The continuing debate between Persson and Savulescu and myself over moral enhancement concerns two dimensions of a very large question. The large question is: what exactly makes something a moral enhancement? This large question needs a book length study and this I provide in my How to be Good, Oxford 2016.. In their latest paper Moral Bioenhancement, Freedom and Reason take my book as their point of departure and the first dimension of the big question they address is one that (...) emphasizes a distinction, not highlighted in their original 2008 paper, between a moral enhancement that will ensure an improvement in morality and one that will simply make people more motivated to be moral. The second issue concerns whether anything that would be a “moral enhancement” properly so called, could involve denying moral agents the very possibility of autonomously choosing to try to be good. In this response, although P&S cover a number of other related issues, I shall concentrate on these two points. (shrink)

Vaccines, when available, will prove to be crucial in the fight against Covid-19. All societies will face acute dilemmas in allocating scarce lifesaving resources in the form of vaccines for Covid-19. The author proposes The Value of Lives Principle as a just and workable plan for equitable and efficient access. After describing what the principle entails, the author contrasts the advantage of this approach with other current proposals such as the Fair Priority Model.

The literature of bioethics suffers from two serious problems. (1) Most authors are unable to take seriously both the rights of the great apes and of severely disabled human infants. Rationalism—moral status rests on rational capacities—wrongly assigns a higher moral status to the great apes than to all severely disabled human infants with less rational capacities than the great apes. Anthropocentrism—moral status depends on membership in the human species—falsely grants all humans a higher moral status than the great apes. Animalism—moral (...) status is dependent on the ability to suffer—mistakenly equates the moral status of humans and most animals. (2) The concept person is widely used for justificatory purposes, but it seems that it cannot play such a role. It seems that it is either redundant or unable to play any justificatory role. I argue that we can solve the second problem by understanding person as a thick evaluative concept. This then enables us to justify assigning a higher moral status to the great apes than to simple animals: the great apes are persons. To solve the first problem, I argue that certain severely disabled infants have a higher moral status than the great apes because they are dependent upon human relationships for their well-being. Only very limited abilities are required for such relationships, and the question who is capable of them must be based on thick evaluative concepts. Thus, it turns out that to make progress in bioethics we must assign thick evaluative concepts a central role. (shrink)

Nicholas Agar, Jeff McMahan and Allen Buchanan have all expressed concerns about enhancing humans far outside the species-typical range. They argue radically enhanced beings will be entitled to greater and more beneficial treatment through an enhanced moral status, or a stronger claim to basic rights. I challenge these claims by first arguing that emerging technologies will likely give the enhanced direct control over their mental states. The lack of control we currently exhibit over our mental lives greatly contributes to our (...) sense of vulnerability. I then argue moral status should be viewed in terms of vulnerability. The enhanced will slowly gain the ability to command their mental states, reducing their vulnerability. These radically enhanced beings will have greater capacities, and possibly an inner life more valuable than our own. They will also be less vulnerable, and as a result, their moral status will be subordinate to our own. (shrink)

Life-saving health resources like organs for transplant and experimental medications are persistently scarce. How ought we, morally speaking, to ration these resources? Many hold that, in any morally acceptable allocation scheme, the young should to some extent be prioritized over the old. Govind Persad, Alan Wertheimer and Ezekiel Emanuel propose a multi-principle allocation scheme called the Complete Lives System, according to which persons roughly between 15 and 40 years old get priority over younger children and older adults, other things being (...) equal. They defend this ‘modified youngest first’ principle in part by appealing to the greater social investment that has been made in 15-year-olds than in younger children. Ruth Tallman has proposed a distinctive defense of modified youngest first, one that appeals not at all to social investment. We find this defense wanting. Tallman’s argument depends on the idea, which we try to show to be implausible, that allocations should maximize the number of people in the midst of a possibly complete life who actually complete their lives. Moreover, Tallman does not justify the priority modified youngest first gives 15-year-olds over, for example, 5-year-olds. Tallman fails to dispel a serious shortcoming with modified youngest first: its fundamental unfairness to pre-adolescents. (shrink)

Organ transplantation has become a proven, cost-effective lifesaving treatment, but its promise is contingent on the number of available organs. The growing gap between the demand and supply results in unnecessary loss and diminished quality of life as well as high costs for surviving patients and health insurers. Twenty years after the enactment of the National Organ Transplantation Act, it is time to rethink the moral basis and overall design of organ transplantation policy. We propose a national plan for organ (...) transplantation insurance under which the federal government would assume responsibility for increasing the organ supply and would cover all costs associated with transplantation for patients not otherwise covered. (shrink)

Hastings Center Report, Volume 51, Issue 5, Page 18-29, September‐October 2021.

Respect is much referred to in professional codes, in health policy documents and in everyday conversation. What respect means and what it requires in everyday contemporary nursing practice is less than clear. Prescriptions in professional codes are insufficient, given the complexity and ambiguity of everyday nursing practice. This article explores the meaning and requirements of respect in relation to nursing practice. Fundamentally, respect is concerned with value: where ethical value or worth is present, respect is indicated. Raz has argued that (...) the two ways of encountering value are to respect and to engage with it. The former requires acknowledgement and preservation. Respect in nursing practice necessarily requires also engagement. Respect is an active value and can be conceptualized within the context of virtue ethics as a hybrid virtue having both intellectual and ethical components. Examples from the literature are provided to illustrate situations where the respectful nurse requires these components or capabilities. (shrink)

This article articulates and defends a dissolution of the so-called repugnant conclusion, which focuses on the notion of life worth living figuring both in Parfit's formulation of the repugnant conclusion and in most responses to such a conclusion. The proposed dissolution demonstrates that the notion of life worth living is plagued by multiple ambiguities and that these ambiguities, in turn, hamper meaningful debate about both the issue of whether the repugnant conclusion can be avoided and the issue of whether the (...) repugnant conclusion is actually repugnant. This result does not exclude that some modified versions of the repugnant conclusion may yield valuable insights about the value of populations and the tenability of different axiological/ethical theories. Still, if the proposed dissolution is correct, then the repugnant conclusion rests on an ill-defined notion and we lack the information required to assess the merits of the repugnant conclusion. (shrink)

One argument which is frequently levelled against the enhancement of human biology is that we do not understand the evolved function of our bodies well enough to meddle in our biology without producing unintended and potentially catastrophic effects. In particular, this argument is levelled against attempts to slow or eliminate the processes of human ageing, or ‘senescence’, which cause us to grow decrepit before we die. In this article, I claim that even if this argument could usefully be applied against (...) attempts to enhance other human traits, it cannot be valid in the case of attempts to enhance the various processes that constitute senescence. I begin by reviewing the biology of ageing to show how it consists of a number of unrelated traits. Then, following the arguments of a number of evolutionary biologists, I explain that every one of these traits is a product of evolutionary ‘neglect’ rather than ‘intent’. Finally, I consider the strongest version of the argument against enhancing senescence, which acknowledges these facts about the evolution of ageing but insists that we have nevertheless have prudential reasons to avoid enhancement wherever there is some uncertainty about the genetics or evolutionary function of a trait. I provide two reasons for rejecting this version of the argument as well, even in the case of human senescence, where such uncertainty is currently significant. (shrink)

With few exceptions, the literature on withdrawing and withholding life-saving treatment considers the bare fact of withdrawing or withholding to lack any ethical significance. If anything, the professional guidelines on this matter are even more uniform. However, while no small degree of progress has been made toward persuading healthcare professionals to withhold treatments that are unlikely to provide significant benefit, it is clear that a certain level of ambivalence remains with regard to withdrawing treatment. Given that the absence of clinical (...) benefit means treating patients is not only ethically questionable but also taxing on resources that could meet the needs of others, this ambivalence is troubling. Equally, the enduring ambivalence of professionals might be taken to indicate that the issue warrants further attention. In this paper, we review the academic literature on the ethical equivalence of withdrawing and withholding medical treatment. While we are not in outright disagreement with the arguments presented, we suggest that asserting theoretical and decontextualized claims about the ethical equivalence of withdrawing and withholding life-saving treatment does not fully illuminate the moral questions associated with the relevant clinical realities. We argue that what is required is a broader perspective, one rooted in an understanding that withdrawing and withholding life-saving treatment are different practices, the meanings of which are fully comprehensible only through an appreciation of their place within the practice of healthcare more generally. Such an account suggests that if one is to engage with the inappropriate protraction of life-saving treatment resulting from healthcare professionals’ disinclination to withdraw it, then the differences between these practices should be taken seriously. (shrink)

Time-limited trials of intensive care have arisen in response to the increasing demand for intensive care treatment for patients with a low chance of surviving their critical illness, and the clinical uncertainty inherent in intensive care decision-making. Intensive care treatment is reported by most patients to be a significantly unpleasant experience. Therefore, patients who do not survive intensive care treatment are exposed to a negative dying experience. Time-limited trials of intensive care treatment in patients with a low chance of surviving (...) have both a small chance of benefiting this patient group and a high chance of harming them by depriving them of a good death. A ‘rule of rescue’ for the critically unwell does not justify time-limiting a trial of intensive care treatment and overlooks the experiential costs that intensive care patients face. Offering time-limited trials of intensive care to all patients, regardless of their chance of survival, overlooks the responsibility of resource-limited intensive care clinicians for suffering caused by their actions. A patient-specific risk–benefit analysis is vital when deciding whether to offer intensive care treatment, to ensure that time-limited trials of intensive care are not undertaken for patients who have a much higher chance of being harmed, rather than benefited by the treatment. The virtue ethics concept of human flourishing has the potential to offer additional ethical guidance to resource-limited clinicians facing these complex decisions, involving the balancing of a quantifiable survival benefit against the qualitative suffering that intensive care treatment may cause. (shrink)

It has been proposed that an old and ill person may have a ‘duty to die’, i.e. to refuse life-saving treatment or to end her own life, when she is dependent on the care of intimates and the burdens of care are becoming too heavy for them. In this paper I argue for three contentions: You cannot have a strict duty to die, correlating to a claim-right of your relatives, because if they reach the point at which the burdens of (...) care are larger than you can reasonably expect them to take, the natural conclusion is that their duty ends. They may be prepared, however, to go on caring for you beyond that point. In that case your responsibility for their wellbeing may require you to refuse this care, even if this results in a situation for you in which death will be preferable to continued life. If this is the correct understanding of your responsibilities, the objection that in the context of family life the burdens of care attached to one family member’s valued existence can never be ‘too heavy’, fails. It postulates unlimited concern on one side and a total lack of concern on the other. (shrink)

Some of the objections to life-extension stem from a concern with overpopulation. I will show that whether or not the overpopulation threat is realistic, arguments from overpopulation cannot ethically demand halting the quest for, nor access to, life-extension. The reason for this is that we have a right to life, which entitles us not to have meaningful life denied to us against our will and which does not allow discrimination solely on the grounds of age. If the threat of overpopulation (...) creates a rights conflict between the right to come into existence, the right to reproduce, the right to more opportunities and space , and the right to life, the latter ought to be given precedence. (shrink)

Some philosophers and segments of the public think age is relevant to healthcare priority-setting. One argument for this is based in equity: “Old” patients have had either more of a relevant good than “young” patients or enough of that good and so have weaker claims to treatment. This article first notes that some discussions of age-based priority that focus in this way on old and young patients exhibit an ambiguity between two claims: that patients classified as old should have a (...) low priority, and that patients classified as young should have high priority. The author next argues, drawing on a problem raised by Christine Overall, that equity cannot justify giving “old” patients low priority, since there is wide variety in the total lifetime experiences of older people, partly influenced by gender, race, class, and disability injustice. Finally, the author suggests that there might be a limited role for age-based prioritization in the context of infant and childhood death, since those who die in childhood are always and uncontroversially among the worst-off. (shrink)

This paper is focused on the analysis of two documents (the Council of Europe's Bioethics Convention and the Additional Cloning Protocol) inasmuch as they refer to the relationship between human dignity and human genetic engineering. After presenting the stipulations of the abovementioned documents, I will review various proposed meanings of human dignity and will try to identify which of these seem to be at the core of their underlying assumptions. Is the concept of dignity proposed in the two documents coherent? (...) Is it morally legitimate? Is it, as some might assume, of Kantian origin? Does it have any philosophical roots? (shrink)

The majority of midwives in the UK are employed within the NHS. They are legally bound to fulfil their contractual obligations to their employers. At the same time they are professionally mandated to interpret and act on the UKCC's Code of professional conduct. Midwives have always maintained that they are autonomous practitioners, and the Code is written in a way that endorses this belief. Underlying the Code is the assumption that midwives have moral and professional freedom to act on its (...) imperatives. However, midwives' claim to autonomy is flawed, and therefore the Code's claim to be a source of empowerment is also flawed. Underlying the difficulties is a conflict derived from the imposition of a deontologically-based professional Code on to a workforce that is constrained within and employed by the utilitarian-based NHS. (shrink)

Allocating scarce organs to transplant candidates is only one stage in the long process of organ transplantation. Before being listed, all candidates must undergo a rigorous assessment by a multidisciplinary transplant team. The Department of Health and NHS Blood and Transplant (NHSBT) are responsible for the development of detailed strategies to ensure a fair and objective assessment experience for all transplant candidates. Difficulties arise when particularly vulnerable candidates, such as candidates with psychiatric illnesses, are assessed. NHSBT has already developed unique (...) assessment guidelines for alcoholic and substance-abusing liver transplant candidates to allow for a more comprehensive evaluation, but candidates with psychiatric illnesses are still assessed against general criteria. Should these candidates be assessed against their own criteria? On what clinical grounds do transplant teams justify excluding such candidates from transplantation? Is redress available for candidates who feel they have been unfairly refused a liver transplant simply because of their psychiatric illness? This essay will critically examine the provisions published by the Department of Health and NHSBT for the assessment of liver transplant candidates with psychiatric illnesses, and will provide a commentary as to whether enough is being done to protect these particularly vulnerable candidates from inconsistent assessment decisions. (shrink)

Animals, in the age of biotechnology, are the subjects of a myriad of scientific procedures, interventions, and modifications. They are created, altered, and experimented upon—often with highly beneficial outcomes for humans in terms of knowledge gained and applied, yet not without concern also for the effects upon the experimental subjects themselves: consideration of the use of animals in research remains an intensely debated topic. Concerns for animal welfare in scientific research have, however, been primarily directed at harm to and suffering (...) of animal subjects and their prevention. Little attention has been paid to the benefits research might potentially produce for animals themselves and the interests that some animals may therefore have in the furtherance of particular avenues of science. (shrink)

The philosophical debate surrounding the moral status of the embryo has reached the public arena. The author of this paper examines some of the common arguments against embryo experimentation, including an influential article by Professor Ian Kennedy. He concludes that these arguments do not succeed in demonstrating that the intentional creation of embryos for research purposes is wrong, unless they also succeed in demonstrating that contemporary liberal abortion laws are also wrong. The author also criticises the conclusions of the Warnock (...) Report, and suggests that the reasons for permitting embryo research must be given a wider public audience. (shrink)

Counting QALYs (quality adjusted life years) has been proposed as a way of deciding how resources should be distributed in the health service: put resources where they will produce the most QALYs. This proposal has encountered strong opposition. There has been a disagreement between some economists favouring QALYs and some philosophers opposing them. But the argument has, I think, mostly been at cross-purposes. Those in favour of QALYs point out what they can do, and those against point out what they (...) can't. There need be no disagreement about this. What is needed is to sort out what is the proper domain of QALYs, and it may be possible to do this amicably. Then we may be able to get on with the more useful job of deciding how well QALYs perform within their domain. In this paper I shall try to accomplish the first task (sections II–IV), and make a start on the second (sections V–VIII). (shrink)

Several authors have discussed and defended what is sometimes called the Asymmetry Thesis in social epistemology: that while reliance on testimony is essentially incontrovertible in epistemology, it is uniquely problematic for moral knowledge. This conclusion results, I argue, from considering the wrong sort of moral testimony: namely, ‘third-personal’ rather than ‘first-personal’ testimony. First-personal moral testimony is an inescapable part of the constitution of legitimate moral norms, and its role cannot be deflated as a form of mere information to be taken (...) up in private deliberation. The consequences of this argument for forms of hypothetical contractualism, in particular, are profound. (shrink)

The global COVID-19 pandemic has brought the issue of rationing finite healthcare resources to the fore. There has been much academic debate, media attention, and conversation in the homes of everyday individuals about the allocation of medical resources, diagnostic testing kits, ventilators, and personal protective equipment. Yet decisions to prioritize treatment for some individuals over others occur implicitly and explicitly in everyday practices. The pandemic has propelled the socially taboo and unavoidably prickly issue of healthcare rationing into the public spotlight—and (...) as such, healthcare rationing demands ongoing public attention and transparent discussion. This article concludes that in the aftermath of COVID-19, policymakers should work towards normalizing rationing discussions by engaging in transparent and honest debate in the wider community and public domain. Further, injecting greater openness and objectivity into rationing decisions might go some way towards dismantling the societal taboo surrounding rationing in healthcare. (shrink)

As the demand for healthcare rises, so does the need for priority setting in healthcare. In this paper, I consider a prominent priority-setting principle: proportional shortfall. My purpose is to argue that proportional shortfall, as a principle, should not be adopted. My key criticism is that proportional shortfall fails to consider past health.Proportional shortfall is justified as it supposedly balances concern for prospective health while still accounting for lifetime health, even though past health is deemed irrelevant. Accounting for this lifetime (...) perspective means that the principle may indirectly consider past health by accounting for how far an individual is from achieving a complete, healthy life. I argue that proportional shortfall does not account for this lifetime perspective as it fails to incorporate the fair innings argument as originally claimed, undermining its purported justification.I go on to demonstrate that the case for ignoring past health is weak, and argue that past health is at least sometimes relevant for priority-setting decisions. Specifically, when an individual’s past health has a direct impact on current or future health, and when one individual has enjoyed significantly more healthy life years than another.Finally, I demonstrate that by ignoring past illnesses, even those entirely unrelated to their current illness, proportional shortfall can lead to instances of double jeopardy, a highly problematic implication. These arguments give us reason to reject proportional shortfall. (shrink)

Age-based rationing remains highly controversial. This question has been paramount during the Covid-19 pandemic. Analyzing the practices, proposals, and guidelines applied or put forward during the current pandemic, three kinds of age-based rationing are identified: an age-based cut-off, age as a tiebreaker, and indirect age rationing, where age matters to the extent that it affects prognosis. Where age is allowed to play a role in terms of who gets treated, it is justified either because this is believed to maximize benefits (...) from scarce resources or because it is believed to be in accordance with the value of fairness understood as (a) fair innings, where less priority is given to those who have lived a full life or (b) an egalitarian concern for the worse off. By critically assessing prominent frameworks and practices for pandemic rationing, this article considers the balance the three kinds of age-based rationing strike between maximizing benefits and fairness. It evaluates whether elements in the proposals are, in fact, contrary to the justifications of these measures. Such shortcomings are highlighted, and it is proposed to adjust prominent proposals to care for the worse off more appropriately and better consider whether the acquired benefits befalls the young or the old. (shrink)

La pandemia de la COVID-19 ha levantado sospechas de edadismo y gerontofobia en diversas prácticas de racionamiento sanitario. La edad es un criterio de triaje controvertido. En este artículo se esclarece la relevancia ética de la edad dentro de los sistemas de triaje, analizando particularmente su rol dentro de los principios de equidad y de eficiencia. La equidad requiere dar más oportunidades a aquellos que han cumplido menos ciclos vitales. La eficiencia tiene en cuenta la edad de manera subrepticia al (...) tratar de maximizar los beneficios a corto plazo (salvar vidas) y a largo plazo (salvar años de vida). Finalmente, la edad no debe ser la última ratio de las decisiones de triaje, aunque es una variable a tener en cuenta debido a su presencia implícita en principios fundamentales de priorización. The COVID-19 pandemic has raised suspicions of ageism and gerontophobia in various health rationing practices. Age is a controversial triage criterion. This article clarifies the ethical relevance of age within triage systems, particularly its role within the principles of fairness and efficiency. Fairness requires giving more opportunities to those who have completed fewer life cycles. Efficiency takes age into account surreptitiously when trying to maximize short-term (saving lives) and long-term (saving years of life) benefits. Finally, age should not be the final rationale in triage decisions, although it is a variable to be taken into account because of its implicit presence in fundamental principles of prioritization. (shrink)

Lääketieteellisten teknologioiden kehitys voi tulevaisuudessa johtaa siihen, että ihmisten elinikä voidaan moninkertaistaa. Eri filosofisista lähtökohdista tällaisen toiminnan toivottavuuteen voidaan suhtautua eri tavoin. Jonathan Glover ja John Harris ovat tervehtineet mahdollisuutta ilolla ja suositelleet pyrkimistä sen toteuttamiseen. Enemmän elämää on heidän mielestään parempi kuin vähemmän, eikä asiaa tarvitse sen kummemmin monimutkaistaa. Leon Kass ja Jürgen Habermas ovat puolestaan torjuneet ajatuksen kauhistuneina. Elämämme arvo ei riipu sen pituudesta, vaan sen annetusta tai lahjana saadusta sisällöstä. Kirjoituksessa teen selkoa näistä kahdesta vastakkaisesta kannasta koskien (...) ”elämän tarkoitusta” ja lisään joukkoon oman tulkintani epikurolaisesta ajattelusta. Viimeksi mainitun mukaan eliniän huomattavasta lisäämisestä ei olisi ihmisille sen paremmin haittaa kuin hyötyäkään. (shrink)

In the context of a global pandemic, there is good health-based reason for governments to impose various social distancing measures. However, such measures also cause economic and other harms to people at low risk from the virus. In this paper, I examine how to make such trade-offs in a way that is respectfully justifiable to their losers. I argue that existing proposals like using standard QALY (quality-adjusted life-year) valuations or WELLBYs (wellbeing-adjusted life-years) as the currency for trade-offs do not allow (...) such justification, because they give weight to utilities that are irrelevant in a life-and-death context. Drawing on work on restricted aggregation in ethics, I articulate an alternative framework for balancing claims arising from prospects of different kinds of harm and benefit, and show how it can be applied to reasoning about trade-offs in a pandemic context. (shrink)

After rejecting Carruthers' conflation of levels of consciousness as implausible and conceptually muddled, and Carruthers' claim that nonhumans are automata as undermined by evolutionary and ethological considerations, we develop a general criticism of contemporary philosophical approaches which, though recognizing nonhuman consciousness, still see animals as mere receptacles of experiences. This is, we argue, due to the fact that, while in the case of humans we grant a self - something that has not only a descriptive but also a prescriptive side, (...) requiring at least non-interference - in the case of nonhumans we focus only on the descriptive aspects. Consequently, we treat humans as equals whatever their capacities, but we order nonhumans in a hierarchy based on their cognitive level. We conclude that such double standards are not only inconsistent but also self-serving. (shrink)