Zentrum für Medizinische Ethik Hans-Martin Sass, Professor für Philosophie an der Ruhr Universität, 44780 Bochum, ist Geschäftsführer des Bochumer Zentrum für Medizinische Ethik und Senior Research Scholar am Kennedy Institute of Ethics, Georgetown University, Washington DC 20057.
Die Studie ist ein Beitrag zum Teilprojekt 'Gesundheitsmündigkeit - Health Literacy' einer Forschergruppe 'Kulturübergreifende Bioethik' unter Leitung von Heiner Roetz (Bochum), gefördert durch die Deutsche Forschungsgemeinschaft.
Herausgeber: Prof. Dr. med. Burkard May Prof. Dr. phil. Hans-Martin Sass Prof. Dr. med. Herbert Viefhues
MEDIZINETHISCHE MATERIALIEN Zentrum für Medizinische Ethik Bochum Ruhr-Universität Gebäude GA 3/53 44780 Bochum
TEL (0234) 32-22749/50 FAX +49 234 3214-598
Email: [email protected] Internet: http://www.medizinethik-bochum.de
Der Inhalt der veröffentlichten Beiträge deckt sich nicht immer mit der Auffassung des Heft 151 ZENTRUMS FÜR MEDIZINISCHE ETHIK BOCHUM. Er wird allein von den Autoren verantwortet. Das Copyright liegt beim Autor.
© Hans-Martin Sass AMBIGUITIES IN BIOPOLITICS OF STEM CELL RESEARCH FOR THERAPY 1. Auflage März 2004; 2. Auflage Juni 2004
Who cares for Gretchen Mueller? Schutzgebühr: € 6,00 Bankverbindung: Sparkasse Bochum Kto.Nr. 133 189 035 Hans-Martin Sass BLZ: 430 500 01
2. Auflage Juni 2004
ISBN: 3-931993-32-9
AMBIGUITIES IN BIOPOLITICS OF STEM CELL RESEARCH FOR THERAPY naturales' maxims of avoiding extremes in Western cultures [Hartmann 2003; Sass 2004A]. Who cares for Gretchen Mueller? Influential Chinese philosopher Mengzi holds, as Rousseau and others did in European Hans-Martin Sass enlightment culture, that 'being compassionate and act humanely .. is innate in everybody's heart'. But in Asian as in Western philosophy, the nature of 'good morality' is controversial. THE CASE: WHO CARES FOR GRETCHEN MUELLER? While Mengzi (391-308 BC) grounds human morality in 'human nature' without much Gretchen Mueller, 42 years old and a mother of 3, suffers from paralysis of her lower metaphysical reasoning and calls for nurturing and practicing moral deeds to further self limbs and trunk, associated with paralysis of her bladder and rectum, due to a car accident a cultivation, Wang Yangming (1472-1529) presents a model of interacting macrocosms and year ago. Her husband Carl, 48, an accountant, who had a heart attack 2 years ago resulting in microcosms, calling on humans to avoid wickedness and evil and returning to original substantial loss of left ventricular heart muscle, takes care of Gretchen and their children of 2, goodness. For Mengzi the role model is the gardener caring, nurturing and beautifying the 4 and 7, as good as he can. New research in cloning and in reprogramming of human embryonic garden, for Wang it is the cat and its innate (sometimes dormant, but never absent) nature to and somatic stem-cells might offer therapies for re-growth of injured muscle and nerve cells catch mice [Ivanhoe 2002:107f]. Controversies in European enlightment over the nature of and eventually better or heal Gretchen's and Carl's health conditions and allow for improved social contract between Rousseau, Hobbes and Locke resemble similar positions. Ratankul individual and family life. But some governments have criminalized stem cell research, others [1999, p. 19] describes it as Buddhist moral duty 'to practice morality (sila), mental discipline have put more or less severe restrictions on human cloning, cell-reprogramming, and research (samadhi) and wisdom (panna)'. on embryonic constructs, in part due to a potential transfer of new therapeutic technologies into St. Paul in his influential letter to the Romans argues that, while the Jews know what to human reproduction; they seem to care more for zygotes and morulae than for citizens in need do by revelation, the pagans have ample opportunity to learn about naturally good and bad by of better medical care and caring governments. studying the laws of nature. Religious commandments, such as fasting during Ramadan for Muslims or obeying the sanctity of Sabbath for Jews, become less demanding and actually need CARING FOR THE SICK IS A PRIME MORAL AND CULTURAL PRINCIPLE to be disregarded, whenever there is need to balance those commandments against saving life There are many differences in cultural traditions and professional cultures, representing and fighting disease: saving life and fighting disease comes first [Sass 2003; 2004]. One of the the richness of humankind's heritage and the diversity of priorities in expertise and ethics in five central requirements for a Muslim is to support generously the poor and the sick [Ilkilic professional ethics. But we rarely see much of a difference when it comes to moral obligations 2002]. The prophet Micah holds that are basically only three rules in obeying the Lord 'to do towards the sick, the poor, those who are weak, in pain, in despair, and cannot help themselves. justly, and to love mercy, and to walk humbly with your God' [Micah 6:8]. Jesus makes an even A common moral prima-facie recognition of individual and communal responsibility toward stronger appeal, suggesting God's appearance and image in the sick, the suffering and the poor: the sick and the poor seems to be strongly supported by religious teaching, philosophical 'inasmuch as ye have done it unto one of the least of these my brethren, ye have done it unto argumentation, and cultural tradition everywhere. me' [Math 25:40]. Schueller SJ defines two 'golden rules' for Christians 'as God has loved us, 'Love your neighbor' is a basic commandment in most cultural and religious traditions we should love one another; as God has forgiven us in Christ, so we should forgive one another [Sass 1986; 2003A]. We find the Golden Rule 'do not do to others what you do not want to be (Eph 4:32)'[1980, p. 212]; he calls this a general orientational model a norma normata, which done to yourself' in Confucian teaching, in Jewish and Christian religion, in Kantian ethics [Qiu needs to be differentiated by 'requirements of morality', as the norma normans, a decisionist 1988:298; Sass 2003A], even in extreme anarchist reasoning such as in Kropotkin's 'Mutual position [Schueller 1980, p. 230] quite close to St. Thomas Aquinas insight that assessment and Aid' [1902]. Avoiding extremes and helping others in doing so and in finding harmony and justification of moral acts and those acts themselves need to be close to the situation: 'actiones re-balancing mental and physical disorders is an essential insight in religions and philosophies humanae secundum circumstantias sunt bone vel male' [S.Th.8I,II,q18,3]. Ivanhoe summarizes of individual and social harmony, of harmonious interactions of microcosms and macrocosms, a similar minimalistic view of applying general doctrines or principles to singular cases in and of supporting the sick and the weak in spiritual and medical healing. Asian cultures of situational ethics 'Mengzi vigorously attacked all attempts to ground morality in any "external" orientation in harmony find responding cultures of the 'meson', the Golden rule and the 'res non standard. No "teaching" or "doctrine" (yan) could ever replace the properly cultivated "heart 3 4 and mind" (xin) as one's guide to moral action' [2002:35]. Asian cultures resemble the two different models of certainty and insight. Confucian notion of the larger family as the role model for moral obligations and rights, in A-priori moral intuition based visions and principles allow for individual or particular towards and of those members in need; from a Western point of view they probably moral-community based personalized concepts of differences between good and evil. Those would favor minimal-metaphysics Aristotelian reasoning over heavy-metaphysics Platonism. sometimes different convictions and attitudes towards moral mid-level principles and their Judaic and Muslim teachings have strong foundations in prioritizing the care for life and implementation in day-to-day moral decision making depend on personal interpretation and health over other religious commands. Christian theologians and churches have accepted application of individually and culturally shaped values and visions. A-priori based scientific cadaveric and life organ transplantation, blood donation, 'immortalization' of human cell lines, experience allows for empirical scientific knowledge which can be verified by everyone using cell-reprogramming of lung cells for the development and ongoing use of vaccination for human rationality for scientific inquiry, independent of individually shaped prescientific measles-mumps-rubella vaccination from aborted fetuses. As far as the acceptance of these understandings or visions of the nature of nature. practices by the Roman Catholic church is concerned, Kevin Fitzgerald SJ, priest and geneticist The final system of reference for a-priori intuition is the individual conscience, taught argues that benefits 'significantly outweighed the drawbacks of using aborted fetal cells' and refined by parents, priest, and neighbors of a specific culture and its internal confirming or [Argetsinger; Goldstein 2004]. critical forces in the implementation and development of moral culture and moral action and Book-based Judaic, Christian, and Muslim religions, also non-book based systems of interaction. A review of historical and contemporary moral positions towards helping fellow reference such as Confucian, Daoist, Hindi, and Buddhists worldviews display quite variety humans sick and poor on one side, and on issues such as moral duties towards unborn forms of and flexibility in the history of ideas in their different branches and in bioethical positions on human life, organ or blood exchange, merci-killing, demonstrate a widely shared common and crucial issues today [ Nationaler Ethikrat 2003; Roetz 2004; Sass 2003A], but none of them universal moral obligation for the former, but reasoned controversies among morally competent does have any elasticity to disregard or actively violate the 'love your fellow-human', the people on the latter; both positions are based on a-priori moral intuition, would not be possible 'solidarity' principle, in particular with the sick, the suffering and the poor. Gretchen and Carl otherwise, and can be understood and assessed as such. have heard the message of 'the good Samaritan', as told by Jesus, over and over again in many While the model of a-priori intuition may serve as a helpful conjecture and counterpart sermons and other church teachings. to Kant's a-priori epistemology in continental European theory-based cultures, Veatch has proposed a convincing model of 'common morality' within the Anglo-American theory-culture THE A-PRIORI INTUITION AND OTHER MODELS TO BASE MORAL THEORY of common sense and analytical philosophy: 'There is a universal inclination that life - at least AND DIVERSITY human life - is good and is to be preserved. Some slogans of professional ethics have have When ethics is about making choices between good and evil, between being moral and summarized that "the duty of the physician is to preserve life". Unless there is some good being wicked, then the human capacity to make distinctions between good and evil, between reason to act otherwise, we are naturally inclined and morally obligated to see that critically ill morality and wickedness, must be an intuitive a-priori, which is different from an people's lives are preserved' [2004]. Differences in opinion crossculturally or different epistemological a-priori, as described by Kant [Sass 1986]. Both the inflexibility of certain positions within one community or society might be solved or eased by what Rawls has called non-controversial 'goods', such as the care for the sick and the needy, and the flexibility in 'considered moral judgment' and what Veatch defines as 'refined common morality', a moral choice regarding controversial issues, as evidenced in the history of cultural and religious reasonability standard holding that '"reasonable people" share a set of pre-theoretical moral ideas and attitudes, give empirical support to the existence of an intuitive moral a-priori as the insights - or would share them if they developed a set of considered moral judgments'[2004]. conditio sine qua non and per quam of ethical reasoning, moral conviction and value-based While Veatch holds that 'almost all reasonable people agree or would agree to the claim principled action. Kant's model of a-priori preconditions in epistemology - sine qua non and per that there is a common morality', he argues that it is 'more difficult to confirm' the content of quam - sets a conceptual framework for clear, reasonable, and undisputable consensus on such a common morality 'if certain standard assessments were made to adjust and fine tune their scientific knowledge by experience, a framework which ex post can be proven empirically naive moral insight so that they became considered moral judgements'. The Hitlers and Stalins again and again. A-priori based moral intuition and a-priori based scientific knowledge lead to are not an issue of controversy in arguing even for naive moral insights into common morality. 5 6 They do not represent soft or hard differences in moral intuition and implementation; they are arguments only for legally tolerating the import of donated cadaveric organs from countries the wicket adversaries and enemies of moral intuitions and differences in moral choice. But such as Austria where consent-to-donate is the legal default position, if people actively by there are, given the nature of moral intuition and moral choice, differences and ambiguities: written statement have not opted out, but strong arguments for criminalizing the import of 'Words such as killing, murder, euthanasia, homicide, and allowing to die are complex terms human organs from countries of questionable practice and no reliable legal standard and that are defined differently by people in different religious and cultural groups even when they oversight. He is aware that differentiating between ideals in bioethics and operational acts in are all speaking English ... Learning that a priest in Rome holds that direct intended killing of biopolitics does not serve the interest of fundamentalists nor the intentions of those who the innocent is immoral does not necessarily conflict with the claim of the Chinese that principled arguments are used in hermeneutics and politics and consensus formation. euthanasia is sometimes moral'. In a model called differential ethics, I have suggested a minimal-theory operational As far as embryonic stem cell research or reprogramming of human cell lines in the model, following methods used technology assessment for integrated value-and-technology conduct of research for therapy is concerned, one could use Veatch' wording and formulate two assessment of specific scenarios or singular cases [Sass 1999; 2003A]. This model different positions in moral culture. (1.) 'Some reasonable people do or would agree that the differentiates between basic moral commodities (liberty, security, dignity, fairness), production of embryonic stem cells for therapeutic research and potential production of semi-finished or amalgamated materials (freedom of expression, respect for privacy, social therapies based on the use of such constructs is morally not acceptable and therefore sick people security, informed consent), and end products (fine tuned principles as precision instruments unfortunately need to be left to die or without adequate therapy'. (2.) 'Almost all reasonable for managing single cases or scenarios of identical moral and technical challenges. Differential people do or would agree that therapy for sick patients and saving of lives of people is a prime ethics assumes that most mid-level principles are based on different revelational or obligation in common morality, and that using embryonic stem cell lines or reprogramming metaphysical insights promoting basic moral maxims, such as 'love your neighbor', and that techniques for such a high moral goal is justified in particular when the destruction of embryos differences among personal and collective understandings or priorities of mid-level principles is not criminalized when performed by hormonal or mechanical antinidativa or early abortion are best be solved by contracting, including contracts not to agree on or tolerate certain moral for less commonly accepted purposes'. The difference in using 'some reasonable people' in goals and deeds as long as others stakeholders in culture and community are not hurt. sentence 1 and 'almost all reasonable people' in sentence 2 can be justified by most models of Differential ethics refers in situations of ambiguous and complex technical and ethical decision moral reasoning and would easily be supported by a vast majority of historical and making to the grass-root level of allowing and entrusting the persons closest to the issue to be contemporary moral, cultural, and religious positions. the prime moral agent. It is not a utilitarian position, as it is not based on utility but on the very Birnbacher understands bioethical maxims as ideals, not as prescriptions or rules for nature of moral intuition and its respect. This position therefore suggests avoiding societal and direct implementation [2004]. Using norms and maxims in bioethics as 'collective moral ideals' cultural fight over words, beliefs, and truths by leaving final decisions to competent individuals allows for understanding, accepting and supporting 'pluralism in bioethics'. Those ideals will as prime moral agents of their beliefs and acts [Sass 1991; 2003A; 2003B]. have to be made operational in self-regulation, laws, regulation, also - as Asian traditions Ivanhoe, in summarizing the mentioned differences in evaluating human nature and tirelessly call for - in self-cultivation. When made operational in legislation ad regulation, the human morality by Mengzi and Wang Yangming, underlines the point of consensus by both of translation of ideals into the real world of real people, having real and quite often different them, a consensus which might also be applicable to global crosscultural and innercultural visions and values in ethics, need to meet high standards in legal and regulatory ethics. If theoretical debates and moral actions: 'Mengzi and Wang offer profoundly moving examples of underlying moral norms and visions are widely shared and non controversial, then justification what it means to work at the improvement of both, self and society ... they also offer revealing of laws and regulation in terms of legal and political ethics is not a problem. However, if such examples of what it is to participate in an ethical tradition while working to adopt and transform a cultural or moral consensus is not existent, such as in areas of abortion or embryo research, its beliefs and practices to fit with the needs and assumptions of one's own age' [2002:142]. then such a justification is 'an issue of some complexity', in particular if governmental Doering [2004] stresses the importance of 'self-perfection (xiu shen)' as a goal well known in resolution occurs 'behind closed doors' and on issues which do not hurt anyone directly [2004]. Chinese as well as in Germany philosophy from Confucius and Plato to Kant and Zhu Xi; as Birnbacher differentiates between 'soft refusal' and 'strong refusal' which e.g. gives soft already mentioned, Buddhism calls for similar moral duties of self-perfection [Ratankul 1999, 7 8 p. 19]. a defined and structured professional obligation in a particular field of human, societal, cultural A-priori moral intuition and refinement and other models of presenting a plausible and political service. The Western culture Hippocratic 'salus aegroti suprema lex' rule, i.e. to theoretical foundation for understanding moral theories and actions in diversity cannot do so make the benefit and sake of the patient the highest rule and law, even when in conflict with without giving highest priority to individual challenge and personal choice between being good political or other rules, is met by Asian traditions requiring the virtuous physician to be like a or being wicked. The dignity of the individual conscience is the core of respect for human brave, prudent and ingenious warrior. Most eminent and influential Chinese physician Yang dignity and rights as civil rights. It can explain and support the diversity of moral cultures and Chuan reminds people to only trust doctors 'who have the heart of humaneness and compassion, actions within a framework of common morality or a-priori moral intuition. Veatch holds 'that are clever and wise, sincere and honest' [Qiu 1988, p. 285f]. Doctor Gong Tingxian formulated once one realizes that postmodern moral philosophy finds it possible for there to be different interactive virtue rules for physicians and patients, stressing the treatment of the patient as a accounts of the morality reality that are not incompatible even though they are person and based on expertise and ethics and compliance of the patient and health competence incommensurable, one discovers that the common sense belief in a universally held set of in lifestyle decisions, a blue print for modern interactive maxims for patient-oriented pretheoretical moral intuitions that become the raw data for theory construction more and more individualized treatment [Sass 1994]. plausible after all' [Veatch 2004]. There is an ongoing debate in all cultures of healing and of expectating help and Koch argues that a loose definition of 'embryo' has led to moral and legal confusion and humaneness from experts and profesionals: Should professional health care fight nature or mishandling of moral and legal assessment. When an embryo is a developing human organism modify the course of nature? Of course, medicine is an action oriented profession determined to from time of fertilization to the end of the eight week after fertilization, as defined by medical safe life or to eliminate or alleviate pain and suffering against naturally progressing diseases terminology, then the re-programming of stem cells, having the ability to give rise to more and symptoms. Thus, medicine and health care is fighting 'nature' in the interest of 'life', but all differentiated cells or tissue, and nuclear transfer in cloning technologies would not meet the life is terminal, and all life is associated with some kind of hunger, pain, suffering. Roetz [2004] definition of fertilization. In order to avoid fight over words, Koch suggests to reserve the term points out that even in Chinese culture some schools exist, such as the one following fertilization for the traditional 'integration of haploid sets of chromosomes by chance from Confucian scholar Xunzi in the third century b. c., that similar to Baconian and Hobbesian humans of different sex' [Koch 2003:113]. Elsewhere in science already the term 'embryonic European traditions of fighting and overcoming cruel and immoral nature , do not see nature as construct' has been used and accepted to define sets or conglomerates of totipotent cells derived a role model for exemplary harmony [Sass 2004A] but as something that needs to be overcome: from cloning or re-programming, not fertilization. Religious and cultural positions would find man as co-creator of (a new) heaven and earth; Bacon's 'Novum Organum Scientiarum' sets the such a definitional distinction helpful in evaluating and differentiating stem cell research for new stage for making nature less cruel, more habitable, more cultivated. therapy from making babies in vivo or in vitro. Pellegrino and Thomasma, based in Western humanist and Christian traditions require Gretchen and Carl know nothing about any of those and other models to base moral of physicians to 'place the good of the patient at the center, possess and maintain competence in theory and to argue for and to understand moral diversity between and among individuals, knowledge and skill, recognize limitations, respect values and beliefs, care for all independent moral communities and cultures. They are devoted Christians in the Roman-Catholic faith; they of their ability to pay, assist patients to make choices, hold in confidence, never participate in go to Holy Mass frequently and have followed instructions of their priest not to use IUD's or killing, fulfill obligations to society, practice what you preach, teach and believe' [1988, p.205f]. hormonal contraceptives. Common sense, moral intuition, and civil sense tell them that Understandable and acceptable by Westerners and Asians alike would be a set of virtues by the authorities should support the improvement of medical care and the reduction of suffering and Chinese Ministry of Health, neither making reference to specific Confucian or Western pain by allowing - even promoting - the development of better medicine. traditions, rather based in Marxist-Maoist reasoning of humanist solidarity and reciprocity: 'healing the wounded, rescue the dying, and practice socialist humanitarianism; keep the CROSSCULTURAL PRIORITIES IN PROFESSIONAL HEALTH CARE ETHICS interests of the patient in your mind and try everything to relieve patient suffering; show respect Professional medical cultures everywhere have made it imperative to put the interest for the patient's dignity and rights and treat all patients alike whatever their nationality, race, sex, and the sake of the patient first, electing to make common morality and a-priori moral intuition occupation, social position and economic status is, .. be honest in performing medical practice, 9 10 keep secrets related to the patient's illness, be rigorous in learning and practicing, education on and informed informed contracts with probands or patients, to have sexual relations with medical ethics and the development of medical ethics must be part of managing and evaluating patients, who are dependant on their physician or nurse, has been stigmatized by medical hospitals' [Cao 1989:16f]. professional traditions and punished within professional organizations. In the commitment and Originally developed in the research setting, now calling itself 'common morality', the service of the healing profession for the best of the patient not everything goes, even though influential Georgetown package 'autonomy, nonmaleficence, beneficence, justice' [Beauchamp, other rules or laws, which will be respected in normal situations, may be violated in favor of a Childress 2001] addresses the same issues as more detailed packages such as 'ahimsa higher law, the 'salus aegroti' as the supreme law. (nonmaleficence), compassion, respect, righteousness, dharma (responsibility)' by Michael Tai, But there are medical situations where moral ambiguity rather than moral certainty or a contemporary Chinese bioethicist [1999]. These and other traditions in medical professional immorality are prevalent. There is, indeed, 'ambiguity in moral choice' as Richard McCormick culture must be understood as expressions of a general intuitive moral a-priori defined and SJ [1973] has assessed from the point of view of moral theology. Caesarian section, first declared in codes of professional ethics, professional self-regulation and professional law. Only performed in order to give birth to a successor to a throne while jeopardizing the life of the in this specifically defined and executed form do they meet customer's and patient's mother, was quite an ambiguous moral choice in feudal societies. Caesarian section or expectations across different cultures and serve as the necessary foundation for trust based pharmacologically induced delivery performed in modern hospitals in order to better schedule communication and cooperation between providers and customers of professional health care workforce, to improve risk-liability balance in certain jurisdictions, or to optimize financial services. rewards based on DRG schemes is questionable. The principled dominance of the regulatory ideal of 'aegroti salus suprema lex' over There is true technical and moral ambiguity and uncertainty in many medical decisions, other moral ideals, even over public and personal obligations and interest, provide for an in prescribing or not prescribing certain drugs, in in-situ surgical decision making, in framing additional layer of moral identity and authenticity of individual health care experts and the medical information in order to get patient's 'informed' consent when such a consent is legally health profession [Sass 2003A; 2004A]. required but the medical situation does not allow for options. There are soft or hard differences Those dominant professional traditions and expectations from patients or potential and ambiguities in fine tuning moral intuition into real-life rules and acts representing the patients in different cultures should give Gretchen and Carl hope that sooner or later treatments cultural and historical richness in diversity of moral choice. These differences may not be will be found and that politicians, lawyers, and theologians will stop 'playing doctor' and stop to confused with true and evident immorality, wicket distortions of and hard contradictions disappoint their and other patient's hopes and anticipations, that biopolitics will stop to deprive towards each and any moral decision. citizens of basic civil and human rights by not allowing or supporting the development of Some, but not all, uncertainties and ambiguities, e.g. deciding whether or not to initiate medical treatment. tube feeding or mechanical ventilation in terminally ill patients, best are dealt with by using the stakeholder model and including patients in making hard choices. Most issues of ambiguity in MORAL AMBIGUITIES AND IMMORALITIES moral and medical choice seem to occur in paternalistic decision making, 'medical experts' While compassion and caritas and activities to serve the sick, the frail, and the poor are following the 'book' or the DGR schemes, not providing individualized treatment. The shared by all major cultures and therefore rightly may be called a cultural heritage of traditional 'salus aegroti', good of the patient, need to be re-evaluated as 'salus ex voluntate humankind, there are also actions clearly definable as immoral such as torturing and killing, aegroti', the good as far as it is expressed by the patient or is in responding to the values, wishes slavery, rape and exploitation. Medical codes of conduct have clear traditions and visions, strict and visions of the individual patient. The 'salus ex voluntate aegroti suprema lex' maxim has principles and virtues, delineating what might be acceptable or even mandatory in certain rare become a global quality standard in contemporary medical ethics [Pellegrino, Thomasma 1988; situations and what it is clearly not acceptable and immoral, even if lives would be saved, Cao 1989; Ni 1999; HUGO 2003] and in interactive models of communication-in-trust and diseases be healed, or suffering be ended. To catch people, slaughter them and sell their organs cooperation-in-trust between experts and lay persons [Kielstein, Sass 2002; Sass 1994]. The for saving the lives of others, to use fellow humans as guinea pigs in clinical research without partnership model of moral reasoning runs against the deontological model of watertight prior appropriate risk-benefit-uncertainty assessment and free and informed consent of or free rational calculation and decision making by experts and related expert ethics. 11 12 Non-book based moral reasoning but also strong fractions in monotheistic moral prime moral intuition supported by many cultures and religions, is a maxim, not an inflexible theology would agree with McCormick SJ [1973, p. 106] that 'moral awareness and judgments fundamental rule, an 'ideal', as Birnbacher [2004] would say, a vision, which needs to be are fuller and deeper than "rational arguments" and rational categories. They are the result of taylored to the situation. There is a difference between breaking off a flower and throwing it evidence in the broadest sense - which includes a good deal more than mere rational arguments. away and breaking off a flower and giving it to a person one loves, and there are only a few While moral judgment must continually be submitted to rational scrutiny in an effort to correct among us who would not flowers to loved ones in respect for life. Killing flying insect just for and nuance them, in the last analysis, rooting as they do in the intransigence and complexity of fun, is not an expression of respecting life, but killing a mosquito on my skin who just starts or reality, they remain deeper and more obscure than the systems and arguments we device to has finished to bite protects me from nuisance and pain, sometimes even from the transmission make them explicit'. of infection. Killing large numbers of mosquitos by insecticides in order to prevent the Communication-in-trust and cooperation-in-trust will allow for morally accepting transmission of malaria or west nile virus infection has become a modern standard in hygiene situations when medical treatment, even the saving of life is technically available, will be and public health. Some worldviews hold that killing animals for protein intake is disrespectful refused by patients based on their individual system of value-and-belief reference, such as of life, and that enough non-animal protein is available for morally sensitive and cultivated Jehovah's Witnesses refusing to accept blood infusions. It was a major moral and legal victory people. Sources in Rabbinic tradition hold that killing a mosquito on Shabbat is a larger sin than that most civilized hospital cultures and health care expert respect such a position, not shared aborting a fetus. Killing a mosquito is not immoral, but depending on the situation is ambiguous by many and widely seen as somewhat strange or even bizarre. This is an exemplary model for and arguments pro and contra might be controversial. 'Killing' an embryonic construct cannot defining the 'good of the patient' and for avoiding the moral 'evil', based on her or his even be compared to the abortion of an embryo, and probably should not even be compared 'value-wish-and-vision profile: 'salus aegroti ex voluntate', determined by professionally morally to the killing of a mosquito. integrating a patient's value status and medical status. Ethics is about making distinctions and basing moral intuition and interpretation on Gretchen and Carl have among their friends followers of the Jehovah's Witness church; differentiated analysis and evaluation of facts and scenarios. New scenarios require particularly they intuitively feel that refusing other people's blood for saving life is somewhat strange, but careful assessment of scientific facts and medical evidence without jumping to early they respect their friend's position as a moral one in their own right. Recently, they read that a conclusions. Recent longitudinal studies of humans born using in-vitro fertilization techniques certain Dr Hwang in Seoul and his colleagues, some of them Christians, have derived a confirm that genetic as well as environmental factors seem to influence genomic development pluripotent embryonic stem cell line from a cloned human blastocyst, a scientific breakthrough and the formation of active polymorphisms in individual DNA codes; thus in-vitro fertilization which might lead to future therapy for both of them. They also read that Dr Hwang, a Korean in has definite and certain shortcomings and contains health risks not associated with the natural the Buddhist-Confucian tradition personally would be very reluctant to accept organs donated way of 'making babies'; more 'natural ways' of assisted reproduction such in-vivo insemination by others humans or donate organs of his own, as such a practice would be running against his (GIFT and other methods) include less risk as the fallial tube environment is more 'natural' than understanding that human bodies as a 'property' of ancestors are not for sale, not for donation a petri dish. Animal studies have confirmed that DNA 'is both inherited and environmentally [Hwang 2004; Faiola 2004]. While those anecdotes might or might not be true; Gretchen and responsive. Behavior is orchestrated by an interplay between inherited and environmental Carl find such arguments strange, but they are grateful that his cultural background and moral influences acting on the same substrate, the genome' [Robinson 2004:397]. Daoists and intuition seem to have motivated Dr Hwang to work on developing transgenic organs in Western natural law philosophies rightly associate means of modifying, manipulating or even animals for human transplantation and on cloning human cells for helping patients such as they fighting and suppressing natural forces as having possible factual as well as moral risk. On the are. other hand, Western and Eastern worldviews also see the cruelty, immorality and inhumanity in untamed natural forces, - a yet unsolved and probably unsolvable ideational battle and DIVERSITY IN MORAL INTERPRETATION OF MEDICAL FACT AND EVIDENCE dialectical challenge in most cultures [Sass 2004A; Roetz 2004]. Ethics is about making differences, making distinctions, making choices and avoiding moral Opponents of embryonic stem cell research for therapy arguing that genetic code asymmetry, also about differences in planning and judging moral actions. 'Respect for life', a defines individuality and character, use an outdated model of individuality as recent scientific 13 14 evidence provides insight into an 'interplay of hereditary and environmental influences on supplemented. Embryonic constructs produced by technologies and procedures existing today genomic activity and individual behavior' already during very early stages of development and are just transitory products for the farming and further developing embryonic stem cells; the gestation [Robinson 2004:398; Jaenisch 2003]. Opponents of human cloning do not take into only value and utility of those stem cells is for therapeutic purposes. account the different environments of test tubes, petri dishes, fallial tubes and the uterus, nor do Moral theology and philosophical arguments using natural law theory are cutting they recognize the constructional shortcomings of cloning techniques. conceptual and analytical corners, as they do not recognize different biological and associated Denker has summarized a number of insufficiently known facts about normal moral properties of embryonic constructs when compared to embryos derived with or without embryogenesis and early pattern formation. We know much less about the formational medical assistance, in vivo or in vitro, from two haploid sets of human DNA. As properties of embryonic stem cells insolated in different types of nutrition medium in vitro: reprogramming human cells has never been a scientific possibility and option until recently, 'Colonies of embryonic stem cells forming in vitro must be expected to lack, as a rule, the cultural, philosophical and religious traditions do not provide ready-made concepts for cultural simple but ordered asymmetries of the embryonic disc of normal embryos that are derived from and ethical evaluation of cell reprogramming and cell cloning. Buddha, Lao Tse, Kant, Jesus, the asymmetries of the egg and the zygote system' [2004:16]; but limited knowledge today Mohammed or Plato had no reason nor a chance to think about it. Scientists so far agree that cannot exclude that an early stage of further embryonic formation 'can start spontaneously as a available methods of cloning embryos are not perfect and do produce 'embryonic constructs' rare event even in standard cultures in human embryonic stem cells' [2004:18], comparable to rather than embryos. Those embryonic constructs definitely do not qualify for reproduction, as yet not well know developmental pattern resulting in twins or Siamese twins. evidenced by animal studies. But as already mentioned, it is a worthwhile intellectual and Enbryonic constructs, also called 'embroyid bodies' and 'coined for the mouse system ethical exercise today to discuss medical, ethical, cultural and legal issues of prospective future and refers to the fact that when mouse teratocarcinoma / embryonal carcinoma cells (EC) or cloning techniques for human reproduction. Those techniques will have to be approved by ESC's (embryonic stem cells) are kept in mouse ascites or in vitro'; they can develop into further professional oversight bodies such as Chambers of Physicians, using existing and yet to be developmental stages, but 'are lacking other extra-embryonic cells which play important roles refined quality control and quality assurance standards. The features of such future quality in embryo implantation and yolk sac formation' [Denker 2004:4]. Given these and other results standards are not yet known and it might take another generation or two until those quality from animal studies, one may safely argue that embryonic constructs or embroyid bodies or requirements even can be formulated and guaranteed. isolates embryonic stem cells derived from human blastocysts or blastocyst constructs in vitro Also, humankind or some moral communities and national or international legislation are not only biologically but also morally different from embryos in utero. Embryonic might not accept cloning for human reproduction even though no medical harm would be constructs were manipulated in vitro for further manipulation into tissue or other remedies. involved. Existing technologies are only good enough for harvesting embryonic and other stem They never will be aborted, i.e. by interventional means separated from a womb, from a mother, cells for further scientific modification targeted at the development of certain cell lines or tissue as they never had been in a womb. They do not have a mother or a father in the traditional for therapeutic purposes. Of ethical importance in in-vitro cloning is the construction method, biological and moral sense. They were constructed by transfering an entire somatic cell nucleus the environment and the purpose. It is unscientific and irresponsible to just apply Newtonian into the denucleid cytoplasm of a human oocyte in an artificial medium outside the womb for laws of physics to specific issues in modern physics; it is similarly unprofessional and a logical medical purposes and for healing, not for implantation and reproduction. Embryonic constructs and moral malpractice to apply fundamental moral laws to each and every situation without therefore are not embryos, neither in the biological nor in the moral sense. As they have no specification, differentiation, and evaluation, to simply use the same arguments in evaluating mother or father in the traditional sense, biologically by merging two haploid oocytes, morally the moral recognition of embryonic constructs in vitro and of embryos in vivo. by having genetic properties from two persons. How could one ever argue that they need to Ethics is about making choices; there are easy choices and there some very hard choices enjoy the protection and respect of genuine embryos whether created in vivo or, in case of to be made by individuals or communities of different kind. Disputes on moral decision making infertility, in vitro. These man-made constructs should not be allowed to be implanted into a are already common in religiously and culturally homogeneous moral communities and legal womb and criminal law in most civilized countries already makes such acts criminal deeds. If systems; qualitatively and quantitatively they increase in dimension in pluralistic societies rich existing laws to not outlaw reproductive cloning, then those laws should be modified or in diverse individual and communal cultures and religious and humanist systems of reference 15 16 and belief. The already mentioned multitude of voices from different cultural and moral and face [Mendelsohn 1819:201]. Ilkilic refers to Paret when similarly arguing that Muslims traditions and a recent report of the German National Ethics Council [Nationaler Ethikrat 2003] have seen the diversity of positions and fatwas in Islam as a special and particular blessing of on cultural and moral diversity in the global cloning debate demonstrate quite clearly different Islam by God [Ilkilic 2004]. cultural and religious attitudes and arguments in regard to re-programming of human cell lines, Should a moral or could a legal request for abortion by a devoted Jewish female in her cloning and the moral assessment of various forms of unborn human life, reincarnated human fourth month of pregnancy be honored in a Frankfurt hospital in Germany, even if physicians life or afterlife. The minutes of the Ethikrat also give a view into the variety of different and nurses would be found, sharing her religious belief as expressed many times in Talmudic positions within the same cultural or religious tradition, similar to differences in Christian teaching that morally to be respected human life only begins after birth [1. Sabbath 107b; 9. traditions. Sabbath XIV,4; 1. Nidda 44b; 1. Sanhedrin 72b and VIII,9; also Exodus 21:22f]? Different Respecting values and visions of individuals and moral communities and at the same countries have different laws on abortion, based on legislative majority decisions or supreme time agreeing on a consensus to accept dissensus in central matters of conviction, morals, is a court rulings. In Germany, abortion is illegal because according to a supreme court decision all challenge for everyone, in each and every culture and among cultures. In Europe, at last since unborn human life shares the protection of the Constitution, but killings of early human life by the Age of Reason, models of conflict solution have been introduced and in many areas hormonal or mechanical antinidatives is not even discussed as possibly a criminal act, and successfully used by applying principles of 'tolerance' and 'self-determination' together with abortion of embryos up to three months will not be prosecuted if certain consultative and other 'respect for humans by respecting individual choice and conscience. Spinoza in 1670 argued means recommended by the same court are fulfilled. It is a challenge to the moral and cultural that law and order would not break down if individual systems of belief would be allowed; environment and legal system of open societies to apply norms to facts and procedures without rather, law and order and the shear existence of a peaceable and harmonious society would be hurting individual judgment and conscience and without differentiation and situational endangered if individual choice and conscience would not be respected in religious and moral sensitivity and responsibility. matters within an integrated framework of security and responsibility. We rightly would feel In regard to evaluating facts and goals of stem cell research for therapeutic purposes, severely violated in our individual civil and human rights if someone would request us to Avram Steinberg summarized that Judaism had different legal approaches to moral issues and believe that Jesus, indeed, walked on water or rose from the grave, that real trans-substantiation does not accept absolute statements and judgments. To destroy a blastocyste is bad as it of bread and wine into the blood and flesh of Jesus Christ occurs when Holy Supper is spend destroys life, he holds. But when destroying a blastocyst in order to safe life, then one has to under correct liturgical conditions. We today would find it not only uncivilized, but rude and ponder whether or not the saving of life of a suffering patient is a virtue higher than the vice of offensive, if someone would force Hindi to eat beef, or Jews and Muslims to eat pork, or destructing a blastocyst. But the destruction of blastocysts for the production of cosmetics or vegetarians to eat any animal products, competent adult Jehovah's Witnesses to forcefully the development of biological weapons carries other moral cost-benefit risk [Nationaler receive other people's blood. Ethikrat 2004:31]. But there are not only modern post-enlightment arguments for respecting human dignity Mary Mahowald recently argued that citizens have a basic right to 'self-preservation', i.e. in honoring different values and visions of fellow humans of different tradition, religion, or 'preservation of one's own bodily integrity of life, provides a persuasive, but not necessarily culture, there is also religious insight supporting value plurality and arguing for freedom of adequate justification for cloning and embryo stem cell retrieval a negative moral right' believe and for the exercise of related actions. It was Moses Mendelsohn, enlightened and [2004:65]. She proposes a model of moral symmetry comparing embryonic constructs, at a conservative Jewish rabbi, who grounded tolerance and individual moral autonomy and cultural stage after embryonic stem cells have been harvested from the blastocyst, to 'surplus embryos' and moral diversity in God's will and creation: 'Brethren, if you want true peacefulness in God in infertility treatment or to ventilated brain dead organ donors after successful explanation and (Gottseligkeit), let us not lie about consensus when plurality seems to have been the plan and suggests they be 'allowed to die rather than actively terminated'. the goal of providence. No one among us reasons and feels precisely the same way the Ethics is about avoiding asymmetric moral judgment. Diversity in moral evaluation of fellow-human does. Why do we hide from each other in masquerades (Mummerei) in the most scientific facts and procedures also includes different moral approaches towards blastocysts important issues of our lives, as God not without reason has given each of us his/her own image depending on novelty of the situation and the role of biopolitics in bioethics. Human blastocysts 17 18 and morulae are destroyed at a rate of about 50% naturally; modern hormonal antinidatives, still value-and-vision, but not the underling. However, in more liberal states the underling then and called contraceptives, and intrauterine devices kill blastocysts, morulae and pre-embryos. now was and is allowed to emigrate. It took a few centuries until such governmental tutelage While the natural abortion rate of about 50% or higher can be understood as natural, the disappeared on issues of trans-substantiation, not because the rulers gave in, but because no one destruction of blastocysts by hormonal or technical devices is intentionally done by human cared any more so much about whether or not the Holy Trinity was one person in three or three intervention and is associated with enjoying unprotected sex. Opponents of embryonic stem persons in one; thus, Spinoza's vision, Mendelsohn's belief, and the liberal tradition in Islam, cell research for therapeutic purposes have yet to explain why they do not object as strongly understanding differences of opinion as God's special blessing found a late real-life justification. against women's choice in sexual activity and why they have not yet called for research Today we have this kind of freedom of choice and following one's conscience for the rich and programs to 'safe' early human life, i.e. blastocysts, from 'premature death'. Asymmetry in well connected, not for the poor and the less flexible and less well connected. Gretchen and Carl ethics is unethical and ruins moral judgment and moral behavior. Patients deprived of hope for feel that it is not only unfortunate, but also unjust to live in a European country where better remedies feel that moral asymmetry is applied to treat blastocysts used for potentially therapeutic research on embryonic stem cells and constructs is severely restricted, if not illegal. developing better medicine if compared to the fate of blastocysts intentionally aborted by Given cultural diversities and moral convictions and visions in open, democratic and hormonal or mechanical devices or 'naturally'. Asymmetry in moral argumentation occurs pluralistic societies, the clash of cultures in controversial fields of morality, value, vision, and easily when theory and real-life are distinctly separated from each other, when intellectual belief is not so much the difference between traditional Christian, humanist, Jewish, Muslim, debates lack virtues of care, love, solidarity, and respect for fellow humans. Real-life cases of Hindi or Confucian cultures but the clash of conflict solution culture within each of these patients in need of better medicines might break the cycles of academic disputes over theories traditions, among them, and within the political and regulatory culture of dealing with issues of and general principles, some of them controversial between cultures and within cultural conflicting visions and values [Sass 2003B]. traditions and religious teachings. A paralyzed mother in a wheelchair in need of neurological As pregnancy is part of nature, so are arguments, attitudes, and controversies over treatment, a father who has lost substantial parts of his left ventricular heart muscle, these are accepting, preventing, or terminating pregnancy a natural part of moral and legal discourse. not theories, even not just 'cases'; these are not embryonic constructs in vitro, these are real-life While only women can become pregnant, abortion decisions and judgments on the moral status fellow humans, citizens caring for other fellow citizens and in need of better medicines and of the fetus have been made by men, by societies, parliaments, courts, priests and philosophers, better medical care [Sass 2004B]. at last by women. Attitudes by political or religious majority towards unborn human life have been cast into state laws and regulations much too directly [Birnbacher 2004; Sass 1991] STEM CELL CONTROVERSIES ALONG THE LINES OF THE ABORTION instead of into religious teachings, sermons, and defined moral communities where they belong. DEBATE Individual choices and the self determination of women have been challenged and even broken The actual debate on ambiguities surrounding human cloning and cell reprogramming those laws and rules. The debate and the conflict is going on; pro-life activists kill abortion occurs along the lines of controversy about the pro and contra of abortion [Walters 2004; Sass performing physicians in the name of the right-to-life, pregnant women elect a pro-choice 1991]. In European countries, sharing a 'common moral heritage' as is often quoted by position and exercise their perceived right-to-choose, i. e. autonomy and self determination. It politicians and regulators, abortion legislation and practice is quite diverse. Pregnant citizens has been mentioned that a woman's very personal decision to terminate a pregnancy lies beyond requiring an abortion for whatever reasons and based on their religious or moral convictions the effective control of criminal law, while others hold that the penal code has to protect human may, if they are rich enough, travel to an neighboring country and get the service which is life, born and unborn [Sass 1991]. It is well documented that the criminalization of abortion refused in her home country. Similar differences exist for preimplantation services and other does stop only some abortions, not all, and that it causes more unsafe abortions. From time medical interventions. immemorial and despite the penalties of criminal law and religious and societal discrimination, It is a situation similar to the half-way solution of value-and-belief conflicts at the many women have pursuit their reproductive choices against civil laws and religious teaching. Muenster peace treaty of 1648 after 30 years of cruel battlings and killings all over central Actual discussions, arguments, legal and societal conflicts in all cultures regarding the use of Europe: cujus regio ejus religio', when the feudal sovereign was given freedom of embryonic constructs and human stem cells in research for therapy represent the ongoing 19 20 debate between the individual's right to responsibly 'choose' and the state's perceived right to of the egg) as theologically and morally binding for full moral recognition of human life. 'protect' the 'fruit of the womb' (Leibesfrucht) as the traditional German legal term for unborn Also, the principle of subsidiarity, teaching that decisions and responsibilities made by human life defines the embryo and the fetus. individuals and small groups should be given precedence over rules and responsibilities of large Richard McCormick SJ and Josef Fuchs SJ have pointed out, abortion is not only a groups, states and courts, has served and might serve in the future to not eliminate, but to reduce challenge to traditional Christian beliefs rooted in a particular moral faith, also a challenge to conflicts between the individual conscience on one side and the institutional and societal level secular humanism. For Fuchs, Christian morality 'is "human" not distinctly Christian' [1980:19], on the other. Application of the subsidiarity principle, successful for centuries and recently in while McCormick hints even stronger at a humanistic test for Christian ethics and actions: 'One social ethics [Vatican 1931], in bioethics and biopolitics would find secular and theological need not to be a Christian to be concerned with the poor, with health, with the food problems, support from Spinoza, Mendelsohn, Muslim and other religious and secular positions. As has and justice and rights. But if one is a Christian and is not so concerned, something is wrong with been pointed out [Roetz 2004; Sass 1986; Sass 2003A] there is a certain elasticity in all that Christianity. It has been ceased to be Christian because it has ceased to what his founder authentic cultures and religious teachings (Roetz: dehnbare Lehren, elasticity in teachings); was - human' [McCormick 1980:172]. Birnbacher calls it the difference between the 'ideal' and the real-life implementation of ideals These various levels of moral reasoning and culture - the individual, the collective, the [Birnbacher 2004], Veatch a 'common morality' which might lead to different refined and theological, the societal and the different traditions in professional ethics - are not easily reasoned arguments and acts [Veatch 2004]. reconciled, in part because traditions also change or are represented in different voices. A Legislators and regulators have no mandate to fight the most common rights of humans, century old Aristotelian and Thomist 'animation model', teaching that God personally after a i.e. the right to have the dignity of their conscience be respected, as supported and called for by period gestation gave his immortal soul into the developing unborn human life at the end of a wide majority of positions in cultural and religious traditions and as expressed as a organogenesis was only abandoned 150 years ago by the Roman Catholic church [Sass 1991]. fundamental vision for humanity in the 'Universal Declaration of Human Rights'. On the As mentioned, in Jewish tradition the direct and individual ensoulment of each newborn by God, contrary, the legislative and regulatory mandate is to support and to protect human rights of as evidenced in sustained breathing after birth plays an important role in morally and spiritually their citizens as civil rights. Solidarity in health care matters belongs to these fundamental civil recognizing born people. In Islam, the animation theory also is of eminent importance in the rights. Cultural traditions on abortion and the moral and legal recognition of unborn early vast majority of historical and contemporary positions, giving different dates up to four months human life, however, differ from culture to culture and within cultures. Biopolitics has to make [Ilkilic 2004], which resembles Aristoteles' influential animation theory also in dominant the not so complicated decision to honor the most basic human rights as civil rights first, while Christian natural law theory up to the Vatican Council 150 years ago for the Roman-Catholic been elastic and impartial towards competing worldviews on God, immortality, ensoulment, branch of Christianity. re-incarnation, and the spiritual value of cells and zygotes. These competing worldviews can Mc Cormick stresses the importance of communication and acceptance over biological and should be respected by conscience clauses and elastic laws in the direction pointed out by stages of development in recognizing the moral standing of unborn human life. Similarily, Spinoza and Mendelsohn in the European tradition and other authorities elsewhere. Such a according to Qiu and Doering, Chinese tradition makes a difference between 'shengming', life strong moral stand on human rights as civil rights for those most in need of help and protection, in the biological sense, and 'shenghuo', life in a social sense:' there is no 'shenghuo' if there is combined with elasticity and tolerance in theoretical matters, is what the most basic principles no relationship between the one and the other; Confucians put greatest emphasis on those of human decency and dignity would require of biopoliticians; setting political priorities and interpersonal relationshsips and draw moral norms from them such as 'xiao' filial piety, 'ci' political ethics right, could open a door of hope for better medical care in the future for kindness between kids and parents, 'di' brotherly relation between brethren and sisters, 'xin' Gretchen, Carl and all the others. trustworthiness between and yi justice between friends, 'ren' humanness and 'hui' benevolence between physicians and patients etc' [Doering 2004]. Only since the First Vatican Council 150 POLICY OPTIONS TO SUPPORT HEALTH CARE AND HUMAN DIGNITY years ago has one of the major branches of Christianity, Roman Catholicism, rigorously Saving life, alleviating pain and suffering, fighting disease and disability, protecting defended a strictly biological stage in human development (defined as successful fertilization health are generally non-controversial within different cultures and between cultures. But there 21 22 are quite a number of conflicting theological and philosophical positions in medical ethics, improved information of and communication with citizens [2003:29ff] which primarily are related to different theories and teachings regarding the beginning and the Whenever and as long as philosophers, theologians, politicians and pressure groups end of human life and afterlife, These are issues of contraception, abortion and various forms fight over principles, theories and rules for action, the preferred course of biopolitical action of withholding available life-prolonging treatment from terminally ill persons with or without should be to refrain from legislative action by majority vote and make sure that the primary their request. Some of these specific opinions and teachings have found their way into public moral agent, i.e. the person closest to the moral challenge, be given the right to follow her or his policy and regulation [Birnbacher 2004], even though citizens disagree deeply over the content conscience and calling, and that individuals, families, neighborhoods and moral communities and the right of such laws and regulations which do not express their own values and wishes and, be given access to information and advice for making those responsible and well reasoned in their eyes, disrespect the dignity of their conscience and their human and civil right to choose choices of their own. The prudent and morally authentic response in political ethics would be as long as other citizens are not hurt or harmed. As more and more so called leading cultures the recognition that globalization of research, reasoning, services and production suggest that (leitkulturen) loose the dominating power in traditionally geographically defined areas, national legislation will be less and less efficacious and that coordinated trans-national differences within cultures and among cultures become manifest everywhere associated with legislation intertwined with legislative and cultural initiates in protecting individual choice, the emancipation of individual visions and values and the forming of new moral communities vision, values and wishes of citizens (as long as they do not hurt other citizens) would be the everywhere, it becomes more and more a challenge to public culture and public policy to politically and morally right thing to do. Elastic laws, at least allowing for conscience clauses respect and to support the dignity of the individual conscience' choice and commitment. for individuals or small moral communities to choose for themselves alternative moral and If citizens disagree or if among a number of states, sharing same cultural traditions such medical options, within the limits of human and civil rights not to be harmed by others, would as in European states, and if there is disagreement on choosing the correct policy option to be the most appropriate way to legislate controversial issues among citizens, who are different provide an optimum of security and liberty to their citizens, then there are two options: If in their visions and values not because one side is 'bad' or 'morally inferior' and the other side is policies are different, but a dormant consent seems to be there, then the right course of action 'good' or 'morally superior', but because they have and are entitled to have different moral would be to have public debates and formal procedures to come to consensus based legal and intuitions and follow different religious or moral teachings [Sass 1991; 2003B]; some different regulatory solutions, including escape clauses for conscientious objectors. But if differences moral visions and acts are 'not incompatible even though they are incommensurable' but based seem to be in different visions and values of individuals and moral and religious communities, 'in a universally held set of pretheoretical moral intuitions' [Veatch 2004]. then, in order to protect the dignity of the individual conscience and civil choice, formal Different definitions of biological and medical terms in legal terminology in the procedures to protect individual choice and conscience, peaceable public discourse, tolerance, German Embryo Protection Law (1991), the recent Stem Cell Law (2002), and regulations and information and counseling services to individuals would be the most favorable solution regarding a central ethics commission for stem cell research (ZESV, 2002) would allow [Sass 2003B:786]. An emancipation of political and regulatory ethics from biopolitical Gretchen and Carl to produce an offspring by means of re-programming somatic stem cells, if paternalism, recognizing the dignity of different systems of belief and the dignity of the technically feasible, without any legal remedy, but they would not be allowed to use DNA individual conscience, would respect citizen's moral intuitions and convictions in global world transfer in cloning for reproductive purposes or therapeutic research, a logically, legally, and of rich individual and collective cultural and moral traditions and values. Whichever morally deficient platform to base trust into biolaw, biopolitics, and biopoliticians [Koch biopolitical solution is found, it must include that free and informed consent of citizens to 2003:113-115]. accept or to refuse to take part in medical research of morally controversial and medically risky Based on rulings of the European High Court in Luxembourg, beer brewed outside of nature and to accept or refuse medication or medical treatment based on knowledge gained by Germany not following century-old German beer-brewing regulations may nevertheless be sold procedures judged as to be not acceptable or even immoral by the non-consenting person. A as beer; since the 'Cassis de Dijon' decision [NJW 1979,1766;EuHC 20.2.1979;Art.30,37 EVG] study by the European Academy in Bad Neuenahr-Ahrweiler on 'Embryo Research in may be sold in other European states as fruit liqueur, even though the alcohol percentile is lower Pluralistic Europe' proposed six procedural policy guidelines for promoting embryo research, than requested in other states; similar court decisions and subsequent European regulations including balancing potential benefits of positive outcomes of research for patients and exist for pasta of different make. Why enjoys the conscience of individual European citizens 23 24 less freedom than making of wine, beer and pasta? the evil caused to the value sought is partially determinative of the posture of the will (whether Rich people may travel to other European countries where medical services are intending or permitting)' [1973:72]. While helping and healing is a prime 'value' in all cultures, provided which are illegal or criminalized in their own country, but that is not a solution for all the dimensions of the 'evil' of omitting to save each and any fertilized human egg or of [Sass 2003B:791] and these differences can be considered a moral and cultural harm to all permitting to let early human life die or intentionally terminating its life by using antinidatives Europeans the same way the European 'cujus region, ejus religio' solution in 1648 was a harm is controversial among and within cultures and religions, but not an issue at all in some cultures. to all European citizens. In an extended review of the legal situation in Germany, Biopoliticians actively criminalizing therapeutic human embryonic stem cell research commissioned by the Deutsche Forschungsgemeinschaft, Eser and Koch conclude that many would need stronger arguments than those permitting research under existing or future embryo research activities in Germany are illegal or will be punished by criminal law, including professional self-regulation and ethics oversight bodies. Many classical positions in ethics those done in cooperation with non-German research institutes outside of Germany [Eser, Koch favor to withhold action, when information is not sufficient or outcome is not clear, rather than 2003:166-178]. While all kinds of beer may be sold in Germany, still only beer brewed under acting by producing theories or laws or initiating action. Such a reasoning also would suggest German brewing standard may be brewed in Germany. Prior to the Luxembourg court decision, regulatory interventional minimalism rather than activism. it had not been discussed whether or not Germans would have committed a crime when Given the wide spectrum of book-based systems of belief on many ethical issues, over drinking beer brewed under different than German standards on German soil. Eser and Koch time and today, Torah and Talmud, Bible and Qur'an have served as guidance to be interpreted have not been commissioned to answer the question whether Gretchen Mueller, given her by individuals, communities and 'holy' persons, not as governance providing ready-made finances would allow her to do so, would commit a crime punishable by German law on her recipes for moral action. Non-book-based reference models tend to be less analytical and return to German soil, if she someday would get successful medical treatment outside of hermeneutical, concentrate more on general guidance and leave ample room for non-uniform Germany or if today she would volunteer in embryonic stem cell research elsewhere. personal or communal moral assessment and action. In general, all cultural positions - except Walters, in a recent review of intercultural perspectives on human embryonic stem cell the most bizarre and fundamentalist ones - allow, and historically have allowed, for modified research discusses six policy options: (1) No human embryo research permitted; (2) research positions [Nationaler Ethikrat 2003; Roetz 2004; Sass 2004A]. This makes cultural and only existing stem cell lines, not on embryos; (3) research only on left-over embryos; (4) religious traditions also a prime target for been exploited in party politics and in the halls of research also on embryos created via IVF for research; (5) research only on embryos created via political lobbying. Biopoliticians inviting experts in religious or cultural traditions for hearing somatic cell nuclear transfer into human eggs or zygotes; (6) research also on embryos created therefore should require that those experts present the full scale of positions within the tradition via transfer of human somatic cell nuclei into non-human eggs. None of these options suggests of their expertise not just one position which might have been the reason for their invitation in to include potential recipients or beneficiaries of in shaping policy options, as Walters the first place [Sass 2000]. Representatives of churches in political hearing, confusing basic unfortunately could not find those policy options prominently present anywhere despite the fact moral intuitions with their specific dogmatics, are quite often more a part of the problem than that a conscience-clause option would be the logical consequence of respecting citizen's dignity of a consensus oriented solution. Naturally, politicians must be and, indeed, are aware of the over politician's authority. Gretchen and Carl, both German citizens and active members in the political character of expert presentations, they choose to ask for; however, this is not an issue German branch of the Roman-Catholic church, have not been consulted by either authority nor of bioethics, but of ethics of biopolitics. been given an opportunity to express their values, wishes and visions in regard to therapeutic research which might hold some promise for their diseases and in regard to the question of how WHO HAS ASKED GRETCHEN MUELLER ON OPTIONS IN BIOPOLITICS? to assess therapeutic cloning and re-programming of human cells in the presence of legally Political and biopolitical establishments have not yet asked Gretchen and Carl as permissible antinidativa and abortion at least within the first trimester. citizens and patients most close to the moral issue of stem cell research for therapeutic purposes, European moral reasoning, similarly to other cultures, has made a distinction between nor have they explained why they have not done so or why they seem to care more for zygotes 'omission' and 'commission'; according to McCormick 'there is a difference between an than for people . So far only option 2, as described by Walters [2004], ambiguous and intending and a permitting will' [McCormick 1973:70]: 'In a conflict situation, the relation of questionable on bioethical and biopolitical terms, seems to be graciously accepted by majority 25 26 vote of German parliament [Eser; Koch 2003]. But this does not give citizens such as Gretchen embryos carrying unknown and uncertain genetic risk factors, would not be 'hurt' by therapeutic and Carl an opportunity to voice their conscience, values and wishes, and to get help. The research as they are not intended to be 'born'. They would be 'hurt' less than oocytes, morulae European Academy, Bad Neuenahr-Ahrweiler calls for more and better information of citizens or fetuses, legally aborted within the first trimester or 'killed' legally by hormonal or mechanical on scientific and related cultural and ethical issues of stem cell research, a goal previously devices disallowing nidation, but not conception. According to Thomas Aquinas, moral acts agreed upon by European governments and the European Commission but never or only need to be judged according to the proportionality of balancing good and evil - 'recipiunt meagerly implemented [2003]. speciem secundum id quod intenditur' [ThAq, STh II-II, q. 64, a. 7] -. The 'good' of therapeutic While other citizens are 'allowed' to make personal choices on antinidativa, abortion, research and medical therapy is uncontested, but the degree of 'evil' in human embryonic stem and the moral value of primitive non-specialized human cells, zygotes, and morulae, Gretchen cell research is controversial. Gretchen and Carl are hurt by the double-standard of politicians is excluded from been given hope for progress in stem cell research and from making choices choosing to care for zygotes and morulae more than for living citizens in need and for their related to her health, wellbeing, even survival. To ask Gretchen and Carl, however, would be families, i.e. caring less for those suffering from severe handicaps, weaknesses and limitations of notable moral and legal importance in order not to hurt or harm them - 'primum nil nocere' in in their lives and in caring for themselves and others. political ethics. The 'do no harm' principle, a most eminent maxim in medical ethics, should not In the presence of many legal and regulatory inconsistencies in the regulatory and moral been excluded from political ethics and its mandate. protection of different forms of unborn human life, of embryonic and somatic stem cells within The 'subsidiarity' principle in political, social, and bio-ethics would suggest that a given country or culture and among cultures and countries, Gretchen and Carl should be given services would best be recognized and delivered at the grass-root level, in this case in the the trust that their fate, their rights and expectations will not be regarded as inferior to the fate research and clinical setting, not in consulting groups of legal and theological experts and in of human cells or conglomerate of cells, stem-cells, embryonic or not. political or parliamentary compromises. The subsidiarity principle would include that everyone Gretchen and Carl recognize that others, healthy people, are enjoying life and using be given the full right to refuse to be part of research or any other activity deemed to be of IUD's and various other abortiva, do so without being criminalized or morally been questionable moral or even immoral nature, or to accept treatment or medication based on discriminated against. What Gretchen and Carl as patients request as a civil right, as a moral questionable or even immoral research as judged by those individuals and taught by religious priority in all cultures of authentic religious and philosophical reasoning, and as a human and or moral groups, branches or communities. political decency is less: the de-criminalization of cell-reprogramming and of embryonic stem The European Academy in Bad Neuenahr-Ahrweiler's report on Embryo Research in cell research for human therapy and the administration of modern medicine based on free and Pluralistic Europe [2003:31] argues that 'research on embryos is not only morally permissible, informed consent. They feel hurt that their government, many bioethicists and biopoliticians, it can be morally mandated when legitimate interests of persons, suffering from non-treatable theologians and judges playing doctors, and so-called experts of all sort, do not seem to honor diseases and disorders .. outweigh the general interest of society to protect embryos'. the most common moral principle to allow and to support the improvement of health care and Gretchen and Carl are harmed and hurt, when research, potentially leading to remedy or medical treatment for both of them, put theories over people, power over the health and to alleviate their disabilities, would not be supported or accepted; they would be harmed even conscience of people, moral tutelage of people over care for people, concern for cells, zygotes more if such research would be prohibited or criminalized. Gretchen and Carl would be harmed, and morulae over concern for citizens as patients. if future treatment, developed on the basis of cloning or human embryonic stem cell research elsewhere, would not be made available in their home country. Citizens richer than Gretchen and Carl would have the moral and medical option to get treatment in Portugal, Israel, an Asian country or wherever treatment is offered, but for financial reasons they most likely will not have that option. Gretchen and Carl are also harmed by confusing and inconsistent legal philosophy, wording, and rhetoric defining embryo, reprogramming, and cloning. Reprogrammed cells, not intended to, but eventually capable of developing into 27 28 LITERATUR Ilkilic, Ilhan (2002) Der muslimische Patient. Medizinethische Aspekte des muslimischen Argetsinger, Amy; Goldstein, Avram (2004) GU to continue controversial research. The Krankheitsverständnisses in einer wertpluralen Gesellschaft, Münster: Lit Washington Post Jan 30, 2004; B1 and B4 Ilkilic, Ilhan (2004A) Biomedizin aus der Sicht des Islam. Kulturelle Aspekte der Biomedizin, Bayertz, Kurt (2004) Dissens in Fragen von Leben und Tod: Können wir damit leben? hg S. Schickhart, Ch. Tannert, P. Wiedemann, Frankfurt: Campus, 56-83 Weltanschauliche Offenheit in der Bioethik, hg E. Baumann, A. Brink, A. May, P. Schröder, Ilkilic, Ilhan (2004B) Der moralische Status des Embryos im Islam und die wertplurale C. Schutzeichel, Berlin: Duncker und Humblot, in print Gesellschaft. Weltanschauliche Offenheit in der Bioethik, hg E. Baumann, A. Brink, A. May, Beauchamp Tom L; Childress, James. (2001) Principles of Biomedical Ethics, New York: P. Schröder, C. Schutzeichel, Berlin: Duncker und Humblot, in print Oxford U Press, 5th ed Ivanhoe, Philip J (2002) Ethics in the Confucian Tradition. The Thought of Mengzi and Wang Cao Zeyi (1989) Medizinethik in China / Richtlinien zur Medizinischen Ethik, Bochum: ZME Yangming, Indianapolis: Hackett [English and German; Chinese China Hospital Administration 1989; 9(3):5] Jaenisch R, Bird A (2003) Epigenetic regulation of gene expression: How the genome Denker HM (2004) Early human development: new data raise important embryological and integrates intrinsic and environmental signals. Nature Genetics 35(Suppl):245-254. 91:1-21 [DOI ethical questions relevant for stem cell research. Naturwissenschaften Koch, Hans-Georg (2003) Vom Embryonenschutzgesetz zum Stammzellengesetz. 10.1007/s00114-003-0490-8]. Überlegungen zum Status des Embryo in vitro aus rechtlicher und rechtsvergleichender Sicht. Doering, Ole (2004) Was bedeutet 'ethische Verständigung zwischen den Kulturen'? Die Forschung an embryonalen Stammzellen in ethischer und rechtlicher Perspektive, hg Weltanschauliche Offenheit in der Bioethik, hg E. Baumann, A. Brink, A. May, P. Schröder, Giovanni Maio, Hanjörg Just, Baden-Baden: Nomos, 97-118
C. Schutzeichel, Berlin: Duncker und Humblot, in print Mahowald MB (2004) Self-Preservation: An argument for therapeutic cloning and a strategy Eser, Albin; Koch, Hans-Georg (2003) Rechtsgutachten. Forschung mit humanen embryonalen for fostering respect for moral integrity. Am J Bioethics 4(2):56-66. Stammzellen. Strafrechtliche Grundlagen und Grenzen, hg Deutsche Forschungsgemeinschaft, McCormick SJ, Richard (1973) Ambiguity in Moral Choice, Milwaukee WI: Marquette U Weinheim: Wiley-VCH, 37-207 Press
European Academy, Bad Neuenahr-Ahrweiler (2003) Embryo Research in Pluralistic Europe, McCormick SJ, Richard. (1980) Does religious faith add to ethical perception? The Distinctiveness of Christian Ethics, ChE Curran, RM McCormick ed, New York: Ramsey, Berlin: Springer pp.156-17 Faiola, Anthony (2004) Dr. Clone: creating life or trying to save it?. The Washington Post Febr Mendelsohn, Moses. (1819) Jerusalem oder uebr religioese Macht und Judentum, Ofen: Burian 29, 2004, A1, A21 Mencius, in: (1895) The Chinese Classics, ed J Legge, vol 2, Oxford: Clarendon Fuchs SJ, Josef (1980) Is there a Christian morality? The Distinctiveness of Christian Ethics, Nationaler Ethikrat (2003) Der Umgang mit vorgeburtlichem Leben in anderen Kulturen. ChE Curran, RM McCormick ed, New York: Ramsey, pp.3-19 Wortprotokoll der Jahrestagung am 23.10.2003, Berlin: Nationaler Ethikrat
Hartmann, Fritz. (2003) Kranke als Gehilfen ihrer Aerzte, Bochum: Zentrum Med Ethik Ni, Peimin (1999) Confucian virtues and personal health. Confucian Bioethics, R Fan ed, Dordrecht: Kluwer, p. 27-44 Have, Henk ten, Sass Hans-Martin, ed. (1998) Consensus Formation, Dordrecht: Kluwer Pellegrino Edmund D, Thomasma David C (1988) For the Patient's Good, New York: Oxford HUGO Ethics Committee HUGO (2003) Statement on Genetic Screening (November 2002). U Press Eubios J Asian Intern Bioethics 13(3) Qiu, Renzong (1988) Medicine, the art of humaneness,: on ethics of traditional Chinese Hwang, Woo Suk; Ryu, Young June; Park, Jong Hyuk; et al (2004) Evidence of a pluripotent medicine. The Journal of Medicine and Philosophy 13(3):277-300 [see also the German human embryonic stem cell line derived from a cloned blastocyst. Science Febr 12 Translation Medizin - die Kunst der Menschlichkeit, Bochum: ZME March 1989] 29 30 Ratanakul, Pinit (1999) Buddhism, health, disease, and Thai culture. A Cross-Cultural Sass, Hans-Martin (2003B) Würde des Gewissens und europäisches Binnenenthikrecht. Dialogue on Health Care Ethics, ed h Coward, P Ratanakul, Waterloo Ont: Laurier, 17-33 Strafrecht, Biorecht, Rechtsphilosophie. Festschrift für Hans-Ludwig Schreiber, Rendtorff JD (2002) Basic ethical principles in European bioethics and biolaw. Medicine, Heidelberg:Mueller, 783-792 Health Care and Philosophy 5(3):235-244 Sass, Hans-Martin (2004A) Asian and Western Bioethics - Converging, Conflicting, Robinson GE (2004) Beyond nature and nurture. Science 304:307-399 Competing? Eubios Journal of Asian and International Bioethics 14 (Jan 2004), 13-22 Roetz, Heiner (2004A) Der Mensch als Mitschöpfer. Bioethik und kulturelle Differenzen, Neue Sass, Hans-Martin (2004B) Genetic screening for drug metabolism and genetic disorders: Zürcher Zeitung, 20 Februar 2004 promotion of individualized drug delivery and lay health care competency, Beijing Roetz, Heiner (2004B) Muss der kulturelle Pluralismus einen substantiellen ethischen Konsens International Conference on Bioethics 2004, Beijing: CAMS / PUMC, 208-217 [abstract verhindern? Zur Bioethik im Zeitalter der Globalisierung. Weltanschauliche Offenheit in der Chinese and English, 102f] Bioethik, hg E. Baumann, A. Brink, A. May, P. Schröder, C. Schutzeichel, Berlin: Duncker und Schueller SJ, Bruno (1980) The debate on the specific character of a Christian ethics. The Humblot, in print Distinctiveness of Christian Ethics, CE Curran, RM McCormick ed, New York: Ramsey, Sass, Hans-Martin. (1985) Wollen wir uns klonen lassen? Leben mit der Technik, ed Chr. pp.207-233 Boehr. Krefeld: Sinus, pp.75-93 Tai, Michael C (1999) The Principles of Medical Ethics of Asians and for Asians. Proceedings Sass, Hans-Martin (1986) The moral a priori and the Diversity of Cultures, Analecta of the 2nd Asian Bioethics Seminar, Univ. Research Center, Nihan University, Tokyo, Japan, Husserliana, 20:407-422 42-51 Sass, Hans-Martin (1991) Can there ever be a Consensus in the Abortion Debate?, Vatican (Pius IX) 1931: Quadrogesimo Anno, Rome: Vatican Bochum:ZME Vatican (John Paul II) 1993: Veritatis Splendor, Vatican City Sass, Hans-Martin (1994) Formulating Global Post-Hippocratic Health Care Virtues, Eubios Veatch Robert M (2004) Common morality and human finitude: a foundation for bioethics, Ethics Institute. Newsletter, 4 (1+2), 1994 [subsequent: japan. transl. Journal of Health Care, Weltanschauliche Offenheit in der Bioethik, hg E. Baumann, A. Brink, A. May, P. Schröder, Medicine and Community, 5, 1994, 3-6; Chinese transl, Newsletter. Centre for Applied Ethics, C. Schutzeichel, Berlin: Duncker und Humblot, in print Hongkong Baptist College, 2(1), 1994, 8-15; Italian. transl. Kos, 118, 1995: 46-51; french Walters, Leroy. (2004) Human embryonic stem cell research . An intercultural perspective. transl. Journal International de Bioethique, 1995, 6(1), 5-7] Kennedy Inst of Ethics Journal 14(1): in print Sass, Hans-Martin (1999) Differentialethik. Über die notwendige Integration von Fakten und Zimmerli, Walther (2004) Natur als technische Kultur: Veränderung der Ethik durch Normen in Medizin und Biowissenschaften Angewandte Ethik, hg P. Kampitz, A. Weiberg, Gentechnik. Weltanschauliche Offenheit in der Bioethik, hg E. Baumann, A. Brink, A. May, P. Wien, 315-332 Schröder, C. Schutzeichel, Berlin: Duncker und Humblot, in print. Sass, Hans-Martin (2000) Ethical decision making in committee. The role of review boards and committees in health care and medical research. Convivium. Revista de Filosofia 13, p. 149-165 Sass, Hans-Martin (2002A) A 'Contract Model' for Genetic Research and Health Care for Individuals and Families, Eubios Journal of Asian and International Bioethics 11 (Sept 2001):180-182 Sass Hans-Martin (2002B) Medical Technologies and Universal Ethics in transcultural perspective. Bioethics and Moral Content. Dordrecht: Kluwer, pp. 49-75 Sass, Hans-Martin (2003A) Common moral principles and cultural diversities. Formosan J Medical Humanities 4(1&2), p. 6-21 31 32 Zentrum für Medizinische Ethik Heft 98: Stotz, Gabriele: Theoretische und ethische Probleme der psychiatrischen Diagnose. März 1995. Medizinethische Materialien Heft 99: Vollmann, Jochen: Fürsorgen und Anteilnehmen: Ethics of Care. April 1995. Heft 100: Hinrichsen, Klaus V.; Sass, Hans-Martin: 10 Jahre Zentrum für Medizinische Ethik. Die unterstrichenen Hefte sind derzeit leider vergriffen, können im Sonderfall aber als Kopie Juni 1996. oder e-file geliefert werden. Heft 101: Schreiber, Hans-Ludwig: Die Todesgrenze als juristisches Problem - Wann darf ein
Organ entnommen werden? Juli 1995. Heft 76: Sass, Hans-Martin; Kielstein, Rita: Die Wertanamnese. Methodische Überlegungen Heft 102: Hartmann, Fritz: Lebens- und Hilfeleistungen im Sterben. 2. Aufl. Februar 1996. und Bewertungsbogen für die Hand des Patienten. 2. überarb. Aufl. Dezember 1992. Heft 103: Kielstein, Rita (Hg.): Ethische Aspekte in der Nephrologie. 2. Aufl. Februar 1995. Heft 77: Uhlenbruck, Wilhelm: Selbstbestimmung im Vorfeld des Sterbens - rechtliche und Heft 104: Bernat, Erwin: Antizipierte Erklärungen und das Recht auf einen selbstbestimmten medizinische Aspekte. September 1992. Tod. Januar 1996. Heft 78: Sass, Hans-Martin: Informierte Zustimmung als Vorstufe zur Autonomie des Heft 105: Richter, Gerd; Schmid, Roland M.: Ethische Perspektiven der Gentherapie 1995. Patienten. September 1992. Januar 1996. Heft 79: Tausch, Reinhard: Vergeben. Von der Bedeutung des Vergebens in Heft 106: Bauer, Axel: Braucht die Medizin Werte? Gedanken über die methodologischen zwischenmenschlichen Beziehungen, auch in der Medizin. Mai 1993. Probleme einer „Bioethik“. März 1996. Heft 80: Schara, Joachim: Patientenaufklärung vor Krebsschmerztherapie. Juni 1993. Heft 107: Tausch, Reinhard: Empirische Untersuchungen zu Sinn-Erfahrungen und Heft 81: Sass, Hans-Martin; Kielstein, Rita: Wertanamnese und Betreuungsverfügung. 3. Wertauffassungen. Juli 1996. überarb. Aufl. Juli 1995. Heft 108: Sass, Hans-Martin: Ethik-Unterricht im Medizinstudium; Methoden, Modelle und Heft 82: Kielstein, Rita: Klinik, Genetik und Ethik der autosomal dominant polyzystischen Ziele der Integration von Medizinethik in die medizinische Aus- und Fortbildung. Nierenerkrankung. 2. überab., erw. Aufl. März 1995. August 1996. Heft 83: Ilkilic, Ilhan: Der Bochumer Arbeitsbogen und der türkische Patient. Pratik Tip Etigi Heft 109: Meyer, Frank P.: Salus aegroti suprema lex; Probleme klinischer Studien aus der Icin Bochum Calisma Tablosu Ve Türk Hastasi. Juli 1993. Sicht eines Mitgliedes einer Ethikkommission - Schwerpunkt Onkologie. August Heft 84: Materialien zur Erstellung von wertanamnestischen Betreuungsverfügungen. 1996. Eingeleitet und zusammengestellt von R. Kielstein, H.-M. Sass. Übersetzt von S. Heft 110: Sass, Hans-Martin: Reform von Gesundheitswesen und Krankenhäusern in Eschen. 3. Aufl. September 1995. verantwortungsethischer Perspektive. August 1996. Heft 85: Timmermann, Jens: Das Thema Sterbehilfe in Thomas Morus' "Utopia". November Heft 111: Sass, Hans-Martin, Kielstein, Rita: Die medizinische Betreuungsverfügung in der 1993. Praxis. Vorbereitungsmaterial, Modell einer Betreuungsverfügung, Hinweise für Heft 86: Tausch, Reinhard: Sinn-Erfahrungen. Förderung, Chancen und Grenzen bei Ärzte, Bevollmächtigte, Geistliche und Anwälte. 7. Auflage Dezember 2000. Betroffenen und Helfenden. November 1993.Heft 87: Vliegen, Josef: Moderne Heft 112: Spittler, Johann F.: Sterbeprozess und Todeszeitpunkt - Die biologischen Psychiatrie und ihr Bild vom Menschen. Dezember 1993. Phänomene und ihre Beurteilung aus medizinischer Sicht. August 1996. Heft 88: Hinrichsen, K.V. (Hg.): Sterben und Schwangerschaft. Mit Beiträgen von M. Heft 113: May, Arnd; Gawrich, Stefan; Stiegel, Katja: Empirische Erfahrungen mit Bissegger, K. Hinrichsen, E. Reichelt, H.-M. Sass, K.-E. Siegel, I. Wolf. 3. Aufl. Juni wertanamnestischen Betreuungsverfügungen. 2. Auflage Juli 1997. 1994. Heft 114: Biller, Nikola: Der Personbegriff in der Reproduktionsmedizin. September 1997. Heft 89: Sass, Hans-Martin: Die Würde des Gewissens und die Diskussion um Heft 115: Kaminsky, Carmen: Gesagt, gemeint, verstanden? Zur Problematik der Validität Schwangerschaftsabbruch und Hirntodkriterien. 3. Aufl. Juni 1994. vorsorglicher Patientenverfügungen. Oktober 1997. Heft 90: Jakobs, Günther: Geschriebenes Recht und wirkliches Recht beim Heft 116: Baumann, Eva: Gesellschaftliche Konsensfindung und Humangenetik. Oktober Schwangerschaftsabbruch. März 1994. 1997. Heft 91: Sass, Hans-Martin: Ethische und bioethische Herausforderungen Heft 117: May, Arnd: Betreuungsrecht und Selbstbestimmung am Lebensende. September molekulargenetischer Prädiktion und Manipulation. 2. Aufl. Juni 1994. 1998. Heft 92: Sass, Hans-Martin: Hippokratisches Ethos und Nachhippokratische Ethik. Juni 1994. Heft 118: Zülicke, Freddy: Chancen und Risiken von Gentechnik und Reproduktionsmedizin. Heft 93: Koch, Hans-Georg; Sass, Hans-Martin; Meran, Johannes Gobertus: September 1998. Patientenverfügung und Stellvertretende Entscheidung in rechtlicher, medizinischer Heft 119: Meyer, Frank P.; Sass, Hans-Martin: Klinische Forschung 2000. Oktober 1998. und ethischer Sicht. 3. Auflage April 1996. Heft 120: Grossmann, Wilfried; Maio, Giovanni, Weiberg, Anja: Ethik im Krankenhausalltag Heft 94: Fuchs, Christoph: Allokation der Mittel im Gesundheitswesen - Rationalisierung - Theorie und Praxis. Oktober 1998. versus Rationierung. Juni 1994. Heft 121: Sponholz, Gerlinde; Allert, Gebhard; Keller, Frieder; Meier-Allmendinger, Diana; Heft 95: Schroeder-Kurth, Traute: Das "Slippery Slope"- Argument in der Medizin und Baitsch, Helmut: Das Ulmer Modell medizinethischer Lehre. Sequenzierte Medizinethik. Dezember 1994. Falldiskussion für die praxisnahe Vermittlung von medizinethischer Kompetenz Heft 96: Pohlmeier, Hermann: Selbstmordverhütung - Zur Ethik von Selbstbestimmung und (Ethikfähigkeit); Uhl, Andreas; Lensing; Claudia: Perspektiven und Gedanken zur Fremdbestimmung. Dezember 1994. medizinethischen Ausbildung. August 1999. Heft 97: Epplen, Jörg T.; Rieß, Angelika; Rieß, Olaf: DNA-Diagnostik in der Humangenetik: Heft 122: Schmitz, Dagmar; Bauer, Axel W.: Evolutionäre Ethik und ihre Rolle bei der Voraussetzungen und Tendenzen. März 1995. Begründung einer zukünftigen Medizin- und Bioethik. März 2000.
Heft 123: Hartmann, Fritz: Chronisch Kranksein als Grenzlage für Kranke und ihre Ärzte. März Heft 146: Sass, Hans-Martin: Angewandte Ethik in der Pharmaforschung. Januar 2004. 2000. Heft 147: Joung, Phillan: Ethische Probleme der selektiven Abtreibung: Die Diskussion in Heft 124: Baberg, Henning T.; Kielstein, Rita; Sass, Hans-Martin (Hg.): Der Südkorea. Januar 2004. Behandlungsverzicht im Blick des Bochumer Inventars zur medizinischen Ethik Heft 148: May, Arnd T; Brandenburg, Birgitta: Einstellungen medizinischer Laien zu (BIME). April 2000. Behandlungsverfügungen. Januar 2004. Heft 125: Spittler, Johann F.: Locked-in-Syndrom und Bewusstsein – in dubio pro vita. August Heft 149: Hartmann, Fritz: Sterbens-Kunde als ärztliche Menschen-Kunde. Was heißt: In 2000. Würde sterben und Sterben-Lassen? Januar 2004. Heft 126: Ilkiliç, Ilhan: Das muslimische Glaubensverständnis von Tod, Gericht, Gottesgnaden Heft 150: Reiter-Theil, Stella: Ethische Probleme der Beihilfe zum Suizid. Die Situation in und deren Bedeutung für die Medizinethik. September 2000. der Schweiz im Lichte internationaler Perspektiven. Februar 2004. Heft 127: Maio, Giovanni: Ethik und die Theorie des "minimalen Risikos" in der medizinischen Heft 151: Ambiguities in Biopolitics of Stem Cell Resarch for Therapy. Who cares for Forschung. September 2000. Gretchen Mueller. 2. Auflage Juni 2004. Heft 128: Zenz, Michael; Illhardt, Franz Josef: Ethik in der Schmerztherapie. November 2000. Heft 152: Ilkilic, Ilhan: Gesundheitsverständnis und Gesundheitsmündigkeit in der Heft 129: Godel-Ehrhardt, Petra; May, Arnd T.: Kommunikation und Qualitätssicherung im islamischen Tradition. April 2004. Betreuungsrecht – Ergebnisse einer Befragung zur Mailingliste Heft 153: Omonzejele, Peter F.: African Concepts of Health, Disease and Treatment [A [email protected]. März 2001. Future for Traditional Medicines and Spiritual Healings? A Postscript on Peter F Heft 130: Dabrock, Peter; Klinnert, Lars: Würde für verwaiste Embryonen? Ein Beitrag zur Omonzeleje by Hans-Martin Sass]. April 2004. ethischen Debatte um embryonale Stammzellen. Juli 2001. Heft 154: Lohmann, Ulrich: Die neuere standesethische und medizinrechtliche Entwicklung Heft 131: Meyer, Frank P.: Ethik der Verantwortung. Verkommt »Evidence Based Medicine« in Deutschland – Wandel des Menschenbildes? Mai 2004. zu »Money Based Medicine«? März 2002. Heft 155: Friebel, Henning; Krause, Dieter; Lohmann, Georg; Meyer, Frank P.: Heft 132: Sass, Hans-Martin: Menschliche Ethik im Streit der Kulturen. 2. Auflage Januar Verantwortungsethik. Interessenkonflikte um das Medikament – Wo steht der 2003. Patient? 2. Auflage Juni 2004. Heft 133: Knoepffler, Nikolaus: Menschenwürde als Konsensprinzip für bioethische Heft 156: Kreß, Hartmut: Sterbehilfe - Geltung und Reichweite des Selbstbestimmungsrechts Konfliktfälle in einer pluralistischen Gesellschaft. März 2002. in ethischer und rechtspolitischer Sicht.1. Auflage September 2004, 3. Auflage März Heft 134: Quante, Michael: Präimplantationsdiagnostik, Stammzellforschung und 2005. Menschenwürde. März 2002. Heft 157: Fröhlich, Günter und Rogler, Gerhard: Das Regensburger Modell zur Ausbildung in Heft 135: Köchy, Kristian: Philosophische Grundlagenreflexion in der Bioethik. März 2002. klinischer Ethik. 1. Auflage Dezember 2004, 2. Auflage Februar 2005. Heft 136: Hengelbrock, Jürgen: Ideengeschichtliche Anmerkungen zu einer Ethik des Sterbens. Heft 158: Ilkilic, Ilhan; Ince, Irfan und Pourgholam-Ernst, Azra: E-Health in muslimischen Juli 2002. Kulturen. Dezember 2004. Heft 137: Schröder, Peter: Vom Sprechzimmer ins Internetcafé: Medizinische Informationen Heft 159: Lenk, Christian; Jakovljevic, Anna-Karina: Ethik und optimierende Eingriffe am und ärztliche Beratung im 21. Jahrhundert. Juli 2002. Menschen. 2.Auflage Februar 2005. Heft 138: Zühlsdorf, Michael T.; Kuhlmann, Jochen: Klinische und ethische Aspekte der Heft 160: Ilkilic, Ilhan: Begegnung und Umgang mit muslimischen Patienten. Eine Pharmakogenetik. August 2002. Handreichung für die Gesundheitsberufe. 1. Auflage Juli 2003 (Tübingen), 5. Heft 139: Frey, Christofer; Dabrock, Peter: Tun und Unterlassen beim klinischen Auflage April 2005. Entscheidungskonfliktfall. Perspektiven einer (nicht nur) theologischen Heft 161: Hartmann, Fritz: Vom Diktat der Menschenverachtung 1946 zur "Medizin ohne Identitätsethik. August 2002. Menschlichkeit" 1960; Zur frühen Wirkungsgeschichte des Nürnberger Heft 140: Meyer, Frank P.: Placeboanwendung – die ethischen Perspektiven. März 2003. Ärzteprozesses. 1. Auflage Februar 2005, 2. Auflage März 2005. Heft 141: Putz, Wolfgang; Geißendörfer, Sylke; May, Arnd: Therapieentscheidung am Heft 162: Strätling, Meinolfus u.a.: Die gesetzliche Regelung der Patientenverfügung in Lebensende- Ein "Fall" für das Vormundschaftsgericht? 2. Auflage August 2003. Deutschland. Juni 2005. Heft 142: Neumann, Herbert A.; Hellwig, Andreas: Ethische und praktische Überlegungen zur Heft 163: Sass, Hans- Martin: Abwägungsprinzipien zum Cloning menschlicher Zellen. Januar Einführung der Diagnosis Related Groups für die Finanzierung der Krankenhäuser. 2006. Januar 2003. Heft 164: Vollmann, Jochen: Klinische Ethikkomitees und klinische Ethikberatung im Heft 143: Hartmann, Fritz: Der Beitrag erfahrungsgesicherter Therapie (EBM) zu einer Krankenhaus. Ein Praxisleitfaden über Strukturen, Aufgaben, Modellen und ärztlichen Indikationen-Lehre. August 2003. Implementierungsschritte. 1. Auflage Januar 2006, 3. Auflage März 2006. Heft 144: Strätling, Meinolfus; Sedemund-Adib, Beate; Bax, Sönke; Scharf, Volker Edwin; Heft 165: Sass, Hans- Martin: Medizinische Ethik bei Notstand, Krieg und Terror. Fieber, Ulrich; Schmucker, Peter: Entscheidungen am Lebensende in Deutschland. Verantwortungskulturen bei Triage, Endemien und Terror. 1. Auflage Februar 2006, Zivilrechtliche Rahmenbedingungen, disziplinübergreifende Operationalisierung 3. Auflage März 2006. und transparente Umsetzung. August 2003. Heft 166: Sass, Hans-Martin: Gesundheitskulturen im Internet. E-Health-Möglichkeiten, Heft 145: Hartmann, Fritz: Kranke als Gehilfen ihrer Ärzte. 2. Auflage Dezember 2003. Leistungen und Risiken. 1. Auflage Februar 2006, 2. Auflage März 2006.
Bestellschein ZUSAMMENFASSUNG Hans-Martin Sass unterscheidet in Unklarheiten in der Biopolitik therapeutischer
Stammzellforschung ein in allen Kulturen unkontroverses ethisches Primat der Hilfe für An das Zentrum für Medizinische Ethik Kranke und Leidende von kulturell und ethisch kontroversen Diskursen und Regelungen im Ruhr-Universität Bochum Umgang mit vorgeburtlichem Leben. Während Lebensrettung und Heilung oder Linderung von Gebäude GA 3/53 Krankheit sich direkt auf eine a-priori moralische Intuition berufen können, sind ethische 44780 Bochum Interpretationen des vorgeburtlichen Lebens zwangsläufig durch individuelles Gewissen und
unterschiedliche religiöse und moralische Kulturen geprägt. Er kritisiert obrigkeitliche Verbote
und Einschränkungen von Forschungen an embryonalen Stammzellen und empfiehlt der
Tel: (0234) 32 22749/50 politischen Ethik und Praxis, Bürger und Patienten selbst entscheiden zu lassen, ob sie an FAX: (0234) 3214 598 solchen Forschungen teilnehmen oder in der Zukunft durch solche Forschung gewonnene Email: [email protected] Homepage: http://www.medizinethik-bochum.de Heilmittel akzeptieren wollen.
Bankverbindung: Konto Nr. 133 189 035, Sparkasse Bochum BLZ 430 500 01 ABSTRACT Name oder Institut: In Ambiguities in Biopolitics of Stem Cell Research for Therapy Hans-Martin Sass
differentiates between a moral a-priori intuition directly calling to care for the sick and
suffering and an indirect application of a-priori moral intuition, refined and argued for by the Adresse: individual conscience and religious and philosophical traditions and cultures. While saving life
and healing or eliviating suffering is morally and culturally not controversial, differences in the
moral assessment of forms of early unborn human life are an indirect expression of genuine and
authentic, but different moral visions and values, refined by individual conscience and different ( ) Hiermit abonniere(n) wir/ich die Reihe MEDIZINETHISCHE MATERIALIEN zum Sonderpreis von € 4,00 pro Stück ab Heft Nr.____. Dieser Preis schließt die Portokosten mit traditions and teachings. In calling to respect the dignity of the individual conscience, he rejects ein. governmental moral tutilage and legal paternalism in criminalizing or severely limiting human
stem cell research; instead, he calls on political ethics and practice to let competent citizens and ( ) Hiermit bestelle(n) wir/ich die folgenden Einzelhefte der Reihe MEDIZINETHISCHE patients decide for themselves whether or not to take part in embryonic stem cell research or MATERIALIEN zum Preis von € 6,00 (bei Abnahme von 10 und mehr Exemplaren € 4,00 pro Stück). accept future medical treatment based on such research.
Hefte Nummer: ______
ISBN: 3-931993-32-9