Contemporary Debates in Bioethics

Arthur L. Caplan, Robert Arp, Arthur L. Caplan, Robert Arp

• Publisher: Wiley-Blackwell
• Year: 2013
• ISBN:
  9781118328477
• Edition: 1
• Topic: Medizin
• Subtopic: Ethik in der Medizin

Contemporary Debates in Bioethics features a timely collection of highly readable, debate-style arguments contributed by many of today's top bioethics scholars, focusing on core bioethical concerns of the twenty-first century.

• Written in an engaging, debate-style format for accessibility to non-specialists
• Features general introductions to each topic that precede scholarly debates
• Presents the latest, cutting-edge thoughts on relevant bioethics ideas, arguments, and debates

Part 1

Are There Universal Ethical Principles That Should Govern the Conduct of Medicine and Research Worldwide?

Introduction

If the question that forms the basis for the debate in this section were “Are there universal ethical principles that do in fact (rather than should) govern the conduct of medicine and research worldwide?” the answer would prima facie be no, and the matter likely settled by appealing to data and facts contrasting the current ethical justifications for the medical practices of one group, culture, or nation with another (or several groups, culture, or nations). For example, female genital mutilation (FGM)—defined by the World Health Organization (WHO) as “all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for nonmedical reasons”—is not practiced in the mainstream medical communities of the US and many other countries based ­primarily on ethical reasons pertaining to principles of autonomy, beneficence, and nonmaleficence. By contrast, the WHO estimates that, as of February 2010, between 100 and 140 million girls and women worldwide have had some form of FGM, and in many of the countries where FGM is practiced there are oftentimes religious, ethical reasons given as justification for the procedure (Boyle, 2002; Skaine, 2005; WHO, 2010). So, by virtue of the fact that FGM is practiced in certain societies around the world, it is apparent that principles of autonomy, beneficence, and nonmaleficence are not governing the conduct of medicine and research worldwide; conversely, by virtue of the fact that FGM is not practiced in ­societies such as the US, it is also apparent that certain religiously based ethical principles also are not governing the conduct of medicine and research worldwide. And there are many other conflicting or contradictory medical and biomedical practices worldwide that can be pointed to as examples of the fact that there seem not to be universal ethical principles governing these practices (Young, 2006; Unschuld, 2009; Caplan, 2010).

A cultural anthropologist, sociologist, psychologist, or any other researcher can look at medical and ­biomedical practices worldwide and note descriptively that it is the case that there are not universal ethical principles governing these practices. Although, we must be cautious here since many thinkers who have argued for one version or another of soft universalism have attempted to show that there are in fact a handful of universal ethical principles in existence, but that these principles make themselves manifest in culturally grounded ways, giving the mere appearance of being relative (Foot, 1979/2002; Nussbaum, 1993; Walzer, 1994; Bok, 2002; Miller, 2002). In any event, the bioethician (and any other thinker, for that matter), as philosopher, can look at medical and biomedical practices worldwide and question whether ­prescriptively there should be universal ethical principles governing these practices. Consider FGM again. The number of good arguments against FGM that appeal to (ostensibly) universalizable principles of autonomy, beneficence, and nonmaleficence would seem to suggest that practitioners of FGM either are unaware of these principles, knowingly disregarding them, or may be pressured into disregarding them due to cultural or religious factors (Nussbaum, 1999; Cohen, Howard, and Nussbaum, 1999; Gruenbaum, 2001). In other words, it can be argued that these ethical principles (and laws emerging from them) should be guiding medical practice worldwide such that FGM stops occurring altogether, no matter what the culture or social situation.

Immanuel Kant’s (1724–1804) deontological moral theory, with its emphasis upon autonomy, respect for persons, and blind justice, as well as John Stuart Mill’s (1806–1873) utilitarian moral theory, with its emphasis upon bringing about the most nonharmful (and hence, pleasurable) and beneficial conse­quences to a person (or sentient being) affected by an action, have acted as the basis for practical moral ­decision-making since the theories were formulated in the eighteenth and nineteenth centuries (Kant, 1785/1998; Mill, 1861/2001; Korsgaard, 1996; Baron, 1999; Hooker, 2000). And many of the standard philosophical ­arguments against FGM appeal to Kant and/or Mill, in one form or another (Nussbaum, 1999; Cohen et al., 1999; Wallis, 2005; Bikoo, 2007; Burkhardt and Nathaniel, 2008; cf. Lander, 1999). The principles emerging from these theories were affirmed in the Nuremberg Code (1946–1949), The Belmont Report (1979), and Tom Beauchamp and James Childress’ famous work, Principles of Biomedical Ethics (NIH, 2011a, 2011b; Beauchamp and Childress, 1979/2009), which has become a standard reference work for medical and other bioethical decisions. Given the wide rational appeal and application of these ­principles to multiple practical issues—bioethical or ­otherwise—along with their success in application in terms of conflict resolution and just policy making in numerous countries, it can be argued that they are the types of universal ethical principles that should govern the conduct of medicine and research worldwide.

In fact, in the first chapter of this section Daryl Pullman affirms what he calls the principle of respect for human dignity, which he argues is present most clearly in Kant’s moral philosophy and acts as the foundation for any moral decision. Thus, it is Pullman’s ­contention that not only is a respect for human dignity ­actually at work universally in moral decision-making (descriptively), but also that it should be at work ­universally in moral decision-making (prescriptively) (also see Walzer, 1994; Macklin, 1999; Bok, 2002). “Our concept of morality is predicated on the assumption of the intrinsic moral worth or dignity of humanity,” Pullman notes, and the “essence of morality is to guard, protect, and advance this fundamental value.” To bolster his position, Pullman appeals to a well-known strategy that has been used against proponents of ethical relativism who think that it is not possible for one group, society, or culture to criticize morally the actions of another group, society, or culture (see Harman, 1975/2000, 1984/2000, 1996), namely, without at least the principle of respect for human dignity, there is “no way to measure moral progress or regress, and no basis for judging the actions of other nations, social groups, or even individuals as either morally praiseworthy or blameworthy.”

“It might seem surprising to demand of ethical principles that they be universal, given that most moral decision-making will concern those fairly close to us: ourselves, our extended family, plus a relatively small community of friends, work associates, and acquaintances.” So claims Kevin Decker in the second chapter of this section. While Decker maintains that he is no ethical relativist, as a pragmatist who thinks that moral judgments and actions are intimately connected and circumstantially grounded, he does subscribe to David Wong’s (1993) view that “moral truth and justifiability, if there are any such things, are in some way relative to factors that are culturally and historically contingent” (p. 442). Principles are just “one part of a balanced breakfast” when making a moral decision, claims Decker, along with other factors such as would be considered by the typical utilitarian (consequences) and virtue ethicist (character), among others. And while principles can be appealed to in some group, society, or culture, it seems inaccurate and illegitimate to maintain that principles are or should be universally binding.

References

Baron, M. (1999). Kantian ethics almost without apology. Ithaca, NY: Cornell University Press.

Beauchamp, T., & Childress, J. (1979/2009). Principles of ­biomedical ethics. Oxford: Oxford University Press.

Bikoo, M. (2007). Female genital mutilation: Classification and management. Nursing Standard, 22(7), 43–49.

Bok, S. (2002). Common values. Columbia, MO: University of Missouri Press.

Boyle, E. (2002). Female genital cutting: Cultural conflict in the global community. Baltimore, MD: The Johns Hopkins University Press.

Burkhardt, M., & Nathaniel, A. (2008). Ethics & issues in contemporary nursing. Clifton Park, NY: Delmar Cengage Learning.

Caplan, A. (2010). Clinical trials of drugs and vaccines among the desperately poor in poor nations: Ethical ­challenges and ethical solutions. Clinical Pharmacology and Therapeutics, 88, 583–584.

Cohen, J., Howard, M., & Nussbaum, M. (Eds.). (1999). Is multiculturalism bad for women? Princeton, NJ: Princeton University Press.

Foot, P. (1979/2002). Moral relativism. In P. Foot (Ed.), Moral dilemmas and other topics in moral philosophy (pp. 20–36). Oxford: Clarendon Press.

Gruenbaum, E. (2001). The female circumcision controversy: An anthropological perspective. Philadelphia: University of Pennsylvania Press.

Harman, G. (1975/2000). Moral relativism defended. In G. Harman (Ed.), Explaining value: and other essays in moral philosophy (pp. 3–19). Oxford: Clarendon Press. Original publication date: 1975.

Harman, G. (1984/2000). Is there a single true morality? In G. Harman (Ed.), Explaining value and other essays in moral philosophy (pp. 77–99). Oxford: Clarendon Press.

Harman, G. (1996). Moral relativism. In G. Harman & J. J. Thompson (Eds.), Moral relativism and moral objectivity (pp. 3–64). Cambridge MA: Blackwell.

Hooker, B. (2000). Ideal code, real world: A rule-consequentialist theory of morality. Oxford: Oxford University Press.

Kant, I. (1785/1998). Groundwork of the metaphysics of morals (M. Gregor, Trans.). (Section I: Transition from common rational to philosophic moral cognition). Cambridge: Cambridge University Press.

Korsgaard, C. (1996). Creating the kingdom of ends. Cambridge: Cambridge University Press.

Lander, M. (1999). Circumcision and virtue ethics. In G. Denniston, F. Hodges, & M. Milos (Eds.), Male and female circumcision: medical, legal, and ethical considerations in ­pediatric practice (pp. 409–412). New York: Kluwer Academic.

Macklin, R. (1999). Against relativism: Cultural diversity and the search for ethical universals in medicine. Oxford: Oxford University Press.

Mill, J. S. (1861/2001). Utilitarianism. Indianapolis, IN: Hackett Publishing Company.

Miller, A. (2002). An introduction to contemporary metaethics. Cambridge: Polity Press.

NIH (National Institutes of Health). (2011a). Trials of war criminals before the Nuremberg military tribunals under control council law no. 10, vol. 2, pp. 181–182. Washington, DC: US Government Printing Office, 1949. Retrieved from: http://ohsr.od.nih.gov/guid lines/nuremberg.html

NIH (National Institutes of Health). (2011b). The Belmont report: Ethical principles and guidelines for the ­protection of human subjects of research, April 18, 1979. Retrieved from: http://ohsr.od.nih.gov/guidelines/­belmont.html

Nussbaum, M. (1993). Non-relative virtues: An Aristotelian approach. In M. Nussbaum & A. Sen (Eds.), The quality of life (pp. 242–269). Oxford: Clarendon Press.

Nussbaum, M. (1999). Sex and social justice. Oxford: Oxford University Press.

Skaine, R. (2005). Female genital mutilation: Legal, cultural and medical issues. Jefferson, NC: McFarland.

Unschuld, P. (2009). What is medicine? Western and Eastern approaches to healing (K. Reimers, Trans.). Berkeley: University of California Press.

Wallis, L. (2005). When rites are wrong. Nursing Standard, 20(4), 24–26.

Walzer, M. (1994). Thick and thin: Moral argument at home and abroad. Notre Dame, IN: University of Notre Dame Press.

WHO (World Health Organization). (2010). Female genital mutilation. Retrieved from: http://www.who.int/mediacentre/factsheets/fs241/en/

Wong, D. (1993). Moral relativism. In P. Singer (Ed.), A companion to ethics (pp. 442–450). Malden, MA: Blackwell.

Young, J. (2006). The medical messiahs: A social history of health quackery in twentieth-century America. Retrieved from: http://www.quackwatch.com/13Hx/MM/00.html

Chapter One

There Are Universal Ethical Principles That Should Govern the Conduct of Medicine and Research Worldwide

Daryl Pullman

In this chapter, I defend the claim that the very notion of morality requires the recognition of at least one overarching, universal moral principle that I call the principle of respect for human dignity. I begin by placing the contemporary universalist versus particularist debate in historical perspective, demonstrating that the current discussion is a continuation of a longstanding argument in moral philosophy. I then outline the conception of human dignity that underwrites the universal principle defended here, arguing that some such overarching principle is essential to the very notion of morality. Nevertheless, while the principle of respect for human dignity acts to constrain moral discourse in the broad sense, I ­demonstrate that the notion of human dignity is nevertheless amenable to particularist interpretations and applications.

Introduction

It is fitting that a book dedicated to contemporary debates in bioethics should open with a discussion of one of the most basic and fundamental questions in moral philosophy, namely, whether there are or can be any universal moral principles. How one responds to this question indicates a great deal about what one thinks about the nature of morality, the process or moral reasoning, the goals of moral discourse, and the possibility of moral progress. Indeed, this question has implications for the nature of the relationship between ethics and the law and the rule of law locally, nationally, and internationally.

In this chapter, I will defend the claim that there is at least one universal moral principle that has been described variously in the history of moral philosophy (at least since Kant, 1785/1948) as the principle of humanity, principle of respect for persons, and principle of human dignity. This is not to say that all of these formulations are equivalent; anyone who has read even a little philosophy has discovered that philosophers are wont to make distinctions and to write treatises on the same, even though such distinctions at times make little if any practical difference. Nevertheless, for the purposes of this discussion, these various formulations of what might be termed the fundamental principle of morality will be treated as roughly equivalent. I will focus on the concept of human dignity in an attempt to demonstrate both the necessity of some such general principle to our understanding of the nature of morality and the process of moral discourse, as well as to outline how such a general moral principle is ­nevertheless amenable to more particular and local interpretations and applications. Although the concept of human dignity has been much discussed and debated in recent years, it is still invoked widely in various national and international ethical and legal codes, including many that pertain to healthcare and health research. Combining aspects of the various formulations listed above, the universal principle defended here will be called the principle of respect for human dignity.

Now, such a general principle is admittedly abstract, and it is not immediately clear what it captures in terms of moral content, or how the principle would be applied to give moral guidance in specific cases. Defenders of principlism, or some version of it, generally argue that more specific action guiding principles are derived from some such fundamental principle. For example, Downie and Telfer (1969) refer to particular principles that deal with such actions as truth-telling and promise-keeping—and the many other specific requirements of morality—as reflecting the existence of moral rules, while the general, universal principle (respect for persons is their preferred formulation) serves as the “supreme regulative principle” for...