Public deliberation about health policy in the United States often hinges on two untenable basic assumptions about political legitimacy. The first assumption, common in public debate throughout the United States, is that federal oversight of health care is justified under a federal compact binding all citizens. This assumption is false because the federal compact precludes such oversight. Indeed, the ascendancy of national government (and demise of federalism) over the past 70 years was engineered through the subversion of the federal compact, (...) creating an expansive legitimation gap. The second assumption—that political legitimacy can be established through appeals to expert consensus about fundamental conceptions of justice or human rights—is prevalent among bioethicists. I argue that this assumption is illicit because it hinges on a weak, rationalistic form of majoritarian democracy that conflates public acquiescence with public approval. If the public mission of academic bioethics involves protecting the integrity of public deliberation, then these two basic assumptions should be challenged. (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)

The claim that democratic politics is the art of compromise is a platitude but we seem allergic to compromise in politics when it happens. This essay explores this paradox. Taking my cue from Machiavelli’s claim that there exists a rift between a morally admirable and a virtuous political life, I argue that: a ‘compromising disposition’ is an ambiguous virtue—something which is politically expedient but not necessarily morally admirable; whilst uncongenial to moral integrity, a ‘compromising disposition’ constitutes an essential aspect of (...) political integrity. In so doing, I question certain moralistic assumptions which fuel contemporary vilifications of compromise—that, in theory, democratic politics should be inhospitable to compromise and that political integrity should be akin to moral integrity—and which are shared by Walzer’s Dirty Hands thesis which professes to be sensitive to the realities of politics. These assumptions displace the complex realities of politics and misconstrue the standards of political excellence; they unsatisfactorily idealize political integrity and the messy context in which democratic politicians operate—a context characterized by a plurality of incompatible traditions, each with its own values and principles. Whilst commitment to a set of principles stemming from one’s tradition or pre-election promises implies commitment to realize these, leading a virtuous political life amidst such a grubby domain often requires abandoning some of these. An innocent, all-or-nothing pursuit of one’s principles in politics might prompt political disaster or defeat: an uncompromising disposition entails the entire abandonment of any hope of realizing all of those principles. (shrink)

‘It is necessary to a Prince to learn how not to be good’. This quotation from Machiavelli’s The Prince has become the mantra of the standard dirty hands thesis. Despite its infamy, it features proudly in most conventional expositions of the dirty hands problem, including Michael Walzer’s original analysis. In this paper, I wish to cast a doubt as to whether the standard conception of the problem of DH—the recognition that, in certain inescapable and tragic circumstances an innocent course of (...) action is unfeasible—fully captures Machiavelli’s message and its terrifying implications. In particular, I argue that the standard DH thesis is inadequately ‘static’: it conceives the conflict between ordinary morality and political morality as a stark, momentary and rare paradox of action—an anomaly disrupting the normality of harmony. As such it misconceives both the extent and the nature of the rupture between morality and politics. In this sense, the argument I shall advance does just involve an exercise in the history of political thought. Rather, I want to suggest that, by virtue of its failure to take Machiavelli’s insights seriously, the standard DH thesis fails to live up to its purported capacity to capture the complexity and fragmentation of our moral cosmos and that, consequently, it is nothing more than a thinly veiled version of the idealism and monism it purports to reject. (shrink)

In most children’s hospitals, there are very few ethics consultations, even though there are many ethically complex cases. We hypothesize that the reason for this may be that hospitals develop different mechanisms to address ethical issues and that many of these mechanisms are closer in spirit to the goals of the pioneers of clinical ethics than is the mechanism of a formal ethics consultation. To show how this is true, we first review the history of collaboration between philosophers and physicians (...) about clinical dilemmas. Then, as a case-study, we describe the different venues that have developed at one children’s hospital to address ethical issues. At our hospital, there are nine different venues in which ethical issues are regularly and explicitly addressed. They are ethics committee meetings, Nursing Ethics Forum, ethics Brown Bag workshops, PICU ethics rounds, Grand Rounds, NICU Comprehensive Care Rounds, Palliative Care Team case conferences, multidisciplinary consults in Fetal Health Center, and ethics consultations. In our hospital, ethics consults account for only a tiny percentage of ethics discussions. We suspect that most hospitals have multiple and varied venues for ethics discussions. We hope this case study will stimulate research in other hospitals analyzing the various ways in which ethicists and ethics committees can build an ethical environment in hospitals. Such research might suggest that ethicists need to develop a different set of “core competencies” than the ones that are needed to do ethics consultations. Instead, they should focus on their skills in creating multiple “moral spaces” in which regular and ongoing discussion of ethical issues would take place. A successful ethicist would empower everyone in the hospital to speak up about the values that they believe are central to respectful, collaborative practice and patient care. Such a role is closer to what the first hospital philosophers set out to do than in the role of the typical hospital ethics consultant today. (shrink)