The exportation of Western biomedicine throughout the world has not resulted in a systematic homogenization of scientific ideology but rather in the proliferation of many forms and practices of biomedicine. Similarly, in the last decade, bioethics has become increasingly an international enterprise. Although there may be consensus regarding the inherent value of ethical discourse as it relates to health and medical care, there are disagreements about the nature and parameters of medical morality. This lack of consensus exists because our beliefs (...) about morality are culturally constituted, embedded in social, religious, and political ideologies that influence particular individuals and communities at specific historical moments. (shrink)

In this issue, contributors engage Timothy Murphy’s proposal for irreligious bioethics over against religious bioethics. Two essays take opposing sides in the debate, while a third seeks middle ground. Another essay questions the meaning of the words “religion,” “irreligion,” and “secular.” The final essay examines the religious nature of human existence and its implications for the debate.

Full-Blooded religion is not acceptable in mainstream bioethics. This article excavates the cultural history that led to the suppression of religion in bioethics. Bioethicists typically fall into one of the following camps. 1) The irreligious, who advocate for suppressing religion, as do Timothy F. Murphy, Sam Harris, and Richard Dawkins. This irreligious camp assumes American Fundamentalist Protestantism is the real substance of all religions. 2) Religious bioethicists, who defend religion by emphasizing its functions and diminishing its metaphysical commitments. Religious defenders (...) empty religion of its theology to present its feel-good functions in a way that is acceptable to the irreligious. However, religion reduced to its functions dissolves into a counter-culture that may counteract materialism but lacks the power to motivate much more. This article criticizes both camps, as both presume Enlightenment myths and consequently neuter religion. Both irreligious and religious bioethicists commonly presume Enlightenment myths about secularity and religion. Secularity is presumed neutral and rational. Religion is presumed divisive and irrational. This myth provides built-in value-judgements; we have already judged secularity as good and religion as bad. Much of the debate over religion in bioethics is arguing over false stereotypes of religion. Consequently, mainstream bioethics neuters religion, while the irreligious are gifted political power to define the field. (shrink)

The origins of professional ethical codes and oaths are explored. Their legitimacy and usefulness within the profession are questioned and an alternative ethical source is suggested. This source relies on a commonly shared, naturally knowable set of principles known as common morality.

From time to time medical ethicists bemoan the loss of a religious perspective in medical ethics. The discipline had its origins in the thinking of explicitly religious thinkers such as Paul Ramsey and Joseph Fletcher. Furthermore, many of those who contributed to the early development of the discipline had training in theology. One thinks of Daniel Callahan, Richard McCormick, Albert Jonsen, Sam. Banks. As the discipline becomes more and more self-reflective, with attention being paid to methodological and conditional concerns, it (...) is only natural that the roots are due for a reexamination. The time has therefore come for some reassessment. The first steps here are taken in the form of a dialogue between the coauthors to clarify authentic contributions and weed out unauthentic ones. (shrink)

The national standards for clinical ethics consultation set forth by the American Society for Bioethics and Humanities endorse an “ethics facilitation” approach, which characterizes the role of the ethicist as one skilled at facilitating consensus within the range of ethically acceptable options. To determine the range of ethically acceptable options, ASBH recommends the standard model of decision-making, which is grounded in the values of autonomy, beneficence, nonmaleficence, and justice. H. Tristram Engelhardt Jr. has sharply criticized the standard model for presuming (...) contentful moral claims in circumscribing the range of ethically acceptable options, which, he argues, cannot be rationally justified in a pluralistic context. Engelhardt’s solution is a secular clinical ethics based on a contentless principle of permission. The first part of this article lays out Engelhardt’s negative claim, that reason cannot establish contentful moral claims, and his positive claim, that secular clinical ethics ought to be based on a contentless principle of permission. The second part critiques these negative and positive claims. The purpose of this paper is to defend secular clinical ethics expertise—defined as the ability of ethicists to offer justified moral recommendations grounded in consensus positions endorsed by the American Society for Bioethics and Humanities—from the radical critiques of Engelhardt, who argues that no moral or metaphysical claims, and hence no bioethical consensus, can be rationally justified. Engelhardt’s critiques have caused some to worry that secular clinical ethics is in a state of theoretical crisis; this article concludes that Engelhardt’s view is an unstable basis for that worry. (shrink)

Even though respect for integrity is hailed in several authoritative legal and ethical documents, and is typically presented as a complement to respect for autonomy, it is largely neglected in many leading works in ethics. Is such neglect warranted, or does it express a prejudice? This article argues that the latter is the case, and that this is due to misplaced conceptual concerns. It offers some proposals as regards the conceptualization of integrity in social ethics in general and in biomedical (...) ethics in particular. Five main directions of interpretation of “integrity” are discerned and shown to be relevant for different areas of biomedical ethics. The defense of respect for integrity is served by a softening of principlism and by greater attention to context among the initial critics of this principle. (shrink)

On one side of his sign board, a nineteenth century surgeon depicted a physician operating on a patient's leg; the other side showed the Good Samaritan taking care of the victim's wounds. Christ's parable has often been quoted and depicted as a primary example of human compassion, to be followed by all persons and, a fortiori, by so-called professionals such as physicians and nurses. If we grant that the parable has not lost its narrative power for 20th century “postmodern” readers (...) living in a “pluralistic” society, it merits a closer analysis. (shrink)

Increasingly, the world seems to shrink due to our ever-expanding technological and communication capacities. Correspondingly, our awareness of other cultures increases. This is especially true in the field of bioethics because the technological progress of medicine throughout the world is causing dramatic and challenging intersections with traditionally held values. Think of the use of pregnancy monitoring technologies like ultrasound to abort fetuses of the “wrong” sex in India, the sale of human organs in and between countries, or the disjunction between (...) the haves and the have-nots in South America when it comes to bone marrow transplants, while thousands of other children die for want of fundamental goods and services like clean water, basic inoculations, and food itself. (shrink)

Staggering advances in biotechnology within the past decade have given rise to pharmacological, surgical and prosthetic techniques capable of enhancing human functioning rather than merely treating or preventing disease. Bioenhancement technologies range from nootropics capable of enhancing cognitive abilities to distraction osteogenesis, a surgical technique capable of increasing height through limb lengthening. This paper examines whether the use of bioenhancements falls inside or outside the proper boundaries of healthcare, and if so, whether clinicians have professional responsibilities to administer bioenhancements to (...) patients. After explicating two theoretical approaches to the concept of health, one objectivist and the other constructivist, I contend that clinicians' corresponding professional responsibilities hinge on which philosophical account of health is endorsed, and illustrate how the lack of analytic clarity with respect to this concept can lead to defective positions on the place of bioenhancements in healthcare. With this conceptual framework in place, an account of health as a cluster concept that incorporates both constructivist and objectivist components is developed and defended. (shrink)

The prospect of germ-line genetic engineering, the ability to engineer genetic changes that can be passed on to subsequent generations, raises a wide range of moral and public policy questions. One of the most provocative questions is, simply put: Are there moral reasons that can be articulated in general secular terms for accepting human nature as we find it? Or, at least in terms of general secular moral restraints, may we reshape human nature better to meet our own interests, as (...) we define them? This question in turn raises the further question of whether human nature as it now exists has a moral standing akin to sacredness that can be understood in nonreligious terms. This essay will take as a given that it is not possible to show in general secular moral terms that human nature has a sanctity or special moral standing that should guide secular health-care policy. In addition, as this essay shows, it is not possible through appeals to considerations of authorizing consent or beneficence toward others to remedy this failure to establish a sanctity or special moral standing for human nature. Absent a religious or culturally normative understanding of human nature and given the availability of germline genetic engineering, there is a plurality of possibilities for refashioning our nature. The unavailability of substantive secular moral constraints on germ-line genetic engineering discloses a secularly licit plurality of possibilities for human nature. The likelihood that we will be able to refashion our human nature reveals how few general secular moral constraints there are to guide us. Paradoxically, the more we are able to reengineer our human nature, the less guidance is available. The plurality of possible conceptions of human well-being that can be pursued through germ-line genetic engineering challenges our self-understanding as humans. Given human freedom, and in the absence of taken-for-granted religious or cultural moral constraints, the likelihood of germ-line genetic engineering opens the possibility of human nature in the plural. (shrink)

Issues of social justice have traditionally been given short shrift by American healthcare professionals, feeling that justice at the bedside is inapplicable and possibly even misplaced. However, perhaps motivated by the realization that escalating costs and maldistribution of healthcare represent an intolerable situation, an ever-growing amount of medical literature and healthcare ethics literature is turning to considerations of justice.

Heated debates over healthcare policy in the United States point to the need for a legal framework that can sustain both moral diversity and peaceful cooperation. It is argued that the classical liberal Rule of Law, with its foundation in the ethical principle of permission, is such a framework. The paper shows to what extent the current healthcare policy landscape in the United States diverges from the rule of law and suggests how the current framework could be modified in order (...) to better approximate that ideal. Two objections are then answered. The first is that the rule of law cannot be realized due to the structure of legislatures. The second objection is that government should guarantee both liberty and all of the necessary conditions of autonomy. (shrink)

Bioethics mediation is increasingly used as a method in clinical ethics cases. My goal in this paper is to examine the implicit theoretical assumptions of the bioethics mediation method developed by Dubler and Liebman. According to them, the distinguishing feature of bioethics mediation is that the method is useful in most cases of clinical ethics in which conflict is the main issue, which implies that there is either no real ethical issue or if there were, they are not the key (...) to finding a resolution. I question the tacit assumption of non-normativity of the mediation method in bioethics by examining the various senses in which bioethics mediation might be non-normative or neutral. The major normative assumption of the mediation method is the existence of common morality. In addition, the four-principle formulation of the theory articulated by Beauchamp and Childress implicitly provides the normative content for the method. Full acknowledgement of the theoretical and normative assumptions of bioethics mediation helps clinical ethicists better understand the nature of their job. In addition, the need for a robust philosophical background even in what appears to be a purely practical method of mediation cannot be overemphasized. Acknowledgement of the normative nature of bioethics mediation method necessitates a more critical attitude of the bioethics mediators towards the norms they usually take for granted uncritically as valid. (shrink)

Physicians have long aided their patients in dying in an effort to ease human suffering. It is only in the nineteenth and twentieth centuries that the prolongation of life has taken on new meaning due to the powers now available to physicians, through new drugs and high technology interventions. Whereas earlier physicians and patients could readily acknowledge that nothing further could be done, today that judgment is problematic.Most often, aiding the dying took the form of not doing anything further to (...) prolong life. Morally, this act of restraint was not difficult, because few options could have been considered. However, some physicians, rarely, would help patients die either by hastening death directly or by increasing pain control with the risk of hastening death, the so-called double effect. When directly hastening death, physicians either directly caused the death of the patient through euthansia, or supplied the means to the patient to bring about death with or without encouragement to use these means. The latter is physician-assisted suicide. (shrink)

Douglas Diekema has argued that it is not the best interest standard, but the harm principle that serves as the moral basis for ethicists, clinicians, and the courts to trigger state intervention to limit parental authority in the clinic. Diekema claims the harm principle is especially effective in justifying state intervention in cases of religiously motivated medical neglect in pediatrics involving Jehovah’s Witnesses and Christian Scientists. I argue that Diekema has not articulated a harm principle that is capable of justifying (...) state intervention in these cases. Where disagreements over appropriate care are tethered to metaphysical disagreements, it is moral-metaphysical standards, rather than merely moral standards, that are needed to provide substantive guidance. I provide a discussion of Diekema’s harm principle to the broader end of highlighting an inconsistency between the theory and practice of secular bioethics when overriding religiously based medical decisions. In a secular state, ethicists, clinicians, and the courts are purportedly neutral with respect to moral-metaphysical positions, especially regarding those claims considered to be religious. However, the practice of overriding religiously based parental requests requires doffing the mantle of neutrality. In the search for a meaningful standard by which to override religiously based parental requests in pediatrics, bioethicists cannot avoid some minimal metaphysical commitments. To resolve this inconsistency, bioethicists must either begin permitting religiously based requests, even at the cost of children’s lives, or admit that at least some moral-metaphysical disputes can be rationally adjudicated. (shrink)

End-of-life decision making constitutes a major challenge for bioethical deliberation and political governance in modern democracies: On the one hand, it touches upon fundamental convictions about life, death, and the human condition. On the other, it is deeply rooted in religious traditions and historical experiences and thus shows great socio-cultural diversity. The bioethical discussion of such cultural issues oscillates between liberal individualism and cultural stereotyping. Our paper confronts the bioethical expert discourse with public moral attitudes. The paper is based on (...) a qualitative study comprising 12 focus group discussions with religious and secular persons in the USA, Germany, and Israel. Considering the respective socio-political and legal frameworks, the thematic analysis focuses on moral attitudes towards end-of-life decision making and explores the complex interplay between individual preferences, culture, and religion. Our findings draw attention to the variety and complexity of cultural and religious aspects of end-of-life decision making. Although there is local consensus that goes beyond radical individualism, positions are not neatly matched with national cultures or religious denominations. Instead, the relevance of the specific situatedness of religious beliefs and cultural communities becomes visible: Their status and role in individual situations, for example, as consensual or conflicting on the level of personal perspectives, family relationships, or broader social contexts, e.g., as a majority or minority culture within a political system. As the group discussions indicate, there are no clear-cut positions anchored in “nationality,” “culture,” or “religion.” Instead, attitudes are personally decided on as part of a negotiated context representing the political, social and existential situatedness of the individual. Therefore, more complex theoretical and practical approaches to cultural diversity have to be developed. (shrink)

Last month, a fifty-eight-year old man developed bleeding into his cheek and oozing from sites where previously he had had blood samples drawn. This bleeding was caused by disseminated intravascular coagulation, a complication of colon cancer that had spread to his liver and lungs. This complication occurred even though he was on chemotherapy for the cancer. In the hospital, he received transfusions and was administered medicine to stop the bleeding. However, his condition did not improve. He developed more bruises. When (...) he tried to go to the bathroom without assistance, he fell, struck his head, requiring stitches, and developed a black, swollen eye. The patient, a successful businessman, had already overcome another type of cancer—lymphoma—through chemotherapy, twenty-five years ago. In a few days, this dynamic individual who expected to start experimental chemotherapy now saw his quality of life deteriorate steadily.We talked about more chemotherapy, about hospice, and about withholding attempts at resuscitation if his heart should stop. (shrink)