from the death of God and the abandonment of a God's eye perspective in secular philosophy, bioethics arose in a context that renders it essentially incapable of giving answers to substantive moral questions, such as concerning the permissibility of abortion, human embryonic stem cell research, euthanasia, etc. Indeed, it is only when bioethics understands its own limitations and those of secular moral philosophy in general can it better appreciate those tasks that (...) it can actually usefully perform in both the clinical and academic setting. It is the task of this paper to understand and reevaluate bioethics by understanding these limits. Academic bioethicists can analyze ideas, concepts, and claims necessary to understanding the moral questions raised in health care, assessing the arguments related to these issues, and provide an understanding of the different moral perspectives on bioethical issues. In the clinical setting, bioethicists can provide legal advice, serve as experts on IRBs, mediating disputes, facilitating decision-making and risk management, and clarifying normative issues. However, understanding this is only possible when one understands the history, genesis, and foundations of bioethics and its inability to provide a resolution to postmodern moral pluralism. (shrink)

The legal basis of informed consent in Texas may on first examination suggest an unqualified affirmation of persons as the source of authority over themselves. This view of individuals in the practice of informed consent tends to present persons outside of any social context in general and outside of their families in particular. The actual functioning of law and medical practice in Texas, however, is far more complex. This study begins with a brief overview of the roots of Texas law (...) and public policy regarding informed consent. This surface account is then contrasted with examples drawn from the actual functioning of Texas law: Texas legislation regarding out-of-hospital do-not-resuscitate (DNR) orders. As a default approach to medical decision-making when patients lose decisional capacity and have failed to appoint a formal proxy or establish their wishes, this law establishes a defeasible presumption in favor of what the law characterizes as “qualified relatives” who can function as decision-makers for those terminal family members who lose decisional capacity. The study shows how, in the face of a general affirmation of the autonomy of individuals as if they were morally and socially isolated agents, space is nevertheless made for families to choose on behalf of their own members. The result is a multi-tier public morality, one affirming individuals as morally authoritative and the other recognizing the decisional standing of families. (shrink)

This paper presents four different understandings of the family and their concomitant views of the authority of the family in pediatric medical decision making. These different views are grounded in robustly developed, and conflicting, worldviews supported by disparate basic premises about the nature of morality. The traditional worldviews are often found within religious communities that embrace foundational metaphysical premises at odds with the commitments of the liberal account of the family dominant in the secular culture of the West. These disputes (...) are substantial and ultimately irresolvable by sound rational argument because of the failure to share common foundational premises and rules of evidence. It is in light of these fundamental disagreements that there is a need to evaluate critically the claims and agenda advanced by the Convention on the Rights of the Child. (shrink)

The project of articulating a coherent, canonical, content-full, secular morality-cum-bioethics fails, because it does not acknowledge sin, which is to say, it does not acknowledge the centrality of holiness, which is essential to a non-distorted understanding of human existence and of morality. Secular morality cannot establish a particular moral content, the harmony of the good and the right, or the necessary precedence of morality over prudence, because such is possible only in terms of an ultimate point of reference: God. The (...) necessity of a rightly ordered appreciation of God places centrally the focus on holiness and the avoidance of sin. Because the cardinal relationship of creatures to their Creator is worship, and because the cardinal corporate act of human worship is the Liturgy, morality in general and bioethics in particular can be understood in terms of the conditions necessary, so as worthily to enter into Eucharistic liturgical participation. Morality can be summed up in terms of the requirements of ritual purity. A liturgical anthropology is foundational to an account of the content-full morality and bioethics that should bind humans, since humans are first and foremost creatures obliged to join in rightly ordered worship of their Creator. When humans worship correctly, when they avoid sin and pursue holiness, they participate in restoring created reality. (shrink)

The philosophy of medicine cum bioethics has become the socially recognized source for moral and epistemic direction in health-care decision-making. Over the last three decades, this field has been accepted politically as an authorized source of guidance for policy and law. The field's political actors have included the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, the Department of Health, Education, and Welfare, the President's Commission for the Study of Ethical Problems in Medicine and Biomedical (...) and Behavioral Research , the National Bioethics Advisory Commission, and the new Council on Bioethics; these groups and agencies have set forth rules on issues ranging from the role of humans in biomedical research to the production of human embryos for research, the definition of death, and the permissibility of human cloning. The members of the field are not just scholars and teachers in an academic realm directed to both theoretical and applied issues. They are, in addition, practitioners of a conceptual and moral trade that possesses a legal and political standing. This essay critically addresses the sudden emergence of bioethics as a societally recognized source of moral guidance, a source replete with authorized moral experts. Attention is directed to moral and conceptual assumptions that have led the philosophy of medicine, and especially bioethics, to acquire a quasi-juridical/political role in guiding clinical choices, framing health-care policy, and directing court holdings. (shrink)

The contemporary societies of the West are characterized by a collision of radically incommensurable cultures, that of traditional Christianity and that of the robustly laicist cultures that took shape in the nineteenth and twentieth centuries, drawing not only on the French Revolution and the Western European Enlightenment but also on deep roots in the synthesis of faith and reason that framed the thirteenth-century Western Christian Middle ages. This article explores the foundational contrast and conflict between traditional Christian bioethics and the (...) now-dominant secular culture through a portrayal of the historical and conceptual geography of the collapse of the Christendom established by St. Constantine the Great, Equal-to-the-Apostles, and on account of the emergence of secular fundamentalist states. The question is addressed anew as to what Athens can have to do with Jerusalem, as well as to what the Academy can have to do with the Church. The differences between a traditional Christian bioethics and a secular bioethics are illustrated in terms of questions bearing on the use of life-prolonging and death-postponing treatment. (shrink)

Long-term care is controversial because it involves foundational disputes. Some are moral-economic, bearing on whether the individual, the family, or the state is primarily responsible for long-term care, as well as on how one can establish a morally and financially sustainable long-term-care policy, given the moral hazard of people over-using entitlements once established, the political hazard of media democracies promising unfundable entitlements, the demographic hazard of relatively fewer workers to support those in need of long-term care, the moral hazard to (...) responsibility of shifting accountability to third parties, and the bureaucratic hazard of moving from individual and family choice to bureaucratic oversight. These disputes are compounded by controversies regarding the nature of the family (Is it to be regarded primarily as a socio-biological category, a fundamental ontological category of social reality, or a construct resulting from the consent of the participants?), as well as its legal and moral autonomy and authority over its members. As the disputes show, there is no common understanding of respect and human dignity that will easily lead out of these disputes. The reflections on long-term care in this issue underscore the plurality of moralities defining bioethics. (shrink)

The philosophy of medicine cum bioethics has become the socially recognized source for moral and epistemic direction in health-care decision-making. Over the last three decades, this field has been accepted politically as an authorized source of guidance for policy and law. The field's political actors have included the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, the Department of Health, Education, and Welfare, the President's Commission for the Study of Ethical Problems in Medicine and Biomedical (...) and Behavioral Research, the National Bioethics Advisory Commission, and the new Council on Bioethics; these groups and agencies have set forth rules on issues ranging from the role of humans in biomedical research to the production of human embryos for research, the definition of death, and the permissibility of human cloning. The members of the field are not just scholars and teachers in an academic realm directed to both theoretical and applied issues. They are, in addition, practitioners of a conceptual and moral trade that possesses a legal and political standing. This essay critically addresses the sudden emergence of bioethics as a societally recognized source of moral guidance, a source replete with authorized moral experts. Attention is directed to moral and conceptual assumptions that have led the philosophy of medicine, and especially bioethics, to acquire a quasi-juridical/political role in guiding clinical choices, framing health-care policy, and directing court holdings. (shrink)

Orthodox Christian theology gives philosophy the same role it played in the Church of the first half-millennium. This article distinguishes among nine senses of philosophy and four senses of theology in order to highlight the characteristic features of Orthodox Christian theology’s use of philosophy and philosophical reasoning. It shows why, given the metaphysics and epistemology of Orthodox Christian theology (e.g., God is recognized as fully transcendent, such thatthere is no analogia entis between created and Uncreated Being, with the result that (...) the experience of the encounter with God can only be recounted apophatically) and its sociology of knowledge (e.g., theology in the strict sense occurs primarily in monasteries, not in the academy), philosophy is regarded as not able to contribute to the development of old doctrines or the fashioning of new doctrines, but only to the clarification of doctrinal statements. As a consequence, Orthodox Christian theology has been committed to severely confining philosophy’s role in theology. (shrink)

Given intractable moral pluralism, what ought one to make of the bioethics that arose in the early 1970s, grounded as it was in the false assumption that there is a common secular morality that secular bioethics ought to apply? It is as if bioethics developed without recognition of the crisis at the heart of secular morality itself. Secular moral rationality cannot of itself provide the foundations to identify a particular morality and its bioethics as canonical. One is not just confronted (...) with intractable moral and bioethical pluralism, but with the absence of a secular ground that can show why one should act morally rather than self-interestedly. The result is not merely the deflation of much of traditional Western morality to life-style and death-style choices, but the threat of deflating to political slogans the now-dominant secular morality, including its affirmation of human autonomy, equality, social justice, and human dignity. All of this invites one critically to reconsider the meaning and force of secular bioethics. (shrink)

Once God is no longer recognized as the ground and the enforcer of morality, the character and force of morality undergoes a significant change, a point made by G.E.M. Anscombe in her observation that without God the significance of morality is changed, as the word criminal would be changed if there were no criminal law and criminal courts. There is no longer in principle a God's-eye perspective from which one can envisage setting moral pluralism aside. In addition, it becomes impossible (...) to show that morality should always trump concerns of prudence, concerns for one's own non-moral interests and the interests of those to whom one is close. Immanuel Kant's attempt to maintain the unity of morality and the force of moral obligation by invoking the idea of God and the postulates of pure practical reason are explored and assessed. Hegel's reconstruction of the status of moral obligation is also examined, given his attempt to eschew Kant's thing-in-itself, as well as Kant's at least possible transcendent God. Severed from any metaphysical anchor, morality gains a contingent content from socio-historical context and its enforcement from the state. Hegel's disengagement from a transcendent God marks a watershed in the place of God in philosophical reflections regarding the status of moral obligations on the European continent. Anscombe is vindicated. Absent the presence of God, there is an important change in the force of moral obligation. (shrink)

H. Tristram Engelhardt, Jr.; The DeChristianization of Christian Health Care Institutions, or, How the Pursuit of Social Justice and Excellence can Obscure the.

Bioethics is not merely a theoretical discipline but a practice as well. Indeed, bioethics is a sort of moral trade. Bioethicists serve on ethics committees, give expert testimony to courts, provide guidance for healthcare policy, and receive payment for these services. The difficulty is that their role as experts able to guide clinical choice and public policy formation is brought into question by the diversity of moral understandings regarding central moral issues at the heart of the culture wars in healthcare. (...) The disconfirmation of the expert role of bioethicists by their apparent actual role as partisans of particular moral schools and perspectives could be set aside, were there an avenue to moral consensus, a door to a common moral vision to guide this new profession of moral experts. This brief article addresses the hunger for consensus in bioethics, its impossibility with respect to the controversial issues that mark the field, and the inclination nevertheless to deny this manifest diversity by appeals to a consensus that could allow bioethicists to function as ethics experts able substantively to guide clinical choices and public policy. (shrink)

The traditional roles of Christian chaplains in aiding patients, physicians, nurses, and hospital administrators in repentance, right belief, right worship, and right conduct are challenged by the contemporary professionalization of chaplaincy guided by post-Christian norms located in a public space structured by three defining postulates: the non-divinity of Christ, robust ecumenism, and the irrelevance of God’s existence. The norms of this emerging post-Christian profession of chaplaincy make interventions with patients, physicians, nurses, and hospital administrators in defense of specifically Christian bioethical (...) norms and goals unprofessional, because the chaplain is now directed as a professional to support health care services held to standards articulated within a secular morality. These changes are exemplar of the profound recasting of the dominant moral culture with wide-ranging implications for bioethics. (shrink)

H. Tristram Engelhardt, Jr.; Generic Chaplaincy: Providing Spiritual Care in a Post-Christian Age, Christian bioethics: Non-Ecumenical Studies in Medical Morali.

This essay is meant as a form of philosophical exorcism. The goal is to dispel the view that there are general secular grounds for holding human germline genetic engineering to be intrinsically wrong, a malum in se, or a morally culpable violation of human nature. The essay endorses the view that major obligations of prudence and care attend the development of this technology. However, these justifiable moral concerns can be seen more clearly when one has dispelled what must, from a (...) secular perspective, be regarded as pseudo-issues. (shrink)

Once God is no longer recognized as the ground and the enforcer of morality, the character and force of morality undergoes a significant change, a point made by G.E.M. Anscombe in her observation that without God the significance of morality is changed, as the word criminal would be changed if there were no criminal law and criminal courts. There is no longer in principle a God's-eye perspective from which one can envisage setting moral pluralism aside. In addition, it becomes impossible (...) to show that morality should always trump concerns of prudence, concerns for one's own non-moral interests and the interests of those to whom one is close. Immanuel Kant's attempt to maintain the unity of morality and the force of moral obligation by invoking the idea of God and the postulates of pure practical reason are explored and assessed. Hegel's reconstruction of the status of moral obligation is also examined, given his attempt to eschew Kant's thing-in-itself, as well as Kant's at least possible transcendent God. Severed from any metaphysical anchor, morality gains a contingent content from socio-historical context and its enforcement from the state. Hegel's disengagement from a transcendent God marks a watershed in the place of God in philosophical reflections regarding the status of moral obligations on the European continent. Anscombe is vindicated. Absent the presence of God, there is an important change in the force of moral obligation. (shrink)

H. Tristram Engelhardt, Jr.; Roman Catholic Social Teaching and Religious Hospital Identity in a Post-Christian Age, Christian bioethics: Non-Ecumenical Studies.

H. Tristram Engelhardt, Jr.; Can Philosophy Save Christianity? Are the Roots of the Foundations of Christian Bioethics Ecumenical? Reflections on the Nature of.

A complex interaction of ideological, financial, social, and moral factors makes the financial sustainability of health care systems a challenge across the world. One difficulty is that some of the moral commitments of some health care systems collide with reality. In particular, commitments to equality in access to health care and to fair equality of opportunity undergird an unachievable promise, namely, to provide all with the best of basic health care. In addition, commitments to fair equality of opportunity are in (...) tension with the existence of families, because families are aimed at advantaging their own members in preference to others. Because the social-democratic state is committed to fair equality of opportunity, it offers a web of publicly funded entitlements that make it easier for persons to exit the family and to have children outside of marriage. In the United States, in 2008, 41% of children were born outside of wedlock, whereas, in 1940, the percentage was only 3.8%, and in 1960, 5%, with the further consequence that the social and financial capital generated through families, which aids in supporting health care in families, is diminished. In order to explore the challenge of creating a sustainable health care system that also supports the traditional family, the claims made for fair equality of opportunity in health care are critically reconsidered. This is done by engaging the expository device of John Rawls’s original position, but with a thin theory of the good that is substantively different from that of Rawls, one that supports a health care system built around significant copayments, financial counseling, and compulsory savings, with a special focus on enhancing the financial and social capital of the family. This radical recasting of Rawls, which draws inspiration from Singapore, is undertaken as a heuristic to aid in articulating an approach to health care allocation that can lead past the difficulties of social-democratic policy. (shrink)

Moral pluralism is a reality. It is grounded, in part, in the intractable pluralism of secular morality and bioethics. There is a wide gulf that separates secular bioethics from Christian bioethics. Christian bioethics, unlike secular bioethics, understand that morality is about coming into a relationship with God. Orthodox Christian bioethics, moreover, understands that the impersonal set of moral principles and goals in secular morality gives a distorted account of the moral life. Therefore, Traditional Christian bioethics is separated from bioethics by (...) a radical difference in paradigms. (shrink)

This essay examines an overlooked element of the precautionary principle: a prudent assessment of the long-range or remote catastrophes possibly associated with technological development must include the catastrophes that may take place because of the absence of such technologies. In short, this brief essay attempts to turn the precautionary principle on its head by arguing that, (1) if the long-term survival of any life form is precarious, and if the survival of the current human population is particularly precarious, especially given (...) contemporary urban population densities, and (2) if technological innovation and progress are necessary in order rapidly to adapt humans to meet environmental threats that would otherwise be catastrophic on a large scale (e.g., pandemics of highly lethal diseases), then (3) the development of biomedical technologies in many forms, but in particular including human germ-line genetic engineering, may be required by the precautionary principle, given the prospect of the obliteration of humans in the absence of such enhanced biotechnology. The precautionary principle thus properly understood requires an ethos that should generally support technological innovation, at least in particular areas of biotechnology. (shrink)