Kennedy Institute of Ethics Journal

David DeGrazia and Joseph Millum’s A Theory of Bioethics 2021 arrives at a curious time for an ambitious effort at systematic theory construction, seemingly out of step with bioethical fashion. At the same time, a prominent group of philosophical bioethicists authored an article, possibly with a touch of defensiveness, to “make the case that philosophy and philosophers still have a very important and meaningful role to play in contemporary bioethics” (Blumenthal-Barby et al. 2021). Meanwhile, the annual meeting of the American Society for Bioethics and Humanities included several expressions of impatience with the historical privileging of philosophy over more empirical, situated, and community-oriented approaches to moral problems in health.

DeGrazia and Millum’s work itself reflects the current state of bioethics and how it has changed since the heyday of grand bioethical theory construction in the late twentieth century. To apply Parfit’s philosophical taxonomy (1984), the general frameworks promulgated by theorists like Veatch, Engelhardt, and Gert, as well as Beauchamp and Childress, were by necessity revisionary. These bioethical theories were whole-cloth alternatives to a conventional and paternalistic medical ethos that was already widely acknowledged as unsatisfactory. Today, however, bioethics is a mature and institutionalized field, with well-established practices and a corpus of accepted tenets (alongside matters of ongoing but generally demarcated controversy). A plausible and fruitful contemporary theory of bioethics must be largely descriptive, in Parfit’s sense, providing an intellectual framework that gives coherence and sense to existing practice, while at the same time clarifying matters of confusion.

In contemporary bioethics, a central component of this practice is the application of the four principles of biomedical ethics—non-maleficence, beneficence, justice and autonomy—not merely as originally proposed by Beauchamp and Childress (2019), but in their refined form, following decades of exchange, critique, and revision. DeGrazia and Millum’s theory begins with two core values: well-being and respect for rights holders. [End Page 321] The bulk of the book then applies the method of reflective equilibrium to specify these two values in terms of the canonical four principles, here treated as “mid-level” constructs with readier application to specific cases than the two core values. Experienced bioethicists may have an uncanny sense of setting off from a new trailhead, and yet, eventually finding themselves still walking a familiar path. However, this way of introducing and explicating the four principles will likely be more accessible to a wider audience, including high-level undergraduates and graduate students not already versed in the revisions, refinements, and compromises embedded in Beauchamp and Childress’s discussions.

Two other features recommend this book as a resource for trainees and interested non-experts seeking to deepen their understanding of bioethics. First, the clarity of its style and organizational approach provides a welcome orientation for non-specialists. The chapters are structured so that major contending perspectives are outlined before the authors develop arguments for their own positions in that context. Each chapter proceeds by considering applications of the broader theory, showing how it can illuminate potential candidate approaches or policies, as well as demonstrating how to use the tools of ethical analysis to evaluate these proposals in both ideal and non-ideal cases. This didactic approach to the relationship between conceptual argument and practice will be accessible to many who are initially unfamiliar with or intimidated by theory. Second the commendable decision to make the book electronically available and accessible also has the potential to broaden the reach of the work, and in particular, to engage parties in under-resourced settings, which have so often been overlooked in bioethical discourse.

As noted above, while the authors’ approach is descriptive in Parfit’s sense, it is not necessarily conservative. In many places, the authors highlight how their theory includes elements or renders conclusions that are not broadly accepted, and following the method of reflective equilibrium, they advocate for these positions both in terms of broad principles and particular judgments about cases. This begins with their dual-value...