Moral teachings from unexpected quarters. Lessons for bioethics from the social sciences and managed care

O n the usual account of moral reasoning, social science is often seen as able to provide “just the facts,” while philosophy attends to moral values and conceptual clarity and builds formally valid arguments. Yet disciplines are informed by epistemic values—and bioethics might do well to see social scientific practices and their attendant normative understandings about what is humanly important as a significant part of ethics generally.     

Moral transhumanism: the next step

Although transhumanism offers hope for the transcendence of human biological limitations, it generates many intrinsic and consequential ethical concerns. The latter include issues such as the exacerbation of social inequalities and the exponentially increasing technological capacity to cause harm. To mitigate these risks, many thinkers have initiated investigations into the possibility of moral enhancement that could limit the power disparities facilitated by biotechnological enhancement. The arguments often focus on whether moral enhancement is morally permissible, or even obligatory, and remain largely in the realm of the hypothetical. This paper proposes that psilocybin may represent a viable, practical option for moral enhancement and that its further research in the context of moral psychology could comprise the next step in the development of moral transhumanism.     

A Man of Vision: Daniel Callahan on the Nasty Problem and the Noxious Brew

This essay, published shortly before the 2020 U.S. presidential election (mired in controversy over a potential judicial appointment to the Supreme Court), celebrates Daniel Callahan's prescient book Abortion: Law, Choice and Morality. Nothing could be timelier. Callahan's central question was the “moral and social” struggle requisite for coherent policies and laws regulating abortion. He rejected “one-value” positions and strove to develop an expansive middle ground. He decried emotion untutored by reason, crude polemics, and bludgeoning: his recipe for a “noxious brew.” Callahan's way of thinking preceded the development of a critical health humanities, the advent of moral foundations theory in psychology, and the philosophical concept of a moral imagination. Each of these inheres in his rigorous approach to the abortion problem. His honesty and humility led to a sea change in his position on abortion. Fifty years later, much can still be learned from Callahan's arguments—about abortion and other bioethics issues—most importantly, in how we address wider social issues in these polarized times.     

So-called "clinical equipoise" and the argument from design

In this article, I review and expand upon arguments showing that Freedman's so-called "clinical equipoise" criterion cannot serve as an appropriate guide and justification for the moral legitimacy of carrying out randomized clinical trials. At the same time, I try to explain why this approach has been given so much credence despite compelling arguments against it, including the fact that Freedman's original discussion framed the issues in a misleading way, making certain things invisible: Clinical equipoise is conflated with community equipoise, and several versions of each are also conflated. But a misleading impression is given that, rather than distinct criteria being arbitrarily conflated, a puzzle is solved and a number of features unified. Various issues are pushed under the rug, hiding flaws of the "clinical equipoise" approach and thus deceiving us into thinking that we have a solution when we do not. Particularly significant is the ignoring of the crucial distinction between the individual patient decision and the policy decision.     

Parental wisdom, empirical blindness, and normative evaluation of prenatal genetic enhancement

The purpose of this paper is to unveil one problem that surrounds the debate over the moral standing of prenatal genetic enhancement (PGE) and to outline a solution to it. The problem is that we have no way to test our speculations about the consequences of prenatal enhancement without begging the question about the moral permissibility of enhancing unborn children. The only way to empirically support our speculations about the consequences of prenatal enhancement is to resort to ethically worrisome (and radical) experimental genetic research. The suggested solution to this problem is to focus on the character of good parents. The virtue of parental wisdom is introduced and used as a basis for evaluating PGE. It is argued that good parents have good reason not to condone PGE for their children (in very many cases), especially as part of the first wave of genetically altered humans.     

The meanings of professional life: teaching across the health professions

Most of professional ethics is grounded on the assumption that we can speak meaningfully about particular, insulated professions with aims and goals, that conceptually there exists a clear "inside and outside" to any given profession. Professional ethics has also inherited the two-part assumption from mainstream moral philosophy that we can speak meaningfully about agent-relative versus agent-neutral moral perspectives, and further, that it is only from the agent-neutral perspective that we can truly evaluate our professional moral aims, rules, and practices. Several important changes that have occurred, or are currently taking place, in the structure of the health care professions, challenge those assumptions and signal the need for teachers of professional ethics to rethink the content of what we teach as well as our teaching methods. The changes include: influences and critique from other professions and from those who are served by the health professions, and influences and critique from professionals themselves, including increased activism and dissent from within the professions. The discussion focuses on changes that have occurred in the health-related fields, but insofar as similar changes are occurring in other professions such as law and business, these arguments will have broader conceptual implications for the way we ought to think about professional ethics more generally.     

The psychology of autonomy

In May 2016, right around the time that this issue of the Hastings Center Report should be published, The Hastings Center is holding a conference in New York City titled “Bioethics Meets Moral Psychology.” The goal of the conference is to consider the lessons that bioethicists should learn from the raft of literature now accumulating on how the mental processes of perception, emotion, and thinking affect things that bioethicists care about, from the education of health care professionals to the conflicts that arise in clinical care, the “culture wars” over bioethical policy issues, the status of different cultures’ value systems, and the very understanding of the values that are foundational in moral thinking. The articles in this issue simply provide more evidence that bioethics is meeting moral psychology.     

The normativity of clinical health care: perspectives on moral realism

The paper argues that a particular version of moral realism constitutes an important basis for ethics in medicine and health care. Moral realism is the position that moral value is a part of the fabric of relational and interpersonal reality. But even though moral values are subject to human interpretations, they are not themselves the sole product of these interpretations. Moral values are not invented but discovered by the subject. Moral realism argues that values are open to perception and experience and that moral subjectivity must be portrayed in how moral values are discovered and perceived by the human subject. Moral values may exist independent of the particular subject's interpretative evaluations as a part of reality. This epistemological point about normativity is particularly significant in medical care and in health care. The clinician perceives moral value in the clinical encounter in a way that is important for competent clinical understanding. Clinical understanding in medical care and health care bears on the encounter with moral values in the direct and embodied relations to patients, with their experiences of illness and their vulnerabilities. Good clinical care is then partly conditioned upon adequate understanding of such moral realities.     

The vagueness of "tradition" and the pain and suffering of children

The argument presented by Jeffrey Bishop that "tradition" justifies female circumcision is grounded on the assumption that reason is always situated within traditions and that traditions are the foundational source of values. I argue that the concept of tradition is inherently vague and, as such, cannot support the weight of the argument that makes it the final arbiter of moral values. The concept especially does not justify intense pain and suffering inflicted on children.     

Passion, activity, and "the care of the self"

To ask whether we should use Prozac or other technologies as “enhancement” is perhaps to ask the wrong question, one that belongs to a life of what Heidegger discerned as technological ordering (die Technik). We might better ask a question belonging to a life of receptivity (Gelassenheit): Can or should we—some of us—live differently than we do?     

Between subway and spaceship: practical ethics at the outset of the twenty-first century

Moral deliberation involves a constant interplay among specific judgments, general moral values and principles, and background beliefs about the world. We may also construct broad moral theories to explain how our judgments and general commitments hang together, but there is little hope of settling on any one comprehensive moral theory.     

Abortion, metaphysics and morality: a review of Francis Beckwith's defending life: a moral and legal case against abortion choice

In Defending Life: A Moral and Legal Case Against Abortion Choice (2007) and an earlier article in this journal, "Defending Abortion Philosophically"(2006), Francis Beckwith argues that fetuses are, from conception, prima facie wrong to kill. His arguments are based on what he calls a "metaphysics of the human person" known as "The Substance View." I argue that Beckwith's metaphysics does not support his abortion ethic: Moral, not metaphysical, claims that are part of this Substance View are the foundation of the argument, and Beckwith inadequately defends these moral claims. Thus, Beckwith's arguments do not provide strong support for what he calls the "pro-life" view of abortion.     

NHS Activism: The Limits and Potentialities of a New Solidarity

Using Thompson’s conceptualization of the moral economy, I describe how NHS activists in the UK utilize moral arguments to form alliances between different occupational groups, in a political battle against health care privatization, reflecting how a consciousness is being built upon solidarity and shared interests. In this context, professional duties of health care professionals are linked to the interests of all citizens. I explore how the deployment of professional ethics elides a moral hierarchy that may hinder the movement’s egalitarian potential.     

Limits on patient responsibility

The medical profession and medical ethics currently place a greater emphasis on physician responsibility than patient responsibility. This imbalance is not due to accident or a mistake but, rather is motivated by strong moral reasons. As we debate the nature and extent of patient responsibility it is important to keep in mind the reasons for giving a relatively minimal role to patient responsibility in medical ethics. It is argued that the medical profession ought to be characterized by two moral asymmetries: (1) Even if some degree of responsible behavior from patients is called for, placing the dominant emphasis on professional responsibility over patient responsibility is largely correct. The value of protecting the right to refuse treatment and arguments against paternalism block a more expansive account of patient responsibility and support a strong notion of professional responsibility. (2) Insofar as we do want to encourage an increase in patient responsibility, we have good reasons to emphasize prospective rather than retrospective notions of responsibility in clinical practice. Concerns about patient vulnerability along with the determined factors in disease leave little room for blame at the bedside. These two asymmetries generate normative limits on any positive account of patient responsibility.     

Human‐Animal Chimeras, “Human” Cognitive Capacities,and Moral Status

In “Human‐Animal Chimeras: The Moral Insignificance of Uniquely Human Capacities,” Julian Koplin explores a promising way of thinking about moral status. Without attempting to develop a model in any detail, Koplin picks up Joshua Shepherd's interesting proposal that we think about moral status in terms of the value of different kinds of conscious experience. For example, a being with the most basic sort of consciousness and sentience would have interests that matter morally, while a being whose consciousness featured the riches of loving affection, say, might have greater moral status and therefore deserve some sort of priority if the interests of the two beings conflicted. This approach represents an improvement over the more common, transparently anthropocentric habits of thinking about moral status, whether in connection with evaluating human‐animal chimera research, deciding what one can ethically eat, or pursuing some other moral inquiry.     

Autonomy,Beneficence, andGezelligheid

American bioethicists lack the theoretical resources to work in cross‐cultural settings. All we have are two approaches to ethics—principles vs. narratives—that are mostly at odds, and neither of which is up to the job. If moral principles are too abstract to be useful, and if stories cannot provide moral authority, then where do we find our moral norms?     

Breaking evolution's chains: the prospect of deliberate genetic modification in humans

Many philosophers invoke the "wisdom of nature" in arguing for varying degrees of caution in the development and use of genetic enhancement technologies. Because they view natural selection as akin to a master engineer that creates functionally and morally optimal design, these authors tend to regard genetic intervention with suspicion. In Part II, we examine and ultimately reject the evolutionary assumptions that underlie the master engineer analogy (MEA). By highlighting the constraints on ordinary unassisted evolution, we show how intentional genetic modification can overcome many of the natural impediments to the human good. Our contention is that genetic engineering offers a solution that is more eff?icient, reliable, versatile, and morally palatable than the lumbering juggernaut of Darwinian evolution. In Part III, we evaluate a recent attempt to ground precautionary enhancement heuristics in adaptive etiology. Our problem with this approach is two-fold: first, it is based on the same "strong adaptationist" interpretation of evolution that motivates the flawed MEA, and second, the etiological concept of function on which it relies provides indirect and potentially misleading information about the likely consequences of genetic intervention. We offer instead enhancement criteria based on causal relationships in ontogeny. We conclude that rather than grounding a presumption against deliberate genetic modification, the causal structure of the living world gives us good moral reason to pursue it.     

Hearing the Mermaids Singing: The Possibility and Limits of Moral Enhancement

The possibility of moral bioenhancement, and the alleged need for it, have been widely discussed both in ethics journals and the media since this type of enhancement was first proposed in the Journal of Medical Ethics in 2008. Most prominently, Ingmar Persson and Julian Savulescu have argued that humans in their current condition are simply not good enough to deal effectively with the global problems we face today and that, if we want to have any hope of saving the world from “ultimate harm,” we need to find ways to morally enhance people, using psychopharmaceuticals, neurostimulation, gene editing, or whatever other biological method we can think of that might do the trick. Persson and Savulescu's 2012 book on the subject, Unfit for the Future: The Need for Moral Enhancement, has very much determined the direction of the debate. However, what remains contentious is the question of whether the kind of enhancement that Persson and Savulescu envisage is really desirable and actually feasible. Earlier in 2016, two books on moral bioenhancement were published, namely John Harris's How to Be Good: The Possibility of Moral Enhancement and Harris Wiseman's The Myth of the Moral Brain: The Limits of Moral Enhancement. Harris's book focuses on the desirability of moral bioenhancement, and Wiseman's primarily (though by no means exclusively) on its feasibility. Both reject Persson and Savulescu's proposal and approach, but for very different reasons.     

Justice and managed care. Four principles for the just allocation of health care resources

The debate about justice and health care has occurred largely at a remove from the institutions it concerns; it has been about our most general moral principles, and about what things we value. This debate has foundered. But if the debate is turned in another direction, toward some moral principles that are widely accepted within those institutions, and toward principles that have to do with control over allocation decisions rather than with actually how to make those decisions, agreement may be nearer at hand.