Winner of the 1975 National Book Award, this brilliant and widely acclaimed book is a powerful philosophical challenge to the most widely held political and social positions of our age--liberal, socialist, and conservative.

Book reviewed in this article: Principles of Biomedical Ethics. By Tom L. Beauchamp and James F. Childress.

Well-Being and Death addresses philosophical questions about death and the good life: what makes a life go well? Is death bad for the one who dies? How is this possible if we go out of existence when we die? Is it worse to die as an infant or as a young adult? Is it bad for animals and fetuses to die? Can the dead be harmed? Is there any way to make death less bad for us? Ben Bradley defends the (...) following views: pleasure, rather than achievement or the satisfaction of desire, is what makes life go well; death is generally bad for its victim, in virtue of depriving the victim of more of a good life; death is bad for its victim at times after death, in particular at all those times at which the victim would have been living well; death is worse the earlier it occurs, and hence it is worse to die as an infant than as an adult; death is usually bad for animals and fetuses, in just the same way it is bad for adult humans; things that happen after someone has died cannot harm that person; the only sensible way to make death less bad is to live so long that no more good life is possible. (shrink)

The topic of self-interest raises large and intractable philosophical questions–most obviously, the question “In what does self-interest consist?” The concept, as opposed to the content of self-interest, however, seems clear enough. Self-interest is interest in one's own good. To act self-interestedly is to act on the motive of advancing one's own good. Whether what one does actually is in one's self-interest depends on whether it actually does advance, or at least, minimize the decline of, one's own good. Though it may (...) be difficult to tell whether a person is motivated by self-interest in a particular instance, and difficult also to determine whether a given act or decision really is in one's self-interest, the meaning of the claims in question seems unproblematic. My main concern in this essay is to make a point about the content of self-interest. Specifically I shall put forward the view that meaningfulness, in a sense I shall elaborate, is an important element of a good life. It follows, then, that it is part of an enlightened self-interest that one wants to secure meaning in one's life, or, at any rate, to allow and promote meaningful activity within it. Accepting this substantial conception of self-interest, however, carries with it a curious consequence: the concept of self-interest which formerly seemed so clear begins to grow fuzzy. Fortunately, it comes to seem less important as well. In Reasons and Persons, Derek Parfit distinguishes three sorts of theories about self-interest–hedonistic theories, preference theories, and what he calls “objective-list theories." Hedonistic theories hold that one's good is a matter of the felt quality of one's experiences. (shrink)

Cultures around the world have regarded self-fulfillment as the ultimate goal of human striving and as the fundamental test of the goodness of a human life. The ideal has also been criticized, however, as egotistical or as so value-neutral that it fails to distinguish between, for example, self-fulfilled sinners and self-fulfilled saints. Alan Gewirth presents here a systematic and highly original study of self-fulfillment that seeks to overcome these and other arguments and to justify the high place that the ideal (...) has been accorded. He does so by developing an ethical theory that ultimately grounds the value of self-fulfillment in the idea of the dignity of human beings.Gewirth begins by distinguishing two models of self- fulfillment--aspiration-fulfillment and capacity-fulfillment--and shows how each of these contributes to the intrinsic value of human life. He then distinguishes between three types of morality--universalist, particularist, and personalist--and shows how each contributes to the values embodied in self-fulfillment. Building on these ideas, he develops a Odialectical' conception of reason that shows how human rights are central to self-fulfillment. Gewirth also argues that self-fulfillment has a social as well as an individual dimension: that the nature of society and the obstacles that disadvantaged groups face affect strongly the character of the self-fulfillment that persons can achieve.Bold in scope and rigorous in execution, Self-Fulfillment is a powerful new contribution to moral, social, and political philosophy. (shrink)

As a part of a research project on Dignity and Older Europeans Programme) I explore in this paper a set of notions of human dignity. The general concept of dignity is introduced and characterized as a position on a value scale and it is further specified through its relations to the notions of right, respect and self-respect. I present four kinds of dignity and spell out their differences: the dignity of merit, the dignity of moral or existential stature, the dignity (...) of identity and the universal human dignity. Menschenwürde pertains to all human beings to the same extent and cannot be lost as long as the persons exist. The dignity of merit depends on social rank and position. There are many species of this kind of dignity and it is very unevenly distributed among human beings. The dignity of merit exists in degrees and it can come and go. The dignity of moral stature is the result of the moral deeds of the subject; likewise it can be reduced or lost through his or her immoral deeds. This kind of dignity is tied to the idea of a dignified character and of dignity as a virtue. The dignity of moral stature is a dignity of degree and it is also unevenly distributed. The dignity of identity is tied to the integrity of the subject's body and mind, and in many instances, although not always, also dependent on the subject's self-image. This dignity can come and go as a result of the deeds of fellow human beings and also as a result of changes in the subject's body and mind. (shrink)

Pascal’s Wager is simply too good to be true—or better, too good to be sound. There must be something wrong with Pascal’s argument that decision-theoretic reasoning shows that one must (resolve to) believe in God, if one is rational. No surprise, then, that critics of the argument are easily found, or that they have attacked it on many fronts. For Pascal has given them no dearth of targets.

Recent neuroscientific evidence brings into question the conclusion that all aspects of consciousness are gone in patients who have descended into a persistent vegetative state (PVS). Here we summarize the evidence from human brain imaging as well as neurological damage in animals and humans suggesting that some form of consciousness can survive brain damage that commonly causes PVS. We also raise the issue that neuroscientific evidence indicates that raw emotional feelings (primary-process affects) can exist without any cognitive awareness of those (...) feelings. Likewise, the basic brain mechanisms for thirst and hunger exist in brain regions typically not damaged by PVS. If affective feelings can exist without cognitive awareness of those feelings, then it is possible that the instinctual emotional actions and pain "reflexes" often exhibited by PVS patients may indicate some level of mentality remaining in PVS patients. Indeed, it is possible such raw affective feelings are intensified when PVS patients are removed from life-supports. They may still experience a variety of primary-process affective states that could constitute forms of suffering. If so, withdrawal of life-support may violate the principle of nonmaleficence and be tantamount to inflicting inadvertent "cruel and unusual punishment" on patients whose potential distress, during the process of dying, needs to be considered in ethical decision-making about how such individuals should be treated, especially when their lives are ended by termination of life-supports. Medical wisdom may dictate the use of more rapid pharmacological forms of euthanasia that minimize distress than the de facto euthanasia of life-support termination that may lead to excruciating feelings of pure thirst and other negative affective feelings in the absence of any reflective awareness. (shrink)

One of the requirements in the Dutch regulation for euthanasia and assisted suicide is that the doctor must be satisfied ‘that the patient's suffering is unbearable, and that there is no prospect of improvement.’ In the notorious Chabot case, a psychiatrist assisted a 50 year old woman in suicide, although she did not suffer from any somatic disease, nor strictly speaking from any psychiatric condition. In Seduced by Death, Herbert Hendin concluded that apparently the Dutch regulation now allows physicians to (...) assist anyone in suicide simply because he or she is unhappy.In this paper, I reject Hendin's conclusion and in particular his description of Mrs Boomsma as someone who was ‘simply unhappy.’ After a detailed narration of her lifestory, I turn to the American philosopher Harry Frankfurt's account of volitional incapacity and love for a more accurate characterization of her suffering. Having been through what she had, she could only go on living as another person than the one she had been when she was a happy mother. That would have violated her integrity, and that she could not bring herself to do. (shrink)

Recent legal rulings concerning the status of advance statements have raised interest in the topic but failed to provide any definitive general guidelines for their enforcement. I examine arguments used to justify the moral authority of such statements. The fundamental ethical issue I am concerned with is how accounts of personal identity underpin our account of moral authority through the connection between personal identity and autonomy. I focus on how recent Animalist accounts of personal identity initially appear to provide a (...) sound basis for extending the moral autonomy of an individual - and hence their autonomous wishes expressed through an advance directive - past the point of severe psychological decline. I argue that neither the traditional psychological account nor the more recent Animalist account of personal identity manage to provide a sufficient basis for extending our moral autonomy past the point of incapacity or incompetence. I briefly explore how analogies to similar areas in law designed to facilitate autonomous decision, such as wills and trusts, provide at best only very limited scope for an alternative justification for granting advance statements any legal or moral authority. I conclude that whilst advance statements play a useful role in formulating what treatment is in a patient’s best interests, such statements do not ultimately have sufficient moral force to take precedence over paternalistic best interest judgements concerning an individual’s care or treatment. (shrink)

It is often accepted that we may legitimately speak about voluntary euthanasia only in cases of persons who are suffering because they are incurably injured or have an incurable disease. This article argues that when we consider the moral acceptability of voluntary euthanasia, we have no good reason to concentrate only on persons who are ill or injured and suffering.

I argue that a version of Pascal's Wager applies to the persistent vegetative state with sufficient force that it ought to part of advance directives.

In the United States, the decision of whether to withdraw or continue to provide artificial nutrition and hydration (ANH) for patients in a permanent vegetative state (PVS) is placed largely in the hands of surrogate decision-makers, such as spouses and immediate family members. This practice would seem to be consistent with a strong national emphasis on autonomy and patient-centered healthcare. When there is ambiguity as to the patient's advanced wishes, the presumption has been that decisions should weigh in favor of (...) maintaining life, and therefore, that it is the withdrawal rather than the continuation of ANH that requires particular justification. I will argue that this default position should be reversed. Instead, I will argue that the burden of justification lies with those who would continue artificial nutrition and hydration (ANH), and in the absence of knowledge as to the patient's advanced wishes, it is better to discontinue ANH. In particular, I will argue that among patients in PVS, there is not a compelling interest in being kept alive; that in general, we commit a worse violation of autonomy by continuing ANH when the patient's wishes are unknown; and that more likely than not, the maintenance of ANH as a bridge to a theoretical future time of recovery goes against the best interests of the patient. (shrink)

I would like to share some reflections on how bioethics fosters dialogue between the sciences and humanities by talking a bit about my work as a physician-ethicist collaborating with neuroscientists studying severe brain injury and mechanisms of recovery. If I am successful in this Pilgrim's Progress, I hope I will convince you that the injured brain can teach us much about ourselves. It is not something I was prepared to believe as a medical student, when I was more certain of (...) things than I am now. (shrink)

Advance directives typically have two defects. First, most advance directives fail to enable people to effectively avoid unwanted medical intervention. Second, most of them have the potential of ending your life in ways you never intended, years before you had to die.

: This article begins with a discussion of persistent vegetative state (PVS), focusing on concerns related to both diagnosis and prognosis and paying special attention to the 1994 Multi-Society Task Force report on the medical aspects of PVS. The article explores the impact of diagnostic and prognostic uncertainties on prospective thinking regarding the possibility of PVS and considers the closely related question of how prospective thinkers might craft advance directives in order to deal most effectively with this possibility.