THE PHILOSOPHICAL DISEASES OF MEDICINE AND THEIR CURE and Medicine

VOLUME 82

Founding Co-Editor Stuart F. Spieker

Editor

H. Tristram Engelhardt, Jr., Department of Philosophy, Rice University, and Baylor College ofMedicine, Houston, Texas

Associate Editor

Kevin Wm. Wildes, S.J., Department ofPhilosophy and Kennedy Institute ofEthics, Georgetown University, Washington, D. C.

Editorial Board

George J. Agieh, Department ofBioethics, The Cleveland Clinic Foundation, Cleveland, Ohio Nicholas Capaldi, Department ofPhilosophy, University of Tulsa, Tulsa, Oklahoma Edmund Erde, University ofMedicine and Dentistry ofNew Jersey, Stratford, New Jersey Eric T. Juengst, Center for Biomedical , Case Western Reserve University, Cleveland, Ohio Christopher Tollefsen, Department of Philosophy, University ofSouth Carolina, Columbia, South Carolina Becky White, Department ofPhilosophy, California State University, Chico, California

The titles published in this series are listed at the end ofthis volume THE PHILOSOPHICAL DISEASES OF MEDICINE AND THEIR CURE PHILOSOPHY AND ETHICS OF MEDICINE, VOL. 1: FOUNDATIONS

by JOSEF SEIFERT International Academy of Philosophy in the Principality of Liechtenstein (lAP) and Chile (lAP-PUC) and Pontificia Universidad Cat6lica de Chile, Santiago

~- Springer Science+Business Media, LLC A C.I.P. Catalogue record for this book is available from the Library of Congress.

ISBN 978-90-481-6736-4 ISBN 978-1-4020-2871-7 (eBook) DOI 10.1007/978-1-4020-2871-7

Printed on acid-free paper

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All Rights Reserved © Springer Science+Business Media New York 2004 Originally published by Springer Netherlands Softcover reprint of the hardcover I st edition 2004 No part of this work may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording or otherwise, without written permission from the Publisher, with the exception of any material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Dedicated to My beloved children Maria Michaela Seifert, who is dedicating her life to philosophy and wrote her first work on the nature and inviolable dignity ofeach human being, and Gabriel Joseph Seifert, who intends to work as a philosophically healthy physician for the high goods entrusted to medicine;

and to my many dear friends in medicine - professors ofmedicine and medical ethics, physicians, and nurses in all the world, who serve the great ends ofmedicine with an unwavering commitment, including: Lejeune t in commemoration ofthe tenth anniversary ofhis death (1994) Madame Jerome Lejeune and to Michael and Charlotte Barthel, Anna Barthel, John and Evelyn Billings, Johannes Bonelli, Judie Brown, Sr. Anna Cappella, Fr. Fernando Chomali, Fr. John Fleming, Petr Hach, Gonzales Herranz, Roy Joseph and Elizabeth Heyne, Joseph Dietrich and Cynthia Heyne, Nicholas Heyne, Thomas Hilgers, Paulina Johnson, Gudrun Lang, Birthe Lejeune, Josef Lingenhole, DetlefLinke, Lorena Mosso, Jorge Neira, Luis Jensen, Antun Lisee, Manfred Lutz, Marcelo Munoz, Tamas Csaky-Pallavicini, Soledad Perez, Wanda Pohawska, M. Loreto Rodriguez, Alberto Rojas, Pedro Rosso, Gottfried Roth, Joseph Santamaria, Philippe Schepen, Beatriz Paulina Shand, Alejandro and Maritza Serani, Daniel Serrao, Alan Shewmon, Anton Svajger t,William F. Sullivan, Paulina Taboada, Nicholas Tonti-Filippini, Sergio Valenzuela and Pamela del Carmen Silva Crespo, Patricio Ventura, Raul Ventura, Dieter Walch, Albert Wick, Tom Watts, Nikolaus Zwicky-Aeberhard TABLE OF CONTENTS

PREFACE AND ACKNOWLEDGMENTS xvii

INTRODUCTION xxvii

CHAPTER 1 THE NATURE AND THE SEVEN GOALS OF MEDICINE AS OBJECTS OF A DRAMATIC FREE CHOICE OF THE PHYSICIAN TODAY 1. On the Nature of Medicine and the Physician. The Physician as Scientifically Trained Healer, as Practitioner ofthe 'Art of Medicine', as Ethicist, and as Moral Subject 1.1. The Physician as Scientifically Trained Healer, the Essence of Medicine as Empirical Inductive Science, and Its a priori Foundations 1.1.1. The Physician and the Role of Empirical Scientific Training 1.1.2. A Justification of Medicine as an Empirical Science against Hume's and Popper's Objections Raised against Induction 2 1.1.3. Immense Progress in Medicine as Experimental Science and as Scientifically Supported Medical Practice 25 1.1.4. Medicine as Practical or 'Pragmatic' Science and the Respective Values of Theoretical versus Practical Sciences 32 1.2. The Physician as 'Practical Artist' and Craftsman-and Progress in Medicine 36 1.3. On the Constitutive Role of a Philosophical Understanding of Man and Morality for Medicine as Science, and of Moral Commitments for the Physician as Practitioner 38 2. The Physician-: Theoretical and Practical Philosophical and Ethical Aspects of Medicine 39 2.1. The Goods Medicine Is Called to Serve and the Indispensable Moral Choice of the Physician 39 2.2. The Seven Goods or 'Seven Ends' the Physician Should Serve and Respect 44 2.2.1. Medical Service to Human Life in Its Uniqueness and Specifically Personal Nature as well as in Its Right Place in the Whole Order of Goods 45 2.3. 'Health' as a Fundamental Goal of Medicine and as Disputed Question 52 2.3.1. The Question "What Is Human Health?" as a Philosophical and as Disputed Question 52

Vll viii TABLE OF CONTENTS

The Nature of Health and Reductionism 54 Utopian Notions of Health 54 Objectivity or Subjectivity of Concepts of Health? 56 2.3.2. The Question "To Which Extent Should Health Be Promoted in Medicine?" as a Disputed Question 57 2.3.3. The Question "What Is the Place of Health in the Hierarchy of Human Goods?" as a Disputed Question 57 2.4. The Fight against Pain (Suffering) and for Pleasure and Physical and Mental Relief: Preventing, Alleviating, or Freeing from Suffering (Palliative Medicine)-Promoting Well-Being and Feeling Well 58 2.5. The Conscious Life of Man as Such and Personal Dignity 61 2.6. Integrity of the Human Bodily Form and Aesthetic Values 68 2.7. The General and Spiritual Good of Man and of His Vocation as Transcendent Goal and Guideline for Medicine 69 2.7.l. General Remarks on the Ways in Which This Transcendent Good of the Human Person Obliges the Physician 69 2.7.2. The Different Ways in Which This Transcendent Good of the Human Person Obliges the Physician 71 2.8. The Special Relationship between the Physician and the Absolute Good (God) 72 2.9. The Religious Transformation of the Image of the Physician and the Goods Medicine Should Serve 76 2.10. The Remarkable World Wide Consensus on the Goods Medicine Should Serve 79 2.11. The Physician-Philosopher and the Nature of the 'Practical' Philosophy in Medicine with Respect to the Seven Goods 80 2.12. Conclusion of Our Reflections on the Goods Medicine Should Serve, and Theophrastus Paracelsus on the Transcendent Ends of Medicine 81 3. The Physician as Moral Agent and Further Hints at the Philosophical Diseases of Medicine and Their Cure 82 3.l. Importance of the Subject of Medicine and His Inalienable Rights as Person: Physicians, Nurses, and Other Health Professionals Are Not Mere Technicians or Instruments in the Service of Health and ofthe Other Goods of Medicine or of Patient Wishes but Acting Persons 82 3.2. Finding Anew Its Roots? A Word on the History and the Essential Ethical Dimension of Medicine-the Hippocratic Oath as More than an Ornament of the Medical Profession 84 3.3. Progress or Decline of Medicine with Respect to Its Value-Base and Third Philosophical-Ethical Dimension: Modem Medicine- Immense Progress or Regress behind the Age of the Medicine Man? 85 TABLE OF CONTENTS ix

CHAPTER 2 THE DIGNITY OF THE HUMAN PERSON AS A 'UNIVERSAL OF MEDICAL ETHICS' 89 1. Prolegomena 89 1.1. The Theoretical and Practical Significance of Understanding Human Dignity 90 1.2. Can Human Dignity Be Known to Be an Objective, Universal and Simultaneously Uniquely Individual Value? 93 1.3. Can Consensus Be Reached about Human Dignity and Can It Function as a Common Ground for Medical Ethics-as a 'Medical Ethical Universal '? 94 1.4. The Role of Realist Phenomenological Philosophy in Showing Human Dignity to Be Truly a 'Medical Ethical Universal' 96 1.5. The Main Theses to Be Defended in This Chapter 99 1.6. Two Ways to Know What It Is to Be a Person: Immediate Phenomenological Experience of Persons, and Intuition into the Ontological Ground that Intelligibly Underlies Experience 99 2. What Is a Person? Ontological and Axiological Understanding of the Person 100 2.1. The Person as Ultimate Individual Subject of Rational Nature 100 2.1.1. Person as a Substance 101 2.1.2. The Person as 'Thing in Itself 102 2.1.3. The Person as a Living Substance 103 2.1.4. Personal Individuality (Uniqueness) 104 2.1.5. The Person as a Spiritual Substance and the Human Soul 104 Arguments for the Existence of the Soul 105 2.1.6. The Person as an Individual Spiritual Substance in Relation to Other Persons 113 2.2. A Definition of the Person by Her 'Inviolable' Dignity 114 3. The Four Sources and Dimensions of Human Dignity and Their Characteristics 115 3.1. Ontological Dignity of the Human Person as Such and from the Very Beginning of Her Existence 115 3.2. Dignity of the Conscious and Rational Person and Its Levels 121 3.3. Third Source and Sort of Dignity: 'Acquired Dignity' and Moral Dignity 126 3.4. Fourth SourcelDimension of Dignity-Dignity as GiftlBestowed Dignity 128 3.5. Relations between the Different Sources and Dimensions of Personal Dignity 132 x TABLE OF CONTENTS

4. Dignity as Object of Rational Knowledge and Answer to Some Objections against the Rational Knowability of Human Dignity 134 5. Human Dignity as a Unifying Bond among Men and Medical Professionals Worldwide 136

CHAPTER 3 FROM THE MORALLY RELEVANT GOALS OF MEDICINE TO MEDICAL Enncs On the Superiority ofMoral Values over All Extramoral Goals ofMedicine 139 1. Introductory Notes on Ethics in Its Relation to Medicine 139 2. The Ambiguity of the Notion of the Good: On the Totally New Quality of Moral Goodness and Evil in Comparison with all Other Goods and Evils 149 3. The Nature of Moral Goodness 151 3.1. Moral Values Are Objectively Good 151 3.2. Intrinsic Goodness 01alue) Rather Than Being Merely Agreeable or Even Only Objectively Goodfor Me 152 3.3. Moral Values Are Necessarily Linked to Freedom 153 3.4. Moral Values Presuppose a Certain Morally Relevant Object or Matter (Which Can Be Grave or Light) 153 3.5. Moral Values Imply a New Type of Ought Which Elucidates the 'Absolute Sense' in Which They Are Good 155 3.6. Moral Values Are Dependent on the Knowledge of Morally Relevant and of Moral Goods and Evils 156 3.7. Moral Values Involve Responsibility 157 3.8. Moral Conscience 158 3.9. Moral Values Deserve Praise or Blame in a New Sense 160 3.10. Moral Goodness Alone Can Constitute a Certain 'Worthiness of Happiness', Moral Evil a 'Deserving of Pain' 160 3.11. Also Guilt and Merit, Reward and Punishment Are Essentially Related to Moral Good and Evil, and to It Alone 161 3.12. Moral Goodness Expresses in an Essentially New and Higher Sense the Idea of Value as Such (Good in a New and More Proper Sense to Which Extramoral Senses of 'Goodness' Are Merely Analogous) 162 3.13. Moral Goodness, As Long As It Really Exists, Cannot Be Abused Like Intellectual, Aesthetic, Temperamental and Other Values 164 3.14. Moral Values Are Absolutely Speaking Good in that They Never Must Be Sacrificed for Any Other Value, because They Are (a) Incomparably Higher and (b) Should Absolutely and 'First' Be Sought For· 165 TABLE OF CONTENTS xi

3.15. Moral Goodness as a Source of the Value of the Person as Such: Only the Person Herself Can Be the Primary Bearer of Moral Values, Never Impersonal Beings, and also Personal Acts Can Be Morally Good Only in a Derivative Sense 166 3.15.1. Only Persons as Opposed to All Impersonal Beings Can Be Morally Good 166 3.15.2. Only the Person Herself Can Be the Primary Bearer of Moral Values-Personal Acts Can Be Morally Good Only in an Analogous Sense 167 3.15.3. Moral Goodness Makes the Person as Such Good in a Deeper Sense Compared with Which all Other Meanings of the Goodness of the Person Are Just Analogous 167 3.16. Moral Values Are the Absolute and Highest Good for the Person: Moral Values Belong to the Unum Necessarium and the 'Three Modes of Participation in Values' Account for Three Ways in Which Moral Values Are the Highest Objective Goods for Persons 169 3.17. Moral Values Are Goods 'in the Unrestricted Sense' by Being Pure Perfections 172 a. Transcendentals 173 b. Pure Perfections 174 3.18. Moral Values Are Unconditionally Good because They Are Never Just 'Means' towards Ends (Happiness). They Are Dominated by a Principle of Dueness and Appropriateness and Arise 'on the Back' of Acts (a Critique ofEudemonism) 176 3.19. Link of Morality to Religion and to God 177 3.20. Moral Values Constitute the Most Direct Link between Morality and Religious Spirituality: Distinction between Philosophical and Theological Assertions 178 3.21. The Unity of Moral Values 180 3.21.1. 'One Moral Value'-Goodness 180 3.21.2. 'No Division of Labor' in the Moral Life 180 3.21.3. 'Existential Moral Unity' 181 3.21.4. The Unity ofthe 'Root' of All Moral Goodness: the 'Oneness of Virtue' 181 3.22. The Superiority of Moral Values over All Others and the Crucial Importance of This Insight Expounded in This Chapter for Medical Ethics 181 3.23. Moral Values Are Characterized as 'Goodness without Qualification' -Its Relationship to Happiness and to the Supreme Good 182 4. Concluding Remarks 185 xii TABLE OF CONTENTS

CHAPTER 4 THE FREEDOM OF CHOICE FOR OR AGAINST THE BASIC GooDS AND ENDS OF MEDICINE Physicians, Nurses, and Other Health Professionals as Agents in the Drama ofFreedom 187 1. Towards a and Epistemology of Freedom 188 1.1. Freedom in the Strong Metaphysical Sense Is Absolutely Inseparable from Personhood 189 1.2. A Metaphysical Detour for Those Readers Who Are Interested in the Ultimate Foundations of Medical Ethics: Some Elements of a Metaphysics of Human Freedom and Answers to Objections against the Existence of Human Freedom 192 1.3. The Nature and Real Existence of Human Freedom Can Be Known with Indubitable Certitude 196 1.4. Some Metaphysical Difficulties and Apories in Admitting Human Freedom and Another Metaphysical Side-Trip to Support Additional Evidence of the Truth of Our Knowledge that We Are Free 198 1.5. Did Neurological Evidence Refute Freedom? 203 1.6. Is Freedom Self-Creation? 210 1.7. Freedom and Its Conditions: Individual Being, Cognition, and Value 211 2. Ethics, Freedom, and Motivation: the Drama of the Physician's Freedom Can Only Be Understood in the Light of the Free Choice of the End and Not Only of the Means 213 2.1. Categories of the 'Good' 213 2.2. The Drama of Human Freedom Can Only Be Understood in the Light of the Free Choice of the End and Not Only of the Means: Categories of the 'Good' as Explanation of This Choice 215 3. Being Free Is Not Restricted to the Sphere of Action but Encompasses Many Spheres of Human Willing 223 3.1. Different Levels of Human Freedom-Actual and Superactual, Direct and Indirect Freedom, Affective Responses, Other Gifts and Cooperative Freedom 223 4. Cooperative Freedom and the Affective Dimension of the Gift of Self as an Important Element of Medical Ethics 233 5. Concluding Remarks on the Fundamental Moral Choices in Medicine 236 TABLE OF CONTENTS xiii

CHAPTER 5 RATIONAL JUSTIFICATION OF AN OBJECTIVE AND PUBLICLY ACCEPTABLE BIOETIllCS A Critique ofEthical Relativism, Skepticism, and Nihilism and an Answer to Engelhardt 237 1. Short Summary of the Results Gained in the Preceding Chapters and of the Problems to Be Treated in Chapter 5 237 2. The Philosophical Plague and Aids of Medicine to Be Discussed in this Chapter and Their Cure 239 3. Are Truth and Goodness Relative? 243 3.1. Relativism, Skepticism, and Their Consequences-a Radical Philosophical Plague of Medicine 243 3.2. The Evident Falsity and the Internal Contradictions of General Relativism and Skepticism 247 3.3. Critique of Ethical Relativism and Skepticism 251 3.3.1. Actual Contradictions of Ethical Relativism and Skepticism 251 3.3.2. Inevitable and Inherent Contradiction in Ethical Relativism and Skepticism 252 3.3.3. Critique ofEmotivist Ethical Relativism 252 3.3.4. Critique of Positivist Forms of Ethical Agnosticism 253 3.3.5. Immediate Evidence of Morally Good and Evil and of Other Values-Value-Seeing (Wertsehen) as a Method of Ethics 255 3.3.6. Refutation ofthe Argument for Ethical Skepticism or Relativism from a Lack of Ethical Consensus-Broad Ethical Consensus Also with Atheists 257 3.3.7. Arguments against Ethical Relativism from the Observation that Many Apparently Moral Disagreements Are Disagreements on Facts, Not on Values 259 3.3.8. Two Arguments against Ethical Agnosticism and Relativism Which Are Insufficient in Themselves but Constitute Additional Reasons against Ethical Subjectivism: Evaluation of Desires and Coherence 260 3.3.9. Is There a Conflict between Intuitive Ethical Knowledge and Ethical Argumentation? 262 3.3.10. Some Excellent Arguments against Purely Consequentialist Ethics Based on a Purely Intersubjective Hermeneutical Objectivism, Which Cannot Overcome Ethical Relativism 262 3.3.11. Arguments against an Ethical Relativism Based on the Alleged Relative and Relational Character of All Values-A New Use of the Distinction between Three Categories of Goodness (of Positive Importance) 263 3.3.12. Intrinsic Value and Affirmability of the Person 264 xiv TABLE OF CONTENTS

4. Is an Objective Rational Bioethics Possible in Our Pluralistic Society? Engelhardt's Negative Reply to the Second and Third Questions Posed Above and the Need to Return to Things Themselves 264 4.1. The First Reason of Engelhardt's Allegation of the Incapacity of Philosophical Moral Reasoning: the 'Private Character' of Moral Commitments and the Ambiguity of This Claim 265 4.2. Does Every Claim of Rational Ethical Knowledge either Beg the Question or Lead to an Infinite Regress?-Critique of Engelhardt's Second Reason to Reject Philosophical Ethical Objectivism 268 4.3. Natural Ethical Knowledge or Total Value Blindness of Secular Society 275 4.4. Does Engelhardt Have any Theory of Error? On the Inner Distinction between Ethical Knowledge and Ethical Errors, and between Ethical Theories and Immediate Ethical Cognitions as Ground of Rejecting Skeptical Conclusions from Ethical Dissent in Society 277 5. Is There a Publicly Acceptable Content-full Bioethics? 278 5.1. Ambiguities in the Term 'Canonical' and the Distinction between Epistemological and Metaphysical Ethical Skepticism 280 5.2. Ambiguities Regarding the 'Political Ethics' and the Relationship between Truth, Private Morality, and Public Ethics 283 5.3. The Need for Phenomenology in the Clarification and Objective Foundation of Content-full Ethical Intuitions 289 5.4. Critique of Engelhardt's Christian 'Fideism' and of His Divorcing Religion from Reason-Ambiguities in His Use of the Term 'Rationalism' and Some Reflections on the Relations between Reason and Faith in Ethics 291 5.5. On the Indispensability of Looking for the Foundation ofBioethics in Objective Values 297 5.6. Can We Derive an Ought From an Is? Another Objection against an Objective Bioethics in a Pluralistic Society 299 5.7. Does a Publicly Acceptable Bioethics Today Require a Utilitarian Basis? On the Irreducibility of Moral Values to Means for the Morally Relevant Values Which Are the Results of Moral Actions 301 5.8. Does a Modem Bioethics in a Pluralist Society Require the Abandonment of' Speciecism', as Singer Postulates? On the Dignity of the Human Person as a Unique Objective Value-the Untenability of Regarding the Insistence on Human Dignity as a Mere 'Speciecism' 303 TABLE OF CONTENTS xv

CHAPTER 6 ARE THERE ABSOLUTE MORAL OBLIGATIONS TOWARDS FINITE GOODS? A CRITIQUE OF 'TELEOLOGICAL ETHICS' AND OF THE DESTRUCTION OF BIOETHICS THROUGH CONSEQUENTIALISM On The Invertebratitis ofMedical Ethics and Its Cure 305 1. Introduction 305 1.1. The Denial of Intrinsically Wrong and Evil Acts as Ethical Invertebratitis 305 1.2. Some Bearing of Our Previous Discussion on the Morally Intrinsic Character of Right and Wrong Actions-Beyond the False Alternative: Kant or Utilitarian Consequentialism 308 2. The Main Theses of a 'Teleological' Foundation of Moral Norms 310 3. Immanent Critique of' Consequentialist Ethics': Its Contents and Implications, Contradictions, and Silent Admissions 312 3.1. The General and Specific Consequences of Consequentialist Ethics (Giiterabwiigungsethik) for Medical Ethics 313 3.2. Immanent Critique Properly Speaking of the Position of 'Teleological Ethics' 321 4. Transcendent Critique of a 'Purely Teleological' Ethics 325 4.1. Positive Insights Contained in Purely Teleological Ethics 325 4.1.1. Serious Difficulties for an Ethics of Moral Absolutes, Which Seem to Speak for Purely Teleological Ethics 325 4.1.2. Is There a Legitimate 'Personalistic Teleologism' Which Is Opposed to 'Teleological' Consequentialism? 326 4.2. Critique of the Central Thesis that No Finite Good Could Ground Absolute Imperatives in the Moral Sense of the Term 327 4.2.1. Absolutely Required Inner Responses to Non-Absolute Goods 328 4.2.2. A Radical Equivocation of 'Absolute' at the Root of the Chief Argument of Teleological Ethics 329 4.3. Are There Intrinsically Good or Evil Acts? 331 4.4. On the Possible More Moderate (Third) Thesis of Consequentialist Teleologism: Only External Actions Which Are Directed towards Finite Goods Are Not Intrinsically Good or Evil 332 4.4.1. The Third Possible Thesis of Consequentia list Teleologism Denies the Unity of Man 333 4.4.2. Teleological Ethics Must Admit at Least One Important Exception to Its Principles: Moral Values. An Internal Contradiction and the Denial of Moral Facts 335 4.4.3. The Abuse of the Distinctions 'Moral-Premoral' and 'Ontic versus Moral' Goods and Evils 337 xvi TABLE OF CONTENTS

4.5. Critique of the Depersonalization of Morality Implied in the Allegedly Personalistic Ethical Teleologism 345 EPILOGUE 349 BIBLIOGRAPHY 355 INDEX OF PERSONAL NAMES 375

SUBJECT INDEX 381 PREFACE AND ACKNOWLEDGMENTS

At the beginning of this work I wish to explain briefly its basic argument and goal. 1 This book does not only seek to develop a philosophy and ethics of medicine but in• tends to show that an at least implicit ethics and philosophy of man are integral parts of medical knowledge and of the medical profession which, divorced from an understanding of, and commitment to, its goals and the goods which it has to serve, ceases to be medicine and becomes anti-medicine. Moreover, knowledge of these goods and ends of medicine lies entirely beyond the reach of experimental natural science and can be clarified only through philosophy, which thus is a foundational part of medical science. In other words, besides biological and experimental knowl• edge pertaining to medical science and underlying medical care of all sorts, and be• sides the diagnostic and practical arts and manifold techniques required for the car• rying out of medical actions, the theoretical and practical aspects of medicine de• pend essentially and constitutively on an understanding of the human person and of

I also wish to explain in a footnote the policy adopted in the present work regarding inclusive lan• guage. In keeping with present usage, as often as it seems reasonably acceptable, I replace the inclu• sive use of the term 'man' by other terms (such as 'human person'). I do not abandon and replace the word 'man' entirely and always, however-for every language needs (and most often possesses) a single word for human being (human person). In German this word (Mensch) is fortunately distinct from man in the sense of a masculine human adult (Mann). And this sense of the word 'man' (Mensch), which cannot be entirely replaced by 'human person', 'human being', etc., happens to be the English word 'man' (as homo in Latin). Therefore, it is in my mind a childish abuse of the English language to introduce the term 'woman' as equivalent to 'man' (Mensch) because, as the German Frau, or the Frenchfemme, there is simply no linguistic sensibility which permits such a use of the word 'woman'. When continuing at times to use the word 'man' for human being, I will also keep using the masculine personal pronouns to stand for 'man' (human being), as well as keep using the masculine pronouns for physicians, scientists, etc., while using the feminine pronoun for 'nurse' even though there are also more and more male nurses. There is no sexism contained in this use of language. Just as I, a man, feel perfectly included in the feminine pronoun used for persons (in German and in this book also in English), I expect my women readers to be perfectly included in the notion of 'man' (Mensch) and in the masculine pronoun in English. To call such a use oflanguage 'sexist', is plainly silly. Just as no German will take the pro• noun 'sie' ('she') for Person as a sign that persons are considered feminine in German and men are excluded, no normal user of the English pronoun 'he' for man (Mensch) will have a 'sexist' meaning in mind. Much rather, Thomas ofErfurt (or ) seem to be right here who distinguished in the Grammatica speculativa four kinds of gender, insisting on the 'inclusive' or 'common' one where masculine or feminine forms and pronouns include both male and female members. Besides the mas• culinum,femininum, and neutrum, there is, according to them, a fourth 'common' gender (sexus com• mune): There is, namely, as the author of the Grammatica speculativa points out quite well (and to recognize this would in my opinion avoid the sexist interpretation of male or female inclusive pro• nouns) a special discretio sexus, namely the genus commune, which in its linguistic form is either masculine or feminine (quod nec differt a masculino nec a feminino) but in its meaning comprises both sexes within itself, such as in homo (man) when this term signifies human persons as such. In spite of all this and the fact, however, that the pronoun for 'person' in English used to be 'he', and today often is 'it', I will neither use the masculine nor the impersonal pronoun in reference to 'person', but will sometimes use 'he or she' and, because this is too cumbersome, most times simply use the feminine pronoun for person (in the inclusive sense), as this is customary in many contempo• rary texts and in many other languages.

xvii xviii PREFACE AND ACKNOWLEDGMENTS values and goals that have crucial ethical implications and inform the entire activity and essence of medicine. At least a pre-philosophical understanding of, and a commitment to, these ends and goals of medicine is not some type of 'luxury' for physicians graced with a phil• osophical mind-set, but is indispensable for any physician and nurse in order to ac• tually be a physician or nurse, instead of turning into a mere medically trained tech• nician or even criminal. The same is true for all other health professionals. The book also argues that we experience a great progress of medicine in those aspects of the discipline that pertain to experimental natural science and diagnostic and practical art, but an unprecedented crisis of the very core of medicine that is constituted by its ends and inseparable from philosophical and ethical dimensions. Insufficient or wrong answers to the questions about the nature of medicine and the goods physicians ought to serve, about knowledge, human nature, and ethical is• sues are among the chief causes of a profound philosophical crisis of medicine. Indeed, as we shall see, the term 'crisis' in its ordinary usage is insufficient to refer to what actually are various life-threatening philosophical diseases that plague medi• cine today. We do not just speak of normal developmental crises such as they occur in the age of puberty, but ofa 'critical medical condition'. Following the meaning of the original Greek words krisis and krinein, which can mean 'to separate' or to 'put asunder', but also 'to decide', a medical crisis in the most serious sense of the term indicates that turning point and critical moment in the development of a disease after which either a sudden change for the better will occur, signaling the imminent or al• ready incipient, but still threatened, cure of the patient, or a decisive change for the worse, heading towards death.2 Faced with the present philosophical 'crisis' ofmedi• cine, we will remain entirely open as to the positive or negative outcome of the cri• sis, without hiding from the reader our impression that the forces of the philosophi• cal diseases of medicine threaten to prevail over those of a cure of these diseases. We will at any rate not only diagnose some deadly philosophical diseases in contem• porary medical theory and praxis, but also indicate ways and methods of their cure. Questions of value theory, ethics and philosophy of man are obviously intimately tied up with medicine. In a similar way, and this becomes specifically relevant in the discussions of chapter 5, questions of epistemology are of crucial importance for bioethics and ethics in general, and the underlying crisis of philosophical epistemo• logy becomes a major reason for the crisis of medicine and medical ethics. No ra• tionally justified ethics is possible if we cannot or do not know the objective nature of things and above all the value of the human person and of many domains of hu• man life. While I cannot in this work present extensive epistemological Prolegom• ena, I will repeatedly refer to the epistemological foundations of ethics and also ex• pound some ofthem.3

2 See also Balduin Schwarz, Wahrheit, [rrtum und Verirrungen. Die sechs grofJen Krisen und sieben Ausfahrten der abendliindischen Philosophie, herausgegeben von Paola Premoli und Josef Seifert (Heidelberg: C. Winter, 1996), chs. 4 and 12.

3 For a more detailed discussion of the nature of knowledge and of value knowledge see Dietrich von Hildebrand, Sittlichkeit und ethische Werterkenntnis. Eine Untersuchung iiber ethische Strukturpro• bleme, 3. durchgesehene Auflage (Vallendar/SchOnstatt: Patris Verlag, 1982); Fritz Wenisch, Die Ob• jektivitiit der Werle (Regensburg: J. Habbel, 1973); Josef Seifert, Erkenntnis objektiver Wahrheit. Die PREFACE AND ACKNOWLEDGMENTS xix

The present work also intends to identify the causes of the deep philosophical crisis of medicine that originates in various dangerous philosophical diseases that risk to turn out deadly for medicine, transforming it into its very opposite, a sort of anti-medicine. This book undertakes a full-scale effort to lead the way to a correct diagnosis and an efficient cure of various philosophical diseases that touch the foundations ofmed• icine and medical ethics. Some of these may be cured by simple philosophical anti• biotics, others require stronger philosophical drugs which attack viruses hidden deeply in the blood and vital organs of the minds of physicians and of the spirit of our age. The profound philosophical crisis of medicine is chiefly a consequence of an underlying and much wider crisis of itself, which is due to the most dangerous diseases that ever have afflicted the science and art of medi• cine throughout its long history. The first volume of this work is dedicated to the foundations of a philosophy and ethics of medicine, while the second one will treat in detail such central anthropo• logical and ethical questions as those which pertain to life and death issues and to health, and will enlarge and deepen the study of each single one of the seven goods medicine should serve, discussed in chapter 1 of this volume: such as the notions, definition, and interpretations of life and death including a critical review of 'brain death', the biological and personalistic concepts of health, of pleasure, suffering, and pain-relief, of the integrity of the human body and aesthetic goods. Besides and above all, volume II will deal with many concrete issues of medical ethics concern• ing the practical application of the theoretical understanding of the goods medicine should serve in medical actions concerning life and death, health and pain, human procreation, organ transplantation, the aesthetic integrity and form of the human body, etc. The present volume on the foundations of philosophy and ethics of medicine will treat, after an introduction, the general nature of medical science, three most general parts of medicine, i.e. three aspects of the physician, and the seven high goods which are the objective goals of medical care, and which to understand is a condition for grasping properly medicine itself as well as the moral drama in the choice for· or against the ends of medicine, a drama which Aristotle was unable to admit• because of certain limits inherent in his eudemonistic ethics-but which we ex• perience painfully today (chapter 1). The foundation of any ethics, but quite particularly of medical ethics, requires a careful and in-depth study of the central value with which most medical actions are concerned and which is centrally present in some ·way in all the seven goods dis• cussed in chapter 1: I refer to the dignity of the human person. The reason why an understanding of this exalted value in which also the fundamental human rights are grounded, on which, since the Universal Declaration of Human Rights in 1946, well over 90% of all nations have expressed agreement, is particularly important for phy• sicians, nurses and other medical professional groups, lies in the fact that they deal daily with human beings of all ages and in all kinds of physical and mental con-

Transzendenz des Menschen in der Erkenntnis, 2. Aufl (Salzburg: A. Pustet, 1976); the same author, Back to Things in Themselves. A Phenomenological Foundation/or Classical Realism (London: Rout• ledge, 1987); and Paola Premoli De Marchi, Etica dell'assenso (Milano: Franco Angeli, 2002). xx PREFACE AND ACKNOWLEDGMENTS ditions. Moreover, an ethics pertaining not only to how we ought to treat hwnan per• sons in their fully experienced and developed being and social presence, i.e., mature and healthy adults and developing normal children, but to how we should treat the unborn, the handicapped, the aged, the terminally ill patients, and even gametes and other cells or tissues that are somehow related to hwnan persons, requires a lucid un• derstanding of the nature of personal dignity and of its radically different sources and dimensions. While we reserve a fuller treatment of hwnan life to volwne II, already volwne I requires a brief examination of the nature of hwnan life and of the person herself, the bearer of hwnan dignity. In this context, the outlines of a philosophy of man ap• propriate for medicine are developed: particularly the existence of the mind and its irreducibility to the body, the irreducibility of the body to a machine, and the phe• nomenon of the 'lived body', as well as the irreducibility of the hwnan person to any level of his or her consciousness and actions. All of these anthropological considerations will prove indispensable for any bio• ethics, secular, Christian, Jewish, Muslim, or other, particularly for supplying the theoretical foundations for avoiding the errors of actualistic and functionalistic con• cepts of the person with their devastating effects on bioethics. Regarding these onto• logical and anthropological issues that touch the nature of personhood (discussed and to be clarified only by philosophy but presupposed in medical ethics and in any psychology or religious creed), the mentioned forms of reductionism (of persons to bodies or to conscious experiences) will have to be refuted. They have equally seri• ous consequences for a secular as for a religiously oriented ethics of abortion, brain death, euthanasia, etc. For however much the contents of one's religious faith change her worldview, any person's positions on these fundamentally philosophical issues (the substantiality of the soul, of the person, as well as her reducibility or irre• ducibility to conscious acts) will have the same consequences regardless ofany reli• gious positions the respective author may embrace. For depending on which ontolo• gy of the person, of the embryo, of the dying or 'brain dead' she holds true, any per• son and ethicist, whether Christian or not, will decide ethical issues differently. In fact, in many cases of the lack of consensus in ethics, which motivates some forms of moral relativism and which, in his The Foundations of Bioethics, stands in the forefront of H. T. Engelhardt's attention, we find in different opinions about ontology and facts, not about values. and Dietrich von Hilde• brand have shown that ethical relativism often falsely rests on the asswnption of a divergence of ethical positions when in fact we find the same ethical positions ap• plied to different opinions about facts. 4 For this reason it is evident that questions of

4 Cf. Max Scheler, Der Formalismus in der Ethik und die materiale Wertethik. Neuer Versuch der Grundlegung eines ethischen Personalismus, 5. AutI. (Bern und Miinchen: Francke, 1966), ch. 5.3; Formalism in Ethics and Non-Formal Ethics of Values. A New attempt toward the Foundation of an Ethical , trans. by Manfred S. Frings and Roger 1. Funk (Evanston: Northwestern Uni• versity Press, 1973), ch. 5.3, "The Meaning of the Thesis of the 'Relativity' and 'Subjectivity' of Val• ues," pp. 265-269. See also Dietrich von Hildebrand, Ethics, 2nd ed. (Chicago: Franciscan Herald Press, 1978), ch. 9. PREFACE AND ACKNOWLEDGMENTS XXI philosophical anthropology and ontology play a crucial role for bioethics (chap• ter 2). 5 The disquisition will then turn to the question which-among the many moral systems in our pluralistic society--ethics the physician should choose and to the out• lines of the foundations of a rational ethics and bioethics, as well as to an ABC of the terminology, epistemology, and objective discoveries of a rigorous ethics. The distinctive essence of specifically moral values, which to understand is a necessary requirement in order to move from a theory of goods that are morally relevant for the medical staff to a theory of the moral life itself and thereby to medical ethics properly speaking, will be elaborated. In this context, the pressing question of a spe• cific novum found in various religiously motivated ethical medical codes and specif• ically in Christian morality and bioethics, and of the place of religiously motivated ethics with respect to a purely philosophical secular ethics, will be briefly discussed (chapter 3). Because of the crucial and absolutely indispensable role of the reality of freedom for morality, and inasmuch as consequently any bioethics without a clear recognition of freedom would be no ethics at all, a relatively detailed analysis of freedom is of• fered as part of the general ethical foundation of bioethics. Such an analysis of free• dom and in particular of the scope of the freedom of choice regarding the ultimate ends of human actions is also necessary in order to justifY the central thesis of this work that the physician and health worker is faced today with a dramatic free choice for the goods medicine ought to serve (chapter 4). Special consideration will be given to a justification of a binding and content-full rational ethics in our pluralistic democratic society, discussing in this context criti• cally the prevailing ethical skepticism, agnosticism, and value relativism. Particular attention will be given to the positions H. T. Engelhardt, Jr., the editor of this series, has expounded in his The Foundations of Bioethics.6 The very different and mostly contrary positions I am defending here I shall explicate in a critical dialogue with the ideas expressed by Engelhardt (chapter 5). Another foundational issue of all ethics, but quite particularly of bioethics and medical ethics, needs to be taken up: are there acts which are intrinsically wrong or can any medical act be justified depending on its results and consequences? Utilitar• ianism, pragmatism, and consequentialism in ethics claim the latter to be the case, while other ethical positions admit that there are a great number of actions that never ought to be done, as is clearly stated in the Hippocratic Oath. It is clear that the an-

5 See for example John F. Crosby, "Evolutionism and the Ontology of the Human Person," Review of Politics, 38 (April, 1976): 208-243; see also by the same author, The Selfhood of the Human Person (Washington, D.C.: The Catholic University of America Press, 1996), and Personalist Papers (Wash• ington, D.C.: The Catholic University of America Press, 2004); see likewise Josef Seifert, Leib und Seele. Ein Beitrag zur philosophischen Anthropologie (Salzburg: A. Pustet, 1973); and Josef Seifert, Essere e persona. Verso una fondazione fenomenologica di una metafisica classica e personalistica (Milano: Vita e Pensiero, 1989). 6 See H. T. Engelhardt, Jr., The Foundations of Bioethics (New York and Oxford: Oxford University Press, 1986), and the substantially different version of the work: H. T. Engelhardt, Jr., The Foundation of Bioethics, 2nd ed. (New York and Oxford: Oxford University Press, 1996); see also Brendan P. Minogue, Gabriel Palmer-Fernandez, James E. Reagan (eds.), Reading Engelhardt. Essays on the Thought ofH T. Engelhardt, Jr. (Dordrecht, Netherlands: Kluwer Academic Publishers, 1997). xxii PREFACE AND ACKNOWLEDGMENTS swer to this foundational ethical question has immense consequences for medical ethics: are such acts as torture, human experimentation by killing or mutilating hu• man patients, abortion, infanticide, or euthanasia always wrong or not? Depending on the reply to this question, almost every chapter of medical ethics will have to be written differently. Therefore, the discussion of this issue very much belongs to a work on the foundations of philosophy and ethics of medicine. I will defend the Hip• pocratic view of this question and of medical ethics against a great number of very serious objections difficult to deal with (chapter 6). In a second part, to be published a year later, the present work will proceed to examine, at greater length and in more detail, some of the most important morally relevant (seven) goals of medicine, justifying the objectivity of their morally rele• vant character and value (most extensively human life and the health of persons). Their anthropological character as well as the ethical dimensions involved by the seven goills of medicine expounded in volume I will be discussed with reference to concrete examples and questions concerning these goods and particular aspects of the objective ends of medical action. In this second volume, I will treat separately and in greater detail some concrete 'issues of bioethics' such as the role of 'brain death' in transplantation medicine, as well as the issues of abortion, assisted suicide, euthanasia, restriction of access to medical care in ICU s, various forms of contracep• tion and In vitro Fertilization, cloning, prenatal screening, genetic engineering, and others. In conclusion, I will treat the specific problems of a 'Christian Bioethics'. Some of the following texts were originally lectures delivered orally, in English, as the first cycle of The Claude Bernard Lectures on Philosophy and Medicine, held at the Unidad Bioetica of the Medical Faculty of the Pontifical Catholic University of Chile in Santiago from August to September 1990. I herewith thank Prof. Juan de Dios Vial Correa, then Rector of the University, and Prorector Professor Pedro Mo• randlS for their invitation. A special word of thanks I address to Professor Carlos Quintana, at the time of my visit Director of the Unidad Bioetica, whose gentle hos• pitality during my stay in Santiago remains unforgettable for me. To him in particu• lar as well as to the former Professors Alejandro Serrani and Manuel Lavados of the Pontifical Catholic University of Chile lowe the honor of this invitation. I am fur• ther greatly indebted to Dr. Pedro Rosso, then Dean of the Medical School, who re• cently became Rector of the Pontifical Catholic University of Chile, and to the whole medical faculty of this University, not only for the opportunity and distinction of having been invited to deliver these lectures but also for the undeserved honor, bestowed on me later, of having been named an honorary member of the Medical Faculty of that same University. A greater gift than the honor they bestowed upon me, however, was their intellectual seriousness and integrity as well as their personal amiability and gracious hospitality. Their and their colleagues' and students' pene• trating questions were and, in view of my recently closer ties to this University, are presently a source of personal and theoretical inspiration for me. In 2001, I received an invitation, for which lowe thanks to Rector Rosso and to Professor Patricio Ventura, now Head of the Unidad Bioetica of the University, to teach the first philosophy course in a newly established Masters program of bioeth• ics at PUC. Especially the second chapter of the present book on human dignity was preceded by vivid discussions with the excellent students of this program and with PREFACE AND ACKNOWLEDGMENTS xxiii colleagues and students in Liechtenstein, , Belgium, Italy, and in other countries where I have lectured on the foundations of human dignity. The text of my Claude Bernard Lectures, as printed here,7 and of some of the chapters of volume II, has been revised repeatedly and essentially, most extensively in connection with a two year research program into the philosophical aspects of the definition of health carried out at the International Academy of Philosophy in the Principality of Liechtenstein,8 with the support of the Schweizerischer Nationalfonds zur Fiirderung wissenschaftlicher Forschung (Swiss National Science Foundation), whose assistance towards the realization of this research and publication project I hereby gratefully acknowledge.9 Other papers on medicine and philosophy which I have written since 1990, in particular the text of some lectures which I held at the same University in 1993, have been added in this two-volume work to the revised texts of the Claude Bernard Lectures so as to form a more comprehensive treatment of a philosophy and ethics of medicine, and of vital issues of bioethics. lowe profound gratitude regarding the issues treated here, and the knowledge gained about them, to many persons. The first of them in rank and dignity is His Holiness Pope John Paul II, who, through his profound work both as philosopherlO and as teacher of the Church, II gave me invaluable inspirations. By nominating me as member of the Pontifical Academy pro Vita, he gave me a precious opportunity and duty to deepen my philosophical reflections on ethical issues regarding human life and death. In this context, lowe special thanks also to Prof. Juan de Dios Vial Correa, President of the Pontifical Academy pro Vita, and to His Excellency, Mon• signore Elio Sgreccia, who as Vice-President of that same Academy and as author of important works on bioethics, inspired my bioethical reflection in so many ways, and to all members and colleagues in the Academy. Needless to say, the responsibil• ity for this text is entirely mine and not of the Pontifical Academy whose member I have the honor to be. Moreover, I wish to insist on the fact that this book is a purely

7 Some of them have been published in their original form in which they were held (i.e., in Spanish translations). See Josef Seifert: "Acerca de la posibilidad de una bioetica publicamente aceptable en nuestra sociedad contempoflinea pluralista," in Educacion Medica 12 (Septembre 1994), Etitada por 1a Facu1tad de Medicina de 1a Pontificia Universidad Cat6lica de Chile (Santiago), pp. 205-217; "Con• sideraciones filos6ficas acerca del impacto social de la legalizaci6n del aborto," in ibid., pp. 234-240; "Pensamiento cristiano y los problemas de la bioetica," in Educacion Medica 11/93 (Santiago, Chile: Facultad de Medicina de la Pontificia Universidad Cat6lica de Chile, 1993), pp. 66--71. 8 During the years 1994-1996. 9 See the published results of this research, "Bedeutung der 'allgemeinen Systemtheorie' in der heuti• gen Debatte tiber den Gesundheitsbegriff," in Paulina Taboada, Kateryna Fedoryka Cuddeback, and Patricia Donohue-White (eds.), Person, Society and Value. Towards a Personalist Concept o/Health (DordrechtIBostonlLondon: Kluwer Academic Publishers, 2002). Having offered the Claude Bernard Lectures in 1997 as a course at the Austrian Campus of an American University and at the Internation• al Academy of Philosophy in the Principality of Liechtenstein, I had a further opportunity to rework the manuscript. Other chapters I have reworked while preparing a paper on ethics for the 20th World Congress of Philosophy in Boston, and during work for papers given at various symposia and Univer• sities. 10 See Karol Wojtyia, The Acting Person (Boston: Reidel, 1979); see also by the same author, Love and Responsibility (San Francisco: Ignatius Press, 1993). See likewise Josef Seifert, "Karol Cardinal Woj• tyia (pope John Paul II) as Philosopher and the CracowlLublin School of Philosophy," in Aletheia II (1981).

II See especially his Salvifici Doloris on pain and suffering, and Uomo e donna 10 credo xxiv PREFACE AND ACKNOWLEDGMENTS philosophical one quite apart from the fact that membership of the Pontificia Acade• mia pro Vita does not entail any ecclesiastic authority.12 At this point, I should also express my gratitude to the Secretary of the Pontifical Academy of the Sciences (of which I am not a member but by which I was invited), Monsignore Ing. Renato Dar• dozzi, whose invitation to participate, as expert in philosophy, in an Academy ses• sion on brain death, and in another one on chaotic and non-chaotic systems and on life,13 greatly enhanced my knowledge and inspired my philosophical reflection on medicine. My gratitude extends quite especially to my former main teacher, Dietrich von Hildebrand, without whose What Is Philosophy? and large ethical work this book could not have been written,14 to Professor Balduin Schwarz who has made me deeply aware of the great crises in the history ofphilosophy,t5 and to many classical , colleagues, friends and students at different schools, especially at the International Academy of Philosophy in the Principality of Liechtenstein. Acknowledging the help I have received from all those many philosopher friends and students who inspired me to rethink the issues treated in this text and from all the doctors and professors of medicine with whom I discussed these subjects in vari• ous Academies and Universities, I wish to thank in particular a few persons to whom lowe a special debt of gratitude besides those already mentioned. First, I have to thank my very close friend and colleague Professor Rocco Buttiglione, now his Ex-

12 I stress this obvious point because recent articles and publications show that there is a widespread misunderstanding as if the Pontifical Academy of Sciences possessed any magisterial role or repre• sented the Vatican position. This is in no way the case. The members of the Pontifical Academy of Sciences are to a large measure not Catholics, differ often radically from the Magisterium's positions regarding population control etc., and lack any official magisterial authority. They are a purely scien• tific community, a free group of scholars who are meant to be useful in informing the Church's Mag• isterium of the opinions, developments, findings, etc., in the sciences and disciplines, or in treating such issues as defmitions of death or the origins of life. In spite of the very different 'idea' of the Pon• tificia Academia pro Vita, neither the Pontificia Academia pro Vita as a whole nor (and even less) its single members can make any claims to their utterances possessing 'ecclesiastic authority' or being .the official positions ofthe . 13 See as record of this my paper, whose content strongly differed from all other Pontifical Academy• members' opinion: Josef Seifert, "Is 'Brain Death' actually Death? A Critique of Redefining Man's Death in Terms of 'Brain Death' ," in R. J. White, H. Angstwurm, I. Carasco de Paola (eds.), Working Group on the Determination of Brain Death and Its Relationship to Human Death (: Pontifical Academy of the Sciences, 1992), pp. 95-143. See also Josef Seifert, "What is Life? On the Irreducibility of Life to Chaotic and Non-Chaotic Physical Systems," Proceedings ofthe 1993 Gener• al Assembly Meeting, Pontifical Academy of the Sciences (Vatican City, 1994); and Josef Seifert, What is Life? The Originality, Irreducibility, and Value ofLife (New York/Amsterdam/Atlanta, GA: RodopiNalue Inquiry Book Series, 1997). 14 Dietrich von Hildebrand, What Is Philosophy? (Milwaukee: Bruce, 1960; 2nd ed. Chicago: Franciscan Herald Press, 1973; 3rd ed., with a new introductory essay by Josef Seifert, London: Routledge, 1991); EthiCS; Die Idee der sittlichen Handlung, phil. Diss. vom 6. November 1912, in JahrbuchjUr Philosophie und phiinomenologische Forschung, 3. Band (Halle: Niemeyer, 1916), pp. 126-251; Sitt• lichkeit und ethische Werterkenntnis; Moralia. Nachgelassenes Werk, Gesammelte Werke V (Regens• burg: JosefHabbel, 1980). Dietrich von Hildebrand and , True Morality and Sit• uation Ethics (New York: David McKay Company; Toronto: Musson. 1955; 2nd ed. entitled Morality and Situation Ethics. With an introduction by Bernhard Hliring and an epilogue by Alice von Hilde• brand. Franciscan Herald Press, 1966); Graven Images. Substitutes for True Morality (New York: David McKay Company, 1957; 2nd ed. Chicago: Franciscan Herald Press, 1976). 15 See Balduin Schwarz, Wahrheit, Irrtum und Verirrungen. Die sechs grofJen Krisen und sieben Aus• fahrten der abendliindischen Philosophie; Ewige Philosophie. PREFACE AND ACKNOWLEDGMENTS xxv cellency, Italian Minister for European Integration, for many ideas and inspirations for the present work, particularly regarding the ethical dimension as constitutive of the essence of medicine, and whose former Full Professorship and continuous and faithful support of the International Academy of Philosophy in the Principality of Liechtenstein and of this project on bioethics and philosophy of medicine became one of its more significant origins. Special gratitude lowe also to Professor D. Alan Shewmon, a pediatric neurol• ogist and expert on surgical treatment of children's epilepsy in California; since his contributions refer to the topics of the second volume of this work, I will acknowl• edge my debt to him in the introduction to volume II. Another person to whom lowe special gratitude with respect to this publication is my former student and dear friend, Dr. med. Dr. phil. Paulina Taboada (who is now directing the Masters Program in the Unidad Bioetica at the Catholic University of Chile in Santiago and teaching ethics and medicine) for having repeatedly pro• vided me, during and after my various lectures in Santiago, with a series of construc• tively critical remarks which helped to improve this text. I appreciate also deeply the precious gift of her friendship and encouragement in the pursuit of knowledge re• garding the crucial matters here discussed. In the summer and fall of 1997, finally, I had the great opportunity to co-teach with Professor H. T. Engelhardt, Jr. a research and discussion seminar on bioethics at the International Academy of Philosophy in the Principality of Liechtenstein (lAP), in which we held dialogues with each other and with students of the Acade• my about his Foundations of Bioethies, about a new text he was preparing at that time on Christian Bioethies and which since then was published, and about portions of the manuscript preceding the present work. Also this opportunity was a precious help towards completing this text and I wish to express my vivid thanks to H. T. En• gelhardt, Jr. for his personal gentleness, despite our profound philosophic disagree• ments, for sharing his vast knowledge with us and for spending several months of his sabbatical year (1997) in Liechtenstein where we discussed some matters con• tained in this text. I also took part in a two-year research project on "Limiting Ac• cess to Medical Resources in Intensive Care Units" which helped me to understand better many issues discussed in volume II of this book. I express my thanks also to my parents who besides life and all other gifts they bestowed on me, made my studies possible and also accompanied my philosophical work always with extreme interest and competence in philosophy and ethics, and to my wife Mary Katherine who suffered my being absorbed by this work for countless hours and who is a very fme philosopher herself. A special word of gratitude I also owe to Mrs. Veronika AI• bicker who prepared this manuscript for print and contributed much to its form and to certain scholarly aspects of it. I include in my thanks many other persons who are here not mentioned by name but to whom I am greatly indebted.

July 20,2001 Gaflei, TriesenbergIVaduz, Principality of Liechtenstein Josef Seifert INTRODUCTION

At all times physicians were bound to pursue not only medical tasks, but to reflect also on the many anthropological and metaphysical aspects of their discipline, such as on the nature of life and death, of health and sickness, and above all on the vital ethical dimensions of their practice. For centuries, almost for two millennia, how• ever, those who practiced medicine lived in a relatively clearly defined ethical and implicitly philosophical or religious 'world-order' within which they could safely turn to medical practice, knowing right from wrong, or at least being told what to do and what not to do. Today, however, the situation has radically changed, mainly due to three quite different reasons: First and most obviously, physicians today are faced with a tremendous development of new possibilities and techniques which allow previously unheard of medical interventions (such as cloning, cryo-conservation, ge• netic interference, etc.) which call out for ethical reflection and wise judgment but regarding which there is no legal and medical ethical tradition. Traditional medical education did not prepare physicians for coping with this new brave world of mod• em medicine. Secondly, there are the deep philosophical crises and the philosophical diseases of medicine mentioned in the preface that lead to a break-down of firm and formative legal and ethical norms for medical actions. And thirdly, in our postmod• em world there are neither the commonly shared religious ethical norms on which medieval medicine could rely nor the rational codes of the enlightenment or of the Universal Declaration of Human Rights on which society and the medical profession used to rely. Consequently, in our pluralistic and rapidly changing society, medical profes• sionals frequently remain without any adequate training in medical ethics and with• out any publicly or universally accepted solutions to even the most basic ethical questions in their field, such as: "Is it ethically justified to assist suicide, to kill the elderly, to abort babies, even up to birth?" They are likewise left without orientation regarding such elementary theoretical and ultimately philosophical problems as lie at the foundations of their discipline, such as: "What is human death?" and "What is human life?" and, more practically, "When does life begin, when end?" But not only in the public life, also in the private consciousness of medical per• sonnel, the type of clarity of concepts, thoughts, and solutions to the philosophical questions of medical practice still found after World War II, especially under the im• pact of the shock over the Nazi horror and its horrendous effects on medicine, has long since disappeared. After the 'Niirnberger ProzeB' had brought to light the cor• ruption of many Nazi doctors, the whole medical world woke up to the evils of eu• genic euthanasia and collaboration of physicians with abortion and euthanasia for racist and political reasons, ruthless medical experimentation on humans, and other Nazi crimes in the field of bioethics. A universal declaration on human rights was signed by many nations in 1946, and similar documents were internationally sanc• tioned thereafter. The forms of human experimentation conducted in Ravensbruck, for example, would shock us even if animals had been used for experiments instead of women. But today the wholesome effect of reflecting on those philosophical and

xxvii xxviii INTRODUCTION moral truths which were gravely violated by Nazi doctors such as Dr. Mengele who, in the concentration camp of Auschwitz and others, used men and women for medi• cal tests in ruthless ways, has long passed. I Weare back into a deep and universal crisis ofbioethics and of the recognition of the very values that lie at its foundations. Behind this crisis in medical ethics we find a much wider and almost universal crisis of philosophy and ethics, a crisis of which one can safely claim that it surpas• ses any of the preceding great crises of philosophy in the history of occidental thought and extends especially to the very foundations of values, of ethics, of moral obligations, of intrinsically good and wrong acts, and of religion. This crisis has also thrown medical ethics into an emergency situation that could well be regarded as a specially revealing concrete appearance of the sixth great crisis of philosophy in the midst of which we find ourselves today.2 The objectivity and the very notions ofhu• man rights and of moral obligations have become doubtful. Bioethics today stands in desperate need of a new voyage, of a new beginning and new foundation of philosophical ethics, which both rediscovers the perennial foundations of ethics and lays its foundations more deeply than any previous ethical system had ever laid them, in accordance with new philosophical discoveries and new challenges and with entirely new practical possibilities of medical action. The picture of philosophy and ethics today is not all gloomy, however. One could apply here Hegel's word according to which Minerva's owl flies at the time of dusk. 3 We encounter today new and better ways of founding ethics than in the past. These new contributions to ethics belong already to the pure air of a new foundation and new beginning of philosophy (the seventh great voyage of philosophy in its his• tory) which philosophy and medical ethics, building on previous philosophical con• tributions, are called to undertake and have begun to undertake today. This greater clarity of some philosophers of the 20th century regarding the true foundations of ethics and bioethics may be precisely due to the gravity of the present crisis which forces us to look for ultimate answers because insufficient and superficial answers will no longer do. A conspicuous absence of commonly accepted public guidelines of medical ac• tion, and of privately achieved clarity about them, is found not only with respect to almost all great traditional problems of medical ethics but also, and even more, with

On the horrors of those experiments see Wanda P6ltawska, Und ichft1rchte meine Triiume, 2. Auflage (Avensberg: Maria aktuell, 1994). On the notion of the six major crises and seven 'voyages' of occidental philosophy, see Balduin Schwarz, Wahrheit, Irrtum und Verirrungen. See also Josef Seifert, "Die 'Siebte Ausfahrt' als Aufga• be der Intemationalen Akademie fUr Philosophie im FUrstentum Liechtenstein (1986--1996)," in Mar• iano Crespo (ed.), Menschenwiirde: Metaphysik und Ethik (Heidelberg: Universitatsverlag C. Winter, 1998), pp. 19-56/3. See Gottfried Wilhelm Friedrich Hegel, Einleitung zur Rechtsphilosophie: Urn noch fiber das Belehren, wie die Welt sein soli, ein Wort zu sagen, so kommt dazu ohnehin die Philosophie immer zu spat. Als der Gedanke der Welt erscheint sie erst in der Zeit, nachdem die Wirklichkeit ihren Bildungs-ProzeB vollendet und sich fertig gemacht hat. ... Mit Grau in Grau laBt sie (eine Gestalt des Lebens) sich nicht verjUngen, sondem nur erkennen; die Eule der Minerva beginnt erst mit der einbre• chenden Dammerung ihren Flug. (G. W. F. Hegel, Werke, Bd. 7 [Frankfurt a. M.: Suhrkamp, 1970], pp. 27-28). INTRODUCTION XXIX respect to the enonnous number of stunning ethical and anthropological problems which are posed by modem medical technology and which by their very nature do not allow solutions by a return to traditions of medical ethics which in these cases do not and cannot exist. This leads us to a further reason why medical ethics and bioethics need to be de• veloped anew with all seriousness: the fact that objectively, and wholly independent• ly of any decline in ethical thinking, countless new problems arise in medicine due to medical development. Artificial life-support systems and the unavoidable limits to medical efforts of prolongation of life pose such ethical problems as: "What are the criteria according to which one should allocate extraordinary means of life-support to patients?" "How should we handle modem reanimation technologies and when is it licit to turn respirators off?" "In which ways may we or ought we limit access to medical treatment?,,4 Organ explantations and transplantation medicine, which in• volve a new concept of human death, likewise pose radically new problems regard• ing the definition of life and death, and regarding the beginning and end of human personal life. The moral aspects of organ donation and harvesting of organs need to be investigated anew because these technologies never existed before and yet touch classical issues such as sacrifice, donation, bodily and personal integrity, as well as mutilation. The possibilities of changing one's sex, IVF (in vitro fertilization), spenn- and egg-donations, GIFT (gamete intrafallopian transfer) in its many fonns, 'cloning', and many other new medical procedures pose crucial moral questions re• garding the origins of human life and the nature of human parenthood as well as re• garding the difference between aid to the marital act and its substitution through the operations of medical teams. New fonns of human reproduction now replace the 'old methods' by 'making babies' from egg-cells collected from women who sell or donate them, and from spenn obtained by masturbation of males - both having been deposited at egg and spenn banks - in processes reminiscent almost of a cook's cooking foods from various ingredients. Modem knowledge of genetics and the abil• ity to alter genetic codes similarly pose multiple new and pressing ethical questions and dilemmas as to whether 'genetic engineering' can ever be right and, if so, whether it is licit only for strictly therapeutic ends. Research on human embryos and countless other new aspects of a rapidly evolving medical science pose a world of ethical, legal, social, and philosophical problems which cannot be solved by mere reliance on tradition, not only for the reasons of the collapse of this tradition under the jolt of the present great philosophical crisis hinted at above, but also because the classical authors were unaware of them. But notwithstanding all the neutral reasons to renew bioethical reflections in re• sponse to an incredibly growing medical science and technology, the most important source of the need to redevelop bioethics lies in the universal crisis of philosophy and ethics today. And this general philosophical and ethical crisis that grew over two or more centuries but had not altered medicine for a long time, has finally reached medicine as well as health care law. The world of professional medical practice and

4 In September 1997, the International Academy of Philosophy in the Principality of Liechtenstein hosted a first meeting of a two-year research project on "Limiting Access to Medical Treatment in an Age of Medical Progress: A Roman Catholic Perspective," directed by Professor H. T. Engelhardt, Jr. xxx INTRODUCTION the laws of most states no longer provide even minimally fIrm and solid, let alone unchanging standards and codes of medical ethics within which the practice of med• icine could confIdently be performed. Acts such as killing unborn babies, which still during my high-school years were illegal and recognized as criminal in my home• land Austria, are now - almost world-wide - virtually forced upon medical students and medical doctors. I had the occasion to discuss such questions for many hours with the director of a department of gynecology and obstetrics in Western Europe, a noble doctor who lives the tragedy of practicing medicine that now has been deprived of a compass and standard for right action. The performance of abortions - as it now, according to his opinion, "belongs to his practice," and which he reserves to himself in order to limit the number of killed babies and to prevent that his assistant doctors handle abortion more 'liberally' - has put on the mind of this doctor the heavy burden of torments of conscience to the point of his hating his own profession. But nowadays a physician like him, who restricts as far as possible committing actions that were rec• ognized before quite generally as murder of the innocent, is even regarded as still too 'restrictive'. This physician, who only a few years ago would have been expelled from his country or gone to prison for his actions, appears today, and perhaps per• sonally feels, almost like a martyr of conscience who stands up against the common trend towards a far more liberal 'handling' of abortion. Consider that students of midwifery presently are not even accepted, for example in Zurich, , for professional training if they refuse to declare that they will assist in abortions - a symptom of a radical change of public ethics in a very short time, and a clear and striking case of violation of the fundamental human right to the freedom of conscience.5 Consider the depth of the public's change of judg• ment on abortion by contemplating the following facts: such a liberal mind as Jo• hann Wolfgang von Goethe during the years of his political career still signed death sentences for abortions (which were recognized as murder of children); a liberal Jewish-Austrian poet such as Joseph Roth wrote that "every civilized society ought to punish abortion as a crime"; and even the world-famous atheist fIlm producer, Pa• solini, in the 20th century wrote: "the very thought oflegalization of abortion shocks me, because I, with many others, regard abortion as murder.,,6 If unborn babies are human persons, abortion is objectively a grave crime and any participation in it is a form of participating in mass murder to which today not only in China but also in most Western countries many more millions of human persons are victims than died in the Nazi holocaust. How much the times changed in this regard even within the last decades often escapes our consciousness. Consider, for example, that after having committed abortions, some thirty years ago, the father of a schoolmate of my brother was expelled by the Austrian Medical Association; he was constrained to flee from indictment and imprisonment in Austria and to practice

In response to this intolerable situation, the association "Betroffenes Spital" ("Concern: Hospital") was formed in Switzerland on May 18, 1996, to protect the freedom of conscience and of religion, and to unite 15,000 medical professionals in the commitment for human life in the face of the estimated 15,000 abortions performed every year in Switzerland. See Karin Struck, Ich sehe mein Kind im Traum. Pliidoyer gegen die Abtreibung (BeriinIFrankfurt a. M.: Verlag Ullstein, 1992), p. 62. INTRODUCTION xxxi medicine in Africa in order to avoid serving a jail term. Today, the very opposite is happening: a physician in Austria was expelled from the official medical association for having said and written that - despite their legalization - abortion and other forms of killing the innocent, of which many medical colleagues are guilty, are crimes. This remark (which was in full harmony with what virtually all medical codes of the world had held till recently) was taken as an attack on the moral integrity of the medical profession, and this doctor was threatened with expulsion from the medical association and supposed to pay a severe fme (though he was later acquitted by the public courts and did not use any polemic language). Similar turns of the tide of prevailing opinion are found in almost all fields of medical ethics: re• garding euthanasia, genetic engineering, sterilization, contraception, assisted suicide, homosexuality, use of deadly abortifacient drugs such as RU 486 (Mifegyne), etc. Until now we have spoken of the public world of the law and of secular medical ethical standards, but this is not all that is in crisis in bioethics. In a thoroughly secu• lar society in which religion lost long ago its strong formative influence, physicians frequently do not even fmd any personally binding religious answers to the pressing philosophical and ethical problems that confront them daily. Also moral theologians in great number, Jewish, Catholic, Protestant, and Orthodox alike, defend - based chiefly on some variety of ethical consequentialism (or 'teleological ethics') - by theological arguments almost all the practices which the pagan Hippocrates, at least as far as we can infer from the text of the Hippocratic Oath/ had regarded as crimes against the goals of the medical profession. Thus we witness today not only a col• lapse of the unity and traditional value commitments of secular ethics and of state law but also a large-scale collapse of traditional moral theology, of the moral and so• cial order dominant in religiously inspired hospitals, and of their medical ethical codes. Some authors have spoken of a deep crisis of the Hippocratic medical tradi• tion,s a crisis and break that also can be seen in the ethical guidelines and policy statements of Catholic Hospitals. (I am thinking, for example, of a specific Catholic

It is true that both in Plato's Republic and in a number oftexts of the Hippocratic tradition these grand ideals were not upheld, as described and defended by Darrel W. Amundsen, "The Physician'S Obliga• tion to Prolong Life: A Medical Duty without Classical Roots," Hastings Center Rep (Aug 1978), 8: 23-30. See for example Nigel M. de S. Cameron, "The Seamless Dress of Hippocratic Medicine," Ethics Med (Autumn 1991): 43-50. Summary in Philosopher's Index (Fall 1998) In the excellent summary in the Philosopher's Index (Fall 1998), the author summarizes his results: The Hippocratic medical tradition, the originally pagan cornerstone of West em med• icine, is in crisis. What is the nature of the distinctive Hippocratic medical values? They have been constitutive not only of medicine as a profession, but of the idea of a profession, as a self-regulating institution with inherent moral as well as technical components. Hippocratic medicine was from the start medicine as moral commit• ment, enshrined in a covenantal context (God-physician, physician-patient, physi• cian-master/profession), based on a twofold obligation (sanctity of life and philan• thropy), and with a single commitment to heal. (Article extracted from the author's The New Medicine [Crossway Books, 19921 ). See also the interesting description of the integration of the Hippocratic tradition of medical eth• ics into the Islamic medical traditions in Azim A. Nanji, "Medical Ethics and the Islamic Tradition," J Med Phil (Aug 1988), 13: 257-275. xxxii INTRODUCTION

Hospital in the United States known to me. 9) In such medical guidelines hardly a trace of the clarity of ethical positions and distinctions that characterized hospital ethics of the past is left intact. In such a confused time as ours, an honest attempt at clarifying - through care• fully conducted and at the same time intelligible philosophical analyses accessible to a wider readership - the important interdisciplinary questions which concern both philosophers and physicians might prove helpful to doctors who are searching eager• ly for the truth about the meaning and theoretical foundations of their noble art. Even those who object against any rational philosophical solution to these prob• lems, while holding that a religious answer to them is possible, cannot avoid offer• ing philosophical opinions and analyses, using philosophical arguments to ground their skepticism regarding the capacity of reason to solve ethical issues; and they keep presupposing philosophical terms, insights, and principles along every step of their religious discussion. \0 Some of these adherents of the position that a content-full ethics is only possible on religious grounds have, apart from their skepticism and despair of reason, another argument for their position, namely the obvious moral preconditions of moral knowledge: rarely do thieves see stealing, murderers assassination, tax-swindlers cheating as wrong. While I fully agree with the conviction that a comprehensive and pure objective knowledge in ethics requires virtue and can be reached fully only by a total conver• sion and not by philosophical analysis and argument alone, I am fIrmly convinced that philosophical reasoning and argumentation never have been more needed than today. These are indeed indispensable if the world-wide crisis of medical ethics, in which false of all sorts play an enormous role and in whose genesis philosophers have a great share of responsibility, should be overcome and physi• cians should again find a reliable guide for medical action. Some bioethicists, perhaps the majority, hold this to be impossible, drawing from this opinion various consequences: The fIrst consequence is a reduction of public ethics to the contents of general consensus or agreement (or to the mere object of tolerance and acceptance), and of private ethics to a fIdeistic ethics whose adoption is judged to be a mere private matter of the conscience of "moral strangers in a pub• lic world." Some authors hold both of these opinions at the same time. The stand-

This hospital has recently been sold to a non-sectarian, non-Catholic health organization. It developed guidelines that allow withdrawal of fluids (with starvation as consequence) even from patients who were still conscious and pleaded for fluids. The argument for such a shocking stance has been that those patients before had signed some living will or similar written agreement no longer to be tube-fed when being in certain physical conditions.

\0 In the new and interesting Journal Christian Bioethics. Non-Ecumenical Studies in Medical Morality (started in 1995) many articles, for example by H. T. Engelhardt, Jr. and Fr. George Eber, seem to im• ply that philosophy can contribute virtually nothing to the solution of problems related to actual con• tents of medical ethics. They regard this, in the tradition of parts of the Orthodox Church, as a vain ef• fort of a secular mode of thinking to solve problems that can only be solved by spiritual religious con• version and liturgical celebration in the faith. Other authors in the 'non-ecumenical' Journal, like Rus• sell E. Smith, Darrell W. Amundsen, and Otto W. Mandahl, Jr., take other positions on these ques• tions. See Christian Bioethics 1 (1995), pp. 128-152; 161-181; 182-199; 213-255. INTRODUCTION xxxiii points of H. T. Engelhardt, Jr." or Fr. George Eberl2 go in this direction and are based on a general view of the eclipse of reason in modernity and its incapacity to reach objective truth. Engelhardt argues that there is no publicly binding reason or ethics today (except some watered-down formal tenets which meet with political consensus or assent in a libertarian democracy). Instead there would only exist ethi• cal systems binding for closed groups, the "moral strangers in a public world.,,1J To these groups the Journal Christian Bioethics. Non-Ecumenical Studies in Medical Morality lends a voice. 14 Two other responses to a similar opinion that all contents of moral judgments are subjective are the attempt to develop some kind of 'objective ethics' based on the evaluation of conflicting subjective desires,15 and a reduction of ethics to a mere 'logic of norms', to an ideal of ethical consistency. In chapter 5 of this volume, we will return to a critical examination of all these views which imply different forms of ethical agnosticism and relativism and which we deem to be a major philosophical disease of medicine. The following reflections are based on the very different conviction, which to elucidate and to establish is the purpose of the subsequent reflections, that philoso• phy as an objective knowledge of reality, of objective values and oughts, not only in the sense of a purely ontological and religious objectivisml6 but also in the sense of an epistemological objectivism, possesses also today a rational justification and foundation. In the face of the profound subjectivist and relativist crisis of philosophy today - the sixth great crisis in the history of occidental philosophy -, such a philo• sophical position is rationally justified only if there exists what could be called the 'seventh voyage' in the history of Westem philosophy. 17 What is needed, in order to grant philosophy an important role in overcoming the huge skeptical and ultimately nihilistic crisis of medical ethics today and to reinstate philosophical knowledge in its rightful place, is a new beginning in philosophy and a new justification of its

11 H. T. Engelhardt, Jr., "Christian Bioethics as Non-Ecumenical," Christian Bioethies, vol. 1, no. 2 (1995): 182-199. 12 Christian Bioethics 1 (1995): 128-152.

13 H. T. Engelhardt, Jr., The Foundations ofBioethics. 14 Though inasmuch as this non-ecumenical journal is partly ecumenical after all, by aiming at fmding points of consensus among various Christian and Jewish groups, and by tolerating opinions differing from those of the editors, it includes also other voices such as mine. 15 See Julian Nida-Riimelin, "Wert des Lebens," in Angewandte Ethik. Die Bereichsethiken und ihre theoretische Fundierung. Ein Handbuch herausgegeben von Julian Nida-Rilmelin (Stuttgart: Alfred Kroner Verlag, 1996), pp. 832-861, especially pp. 834 ff., 841 ff. Cf. for example, p. 841: "Die ent• scheidungstheoretischen Kohtirenzbedingungen markieren eine Form des Uberganges von subjektiven zu objektiven Wiinschen bzw. Interessen." Nida-Riimelin defends the position that the theory of deci• sion, based on the principle of the coherence necessary among an individual's different decisions, can provide objective standards of the logic of decision excluding certain contradictions and incoherences within the sphere of subjective value-decisions. 16 H. T. Engelhardt, Jr. considers himself a metaphysical objectivist (on religious grounds) and an epis• temological skeptic. 17 See on this Balduin Schwarz, Wahrheit, Irrtum und Verirrungen Die sechs grofJen Krisen und sieben Ausfahrten der abendliindischen Philosophie, particularly "Die sechs groBen Krisen der abendllindi• schen Philosophie," in ibid., pp. 1-21; Josef Seifert, "Vorwort," in ibid., pp. XXIX-LXXI. xxxiv INTRODUCTION methods, which preserves all discoveries of the philosophia perennis but copes with the challenges of the present time. Such a seventh voyage, which cannot simply con• sist in a naive textbook-like going back to earlier philosophies, gives rise to new dis• coveries and brings once again to evidence the fundamental capacity of human rea• son to reach an objective knowledge of reality. This fundamental capacity has no doubt moral preconditions!8 but cannot be sub• stituted by religion or morality, already because these always and necessarily pre• suppose rational insights without which religion becomes superstition and sheer in• tolerable abdication of reason and loses its own presuppositions. The love of truth requires not only the love of religious truth but of all truth, including that part of it which is accessible to human reason, and only to reason, and which any meaningful religious faith but also any ordered democratic state in which fundamental human rights are recognized presuppose. Moreover, any bioethics today needs to proceed by means of a carefully worked out method that overcomes three deadly opponents of objectivist philosophy: (I) a radical skepticism or cognitive nihilism and irrationalism which identifies philosophy with mere constructions, games, or inventions in which everything is permitted and truth never attained; (2) German idealism, with the many forms of subjectivist explanations of the 'a priori' implied in Kant's, Hegel's and other positions, and partly following there• from: such as historicism or the reduction of philosophy to historically changing per• spectives of hermeneutics of changing ideas and texts, Marxism, and many others; (3) any form of empiricism and reduction of philosophy to language analysis, so• ciological or psychological factors, and in particular the emotivist ethical relativism!9 or a purely linguistic and conceptual objectivism of values, such as Mackie's, which entails an epistemological skepticism and metaphysical nihilism of values. I am convinced that the basic outlines of the necessary seventh voyage of philos• ophy, which overcomes all of the 'suicides' and abdications of philosophy, were al• ready procured - even if the work of those who undertook the first part of the sev• enth voyage is still recognized only by a few. In view of the preceding brief remarks it is clear that the metaphysical and at least the epistemologicafO subjectivism and skepticism prevalent in many contempo-

18 These moral preconditions of knowledge in general and ethical knowledge in particular lie in the love of truth and in many other attitudes without which value blindness or errors can easily result. Cf. Diet• rich von Hildebrand, Sittlichkeit und ethische Werterkenntnis. Also regarding the mentioned positions of Engelhardt and Eber I agree with the thesis that-as al• ready Plato suggests in the Myth of the Cave in his Politeia- only a metanoia, a moral or religious conversion, can fully overcome the moral obstacles to true knowledge. But in philosophy, more and other conditions are required and often very religious people hold catastrophic philosophical errors such as fideism or general skepticism. Hence the relationship between ethical (at least philosophical ethical) knowledge and religious spiritual life is far more complex than suggested by the main authors of Christian Bioethics.

19 See on the emotivist relativism in ethics-besides David Hume, Enquiry Concerning the Principles of Morals-Charles L. Stevenson, Ethics and Language (New Haven: Yale University Press, 1976); see an excellent critique of these positions in John Barger, "The Meaningful Character of Value-Lan• guage: A Critique of the Linguistic Foundations of Emotivism," J Value Inquiry 14 (1980): 77-91.

20 See H. T. Engelhardt, Jr., The Foundation ofBioethics; see also the same author, "Towards a Chris• tian Bioethics," Christian Bioethics, vol. 1, no. 1 (1995): 1-10. INTRODUCTION xxxv rary philosophies of medicine21 are far from me. I do not think that philosophy "must no longer dream the rationalistic dream" of discovering universally intelligible and rational foundations of ethics (which was and remains the task of philosophy), nor that there are today no content-full ethics and legal knowledge as basis of the public life. I reject wholeheartedly the idea that the ethics of the 'public world' has no other cognitive basis except mere democratic tolerance and acceptance, and that a content• full ethics belongs solely to "moral strangers in a public world," i.e. amounts to nothing but a personally adopted ethical viewpoint in a world in which neither faith nor reason can provide an objectively knowable, true, and universally valid founda• tion of ethics. No, medical ethics does have objective and intelligible foundations, some accessible only to believers, but many accessible to every intellect open to truth. Thus the viewpoint recently expressed in the 'non-ecumenical' Journal Christian Bioethics (according to whose general guidelines neither in the world nor in reli• gious communities a universally valid and defensible ethics can be reached but only 'sectarian' standpoints can be taken) seems to be based on a failure to recognize the universality of truth in itself and its accessibility to humans, partly through reason, partly through faith. The new epistemological skepticism in bioethics seems to adopt a new fide ism that separates religious faith, far more radically than Protestantism in general,22 from reason. In reality, ethics based on authentic and 'rational' religious faith (i.e. a faith that follows the Pauline saying "scio cui credidi," "I know in whom I put faith") is not only itself rational but shares innumerable truths which also unaided human reason can get to know. A religiously motivated Jewish or Christian bioethics, while it can go far beyond what philosophy or pure reason can establish, cannot ever substitute for reason, nor dispense of reason. Also Islamic, Buddhist, or other forms of 'reli• gious ethics' stand in need to clarify concrete ethical contents by means of reason. Moreover, any fideist attempt to replace philosophy by personal private faith, as pro• posed in the guidelines of the Journal Christian Bioethics. Non-Ecumenical Studies in Medical Morality,23 cannot avoid appealing to philosophical and rational evi• dences. Philosophy as a rational knowledge of ethical norms which appeals to all persons of good will and to every human person who loves truth, has its indispensable role in ethics today, a role as significant as ever before, and even more so in a world in which the religious unity of the Middle Ages has disappeared. Closed communities

21 See Lennart Nordenfelt, On the Nature ofHealth (Dordrecht: Reidel Publishing Company, 1987); see likewise Nordenfelt, "Health and Disease: Two Philosophical Perspectives," Journal ofEpidemiology and Community Health, 41 (1986): 281-284. See the critique of these views in Kateryna Fedoryka, Understanding Health: The Foundations of Its Normativity and Its Foundational Normativity for Medicine (Schaan, FL: International Academy of Philosophy in the Principality of Liechtenstein, un• published doctoral dissertation, 1996). 22 See on this the excellent critique of Eber's and Engelhardt's fideistic views in Darrell W. Amundsen and Otto W. Mandahl, Jr., "Ecumenical in Spite of Ourselves: A Protestant Assessment of Roman Catholic, Eastern Orthodox, and Anglican Catholic Approaches to Bioethics," Christian Bioethies, vol. 1, no. 2 (1995): 213-145.

23 See H. T. Engelhardt, Jr., ''Towards a Christian Bioethics." XXXVl INTRODUCTION

united in the Christian, Islamic, or other religions, which provide firm moral founda• tions for whole states, cease to exist more and more. And no single religion, whether it makes justified or unjustified claims to being the true religion, can claim dominion over the convictions of society at large, at least not in our modem Western states. In today's secular and pluralistic society not the whole truth (that ideally speaking should in/act bind all societies) but only that 'part of truth' which is open in princi• ple to any human reason can be that truth that provides the foundations of modem civil society - independently of religious creed. And to clarify this common basis so desperately needed as foundation of medical ethics in a secular world, is precisely the task of a philosophy and philosophical ethics of medicine. The following work is based, at any rate, on the firm conviction that philosophy can be established as a rational and rigorous science, which uses methods that allow it to grasp the objective nature and existence of things,24 especially the necessary essences of things, as well as the objective values founded on the natures of things, many of which give rise to moral imperatives. In other words, the following reflec• tions are based on previous works of various thinkers who attempted to establish in the midst of the sixth and greatest crisis in the history of occidental philosophy that an objective and true philosophical knowledge is possible and is of decisive impor• tance for the world and for philosophy today. I can here only refer the reader to some of the works in which this task has been carried out, but not develop extensive• ly the epistemological foundations of such a philosophy, except to the extent to which they will inevitably be touched and elucidated in the course of the following bioethical reflections. 25

24 See D. von Hildebrand, "Das Cogito und die Erkenntnis der realen Welt. Teilveroffentlichung der Salzburger Vorlesungen Hildebrands: 'Wesen und Wert menschlicher Erkenntnis'," in Aletheia VI/1993-1994 (1994), pp. 2-27. See also Josef Seifert, Sein und Wesen (Heidelberg: Universitats• verlag C. Winter, 1996), chs. 1-2; or the earlier English work of mine, "Essence and Existence. A New Foundation of Classical Metaphysics on the Basis of 'Phenomenological Realism', and a Critical Investigation of 'Existentialist '," in Aletheia I (1977), pp. 17-157; 1,2 (1977), pp. 371-459. 25 See AdolfReinach, "Uber Phanomenologie," in , Siimtliche Werke. Kritische Ausgabe mit Kommentar, Bd. I: Die Werke, Teil I: Kritische Neuausgabe (1905-1914), Teil II: Nachgelassene Texte (1906-1917); Bd. II: Kommentar und Textkritik, hrsg. v. Barry Smith und Karl Schuhmann. (Mlinchen und Wien: Philosophia Verlag, 1989), Bd. I, pp. 531-550; Dietrich von Hildebrand, What Is philosophy?; Fritz Wenisch, Die Philosophie und ihre Methode (Salzburg: A. Pustet, 1976); Josef Seifert, Erkenntnis objektiver Wahrheit; the same author, Back to Things in Themselves; "Philoso• phie als strenge Wissenschaft. Zur Grundlegung einer realistischen phanomenologischen Methode - in kritischem Dialog mit Edmund Husserls Ideen liber die Philosophie als strenge Wissenschaft" (in Lithuanian), Logos (1988/13-14),19-39. In Czech and German: in Filosofie, Pravda, Nesmrtlenost. TN praiske prednd§kyIPhilosophie, Wahrheit, Unsterblichkeit. Drei Prager Vorlesungen pp. 14-50. Preklad, uvod a bibliografi Martin Cajthaml. Prague: Vydala Ki'estanska akademie Rim, svazek, edice Studium, 1998. In Russian: "Philosophy as a Rigorous Science. Towards the Foundations ofa Realist Phenomenological Method-in Critical Dialogue with 's Ideas about Philos• ophy as a Rigorous Science," Logos 74, 9 (1997), 54-76. In Czech: "Filosofie jako prisna veda. Prispevek k zalozeni realisticke fenomenologicke metody v kritickem dialogu s Husserlovou ideou filosofie jako pfisne vedy," in Filosoficky Casopis 6, 44 (1996), pp. 903-922.