Bioethics in the twenty-first century: why we should pay attention to eighteenth-century medical ethics.

Those of us who work in the field of bioethics tend to think that, because the word "bioethics" is new, so too the field is new in all respects, but we are not the first to do bioethics. John Gregory (1724-1773) did bioethics just as we do it, at least two centuries before we thought to do it. He deployed philosophical methods as sophisticated as our own. Indeed, Gregory took up the very best moral philosophy available to thinkers of the Scottish Enlightenment, namely, David Hume's moral philosophy and its core concept of sympathy. Gregory also responded in a conceptually powerful and clinically applicable way to the problems of his time, just as we do. I want here to outline Gregory's accomplishment and to identify some aspects of its importance for bioethics in the twenty-first century.     

The "wider view": André Helleger's passionate, integrating intellect and the creation of bioethics

This article provides an account of how André Hellegers, founder and first Director of the Kennedy Institute of Ethics at Georgetown University, laid medicine open to bioethics. Helleger's approach to bioethics, as to morality generally and also to medicine and biomedical science, involved taking the "wider view" -- a value-filled vision that integrated and gave meaning to what otherwise was disparate, precarious, and conflicting. This article shows how Helleger's wider view of bioethics was shaped by events in his own life, his resultant sense of the precariousness of life and health, his commitment to religious inclusiveness, his research in fetal medicine, his clinical experience in obstetrics, his role in the struggle to change the teaching of the Roman Catholic Church on fertility control, and his developing concepts of health and disease. Hellegers was committed to and worked toward bioethics as a self-consciously interdisciplinary field in which the contributing disciplines adapt to each other -- rather than sustain themselves as autonomous disciplines -- to create a dynamic and complex intellectual, clinical, and social activity.     

Between morality and repentance: recapturing "sin" for bioethics.

Distinguishing within "sin" the dimensions of anomia, hamartia, and asthenia makes it possible to analyze in greater detail the contrary manners in which traditional and post-traditional Christianities in this issue of Christian Bioethics endeavor to recapture what was lost when secular bioethics reconstructed the specifically spiritual-context-oriented normative commitments of Christianity in one-dimensionally moral terms. Various post-traditional attempts at securing moral orientation and resources for forgiveness, both of which secular bioethics finds increasingly difficult to provide, are critically reviewed. Their engagement of secular moral concepts and concerns, and even their adoption of an academically philosophical posture and language, is presented as responsible for their failure to adequately preserve what in traditional Christianity would count as prohibited vs. permitted, and advisable vs. non-advisable, or what would allow to resolve "tragic conflicts." The deeper reason for this failure lies in post-traditional Christianity's restricting the Christian life (with its central tension between love and the law) to what can be captured by cognitive categories. As the survey of several traditionally Christian accounts of sin in bioethics makes clear, both moral orientation (along with the resolution of "tragic" conflicts) and the sources of forgiveness are available, once that Christian life is framed in terms of persons' spirit-supported practical involvement in ascesis and liturgy, and once bioethical reflections are situated in the experiential context of such involvement.     

Bioethics as politics: the limits of moral expertise

The increasing reliance upon, and perhaps the growing public and professional skepticism about, the special expertise of bioethicists suggests the need to consider the limits of moral expertise. For all the talk about method in bioethics, we, bioethicists, are still rather far off the mark in understanding what we are doing, even when we may be going about what we are doing fairly well. Quite often, what is most fundamentally at stake, but equally often insufficiently acknowledged, are inherently political, essentially contested visions of the most compelling and attractive forms of life for individuals and social organization. The current situation in bioethics parallels similar debates in eighteenth-century jurisprudence, especially Jeremy Bentham's withering critique of the prevalent forms of judicial argument and his own, equally unsuccessful, attempt to develop a decision-making procedure in ethics that would operate on a plane above politics. The risk, both then and now, is that we will fail to appreciate the wide range of reasonable disagreement that will remain past the point of extended reflection and discussion.     

Christian bioethics, secular bioethics, and the claim to cultural authority.

Though the papers in this volume for the most part address the question, "What is Christian about Christian Bioethics", this paper addresses instead a closely related question, "How would a Christian approach to bioethics differ from the kind of secular academic bioethics that has emerged as such an important field in the contemporary university?" While it is generally assumed that a secular bioethics rooted in moral philosophy will be more culturally authoritative than an approach to bioethics grounded in the contingent particularities of a religious tradition, I will give reasons for rejecting this assumption. By examining the history of the recent revival of academic bioethics as well as the state of the contemporary moral philosophy on which it is based I will suggest that secular bioethics suffers from many of the same liabilities as a carefully articulated Christian bioethics. At the end of the paper I will turn briefly to examine the question of how, in light of this discussion, a Christian bioethics might best be pursued.     

Accounting for context: Future directions in bioethics theory and research

Many physicians have found that the traditional approach to bioethics fails to account for important aspects of their moral experience in practice. New approaches to bioethics theory are challenging the traditional application of universal moral principles based in liberal moral theory. At the same time, a shift in both the goals and methods of bioethics education has accompanied its “coming of age” in the medical school curriculum. Taken together, these changes challenge both bioethics educators and theorists to come closer to the details and nuances of real clinical encounters. The emerging trend emphasizes the importance of context in bioethics education and in the moral theory and research under-girding it. This article introduces one research approach examining the practical life contexts of medical students' ethical experiences and learning. It calls for increased attention to research and theory in bioethics that more adequately accounts for the ways different contexts produce significant changes in meaning and understanding in medical encounters.     

A theory of international bioethics: multiculturalism, postmodernism, and the bankruptcy of fundamentalism

The first of two articles analyzing the justifiability of international bioethical codes and of cross-cultural moral judgments reviews "moral fundamentalism," the theory that cross-cultural moral judgments and international bioethical codes are justified by certain "basic" or "fundamental" moral priniciples that are universally accepted in all cultures and eras. Initially propounded by the judges at the 1947 Nuremberg Tribunal, moral fundamentalism has become the received justification of international bioethics, and of cross-temporal and cross-cultural moral judgments. Yet today we are said to live in a multicultural and postmodern world. This article assesses the challenges that multiculturalism and postmodernism pose to fundamentalism and concludes that these challenges render the position philosophically untenable, thereby undermining the received conception of the foundations of international bioethics. The second article, which follows, offers an alternative model -- a model of negotiated moral order -- as a viable justification for international bioethics and for transcultural and transtemporal moral judgments.     

An ethics of suffering: does it solve the problems we want to solve?: commentary

Erich H. Loewy proposes to elevate the moral obligation to prevent and relieve suffering to the level of a prima facie moral duty by delineating which beings are of primary moral worth and which are of secondary moral worth. Sentient beings have a capacity to suffer and are therefore of primary moral worth. Beings that are insentient cannot suffer; therefore such beings are only of secondary moral worth. Objects of secondary moral worth include patients in a persistent vegetative state (PVS) and brain-dead patients. This proposal, he says, would solve a number of problems in clinical bioethics. First, it would help to clarify our moral duties at the bedside. And secondly, by creating a hierarchy of moral values, it helps to differentiate which patients are owed our primary allegiance and resources. Despite his extensive and painstaking proof, I believe several questions remain about the use of the "capacity of sentient beings to suffer" as a basis for a universal grounding in ethics.     

Honoring the Bios in Lutheran Bioethics

Abstract:  A Lutheran bioethic honors the body by being anti‐Gnostic (and finding moral wisdom in the body's limits), by being anti‐Pelagian (and requiring the reshaping of our disordered desires), and by being anti‐Sadducean (in affirming that the new creation, though continuous with and fulfilling the old, also transforms and perfects it in ways that go beyond the earthly life we know). Such an approach to bioethics is illustrated here through discussion of the way in which new reproductive technologies may distort our understanding of the relation between the generations, thereby losing sight of the bios in bioethics.     

A theory of international bioethics: the negotiable and the non-negotiable

The preceding article in this issue of the Kennedy Institute of Ethics Journal presents the argument that "moral fundamentalism," the position that international bioethics rests on "basic" or "fundamental" moral prinicples that are universally accepted in all eras and cultures, collapses under a variety of multicultural and postmodern critiques. The present article looks to the contractarian tradition of Hobbes and Locke -- as reinterpreted by David Gauthier, Robert Nozick, and John Rawls -- for an alternative justification for international bioethics. Drawing on the central themes of this tradition, it is argued that international bioethics can be rationally reconstructed as a negotiated moral order that respects culturally and individually defined areas of nonnegotiability. Further, the theory of a negotiated moral order is consistent with traditional ideals about human rights, is flexible enough to absorb the genuine insights of multiculturalism and postmodernism, and yet is strong enough to justify transcultural and transtemporal moral judgments, including the condemnation of the Nazi doctors at Nuremberg. This theory also is consistent with the history of the ethics of human subjects experimentation and offers insights into current controversies such as the controversy over changing the consent rule for experiments in emergency medicine and the controversy over exempting certain clinical trials of inexpensive treatments for preventing the perinatal transmission of AIDS from the ethical standards of the sponsoring country.     

Nihilism,Relativism, and Engelhardt

This paper is a critical analysis of Tristram Engelhardt's attempts to avoid unrestricted nihilism and relativism. The focus of attention is his recent book, The Foundations of Bioethics (Oxford University Press, 1996). No substantive or content-full bioethics (e.g., that of Roman Catholicism or the Samurai) has an intersubjectively verifiable and universally binding foundation, Engelhardt thinks, for unaided secular reason cannot show that any particular substantive morality (or moral code) is correct. He thus seems to be committed to either nihilism or relativism. The first is the view that there is not even one true or valid moral code, and the second is the view that there is a plurality of true or valid moral codes. However, Engelhardt rejects both nihilism and relativism, at least in unrestricted form. Strictly speaking, he himself is a universalist, someone who believes that there is a single true moral code. Two argumentative strategies are employed by him to fend off unconstrained nihilism and relativism. The first argues that although all attempts to establish a content-full morality on the basis of secular reason fail, secular reason can still establish a content-less, purely procedural morality. Although not content-full and incapable of providing positive direction in life, much less a meaning of life, such a morality does limit the range of relativism and nihilism. The second argues that there is a single true, content-full morality. Grace and revelation, however, are needed to make it available to us; secular reason alone is not up to the task. This second line of argument is not pursued in The Foundations at any length, but it does crop up at times, and if it is sound, nihilism and relativism can be much more thoroughly routed than the first line of argument has it.Engelhardt's position and argumentative strategies are exposed at length and accorded a detailed critical examination. In the end, it is concluded that neither strategy will do, and that Engelhardt is probably committed to some form of relativism.     

Pragmatism as a research program--a reply to Arras

This paper is a reaction to an article by John Arras published earlier in this journal. In this article Arras argues that freestanding pragmatism has little new to offer to bioethics. We respond to some of Arras' arguments and conclude that, although he overstates his case at certain points, his critique is, broadly speaking, correct. We then introduce and discuss an alternative approach to pragmatist ethics, one which puts to work the ideas and insights of pragmatism conceived as a broad philosophical movement, without lapsing into a canon dependent approach. The approach we propose exhibits a number of characteristics that differ from Arras'saccount of freestanding pragmatism and offers something new to bioethics.     

Christian Bioethics in a Western Europe after Christendom

Europe has taken on a new, post-Christian, if not a somewhatanti-Christian character. The tension between Western Europe'sever more secular present and its substantial Christian pastlies at the heart of Western Europe's current struggle to articulatea coherent cultural and moral identity. The result is that WesternEuropean mainline churches are themselves in the midst of anidentity crisis, thus compounding Western Europe's identitycrisis. Christian bioethics in Europe exists against the backdropof these profound cultural cross currents that define the Europeancondition, engender conflicts regarding the meaning of beingWestern European and being Christian, and bring the public significanceand role of Western European bioethics, especially Western EuropeanChristian bioethics, into question. The dominant culture ofthe public forum is post-Christian and post-traditional, althoughtraditional Christianity still asserts its voice. Denis Müllerin his paper has clarified the choice between a traditional-fundamentalistChristian Bioethics and a revisionist, progressive ChristianBioethics.     

The mettle of moral fundamentalism: a reply to Robert Baker

This article is a reply to Robert Baker's attempt to rebut moral fundamentalism, while grounding international bioethics in a form of contractarianism. Baker is mistaken in several of his interpretations of the alleged moral fundamentalism and findings of the Advisory Committee on Human Radiation Experiments. He also misunderstands moral fundamentalism generally and wrongly categorizes it as morally bankrupt. His negotiated contract model is, in the final analysis, itself a form of the moral fundamentalism he declares bankrupt.     

Documentary Bioethics: Visual Narratives for Generations X and Y

Narrative bioethics is primarily understood to involve storytelling through the use of literature. This article suggests that other forms of media are necessary to convey stories of an ethical nature to an audience broader than one being trained as medical professionals. "Documentary bioethics" is a manner to present and interpret stories of an ethical nature using forms of popular electronic media in a reality-based documentary style to society at large, specifically Generations X and Y.     

Wide reflective equilibrium as a method of justification in bioethics

Carson Strong has recently argued that wide reflective equilibrium (WRE) is an unacceptable method of justification in bioethics. In its place, Strong recommends a methodology in which certain foundational moral judgments play a central role in the justification of moral beliefs, and coherence plays a limited justificatory role in that the rest of our judgments are made to cohere with these foundational judgments. In this paper, I argue that Strong??s chief criticisms of WRE are unsuccessful and that his proposed alternative is in fact just another version of WRE. In the course of doing so, I specify which theses are central to WRE and which are not, and thus, provide a response to an additional objection, advanced by Peter Singer, that WRE is vacuous. I conclude by arguing that there may be better prospects for advancing the debate regarding methodology in bioethics if we focus on restricted epistemic and methodological theses rather than broad approaches, such as WRE, that come in many different varieties.     

Medical ethics' appropriation of moral philosophy: the case of the sympathetic and the unsympathetic physician

Philosophy textbooks typically treat bioethics as a form of "applied ethics"-i.e., an attempt to apply a moral theory, like utilitarianism, to controversial ethical issues in biology and medicine. Historians, however, can find virtually no cases in which applied philosophical moral theory influenced ethical practice in biology or medicine. In light of the absence of historical evidence, the authors of this paper advance an alternative model of the historical relationship between philosophical ethics and medical ethics, the appropriation model. They offer two historical case studies to illustrate the ways in which physicians have "appropriated" concepts and theory fragments from philosophers, and demonstrate how appropriated moral philosophy profoundly influenced the way medical morality was conceived and practiced.     

Protection of Life and Human Dignity: The German Debate between Christian Norms and Secular Expectations

The German debate on bioethics and medical ethics turns on achange in the meaning of human dignity. Such dignity is increasinglyrendered contingent upon a person's empirically assessable qualityof life. In contrast to such dignity-endowed human life, a merelybiological human life is taken to disqualify its bearer fromsuch dignity, depriving his life of the protection "respectfor human dignity" would otherwise guarantee. The idea of a"life not worth living" or "undignified life" evokes categories,which were developed at the beginning of the 20th century, andlater informed the crimes of National Socialist medicine inGermany. Against this secular development, this article analysesthe theological and church-based discussion of basic bioethicalquestions in Germany, especially the controversy among Protestants:once Protestant ethicists abandon an explicitly theologicalbasis for their arguments, their conclusions come to closelyresemble those of the secular participants in the debate. Asa result, such Protestants relativize fundamental ethical norms.They subordinate, along with their secular environment, theprotection of life to respect for autonomy. They thus preparethe ground for a revival of the risky concepts of the past.