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Bioethics
Principles, Issues, and Cases
Fourth Edition
Lewis Vaughn
This fourth edition of Bioethics embodies all the features filling out the discussions with background on the
that have made it a best-selling textbook and includes all latest medical, legal, and social developments. The
the most important changes and improvements that main issues include paternalism and patient auton-
dozens of teachers have asked for recently and over the omy, truth-telling, confidentiality, informed consent,
years. The book is, therefore, better than ever. And if it research ethics, clinical trials, abortion, assisted re-
isn’t, let even more good teachers say so and let the cor- production, surrogacy, cloning, genetic testing, gene
rections and enhancements continue. And may the book therapy, stem cells, euthanasia, physician-assisted
remain, as so many teachers have said, exactly suitable to suicide, and the just allocation of health care.
their teaching approach. Every issues chapter contains five to twelve read-
Bioethics provides in-depth discussions of the ings, with each selection prefaced by a brief s ummary.
philosophical, medical, scientific, social, and legal The a rticles—old standards as well as new ones—
aspects of controversial bioethical issues and reflect the major arguments and latest thinking in
combines this material with a varied collection of each debate. They present a diversity of perspectives
thought-provoking readings. But on this foundation on each topic, with pro and con positions well rep-
are laid elements that other texts sometimes forgo: resented. In most cases, the relevant court rulings
are also included.
1. An extensive introduction to ethics, bioethics,
moral principles, critical thinking, and moral
reasoning special features
2. Full coverage of influential moral theories, A two-chapter introduction to bioethics, moral
including criteria and guidelines for evaluat- reasoning, moral theories, and critical thinking.
ing them (the focus is on utilitarianism, These chapters are designed not only to introduce
Kantian ethics, natural law theory, Rawls’ the subject matter of bioethics but also to add co-
contract theory, virtue ethics, the ethics of herence to subsequent chapter material and to
care, and feminist ethics) provide the student with a framework for thinking
3. Detailed examinations of the classic cases critically about issues and cases. Chapter 1 is an in
that have helped shape debate in major issues troduction to basic ethical concepts, the field of
4. Collections of current, news-making cases for bioethics, moral principles and judgments, moral
evaluation reasoning and arguments, the challenges of rela-
5. Many pedagogical features to engage students tivism, and the relationship between ethics and
and reinforce lessons in the main text both religion and the law. Chapter 2 explores moral
6. Writing that strives hard for clarity and conci- theory, shows how theories relate to moral princi-
sion to convey both the excitement and com- ples and judgments, examines influential theories
plexity of issues without sacrificing accuracy (including virtue ethics, the ethics of care, and
feminist ethics), and demonstrates how they can be
topics and readings applied to moral problems. It also explains how to
Nine chapters cover many of the most controversial evaluate moral theories using plausible criteria of
issues in bioethics, detailing the main arguments and adequacy.
Helpful chapter elements. Each issues chapter • Annette C. Baier, “The Need for More Than
contains: Justice”
• Ezekiel J. Emanuel and Linda L. Emanuel,
1. Analyses of the most important arguments
“Four Models of the Physician-Patient
offered by the various parties to the debate.
Relationship”
They reinforce and illustrate the lessons on
• Dax Cowart and Robert Burt, “Confronting
moral reasoning in Chapter 1.
Death: Who Chooses, Who Controls? A Di-
2. A section called “Applying Major Theories”
alogue Between Dax Cowart and Robert
showing how the moral theories can be applied
Burt”
to the issues. It ties the discussions of moral
• Harriet Hall, “Paternalism Revisited”
theories in Chapter 2 to the moral problems and
• Angus Chen, “Is It Time to Stop Using Race
illustrates the theories’ relevance.
in Medical Research?”
3. A section labeled “Classic Case File” that
• Liz Carr, “Legalizing Assisted Dying Is
examines in detail a famous bioethics case. The
Dangerous for Disabled People”
stories covered in these sections include those
• Felicia Ackerman, “‘For Now I Have My
of Elizabeth Bouvia, Jerry Canterbury, Nancy
Death’: The ‘Duty to Die’ Versus the Duty to
Klein, Baby M, Nancy Cruzan, the Kingsburys,
Help the Ill Stay Alive”
Christine deMeurers, and the UCLA Schizo-
• Eric C. Schneider, Dana O. Sarnak, David
phrenia Study. These are in addition to many
Squires, et al., “Mirror, Mirror 2017: Interna-
other controversial cases covered elsewhere in
tional Comparison Reflects Flaws and Op-
the book—for example, the Terri Schiavo con-
portunities for Better U.S. Health Care”
troversy, the Tuskegee tragedy, the Willow-
Clarifications and Further Discussions
brook experiments, and the U.S. government’s
• Principlism and prima facie principles
human radiation studies.
• Feminist ethics
4. A bank of “Cases for Evaluation” at the end
• Abortion and Judaism
of each chapter. These are recent news stories
• Research on euthanasia in Oregon and the
followed by discussion questions. They give stu-
Netherlands
dents the chance to test their moral reasoning
• End-of-life decisions in the Netherlands
on challenging new scenarios that range across
(statistics)
a broad spectrum of current topics.
• Advance directives
A diverse package of pedagogical aids. Each Updates
issues chapter contains a chapter summary, sugges- • Important informed consent cases
tions for further reading, and a variety of text boxes. • U.S. abortion (statistics)
The boxes are mainly of three types: • Abortion and public opinion (survey)
• Recent breakthroughs in gene therapy
1. “In Depth”—additional information, illustra-
• Euthanasia and assisted suicide: major
tions, or analyses of matters touched on in
developments
the main text.
• Assisted suicide: What do doctors think?
2. “Fact File”—statistics on the social, medical,
(survey)
and scientific aspects of the chapter’s topic.
• Public opinion: physician-assisted suicide
3. “Legal Brief”—summaries of important court rul-
(survey)
ings or updates on the status of legislation.
• Health care: the uninsured, per capita
spending, U.S. health care quality
new to this edition
• Comparing health care systems: U.S.,
Ten New Readings Canada, Germany
• Aristotle, Nicomachean Ethics, Books I and II • Public opinion: views on the ACA
• Nel Noddings, “Caring” (“Obamacare”)
big questions through critical reasoning, logical some or all of these as proper guides for our ac-
argument, and careful reflection. Thus ethics— tions and judgments. In normative ethics, we
also known as moral philosophy—is a reasoned ask questions like these: What moral principles,
way of delving into the meaning and import of if any, should inform our moral judgments?
moral concepts and issues and of evaluating the What role should virtues play in our lives? Is the
merits of moral judgments and standards. (As principle of autonomy justified? Are there any
with morality and moral, we may use ethics to exceptions to the moral principle of “do not
say such things as “Kant’s ethics” or may use kill”? How should we resolve conflicts between
ethical or unethical to mean right or wrong, moral norms? Is contractarianism a good moral
good or bad.) Ethics seeks to know whether an theory? Is utilitarianism a better theory?
action is right or wrong, what moral standards A branch that deals with much deeper ethical
should guide our conduct, whether moral prin- issues is metaethics. Metaethics is the study of
ciples can be justified, what moral virtues are the meaning and justification of basic moral be-
worth cultivating and why, what ultimate ends liefs. In normative ethics we might ask whether
people should pursue in life, whether there are an action is right or whether a person is good,
good reasons for accepting a particular moral but in metaethics we would more likely ask what
theory, and what the meaning is of such notions it means for an action to be right or for a person
as right, wrong, good, and bad. Whenever we try to be good. For example, does right mean has the
to reason carefully about such things, we enter best consequences, or produces the most happi-
the realm of ethics: We do ethics. ness, or commanded by God? It is the business of
Science offers another way to study morality, metaethics to explore these and other equally
and we must carefully distinguish this approach fundamental questions: What, if anything, is
from that of moral philosophy. Descriptive the difference between moral and nonmoral be-
ethics is the study of morality using the meth- liefs? Are there such things as moral facts? If so,
odology of science. Its purpose is to investigate what sort of things are they, and how can they
the empirical facts of morality—the actual be- be known? Can moral statements be true or
liefs, behaviors, and practices that constitute false—or are they just expressions of emotions
people’s moral experience. Those who carry out or attitudes without any truth value? Can moral
these inquiries (usually anthropologists, sociol- norms be justified or proven?
ogists, historians, and psychologists) want to The third main branch is applied ethics, the
know, among other things, what moral beliefs a use of moral norms and concepts to resolve
person or group has, what caused the subjects to practical moral issues. Here, the usual challenge
have them, and how the beliefs influence behav- is to employ moral principles, theories, argu-
ior or social interaction. Very generally, the dif- ments, or analyses to try to answer moral ques-
ference between ethics and descriptive ethics is tions that confront people every day. Many such
this: In ethics we ask, as Socrates did, How ought questions relate to a particular professional field
we to live? In descriptive ethics we ask, How do such as law, business, or journalism, so we have
we in fact live? specialized subfields of applied ethics like legal
Ethics is a big subject, so we should not be ethics, business ethics, and journalistic ethics.
surprised that it has three main branches, each Probably the largest and most energetic subfield
dealing with more or less separate but related is bioethics.
sets of ethical questions. Normative ethics is the Bioethics is applied ethics focused on health
search for, and justification of, moral standards, care, medical science, and medical technology.
or norms. Most often the standards are moral (Biomedical ethics is often used as a synonym,
principles, rules, virtues, and theories, and the and medical ethics is a related but narrower term
lofty aim of this branch is to establish rationally used most often to refer to ethical problems in
medical practice.) Ranging far and wide, bio- about art; norms of etiquette about polite social
ethics seeks answers to a vast array of tough behavior; grammatical norms about correct use
ethical questions: Is abortion ever morally per- of language; prudential norms about what is in
missible? Is a woman justified in having an abor- one’s interests; and legal norms about lawful and
tion if prenatal genetic testing reveals that her unlawful acts. But moral norms differ from these
fetus has a developmental defect? Should people nonmoral kinds. Some of the features they are
be allowed to select embryos by the embryos’ sex thought to possess include the following.
or other genetic characteristics? Should human
embryos be used in medical research? Should Normative Dominance. In our moral practice,
human cloning be prohibited? Should physicians, moral norms are presumed to dominate other
nurses, physicians’ assistants, and other health kinds of norms, to take precedence over them.
care professionals always be truthful with patients Philosophers call this characteristic of moral
whatever the consequences? Should severely im- norms overridingness because moral consider-
paired newborns be given life-prolonging treat- ations so often seem to override other factors.
ment or be allowed to die? Should people in A maxim of prudence, for example, may suggest
persistent vegetative states be removed from life that you should steal if you can avoid getting
support? Should physicians help terminally ill caught, but a moral prohibition against stealing
patients commit suicide? Is it morally right to con would overrule such a principle. An aesthetic (or
duct medical research on patients without their pragmatic) norm implying that homeless people
consent if the research would save lives? Should should be thrown in jail for blocking the view of
human stem-cell research be banned? How a beautiful public mural would have to yield to
should we decide who gets life-saving organ trans moral principles demanding more humane treat-
plants when usable organs are scarce and many ment of the homeless. A law mandating brutal
patients who do not get transplants will die? actions against a minority group would conflict
Should animals be used in biomedical research? with moral principles of justice and would there-
The ethical and technical scope of bioethics is fore be deemed illegitimate. We usually think
wide. Bioethical questions and deliberations that immoral laws are defective, that they need to
now fall to nonexpert and expert alike—to pa- be changed, or that, in rare cases, they should be
tients, families, and others as well as to philoso- defied through acts of civil disobedience.
phers, health care professionals, lawyers, judges,
scientists, clergy, and public policy specialists. Universality. Moral norms (but not exclusively
Though the heart of bioethics is moral philoso- moral norms) have universality: Moral princi-
phy, fully informed bioethics cannot be done ples or judgments apply in all relevantly similar
without a good understanding of the relevant situations. If it is wrong for you to tell a lie in
nonmoral facts and issues, especially the medi- a particular circumstance, then it is wrong for
cal, scientific, technological, and legal ones. everyone in relevantly similar circumstances to
tell a lie. Logic demands this sort of consistency.
It makes no sense to say that Maria’s doing
ethics and the moral life
action A in circumstances C is morally wrong,
Morality then is a normative, or evaluative, enter- but John’s doing A in circumstances relevantly
prise. It concerns moral norms or standards that similar to C is morally right. Universality, how-
help us decide the rightness of actions, judge the ever, is not unique to moral norms; it’s a charac-
goodness of persons or character, and prescribe the teristic of all normative spheres.
form of moral conduct. There are, of course, other
sorts of norms we apply in life—nonmoral norms. Impartiality. Implicit in moral norms is the
Aesthetic norms help us make value judgments notion of impartiality—the idea that everyone
should be considered equal, that everyone’s inter- the moral life—is to do moral reasoning. If our
ests should count the same. From the perspective moral judgments are to have any weight at all, if
of morality, no person is any better than any they are to be anything more than mere per-
other. Everyone should be treated the same unless sonal taste or knee-jerk emotional response,
there is a morally relevant difference between they must be backed by the best of reasons. They
persons. We probably would be completely baf- must be the result of careful reflection in which
fled if someone seriously said something like we arrive at good reasons for accepting them,
“murder is wrong . . . except when committed by reasons that could be acknowledged as such by
myself,” when there was no morally relevant dif- any other reasoning persons.
ference between that person and the rest of the Both logic and our commonsense moral ex-
world. If we took such a statement seriously at all, perience demand that the thorough sifting of
we would likely not only reject it but also would reasons constitutes the main work of our moral
not even consider it a bona fide moral statement. deliberations—regardless of our particular moral
The requirement of moral impartiality pro- outlook or theory. We would think it odd, per-
hibits discrimination against people merely be- haps even perverse, if someone asserted that
cause they are different—different in ways that physician-assisted suicide is always morally
are not morally relevant. Two people can be dif- wrong—and then said she has no reasons at all for
ferent in many ways: skin color, weight, gender, believing such a judgment but just does. What-
income, age, occupation, and so forth. But these ever our views on physician-assisted suicide, we
are not differences relevant to the way they would be justified in ignoring her judgment, for
should be treated as persons. On the other hand, we would have no way to distinguish it from
if there are morally relevant differences between personal whim or wishful thinking. Likewise she
people, then we may have good reasons to treat herself (if she genuinely had no good reasons for
them differently, and this treatment would not her assertion) would be in the same boat, adrift
be a violation of impartiality. This is how phi- with a firm opinion moored to nothing solid.
losopher James Rachels explains the point: Our feelings, of course, are also part of our
moral experience. When we ponder a moral
The requirement of impartiality, then, is at issue we care about (abortion, for example), we
bottom nothing more than a proscription against may feel anger, sadness, disgust, fear, irritation,
arbitrariness in dealing with people. It is a rule or sympathy. Such strong emotions are normal
that forbids us from treating one person differ- and often useful, helping us empathize with
ently from another when there is no good reason others, deepening our understanding of human
to do so. But if this explains what is wrong with suffering, and sharpening our insight into the
racism, it also explains why, in some special consequences of our moral decisions. But our
kinds of cases, it is not racist to treat people dif- feelings can mislead us by reflecting not moral
ferently. Suppose a film director was making a truth but our own psychological needs, our own
movie about the life of Martin Luther King, Jr. personal or cultural biases, or our concern for
He would have a perfectly good reason for ruling personal advantage. Throughout history, some
out Tom Cruise for the starring role. Obviously, people’s feelings led them to conclude that
such casting would make no sense. Because there women should be burned for witchcraft, that
would be a good reason for it, the director’s “dis- whole races should be exterminated, that black
crimination” would not be arbitrary and so men should be lynched, and that adherents of a
would not be open to criticism.1 different religion were evil. Critical reasoning
can help restrain such terrible impulses. It can
Reasonableness. To participate in morality—to help us put our feelings in proper perspective
engage in the essential, unavoidable practices of and achieve a measure of impartiality. Most of
all, it can guide us to moral judgments that are purports to explain right actions, or make judg-
trustworthy because they are supported by the ments about right or wrong actions.
best of reasons. Moral values, on the other hand, generally
The moral life, then, is about grappling with a concern those things that we judge to be morally
distinctive class of norms marked by normative good, bad, praiseworthy, or blameworthy. Nor-
dominance, universality, impartiality, and rea- mally we use such words to describe persons (as
sonableness. As we saw earlier, these norms can in “He is a good person” or “She is to blame for
include moral principles, rules, theories, and hurting them”), their character (“He is virtu-
judgments. We should notice that we commonly ous”; “She is honest”), or their motives (“She did
apply these norms to two distinct spheres of our wrong but did not mean to”). Note that we also
moral experience— to both moral obligations attribute nonmoral value to things. If we say that
and moral values. a book or bicycle or vacation is good, we mean
Moral obligations concern our duty, what we good in a nonmoral sense. Such things in them-
are obligated to do. That is, obligations are about selves cannot have moral value.
conduct, how we ought or ought not to behave. Strictly speaking, only actions are morally
In this sphere, we talk primarily about actions. right or wrong, but persons are morally good or
We may look to moral principles or rules to bad (or some degree of goodness or badness).
guide our actions, or study a moral theory that With this distinction we can acknowledge a
simple fact of the moral life: A good person can We can see appeals to moral principles in
do something wrong, and a bad person can do countless cases. Confronted by a pain-racked,
something right. A Gandhi can tell a lie, and a terminally ill patient who demands to have his
Hitler can save a drowning man. life ended, his physician refuses to comply, rely-
In addition, we may judge an action right or ing on the principle that “it is wrong to inten-
wrong depending on the motive behind it. If tionally take a life.” Another physician makes a
John knocks a stranger down in the street to pre- different choice in similar circumstances, insist-
vent her from being hit by a car, we would deem ing that the relevant principle is “ending the suf-
his action right (and might judge him a good fering of a hopelessly ill patient is morally
person). But if he knocks her down because he permissible.” An infant is born anencephalic
dislikes the color of her skin, we would believe (without a brain); it will never have a conscious
his action wrong (and likely think him evil). life and will die in a few days. The parents decide
The general meaning of right and wrong seems to donate the infant’s organs to other children
clear to just about everyone. But we should be so they might live, which involves taking the
careful to differentiate degrees of meaning in organs right away before they deteriorate. A
these moral terms. Right can mean either “obliga- critic of the parents’ decision argues that “it is
tory” or “permissible.” An obligatory action is one unethical to kill in order to save.” But someone
that would be wrong not to perform. We are obli- else appeals to the principle “save as many chil-
gated or required to do it. A permissible action is dren as possible.”2 In such ways moral principles
one that is permitted. It is not wrong to perform it. help guide our actions and inform our judg-
Wrong means “prohibited.” A prohibited action is ments about right and wrong, good and evil.
one that would be wrong to perform. We are obli- As discussed in Chapter 2, moral principles
gated or required not to do it. A supererogatory are often drawn from a moral theory, which is a
action is one that is “above and beyond” our duty. moral standard on the most general level. The
It is praiseworthy—a good thing to do—but not principles are derived from or supported by the
required. Giving all your possessions to the poor theory. Many times we simply appeal directly to
is generally considered a supererogatory act. a plausible moral principle without thinking
much about its theoretical underpinnings.
Philosophers make a distinction between ab-
moral principles in bioethics
solute and prima facie principles (or duties). An
As noted earlier, the main work of bioethics is absolute principle applies without exceptions.
trying to solve bioethical problems using the An absolute principle that we should not lie de-
potent resources and methods of moral phi- mands that we never lie regardless of the cir-
losophy, which include, at a minimum, critical cumstances or the consequences. In contrast, a
reasoning, logical argument, and conceptual prima facie principle applies in all cases unless
analysis. Many, perhaps most, moral philoso- an exception is warranted. Exceptions are justi-
phers would be quick to point out that beyond fied when the principle conflicts with other
these tools of reason we also have the consider- principles and is thereby overridden. W. D. Ross
able help of moral principles. (The same could be is given credit for drawing this distinction in his
said about moral theories, which we explore in 1930 book The Right and the Good.3 It is essen-
the next chapter.) Certainly to be useful, moral tial to his account of ethics, which has a core of
principles must be interpreted, often filled out several moral principles or duties, any of which
with specifics, and balanced with other moral might come into conflict.
concerns. But both in everyday life and in bio- Physicians have a prima facie duty to be truth
ethics, moral principles are widely thought to be ful to their patients as well as a prima facie duty
indispensable to moral decision-making. to promote their welfare. But if these duties come
in conflict—if, for example, telling a patient the their consent, treating competent patients against
truth about his condition would somehow result their will, physically restraining or confining pa-
in his death—a physician might decide that the tients for no medical reason—such practices con-
duty of truthfulness should yield to the weight- stitute obvious violations of personal autonomy.
ier duty to do good for the patient. Not all restrictions on autonomy, however,
Moral principles are many and varied, but in are of the physical kind. Autonomy involves the
bioethics the following have traditionally been capacity to make personal choices, but choices
extremely influential and particularly relevant cannot be considered entirely autonomous unless
to the kinds of moral issues that arise in health they are fully informed. When we make decisions
care, medical research, and biotechnology. In in ignorance—without relevant information or
fact, many—perhaps most—of the thorniest issues blinded by misinformation—our autonomy is
in bioethics arise from conflicts among these diminished just as surely as if someone physi-
basic principles. In one formulation or another, cally manipulated us. If this is correct, then we
each one has been integral to major moral have a plausible explanation of why lying is
theories, providing evidence that the principles generally prohibited: Lying is wrong because it
capture something essential in our moral expe- undermines personal autonomy. Enshrined in
rience. The principles are (1) autonomy, (2) non bioethics and in the law, then, is the precept of
maleficence, (3) beneficence, (4) utility, and informed consent, which demands that patients
(5) justice.4 be allowed to freely consent to or decline treat-
ments and that they receive the information they
Autonomy need to make informed judgments about them.
Autonomy refers to a person’s rational capacity In many ways, autonomy is a delicate thing,
for self-governance or self-determination— the easily compromised and readily thwarted. Often
ability to direct one’s own life and choose for a person’s autonomy is severely undermined not
oneself. The principle of autonomy insists on full by other people but by nature, nurture, or his or
respect for autonomy. One way to express the prin- her own actions. Some drug addicts and alcohol-
ciple is: Autonomous persons should be allowed ics, people with serious psychiatric illness, and
to exercise their capacity for self-determination. those with severe mental impairment are thought
According to one major ethical tradition, autono- to have drastically diminished autonomy (or to
mous persons have intrinsic worth precisely be essentially nonautonomous). Bioethical ques-
because they have the power to make rational tions then arise about what is permissible to do
decisions and moral choices. They therefore must to them and who will represent their interests or
be treated with respect, which means not violating make decisions regarding their care. Infants and
their autonomy by ignoring or thwarting their children are also not fully autonomous, and the
ability to choose their own paths and make their same sorts of questions are forced on parents,
own judgments. guardians, and health care workers.
The principle of respect for autonomy places Like all the other major principles discussed
severe restraints on what can be done to an here, respect for autonomy is thought to be
autonomous person. There are exceptions, but in prima facie. It can sometimes be overridden by
general we are not permitted to violate people’s considerations that seem more important or
autonomy just because we disagree with their compelling— considerations that philosophers
decisions, or because society might benefit, or and other thinkers have formulated as princi-
because the violation is for their own good. We ples of autonomy restriction. The principles are
cannot legitimately impair someone’s autonomy articulated in various ways, are applied widely
without strong justification for doing so. Con- to all sorts of social and moral issues, and are
ducting medical experiments on patients without themselves the subject of debate. Chief among
these is the harm principle: a person’s autonomy A health care professional violates this prin-
may be curtailed to prevent harm to others. To ciple if he or she deliberately performs an action
prevent people from being victimized by thieves that harms or injures a patient. If a physician
and murderers, we have a justice system that intentionally administers a drug that she knows
prosecutes and imprisons the perpetrators. To will induce a heart attack in a patient, she obvi-
discourage hospitals and health care workers ously violates the principle—she clearly does
from hurting patients through carelessness or something that is morally (and legally) wrong.
fraud, laws and regulations limit what they can But she also violates it if she injures a patient
do to people in their care. To stop someone from through recklessness, negligence, or inexcusable
spreading a deadly, contagious disease, health ignorance. She may not intend to hurt anyone,
officials may quarantine him against his will. but she is guilty of the violation just the same.
Another principle of autonomy restriction is Implicit in the principle of nonmaleficence is
paternalism. Paternalism is the overriding of a the notion that health professionals must exer-
person’s actions or decision-making for her own cise “due care.” The possibility of causing some
good. Some cases of paternalism (sometimes pain, suffering, or injury is inherent in the care
called weak paternalism) seem permissible to and treatment of patients, so we cannot realisti-
many people—when, for example, seriously de- cally expect health professionals never to harm
pressed or psychotic patients are temporarily anyone. But we do expect them to use due care—
restrained to prevent them from injuring or kill- to act reasonably and responsibly to minimize
ing themselves. Other cases are more controver- the harm or the chances of causing harm. If a
sial. Researchers hoping to develop a life-saving physician must cause patients some harm to
treatment give an experimental drug to some- effect a cure, we expect her to try to produce the
one without his knowledge or consent. Or a least amount of harm possible to achieve the re-
physician tries to spare the feelings of a compe- sults. And even if her treatments cause no actual
tent, terminally ill patient by telling her that she pain or injury in a particular instance, we expect
will eventually get better, even though she in- her not to use treatments that have a higher
sists on being told the truth. The paternalism in chance of causing harm than necessary. By the
such scenarios (known as strong paternalism) is lights of the nonmaleficence principle, subjecting
usually thought to be morally objectionable. patients to unnecessary risks is wrong even if no
Many controversies in bioethics center on the damage is done.
morality of strong paternalism.
Beneficence
Nonmaleficence The principle of beneficence has seemed to many
The principle of nonmaleficence asks us not to to constitute the very soul of morality—or very
intentionally or unintentionally inflict harm on close to it. In its most general form, it says that
others. In bioethics, nonmaleficence is the most we should do good to others. (Benevolence is dif-
widely recognized moral principle. Its aphoris- ferent, referring more to an attitude of goodwill
tic expression has been embraced by practitio- toward others than to a principle of right action.)
ners of medicine for centuries: “Above all, do no Beneficence enjoins us to advance the welfare of
harm.” A more precise formulation of the prin- others and prevent or remove harm to them.
ciple is: We should not cause unnecessary injury Beneficence demands that we do more than
or harm to those in our care. In whatever form, just avoid inflicting pain and suffering. It says
nonmaleficence is the bedrock precept of count- that we should actively promote the well-being of
less codes of professional conduct, institutional others and prevent or remove harm to them. In
regulations, and governmental rules and laws bioethics, there is little doubt that physicians,
designed to protect the welfare of patients. nurses, researchers, and other professionals have
such a duty. After all, helping others, promoting possible benefits of the treatment outweigh its
their good, is a large part of what these profes- risks by an acceptable margin. Suppose a man’s
sionals are obliged to do. clogged artery can be successfully treated with
But not everyone thinks that we all have a open-heart surgery, a procedure that carries a
duty of active beneficence. Some argue that considerable risk of injury and death. But imag-
though there is a general (applicable to all) duty ine that the artery can also be successfully
not to harm others, there is no general duty to opened with a regimen of cholesterol-lowering
help others. They say we are not obligated to aid drugs and a low-fat diet, both of which have a
the poor, feed the hungry, or tend to the sick. much lower chance of serious complications.
Such acts are not required, but are supererogatory, The principle of utility seems to suggest that the
beyond the call of duty. Others contend that latter course is best and that the former is mor-
though we do not have a general duty of active ally impermissible.
beneficence, we are at least sometimes obligated The principle also plays a major role in the
to look to the welfare of people we care about creation and evaluation of the health policies of
most—such as our parents, children, spouses, institutions and society. In these large arenas,
and friends. In any case, it is clear that in cer- most people aspire to fulfill the requirements of
tain professions—particularly medicine, law, and beneficence and maleficence, but they recognize
nursing—benefiting others is often not just that perfect beneficence or maleficence is im-
supererogatory but obligatory and basic. possible: Trade-offs and compromises must be
made, scarce resources must be allotted, help and
Utility harm must be balanced, life and death must be
The principle of utility says that we should pro- weighed—tasks almost always informed by the
duce the most favorable balance of good over bad principle of utility.
(or benefit over harm) for all concerned. The prin- Suppose, for example, we want to mandate
ciple acknowledges that in the real world, we the immunization of all schoolchildren to pre-
cannot always just benefit others or just avoid vent the spread of deadly communicable dis-
harming them. Often we cannot do good for eases. The cost in time and money will be great,
people without also bringing them some harm, but such a program could save many lives.
or we cannot help everyone who needs to be There is a down side, however: A small number
helped, or we cannot help some without also of children—perhaps as many as 2 for every
hurting or neglecting others. In such situations, 400,000 immunizations—w ill die because of a
the principle says, we should do what yields the rare allergic reaction to the vaccine. It is impos-
best overall outcome—the maximum good and sible to predict who will have such a reaction
minimum evil, everyone considered. The utility (and impossible to prevent it), but it is almost
principle, then, is a supplement to, not a substi- certain to occur in a few cases. If our goal is social
tute for, the principles of autonomy, beneficence, beneficence, what should we do? Children are
and justice. likely to die whether we institute the program
In ethics this maxim comes into play in sev- or not. Guided by the principle of utility (as well
eral ways. Most famously it is the defining pre- as other principles), we may decide to proceed
cept of the moral theory known as utilitarianism with the program since many more lives would
(discussed in Chapter 2). But it is also a stand- likely be saved by it than lost because of its
alone moral principle applied everywhere in implementation.
bioethics to help resolve the kind of dilemmas Again, suppose governmental health agencies
just mentioned. A physician, for example, must have enough knowledge and resources to de-
decide whether a treatment is right for a patient, velop fully a cure for only one disease—either a
and that decision often hinges on whether the rare heart disorder or a common form of skin
cancer. Trying to split resources between these justify the properties, or traits, of just distribu-
two is sure to prevent development of any cure tions. A basic precept of most of these theories is
at all. The heart disorder kills 200 adults each what may plausibly be regarded as the core of
year; the cancer occurs in thousands of people, the principle of justice: Equals should be treated
causing them great pain and distress, but is equally. (Recall that this is one of the defining
rarely fatal. How best to maximize the good? On elements of ethics itself, impartiality.) The idea
which disease should the government spend its is that people should be treated the same unless
time and treasure? Answering this question there is a morally relevant reason for treating
(and others like it) requires trying to apply the them differently. We would think it unjust for
utility principle—a job often involving complex a physician or nurse to treat his white diabetic
calculations of costs and benefits and frequently patients more carefully than he does his black
generating controversy. diabetic patients—and to do so without a sound
medical reason. We would think it unfair to
Justice award the only available kidney to the trans-
In its broadest sense, justice refers to people get- plant candidate who belongs to the “right” po-
ting what is fair or what is their due. In practice, litical party or has the best personal relationship
most of us seem to have a rough idea of what with hospital administrators.
justice entails in many situations, even if we The principle of justice has been at the heart
cannot articulate exactly what it is. We know, of debates about just distribution of benefits and
for example, that it is unjust for a bus driver to burdens (including health care) for society as a
make a woman sit in the back of the bus because whole. The disagreements have generally not been
of her religious beliefs, or for a judicial system to about the legitimacy of the principle, but about
arbitrarily treat one group of citizens more how it should be interpreted. Different theories
harshly than others, or for a doctor to care for of justice try to explain in what respects equals
some patients but refuse to treat others just be- should be treated equally.
cause he dislikes them. Libertarian theories emphasize personal free-
Questions of justice arise in different spheres doms and the right to pursue one’s own social
of human endeavor. Retributive justice, for ex- and economic well-being in a free market with-
ample, concerns the fair meting out of punish- out interference from others. Ideally the role
ment for wrongdoing. On this matter, some of government is limited to night-watchman
argue that justice is served only when people are functions— the protection of society and free
punished for past wrongs, when they get their economic systems from coercion and fraud. All
just deserts. Others insist that justice demands other social or economic benefits are the respon-
that people be punished not because they de- sibility of individuals. Government should not
serve punishment, but because the punishment be in the business of helping the socially or eco-
will deter further unacceptable behavior. Dis- nomically disadvantaged, for that would require
tributive justice concerns the fair distribution violating people’s liberty by taking resources
of society’s advantages and disadvantages—for from the haves to give to the have-nots. So uni-
example, jobs, income, welfare aid, health care, versal health care is out of the question. For the
rights, taxes, and public service. Distributive jus- libertarian, then, people have equal intrinsic
tice is a major issue in bioethics, where many of worth, but this does not entitle them to an equal
the most intensely debated questions are about distribution of economic advantages. Individu-
who gets health care, what or how much they als are entitled only to what they can acquire
should get, and who should pay for it. through their own hard work and ingenuity.
Distributive justice is a vast topic, and many Egalitarian theories maintain that a just dis-
theories have been proposed to identify and tribution is an equal distribution. Ideally, social
benefits—whether jobs, food, health care, or But moral objectivism is directly challenged
something else—should be allotted so that every- by a doctrine that some find extremely appeal-
one has an equal share. Treating people equally ing and that, if true, would undermine ethics
means making sure everyone has equal access to itself: ethical relativism. According to this view,
certain minimal goods and services. To achieve moral standards are not objective but are rela-
this level of equality, individual liberties will tive to what individuals or cultures believe.
have to be restricted, measures that libertari- There simply are no objective moral truths, only
ans would never countenance. In a pure egali- relative ones. An action is morally right if en-
tarian society, universal health care would be dorsed by a person or culture and morally wrong
guaranteed. if condemned by a person or culture. So eutha-
Between strict libertarian and egalitarian views nasia is right for person A if he approves of it but
of justice lie some theories that try to achieve a wrong for person B if she disapproves of it, and
plausible fusion of both perspectives. With a the same would go for cultures with similarly
nod toward libertarianism, these theories may diverging views on the subject. In this way, moral
exhibit a healthy respect for individual liberty norms are not discovered but made; the indi-
and limit governmental interference in econo vidual or culture makes right and wrong. Ethi-
mic enterprises. But leaning toward egalitarian- cal relativism pertaining to individuals is known
ism, they may also mandate that the basic needs as subjective relativism, more precisely stated as
of the least well-off citizens be met. the view that right actions are those sanctioned
In bioethics, the principle of justice and the by a person. Ethical relativism regarding cultures
theories used to explain it are constantly being is called cultural relativism, the view that right
marshaled to support or reject health care poli- actions are those sanctioned by one’s culture.
cies of all kinds. They are frequently used—along In some ways, subjective relativism is a com-
with other moral principles—to evaluate, design, forting position. It relieves individuals of the
and challenge a wide range of health care pro- burden of serious critical reasoning about mo-
grams and strategies. They are, in other words, rality. After all, determining right and wrong is
far from being merely academic. a matter of inventorying one’s beliefs, and any
sincerely held beliefs will do. Morality is essen-
tially a matter of personal taste, which is an ex-
ethical relativism
tremely easy thing to establish. Determining
The commonsense view of morality and moral what one’s moral views are may indeed involve
standards is this: There are moral norms or deliberation and analysis—but neither of these
principles that are valid or true for everyone. is a necessary requirement for the job. Subjective
This claim is known as moral objectivism, the relativism also helps people short-circuit the un-
idea that at least some moral standards are ob- pleasantness of moral debate. The subjective
jective. Moral objectivism, however, is distinct relativist’s familiar refrain—“That may be your
from moral absolutism, the belief that objective truth, but it’s not my truth”—has a way of stop-
moral principles allow no exceptions or must be ping conversations and putting an end to rea-
applied the same way in all cases and cultures. A soned arguments.
moral objectivist can be absolutist about moral The doctrine, however, is difficult to maintain
principles, or she can avoid absolutism by ac- consistently. On issues that the relativist cares
cepting that moral principles are prima facie. In little about (the moral rightness of gambling,
any case, most people probably assume some say), she may be content to point out that moral
form of moral objectivism and would not take norms are relative to each individual and that
seriously any claim implying that valid moral “to each his own.” But on more momentous
norms can be whatever we want them to be. topics (such as genocide in Africa or the Middle
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