Principles and Metaphors in Biomedical

Philosophy 179-757-01, , Fall 1985 Friday, 1: 15- 2:55, Kennedy Institute Conference Room

James F. Childress

This seminar offers a systematic examination of the way principles and metaphors shape practical and theoretical discourse in biomedical ethics. We will use several principles and metaphors to explore some major problems (such as the authority of professionals, the allocation of health care resources, the procurement and distribution of organs for trans- plantation, and withholding or withdrawing artificial nutrition and hydration) and to analyze critically some important recent literature in biomedical ethics.

Format, procedures, requirements, and readings will be discussed at th first meeting.

Tentative list of topics for each session:

1. Principles

2. Metaphors

3. Metaphors and Models of Relationships between Health Care Professionals and Patients

4. Professional Paternalism and Patient Autonomy

5. The Significance of Theological Perspectives: The Problem of Suicide

6. Virtues and Vices: Self, Character, and Conduct

7. Moral Distance

8. Withholding or Withdrawing Medical Nutrition and Hydration: The Significance of Symbolic Actions

9. Valuing Lives

10. Justice, Triage, and Rationing

11. The Gift of Life: Justice and Charity in the Procurement and Distribution of Organs for Transplantation

12. Conclusions Readings

Session #1, “Moral Principles”

Required Readings:

Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 2nd ed. (1983), chaps, 1-2, the first part of chaps. 3-6 Steven Toulmin, “The Tyranny of Principles,” Hastings Center Report 11 (December 1981 )

Additional Readings

R.M. Hare, “Principles,” Freedom and Reason (1963) Marcus Singer, “Moral Rules and Principles,” Essays in Moral Philosophy, ed., A. I. Melden (1958) I.. M. Crombie, “Moral Principles,” Christian Ethics and Contemporary Philosophy, ed. I. T. Ramsey (1966) J. B. Schneewind, “Moral Knowledge and Moral Principles,” Knowledge and Necessity, Royal Institute of Philosophy Lectures, Vol. 3 (1979) Albert Jonsen, Mark Siegler, William Winslade, Clinical Ethics (1982) Stanley Hauerwas and Alasdair MacIntyre, eds., Revisions: Changing Perspectives in Moral Philosophy (1983) James M. Gustafson, “Moral Discernment in the Christian Life,” Theology and Christian Ethics (1974)

Session #2, “Metaphors”

Required Readings:

George Lakoff and Mark Johnson, “Conceptual Metaphor in Everyday Language,” Journal of Philosophy 77 (August 1980): 453-86 Virginia Warren, “A Powerful Metaphor: Medicine is War” John Noonan, “How to Argue About Abortion,” in Contemporary Issues in , eds. Tom L. Beauchamp and LeRoy Walters (1978)

Additional Readings:

George Lakoff and Mark Johnson, Metaphors We Live By (1980) Susan Sontag, Illness as Metaphor (1979) Samuel Vaisrub, Medicine's Metaphors: Messages and Menaces (1977) Mark Johnson, ed., Philosophical Perspectives on Metaphor (1981) Paul Ricoeur, The Rule of Metaphor (1977) Seldon Sacks, ed., On Metaphor (1979) Max Black, “Metaphors,” Models and Metaphors (1962) Ian Barbour, Myths, Models and Paradigms (1974) Andrew Ortony, ed., Metaphor and Thought (1979) Donald A. Schön, “Generative Metaphor: A Perspective on Problem-Setting in Social Policy,” in Ortony, ed., Metaphor and Thought (1979) H. Richard Niebuhr, The Responsible Self (1963), esp. I and app. A Stanley Hauerwas, “The Significance of Vision: Toward an Aesthetic Ethics,” Vision and Virtue (1974) Margaret Macdonald “The Language of Political Theory,” in Logic and Language, 1st and 2nd Series, ed. Antony Flew (1965), pp. 174-94 Philip Wheelwright, Metaphor and Reality (1962) Debra C. Rosenthal, “Metaphors, Models, and Analogies in Social Science and Public Policy,” Political Behavior 4 (1982): 283-301 Lawrence Pray, Journey of a Diabetic (1983)

Session #3, “Metaphors and Models of Relationships between Health Care Pro- fessionals and Patients”

Required Readings:

Robert Veatch, A Theory of (1981), chaps. 4 & 5 “Models for Ethical Medicine in a Revolutionary Age,” HCR 2 (1972): 5-7 Mark Siegler, “Searching for Moral Certainty in Medicine: A Proposal for a New Model of the Doctor-Patient Encounter,” Bulletin of New York Academy of Medicine 57 (1981): 56-69 , Gerald R. Winslow, “From Loyalty to Advisory: A New Metaphor for Nursing,” HCR 14 (1984): 32-40 “Code, Covenant, Contract or Philanthropy,” HCR 5 (1975): 29-38

Additional Readings:

Jay Katz, The Silent World of Doctor and Patient (1984) James F. Childress, Who Should Decide? Paternalism in Health Care (1982), chap. 1 Tom L. Beauchamp and Laurence B. .McCullough, Medical Ethics: The Moral Responsibilities of Physicians (1984) Paul Ramsey, The Patient as Person (1970), preface, chap. 1 Charles Fried, Medical Experimentation (1974) “The Lawyer as Friend: The Moral Foundations of the Lawyer-Client Relation,” Yale Law Journal 85 (July 1976): 1060-89 Roy Branson, “The Secularization of American Medicine,” Hastings Center Studies 1, no. 2 (1973): 11-28 Leon Kass, “Ethical Dilemmas in the Care of the Ill: I. What is the Physician's Service?” JAMA 244 (October 17, 1980) Robert A. Burt, Taking; Care of Strangers: The Rule of Law in Doctor-Patient Relations (1979) Bernard Barber, Informed Consent in Medical Therapy and Research (1979), chap. 4 Miriam Siegler and Humphry Osmond, Patienthood: The Art of Being a Responsible Patient (1979) Thomas Szasz and Marc H. Hollender, “A Contribution to the Philosophy of Medicine: The Basic Models of the Doctor-Patient Relationship,” Archives of Internal Medicine 97 (May 1956): 585-92 Thomas Szasz, William F. Knoff, and Marc H. Hollender, “The Doctor-Patient Relationship and its Historical Context,” The American Journal of Psychiatry, Vol. 115 (December 1958) P. Lain Entralgo, Doctor and Patient (1969) Roger D. Masters, “Is Contract an Adequate Basis for Medical Care?” HCR 5 (December 1975): 24-28 Eric Cassell, The Healer's Art (1976) Talcott Parsons, “The Sick Role and the Role of the Physician Reconsidered,” Milbank Memorial Fund Quarterly (Summer 1975): 257-77 President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Making Health Care Decisions (1982), report and two appendices Edmund D. Pellegrino and David C. Thomasma, A Philosophical Basis of Medical Practice (1981) “Autonomy and the Doctor-Patient Relationship”" Theoretical Medicine 5, no. 1 (February 1984) Earl Shelp, ed., The Clinical Encounter: The Moral Fabric of the Patient-Physician Relationship, Philosophy and Medicine 14 (1983)

Session #4, “Paternalism and Autonomy”

Required Readings:

Robert Veatch, A Theory of Medical Ethics, chaps. 6 & 8 James F. Childress, Who Should Decide?, chaps. 1,4 & 5

Additional Readings:

David Jackson and Stuart Youngner, “Patient-Autonomy and 'Death with Dignity,'” The New England Journal of Medicine 301 (August 23, 1979): 404-408 S. Imbus and B. Zawacki, “Autonomy for Burned Patients....” NEJM 297 (August 11,1977): 308ff. Bruce Miller, “Autonomy and the Refusal of Lifesaving Treatment,” HCR 11 (August 1981): 22-28 Wade Robison and Michael Pritchard, eds., Medical Responsibility (1979) Richard Sennett, Authority (1980), esp. 2 & 3 John Kleinig, Paternalism (1983) Rolf Sartorius, ed., Paternalism (1983) Tom L. Beauchamp and Laurence B. McCullough, Medical Ethics: The Moral Responsibilities of Physicians (1984) Tristram Engelhardt, Foundations of Bioethics (1985) H.L.A. Hart, Law, Liberty and Morality (1963), chap. 1 Tom L. Beauchamp, “Paternalism,” Encyclopedia of Bioethics (1978) “Paternalism and Bio-behavioral Control,” Monist 60 (January 1977) Gerald Dworkin, “Paternalism,” Morality and the Law, ed. Richard Wasserstrom (1971) . Dan Wikler, “Paternalism and the Mildly Retarded,” Philosophy and Public Affairs 8 (1979) Bernard Gert and Charles Culver, Philosophy in Medicine (1982), as well as various articles A. Buchanan, “Medical Paternalism,” Philosophy and Public Affairs 7 (1978) Joel Feinberg, Social Philosophy (1973)

Session #5, “The Significance of Theological Perspectives”

In some areas of moral disagreement in medicine and health care, theological perspectives are significant, and theologians frequently appeal to perspectives, vision, metaphors, stories, and narratives, as well as to principles, in developing biomedical ethics. Two major areas will be used to explicate some differences between many theological and many (though by no means all) philosophical approaches: suicide and refusal of life-sustaining treatment. Of particular interest is the work of James Gustafson and Stanley Hauerwas-- the former offering a theocentric perspective and the latter a narrative-shaped-character – over against the principle of autonomy. General theological convictions undergird or are expressed in several images, metaphors, and analogies (e.g., the body as property, given, loaned or entrusted by God to human beings for thoughtful stewardship) and principles for guiding that stewardship.

Required Readings:

M. Pabst Battin, Ethical Issues in Suicide (1982), excerpts James M. Gustafson, Ethics from a Theocentric Perspective, Vol. II, (1984), excerpts Stanley Hauerwas, “Rational Suicide and Reasons for Living,” in Rights and Responsibilities in Medicine, ed. Marc Basson (1981)

Additional Readings:

Paul Ramsey, The Patient as Person (1970) Richard McCormick, S.J. How Brave a New World? (1981) M..Pabst Battin and David Mayo, eds., Suicide: The Philosophical Issues (1980) Karen Lebacqz and H. Tristram Engelhardt, “Suicide,” Death, Dying and Euthanasia, ed., Dennis J. Horan and David Mall (1977) The Journal of Medicine and Philosophy 4 (1979) John Mahoney, Bioethics and Belief (1984) Stanley Hauerwas, Truthfulness and Tragedy (1977) Philip Devine, The Ethics of Homicide (1978) P. R. Bae1z, “Voluntary Euthanasia: Some Theological Reflections,” Theology 75 (May 1972) R.F. Holland, “Suicide,” Moral Problems, ed. (1971) Tom L. Beauchamp, “Suicide,” Matters of Life and Death, ed. (1980) Samuel E. Wallace and Albin Eser, eds., Suicide and Euthanasia: The Rights of Personhood (1981) . Richard Brandt, “The Morality and Rationality of Suicide,” A Hand-book for the Study of Suicide, ed. Seymour Perlin (1975) M. Pabst Battin and Ronald W. Maris, eds., Suicide and Ethics (1983) Such classical writings as Plato. Cicero. Seneca, Augustine, Thomas Aquinas, , John Donne, and Immanuel Kant

Session #6, “Virtues and Vices: Self, Character, and Conduct”

Is an ethic of virtue or character an alternative to, a supplement to, or an ingredient in an ethic of principle? Proponents of an ethic of virtue or character tend to emphasize stories and narratives as well as images and metaphors. What are the implications of such an ethic for science, medicine, and health care? Can it contribute to an ethos of medicine in ways that an ethic of principle, often structured around dilemmas and quandaries, cannot? Can it obviate the need for procedures? However such an ethic is conceived, which virtues should be emphasized, how do they relate to principles of conduct, and how can they be displayed by both agents and practices in health care?

Required Readings:

Alasdair MacIntyre, After Virtue (1981), excerpts Leon Kass. “Ethical Dilemmas in the Care of the Ill,” JAMA 244, no. 16 (October 17, 1980); 1811-16 and no. 17 (October 24/31, 1980): 1946-49 Tom Beauchamp and James Childress, Principles of Biomedical Ethics, chap. 8

Additional Readings:

Gilbert Meilaender, The Theory and Practice of Virtue (1984) Gregory Pence, Ethical Options in Medicine (1980) Philippa Foot, Virtues and Vices (1978) James D. Wallace, Virtues and Vices (1978) Arthur Flemming, “Reviewing the Virtues,” Ethics 90, no. 4 (July 1980): 587-95 (review of Foot and Wallace) Peter Geach, The Virtues (1977) Lawrence C. Becker, “The Neglect of Virtue,” Ethics 95 (January 1975) James M. Gustafson, The Contributions of Theology to Medicine (1975) Stanley Hauerwas, Vision and Virtue (1974) Truthfulness and Tragedy (1977) A Community of Character (1981) Character and the Christian Life (1975) David B. Harned, Faith and Virtue (1981) Alasdair MacIntyre, “The Nature of the Virtues,” HCR 11 (April 1981): 27-34 Iris Murdoch, The Sovereignty of Good (1971) James M. Gustafson, Can Ethics Be Christian? (1975) Christina Hoff Sommers, ed., Vice and Virtue in Everyday Life (1985)

Session #7, “Moral Distance”

Moral distance – as structured by principles and rules and by metaphors and symbols. An examination of several distinctions that are invoked in debates about death and dying. Several of these distinctions establish moral distance often by suggesting temporal, spatial, or causal distance between persons and their acts or between acts and their consequences. Examples include the rule of double effect, which contrasts direct and indirect courses of action, and the distinctions between killing and letting die, withholding and withdrawing treatments, and ordinary and extraordinary means of treatment. We will examine the bases of these categories, the principles and metaphors they reflect, and their adequacy for several cases, emphasizing the danger of self-deception.

Required Readings:

Jonathan Glover, Causing Death and Saving Lives (1977), esp. the last chapter. Paul Ramsey, Ethics at the Edges of Life (1978), chap. 4 President's Commission, Deciding to Forego Life-Sustaining Treatment (1983), intro. and chaps. 1-3

Additional Readings:

Robert Veatch, Death, Dying and the Biological Revolution (1976) Paul Ramsey, The Patient as Person (1970) Eike-Henner W. Kluge, The Practice of Death (1975) Philip E. Devine, The Ethics of Homicide (1978) Germain Grisez and Joseph Boyle, Life and Death with Liberty and Justice (1979) Bonnie Steinbock, ed., Killing and Letting Die (1980) John Ladd, ed., Ethical Issues Relating to Life and Death (1979) Tom Beauchamp and Seymour Perlin, eds., Ethical Issues in Death and Dying (1978) Robert Weir, ed., Ethical Issues in Death and Dying (1977) ed., Death in Literature (1980) Selective Nontreatment of Handicapped Newborns (1984) Owsei Temkin, William K. Frankena, and Sanford H. Kadish, Respect for Life in Medicine, Philosophy, and the Law (1977) Dennis J. Horan and David Mall, eds., Death, Dying and Euthanasia (1977) Marvin Kohl, The Morality of Killing: Sanctity of Life, Abortion and Euthanasia (1974) Beneficent Euthanasia (1975) Joel Feinberg, “Voluntary Euthanasia and the Inalienable Right to Life,” Philosophy and Public Affairs 7, no. 2 (Winter 1978): 93-123 Philippa Foot, “Euthanasia,” Philosophy and Public Affairs 6, no. 2 (Winter 1977): 85-112 Stanley Hauerwas, “The Ethics of Death: Letting Die or Putting to Death,” Vision and Virtue (1974) Daniel Maguire, Death by Choice (1975) Richard McCormick, S.J., How Brave a New World? (1981)

Session #8, “Withholding or Withdrawing Medical Nutrition and Hydration”

In the last two years the debate about the care of the terminally ill has focused on medical nutrition and hydration in increasingly dramatic and controversial ways (e.g., the Claire Conroy case in New Jersey). Part of this debate concerns what the distinctions discussed under “Moral Distance” imply for medical nutrition and hydration: are medical nutrition and hydration more similar to other medical treatments, such as a respirator, which may be discontinued, or are they more similar to the normal provision of food and water, which may not be discontinued? Central to the debate is the symbolic significance of food and water, especially in relation to the virtue of benevolence and the duty of beneficence. Images of thirst, hunger and starvation are very powerful. In addition, the metaphor of the wedge or slippery slope is frequently invoked and merits careful examination, rather than uncritical acceptance or unqualified dismissal.

Required Readings:

Joanne Lynn and James F. Childress, “Must Patients Always Be Given Food and Water?” HCR 13 (October 1983): 17-21 Daniel Callahan, “On Feeding the Dying,” HCR 13 (October 1983): 22 Gilbert Meilaender, “On Removing Food and-water: Against the Stream,” HCR 14 (December 1984): 11-13 Mark Siegler and Alan Weisbard, “Against the Emerging Stream: Should Fluids and Nutritional Support Be Discontinued?” Archives of Internal Medicine 145 (January 1985): 129-31

Additional Readings:

Joanne Lynn, ed., The Choice to Forgo Life-Sustaining Food and Water (1985 or 1986) D. W. Meyers, “Legal Aspects of Withdrawing Nourishment from an Incurably Ill Patient,” Archives of Internal Medicine 145 (1985):125-28 R. S. Dresser and E. V. Boisaubin, Jr., “Ethics, Law, and Nutritional Support,” Archives of Internal Medicine 145 (1985): 122-24 George J. Annas, “Non-feeding: Lawful Killing in California, Homicide in New Jersey,” HCR 13 (1983): 19-20 Eric J. Cassell, “Life as a Work of Art,” HCR 14 (October 1984): 35-37 Alexander M. Capron, “Ironies and Tension Feeding the Dying,” HCR 14 (October 1984): 32-35 B. Lo, “The Death Clarence Herbert: Withdrawing Care is Not Murder,” Annals of Internal Medicine 101 (1984): 248-51 S. H. Wanzer, et a1., “The Physician's Responsibility toward Hopelessly Ill Patients,” NEJM 310 (1984): 955-59 Joyce V. Zerwekh, “The Dehydration Question,” Nursing' 83 (January 1983): 47-51 Joel Feinberg, “Sentiment and Sentimentality in Practical Ethics,” Proceedings and Addresses of the APA 56, no. 1 (September 1982) Kenneth C. Micetich, Patricia H. Steinecker, and David C. Thomasma , “Are Intravenous Fluids Morally Required for a Dying Patient?” Archives of Internal Medicine 143 (May 1983): 975-80 Gerald Kelly, S.J., “The Duty to Preserve Life,” Theological Studies 12 (December 1951)

Session #9, “Valuing Lives”

There is widespread debate about whether it is possible, appropriate, and desirable to attempt to put a value on human life for purposes of decisions about policies, practices, and actions in health care and elsewhere. This debate usually reflects disagreements about the principle of utility or proportionality and its modern applications through cost-benefit (or cost-effectiveness) analysis and risk-benefit analysis. When it is impossible only to do good and to avoid evil, it is often considered right and even obligatory to weigh benefits and harms and to attempt to bring about a net balance of good effects over bad effects. We will explore the metaphors of “weighing” and “balancing”; the possibilities and limitations of utilitarianism; the possibility of accepting the principle of uti1ity without accepting utilitarianism; other limiting principles, particularly in distribution; and the implications of procedures for valuing life in debates about technology assessment, itself more an “art” (Coates) than a science.

Required Readings:

Steven Rhoads, ed., Valuing Lives (1980), selections Alasdair MacIntyre, “Utilitarianism and Cost-Benefit Analysis... .” and Tom Beauchamp, “...A Reply to MacIntyre,” in Ethical Theory and Business, eds. Tom Beauchamp and Norman Bowie (1979) Additional Readings:

Charles Fried, An Anatomy of Values (1970) Edmund A. C. Crouch and Richard Wilson, Risk/Benefit Analysis (1982) Nicholas Rescher, Risk (1983) Jonathan Glover, Causing Death and Saving Lives (1977) Douglas and Aaron Wildavsky, Risk and Culture (1982) Chrostoph Hohenemser and Jeanne X. Kasperson, eds., Risk in the Technological Society (1982) B. Fischoff, et al., Acceptable Risk (1981) George Washington Law Review 45 (August 1977) E. J. Mishan, Cost-Benefit Analysis (1976) John P. Bunker, et a1., Costs, Risks, and Benefits of Surgery (1977) Amartya Sen and Bernard Williams, eds., Utilitarianism and Beyond (1982) Harlan B. Miller and William H. Williams, eds., The Limits of Utilitarianism (1982) Samuel Scheffler, The Rejection of Consequentialism (1982) Richard Brandt, A Theory of the Good and the Right (1979) R. M. Hare, Moral Thinking (1982) J. L. Mackie, Ethics (1977), chaps. 6-7 J. J. C. Smart and Bernard Williams, Utilitarianism: For and Against (1973) John Stuart Mill, Utilitarianism (1861) , An Introduction to the Principles of Morals and Legislation (1789) David Lyons, Forms and Limits of Utilitarianism (1965)

Session # 10, “Justice, Rights, and Health Care”

There are two common moral arguments for a political-legal right to health care (or for a societal obligation to provide health care): One argument rests on beneficence, care or compassion; the other on justice or fairness. Both often use the metaphor of the “natural lottery” to explicate the nature of health needs, which are seen as largely the result of a random, impersonal process (the “natural lottery”) and thus as largely undeserved. Such undeserved needs may be construed as unfortunate or as also unfair. If these needs are merely unfortunate (and not also unfair), they may be the object of care or compassion of individuals, groups, or the society itself-- for example, the society may express, symbolize, and convey care and compassion for the victims of the natural lottery by providing medical care. If these needs are also unfair, they become the object of justice and require the provision of funds for their treatment. By contrast, libertarians contend that there is no moral duty, either of compassion or justice, to blunt the effects of the natural lottery. Among those who accept a right to health care, there are debates about whether it should encompass equal access or only a decent minimum (“safety net”). Of particular importance is determining relevant similarities, and different theories of justice emphasize different material criteria for determining relevant similarities (such as need, merit, effort, money, or status) for the distribution of benefits and burdens.

Required Readings:

H. Tristram Engelhardt, Jr. “Shattuck Lecture-- Allocating Scarce Medical Resources and the Availability of Organ Transplantation,” NEJM 311 (July 5, 1984): 66-71 Earl Shelp, ed., Justice and Health Care (1981), several essays including Engelhardt, “Health Care Allocations: Responses to the Unjust, the Unfortunate, and the Undesirable.” Gene Outka, “Social Justice and Equal Access to Health Care,” Journal of Religious Ethics 2 (Spring 1974): 11-32 Charles Fried, “Equality and Rights in Medical Care,” HCR 6 (February 1976): 29-34

Additional Readings:

Robert M. Veatch, A Theory of Medical Ethics (1981), chap. 11 Tom Beauchamp and James Childress, Principles of Biomedical Ethics (1983), chap. 6 Journal of Medicine and Philosophy 4 (June 1979)-- Rights to Health Care President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Securing Access to Health Care (1983) report and two volumes of appendices Robe Veatch and Roy Branson, eds., Ethics and Health Policy (1976) James F. Childress, “Rights to Health Care in a Democratic Society,” Biomedical Ethics Reviews, eds. Robert Almeder and James Humber Vol. II (1984) Henry J. Aaron and William B. Schwartz, The Painful Prescription: Rationing Hospital Care (1984) Jay Katz and Alexander M. Capron, Catastrophic Diseases: Who Decides What? (1974)

Session # 11, “Justice, Triage, and Rationing”

Richard Rettig and Kathleen Lohr have noted that “earlier policymakers spoke of the general problem of allocating scarce medical resources, a formulation that implied hard but generally manageable choices of a largely pragmatic nature. Now the discussion increasingly is of rationing scarce medical resources, a harsher term that connotes emergency-- even war-time-- circumstances requiring some societal triage mechanism.” The general language is that of “tragic choices,” and the specific language that of “triage” or “rationing.” We will explore several metaphors of distribution and allocation-- triage (which was first applied to medical care in military settings) and rationing (which also has a wartime or emergency setting)-- in order to determine what they illuminate and distort about both the situations to which they are applied and the principles they reflect (e.g., the different interpretations of “salvageability” in judgments of medical utility and social utility).

Required Readings: .

Gerald Winslow, Triage and Justice (1982)

Additional Readings:

Paul Ramsey, The Patient as Person (1970), chap. 6 Guido Calabresi and Philip Bobbitt, Tragic Choices (1978) Henry J. Aaron and William B. Schwartz, The Painful Prescription: Rationing Hospital Care (1984) George Annas, “Allocation of Artificial Hearts in the Year 2002: ‘Minerva v. National Health Agency,’” American Journal of Law and Medicine 3 (Spring 1977): 59-76 James F. Childress, “Ensuring Care, Respect, and Fairness for the Elderly,” HCR 14 (October 1984): 27-31 “Who Shall Live When Not All Can Live?” Soundings 53 (1970): 339-62 (reprinted in various anthologies) “Triage in Neonatal Intensive Care: .The Limitations of a Metaphor,” Virginia Law Review 69 (April 1983): 547-61 John Kilner, “A Moral Allocation of Scarce Lifesaving Medical Resources,” Journal of Religious Ethics 9 (Fall 1981): 245-85 Nicholas Rescher, “The Allocation of Exotic Medical Lifesaving Therapy,” Ethics 79 (April 1979): 173-86 (reprinted in various anthologies) Marc Basson, “Choosing among Candidates for Scarce Medical Resources,” Journal of Medicine and Philosophy 4 (September 1979): 313-33 For additional readings, see Winslow, Triage and Justice and Kilner, “A Moral Allocation...”

Session # 12, “The Gift of Lite: Ethical Problems and Policies in Obtaining and Distributing Organs for Transplantation”

Several years ago two sociologists noted that “the largest and perhaps most enduring significance of organ transplantation and dialysis lies in the ethical and existential questions they raise. Problems of uncertainty, meaning of life and death, scarcity, justice, equity, solidarity, and intervention in the human condition are all evoked by these therapeutic innovations.” Recent developments in organ transplantation (particularly improved immunosuppressive drugs) have highlighted the major problems that limit transplantation: the scarcity of organs and the costs of transplantation. The seminar will examine various proposals to increase the supply of organs-- for example, requiring a decision for or against donation, presuming consent, salvaging organs, and the sale of organs-- in terms of their consistency with various moral principles and their symbolic significance (for example, the symbolism of the body, of giving, of taking, and of commercial transfers).

Required Readings:

Paul Ramsey, The Patient as Person (1970), selections William F. May, “Attitudes Toward the Newly Dead,” Hastings Center Studies 1, no. 1 (1973) Joel Feinberg, “Sentiment and Sentimentality in Practical Ethics,” Preceedings and Addresses of the American Philosophical Association 56 (September 1982): 19-46

Additional Readings:

Renee Fox and Judith Swazey, The Courage to Fail, 2nd ed. (1979) M. Mauss, The Gift (1967) Lewis Hyde, The Gift: Imagination and the Erotic Life of Property R. Scott, The Body as Property (1980) Richard Titmuss, The Gift Relationship (1971) B. Dickens, “Control of Living Body Materials,” Toronto Law Review 27 (1977) J. Dukeminier and D. Sanders, “Organ Transplantation: Proposal for Routine Salvaging of Cadaver Organs,” NEJM 279 (1968): 413-19 Hearings on Organ Transplants before the- Subcommittee on Investigations and Oversight of the Committee on Science and Technology, U.S. House of Representatives, April1983 Jay Katz and Alexander Capron, Catastrophic Diseases: Who Decides What? (1975) George Annas, “Life, Liberty and the Pursuit of Organ Sales,” HCR 14 (February 1984): 22-23 K. J. Bart, et al., “Increasing the Supply of Cadaveric Kidneys for Transplantation,” Transplantation 31 (1981): 383-87 Arthur Caplan, “Organ Procurement: It’s Not in the Cards,” HCR 14 (October 1984): 9-12 “Organ Transplants: The Costs of Success,” HCR 13 (December 1983): 23-32 Robert L. Steinbrook, “Kidneys for Transplantation,” Journal of Health Politics, Policy and Law 6 (1981): 504-19 Robert L. Steinbrook, “Unrelated Volunteers as Bone Marrow Donors,” HCR 10 (1980): 11-14 F. P. Stuart, F. J. Veith, and R. E. Cranford, “Brain Death Laws and Patterns of Consent to Remove Organs for Transplantation from Cadavers in the United States and 28 Other Countries,” Transplantation 31 (1981): 238-44 A. M. Sadler, Jr. and B. L. Sadler, “A Community of Givers, Not Takers,” HCR 14 (October 1984): 6-9 A. M. Sadler, Jr., B. L. Sadler, E. B. Stason, et al: “Transplantation: A Case for Consent,” NEJM 280 (1969): 862-67 D. Sander and J. Dukeminier, Jr., “Medical Advance and Legal Lag: Hemodialysis and Kidney Transplantation,” UCLA Law Review l5 (1968): 357-413 Ian Kennedy, “The Donation and Transplantation of Kidneys: Should the Law Be Changed?” Journal of Medical Ethics 5 (1979): 13-21 R. A. Sells, “Let's Not Opt Out: Kidney Donation and Transplantation,” Journal of Medical Ethics 5 (1979): 165-69 Jeffrey M. Prottas, “Encouraging Altruism: Public Attitudes and the Marketing of Organ Donation,” Milbank Memorial Fund Quarterly/ Health and Society 61 (1983): 278-306 “Obtaining Replacements: The Organizational Framework of Organ Procurement,” Journal of Health Politics, Policy and Law 8 (1983): .235-50 J. Muyskens, “An Alternative Policy for Obtaining Cadaver Organs for Transplantation,” Philosophy and Public Affairs 8 (1978): 88-99 George Mavrodes, “The Morality of Selling Human Organs,” in Ethics, Humanism, and Medicine, ed. M.D. Basson (1980) Richard A. McCormick, “Organ Transplantation: Ethical Principles, Encyclopedia of Bioethics, ed. Warren Reich (1978) Clifton Perry, “Human Organs and the Open Market,” Ethics 91 (1980): 63-71 A. J. Matas and F. J. Veith, “Presumed Consent for Organ Retrieval,” Theoretical Medicine 5 (1984): 155-66 William F. May, “Religious Obstacles and Warrants for the Donation of Organs, Blood, and Tissue,”HCR, forthcoming C. H. Fellner and S.H. Schwartz, “Altruism in Disrepute: Medical vs. Public Attitudes Toward the Living Organ Donor,” NEJM 284 (1971): 582-85 Norman Fost, “Children as Renal Donors,” NEJM 296 (1977): 363-67 John Robertson, “Organ Donations by Incompetents and the Substituted Judgment Doctrine,” Columbia Law Review 76 (1976): 48-78