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.

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)

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 collection of essays, Global Bioethics: The Collapse of Consensus, deals with the issue of the repeated failure of attempts to derive a universal set of ...

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 and its sociology of knowledge, 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)

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)

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)

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)

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)

Of all the moral concerns regarding privacy in its various meanings, this essay selects only one: the right to be left alone by others, in particular, by government. Because moral controversies in pluralist societies tend to be interminable, and surely controversies regarding privacy are no exception, I approach the right to privacy in terms of the centrality of persons. When there are foundational disputes about which content-full moral view should govern, it is not possible to resolve such controversies without begging (...) the question or conceding at the outset crucial moral premises. This observation is not to affirm a moral skepticism or relativism. At worst, it involves an epistemic skepticism, a skepticism about the possibility of resolving controversies by sound rational argument without begging the question or engaging in an infinite regress. (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)

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)

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)

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)

The globalizing or totalizing imposition of a particular understanding of justice, fairness, or equality, as seen, for example, in Canada's single health care system, which forbids the sale of private insurance and the purchase of better basic health care, cannot be justified in general secular terms because of the following limitations: the plurality of understandings of justice, fairness, and equality, and the inability to establish one understanding as canonical. The secular state lacks plausible moral authority for the coercive imposition of (...) one such account on peaceable, consenting adults. This state of affairs, with regard to the weakness of human moral epistemological powers, means that the secular state fails to have the moral authority to forbid coercively the sale and purchase of organs. It further lacks the secular, moral authority to impose equal access to organ transplantations. Assertions of such authority amount to reckless claims of fairness, and for this reason, health care policy must be set within the constraints of limited, constitutional regimes. (shrink)

Contemporary Christians are separated by foundationally disparate understandings of Christianity itself. Christians do not share one theology, much less a common understanding of the significance of sin, suffering, disease, and death. These foundational disagreements not only stand as impediments to an intellectually defensible ecumenism, but they also form the underpinnings of major disputes in the culture wars, particularly as these are expressed in healthcare. There is not one Christian bioethics of sin, suffering, sickness, and death. In this article, the character (...) of the moral-theological visions separating the various Christianities and thus their bioethics is examined. Particular emphasis is placed on the differences that set contemporary Western theology at odds with the theology of the Christianity of the first millennium. As is shown, the ground for this gulf lies in the divide between traditional and post-traditional views of the appropriate role of philosophy in theology, a difference rooted in disparate understandings of the meaning of church and of the meaning of the logos, the Son of God. (shrink)

Instead of benefitting from open meetings and public discussions, the Clintons drafted their health care plan in private and asked that it be accepted in haste. They advance an ideology that claims we can receive the best care for all without any increase in cost or rationing, and then they use "ethicists" to justify this ideology through a supposedly common morality. However, there is no such common morality. In the context of American pluralism, one must look to the actual consent (...) of the governed and recognize the limits on state authority. The result will be a two tiered system of health care, with a basic tier focusing on cost-effective care for the poor that eliminates suffering rather than equalizing inputs, and a space for collateral private insurance. Keywords: Clinton health plan, egalitarianism of envy, egalitarianism of altrusim, limited democracy, moral pluralism CiteULike Connotea Del.icio.us What's this? (shrink)

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)

In his 1993 health-care reform proposal, Bill Clinton offered health care as a civil right. If his proposal had been accepted, all Americans would have been guaranteed a basic package of health care. At the same time, they would have been forbidden to provide or purchase better basic health care, as a cost of participating in a national system to which they were compelled to contribute. A welfare entitlement would have been created and an egalitarian ethos enforced. This essay will (...) address why such egalitarian proposals are morally unjustifiable, both in terms of the establishment of a uniform health-care welfare right, and in terms of the egalitarian constraints these proposals impose against the use of private resources in the purchase of better-quality basic health care, not to mention luxury care. (shrink)