189mm 24mm 189mm Contemporary Debates in Contemporary

“This outstanding volume brings the contemporary debates of bioethics to Contemporary Debates In Philosophy life. Thoughtful introductions to contextualize each topic combined with interactive debates result in an outstanding and unique resource.” David Magnus, Director, Center for Biomedical Ethics, Stanford University

“I savor controversies and debates and this riveting new book has 15 great ones from the field of bioethics, debates that transcend academic disputes to engage the public, public intellectuals, and the Supreme Court on topics like assisted suicide, gene patenting, human cloning, and health reform.” Mark Siegler, University of Chicago

Modern advances in medicine and are accompanied by an increasingly complex swirl of ethical dilemmas and debates. Contemporary Contemporary Debates in Bioethics features a collection of divergent arguments contributed by today’s top bioethics scholars that focus on core bioethical concerns of the twenty-first century. After presenting highly accessible introductions to specific issues, chapters proceed to tackle each side of such topical Debates in concerns as international medical research, human cloning, markets in human organs, abortion, gene and embryo copyrighting, physician-assisted

suicide, stem-cell research, primate research, biomedical enhancement, and 246mm more. Provocative and timely, Contemporary Debates in Bioethics introduces a Bioethics variety of perspectives that allow readers at all levels to gain critical insights and a deeper understanding of some of the most controversial and important issues of our day.

Arthur L. Caplan is the Drs William F. and Virginia Connolly Mitty Professor Edited by and Head of the Division of Bioethics at New York University Langone Medical Center in New York City. He is the author or editor of 30 books and more than 550 papers in refereed journals. His most recent books are Smart Mice Not So Smart People (2006) and the Penn Guide to Bioethics (2009). Caplan and Arp

Robert Arp is co-editor of Contemporary Debates in (2009), author of Scenario Visualization: An Evolutionary Account of Creative Problem Solving (2008), and co-editor of Information and Living Systems: Edited by Philosophical and Scientific Perspectives (2011). Arthur L. Caplan and Robert Arp

Contemporary Debates in Bioethics Contemporary Debates in Philosophy

In teaching and research, philosophy makes progress through argumentation and debate. Contemporary Debates in Philosophy provides a forum for students and their teachers to follow and participate in the debates that ani- mate philosophy today in the western world. Each volume presents pairs of opposing viewpoints on contested themes and topics in the central subfields of philosophy. Each volume is edited and introduced by an expert in the field, and also includes an index, bibliography, and suggestions for further reading. The opposing essays, commissioned especially for the volumes in the series, are thorough but accessible presentations of opposing points of view.

1. Contemporary Debates in Philosophy of Religion edited by Michael L. Peterson and Raymond J. Vanarragon 2. Contemporary Debates in edited by Christopher Hitchcock 3. Contemporary Debates in Epistemology edited by Matthias Steup and Ernest Sosa 4. Contemporary Debates in edited by Andrew I. Cohen and Christopher Heath Wellman 5. Contemporary Debates in Aesthetics and the Philosophy of Art edited by Matthew Kieran 6. Contemporary Debates in Moral Theory edited by James Dreier 7. Contemporary Debates in edited by Robert Stainton 8. Contemporary Debates in Philosophy of Mind edited by Brian McLaughlin and Jonathan Cohen 9. Contemporary Debates in Social Philosophy edited by Laurence Thomas 10. Contemporary Debates in Metaphysics edited by Theodore Sider, John Hawthorne, and Dean W. Zimmerman 11. Contemporary Debates in Political Philosophy edited by Thomas Christiano and John Christman 12. Contemporary Debates in Philosophy of Biology edited by Francisco J. Ayala and Robert Arp 13. Contemporary Debates in Bioethics edited by Arthur L. Caplan and Robert Arp Contemporary Debates in Bioethics

Edited by Arthur L. Caplan and Robert Arp This edition first published 2014 © 2014 John & Sons, Inc. Wiley-Blackwell is an imprint of John Wiley & Sons, formed by the merger of Wiley’s global Scientific, Technical and Medical business with Blackwell Publishing. Registered Office John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial Offices 350 Main Street, Malden, MA 02148-5020, USA 9600 Garsington Road, Oxford, OX4 2DQ, UK The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK For details of our global editorial offices, for customer services, and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell. The right of Arthur L. Caplan and Robert Arp to be identified as the authors of the editorial material in this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. Library of Congress Cataloging-in-Publication Data Contemporary debates in bioethics / edited by Arthur L. Caplan, Robert Arp. p. ; cm. – (Contemporary debates in philosophy ; 13) Includes bibliographical references and index. ISBN 978-1-4443-3713-6 (cloth : alk. paper) – ISBN 978-1-4443-3714-3 (pbk. : alk. paper) I. Caplan, Arthur L. II. Arp, Robert. III. Series: Contemporary debates in philosophy ; 13. [DNLM: 1. Bioethical Issues. 2. Biomedical Research–ethics. 3. Genetic Enhancement–ethics. 4. Patient Rights–ethics. 5. Reproductive Techniques–ethics. WB 60] R724 174.2–dc23 2013006628 A catalogue record for this book is available from the British Library. Cover design by www.cyandesign.co.uk Set in 10/12pt Bembo by SPi Publisher Services, Pondicherry, India

1 2014 Contents

Notes on Contributors x Acknowledgments xiv General Introduction 1 References 8

Part 1 Are There Universal Ethical Principles That Should Govern the Conduct of Medicine and Research Worldwide? 13 Introduction 13 References 15 1 There Are Universal Ethical Principles That Should Govern the Conduct of Medicine and Research Worldwide 17 Daryl Pullman 2 There Are No Universal Ethical Principles That Should Govern the Conduct of Medicine and Research Worldwide 27 Kevin S. Decker Reply to Decker 36 Reply to Pullman 39

Part 2 Is It Morally Acceptable to Buy and Sell Organs for Human Transplantation? 43 Introduction 43 References 45 3 It Is Morally Acceptable to Buy and Sell Organs for Human Transplantation: Moral Puzzles and Policy Failures 47 Mark J. Cherry 4 It Is Not Morally Acceptable to Buy and Sell Organs for Human Transplantation: A Very Poor Solution to a Very Pressing Problem 59 Arthur L. Caplan Reply to Caplan 68 Reply to Cherry 70 Part 3 Were It Physically Safe, Would Human Reproductive Cloning Be Acceptable? 73 Introduction 73 References 76 5 Were It Physically Safe, Human Reproductive Cloning Would Be Acceptable 79 Katrien Devolder 6 Were It Physically Safe, Human Reproductive Cloning Would Not Be Acceptable 89 Stephen E. Levick Reply to Levick 98 Reply to Devolder 101 Part 4 Is the Deliberately Induced Abortion of a Human Pregnancy Ethically Justifiable? 105 Introduction 105 References 109 7 The Deliberately Induced Abortion of a Human Pregnancy Is Ethically Justifiable 111 Jeffrey Reiman 8 The Deliberately Induced Abortion of a Human Pregnancy Is Not Ethically Justifiable 120 Don Marquis Reply to Marquis 129 Reply to Reiman 132 Part 5 Is It Ethical to Patent or Copyright Genes, Embryos, or Their Parts? 137 Introduction 137 References 141 9 It Is Ethical to Patent or Copyright Genes, Embryos, or Their Parts 143 Lawrence M. Sung 10 It Is Not Ethical to Patent or Copyright Genes, Embryos, or Their Parts 152 David Koepsell Reply to Koepsell 162 Reply to Sung 164 Part 6 Should a Child Have the Right to Refuse Medical Treatment to Which the Child’s Parents or Guardians Have Consented? 167 Introduction 167 References 171 vi Contents 11 The Child Should Have the Right to Refuse Medical Treatment to Which the Child’s Parents or Guardians Have Consented 173 William J. Winslade 12 The Child Should Not Have the Right to Refuse Medical Treatment to Which the Child’s Parents or Guardians Have Consented 181 Catherine M. Brooks Reply to Brooks 192 Reply to Winslade 194 Part 7 Is Physician-Assisted Suicide Ever Ethical? 197 Introduction 197 References 201 13 Physician-Assisted Suicide Is Ethical 203 John Lachs 14 Physician-Assisted Suicide Is Not Ethical 213 Patrick Lee Reply to Lee 222 Reply to Lachs 225 Part 8 Should Stem-Cell Research Utilizing Embryonic Tissue Be Conducted? 229 Introduction 229 References 233 15 Stem-Cell Research Utilizing Embryonic Tissue Should Be Conducted 237 Jane Maienschein 16 Stem-Cell Research Utilizing Embryonic Tissue Should Not Be Conducted 248 Bertha Alvarez Manninen Joint Reply 259 Part 9 Should We Prohibit the Use of Chimpanzees and Other Great Apes in Biomedical Research? 261 Introduction 261 References 268

17 We Should Prohibit the Use of Chimpanzees and Other Great Apes in Biomedical Research 271 Jean Kazez 18 We Should Not Prohibit the Use of Chimpanzees and Other Great Apes in Biomedical Research 281 Carl Cohen

Contents vii Reply to Cohen 291 Reply to Kazez 294

Part 10 Should the United States of America Adopt Universal Healthcare? 297 Introduction 297 References 301 19 The United States of America Should Adopt Universal Healthcare 303 John Geyman 20 The United States of America Should Not Adopt Universal Healthcare: Let’s Try Freedom Instead 314 Glen Whitman Reply to Whitman 327 Reply to Geyman 331

Part 11 Is There a Legitimate Place for Human Genetic Enhancement? 335 Introduction 335 References 339 21 There Is a Legitimate Place for Human Genetic Enhancement 343 Nicholas Agar 22 There Is No Legitimate Place for Human Genetic Enhancement: The Slippery Slope to Genocide 353 Edwin Black Reply to Black 363 Reply to Agar 366

Part 12 Can There Be Agreement as to What Constitutes Human Death? 369 Introduction 369 References 374 23 There Can Be Agreement as to What Constitutes Human Death 377 James L. Bernat 24 There Cannot Be Agreement as to What Constitutes Human Death: Against Definitions, Necessary and Sufficient Conditions, and Determinate Boundaries 388 Winston Chiong Reply to Chiong 397 Reply to Bernat 399

viii Contents Part 13 Is There Ever a Circumstance in Which a Doctor May Withhold Information? 401 Introduction 401 References 407 25 There Are Circumstances in Which a Doctor May Withhold Information 409 Tom L. Beauchamp 26 There Are No Circumstances in Which a Doctor May Withhold Information 418 Jason T. Eberl Reply to Eberl 428 Reply to Beauchamp 431

Part 14 Should In Vitro Fertilization Be an Option for a Woman? 435 Introduction 435 References 439 27 In Vitro Fertilization Should Be an Option for a Woman 441 Laura Purdy 28 In Vitro Fertilization Should Not Be an Option for a Woman 451 Christopher Tollefsen Reply to Tollefsen 460 Reply to Purdy 462

Part 15 Are International Clinical Trials Exploitative? 465 Introduction 465 References 470 29 Clinical Trials Are Inherently Exploitative: The Likelihood That They Are Is High 473 Jamie Carlin Watson 30 International Clinical Trials Are Not Inherently Exploitative 485 Richard J. Arneson Reply to Arneson 495 Reply to Watson 498

Index 501

Contents ix Notes on Contributors

Nicholas Agar, Ph.D., is Reader in Philosophy at Tom L. Beauchamp, Ph.D., is Professor of Philo­ Victoria University of Wellington, New Zealand. He sophy and Senior Research Scholar, Kennedy Institute is interested in ethical issues arising out of human of Ethics, Georgetown University. His research inter- enhancement. His most recent book on this topic ests are in the ethics of human-subjects research, the is Humanity’s End: Why We Should Reject Radical ethics of animal-subjects research and human uses of Enhancement (2010). animals, the place of universal principles and rights in biomedical ethics, methods of bioethics, Hume and Richard J. Arneson, Ph.D., holds the Valtz the history of , and business ethics. Family Chair in Philosophy in the Department of Philosophy at the University of California, San James L. Bernat, M.D., is the Louis and Ruth Frank Diego. His recent current research is on distributive Professor of Neuroscience, and Professor of Neurology . Some of this work explores how one might and Medicine at the Geisel School of Medicine best incorporate a reasonable account of personal at Dartmouth. He is a neurologist at Dartmouth- responsibility into a broadly egalitarian theory of jus- Hitchcock Medical Center where he directs the tice. He also considers how consequentialist morality program in clinical ethics. [email protected]. (one ought always to do an act the consequences of which are no worse than those of any alternative Edwin Black is the award-winning, New York Times- available act) might be developed in a version that is bestselling and international investigative author of appealing and appropriately responsive to its critics. 80 award-winning editions in 14 languages in 65 This latter project involves exploring the structure countries, as well as scores of newspaper and maga- of moderate deontology to identify the best rival of zine articles in the leading publications of the United consequentialism. States, Europe, and Israel. With more than a million books in print, his work focuses on genocide and hate, Robert Arp, Ph.D., is author of Scenario Visualization: corporate criminality and corruption, governmental An Evolutionary Account of Creative Problem Solving misconduct, academic fraud, philanthropic abuse, oil (2008), co-editor with George Terzis of Information addiction, alternative energy, and historical inves- and Living Systems: Philosophical and Scientific Pers­ tigation. For his award-winning eugenic work, War pectives (2011), co-editor with Francisco Ayala of Against the Weak: Eugenics and America’s Campaign to Contemporary Debates in Philosophy of Biology (Wiley- Create a Master Race, he has received the Justice for All Blackwell, 2009), and co-editor with Alex Rosenberg Award, the International Human Rights Award, and of Philosophy of Biology: An Anthology (Wiley- numerous other citations. Blackwell, 2009), and he has interests in bioethics as well. He works as a data analyst and modeler (see Catherine M. Brooks, J.D., is a professor of law www.robertarp.webs.com). at Creighton University in Omaha, Nebraska, ­specializing in children’s and family law. She is the Winston Chiong, M.D., Ph.D., is a clinical fellow­ co-founder of the Creighton Center for the Study of in the University of California, San Francisco Children’s Issues and co-editor of the Nebraska Juvenile Department of Neurology, and is a postdoctoral Court Procedures Manual. She has numerous publi- research fellow in the Helen Wills Neuroscience cations in peer-reviewed journals and law reviews. Institute at the University of California, Berkeley. Professor Brooks provides consultations to family His current research encompasses neuroscientific law practitioners, child advocacy groups, and other and conceptual methods to investigate changes in social-service organizations, particularly in ­matters decision-making, moral agency, and personhood in involving child custody disputes and child protec- the context of neurological illness. tion. She earned her law degree from the University of Virginia and her bachelor’s and master’s degrees Carl Cohen, Ph.D., is Professor of Philosophy at from Thomas More College of Fordham University the University of Michigan, and co-author (with and the Graduate School of Arts and Sciences of Tom Regan) of The Animal Rights Debate (2001). He Fordham University. Her current work focuses on the was for years a member of the Animal Care and Use use of mediation and negotiation in resolving disputes Committee of the Pfizer Corporation, and has served within families and between families and state protec- for decades on the Institutional Review Board of the tion agencies. University of Michigan Medical Center in Ann Arbor. Arthur L. Caplan, Ph.D., is the Drs William F. and Kevin S. Decker, Ph.D., is Associate Professor of Virginia Connolly Mitty Professor and founding Philosophy and Associate Dean of the College of Arts head of the Division of Bioethics at New York and Letters at Eastern Washington University near University Langone Medical Center in New York Spokane, Washington. His areas of research interest City. Prior to coming to NYU, he was the Sidney include American pragmatism, social and political D. Caplan Professor of Bioethics at the University theory, and applied ethics. He is the co-editor of three of Pennsylvania Perelman School of Medicine books on philosophy and popular culture. in Philadelphia where he created the Center for Katrien Devolder, Ph.D., is Senior Research Fellow Bioethics and the Department of Medical Ethics. at Bioethics Institute Ghent at Ghent University. Her He is the author or editor of 30 books and over 550 research interests include medical ethics (in particular, papers in refereed journals. His most recent books are the ethics of cloning), stem-cell research, genetic Smart Mice Not So Smart People (2006) and the Penn selection, chemical castration, and medical complicity Guide to Bioethics (2009). in others’ wrongdoing. Mark J. Cherry, Ph.D., is the Dr Patricia A. Jason T. Eberl, Ph.D., is Associate Professor and Hayes Professor in Applied Ethics and Professor of Graduate Director of Philosophy in the Indiana Philosophy at St. Edward’s University. He earned University School of Liberal Arts at Indiana his undergraduate degree in philosophy from the University-Purdue University, Indianapolis. He is University of Houston and his doctorate degree also an affiliate faculty member of the IU Center in philosophy from Rice University in Houston, for Bioethics and the IUPUI Medical Humanities & Texas. His research compasses ethics and bioethics, Health Studies program. He has published articles and together with social and political philosophy. He is reviews in American Journal of Bioethics, Bioethics, Journal author of Kidney for Sale by Owner: Human Organs, of Medicine and Philosophy, National Catholic Bioethics Transplantation and the Market (2005) as well as editor Quarterly, and Linacre Quarterly. His book Thomistic of The Journal of Medicine and Philosophy, associate Principles and Bioethics was published in 2006. senior editor of Christian Bioethics, Editor-in-Chief of HealthCare Ethics Committee Forum, co-editor of John Geyman, M.D., is Professor Emeritus of Family the book series The Annals of Bioethics, and editor of Medicine at the University of Washington School the book series Philosophical Studies in Contemporary of Medicine, where he chaired the Department of Culture. Family Medicine from 1976 to 1990. He has also

Notes on Contributors xi practiced family medicine in rural communities for siege engines and battlements in his debate with 13 years, edited family-medicine journals for 30 years, Dr Devolder on the issue in this volume. served as president of Physicians for a National Health Jane Maienschein, Ph.D., is Regents’ Professor, Program from 2005 to 2007, and is a member of the President’s Professor, and Parents Association Profes­ Institute of Medicine. His books include The Corporate sor at Arizona State University, where she serves as Transformation of Health Care: Can the Public Interest Still Director of the Center for Biology and Society. She Be Served? (2004), The Corrosion of Medicine: Can the is also Adjunct Scientist and Director of the History Profession Reclaim Its Moral Legacy? (2008), and Health and Philosophy of Science Program at the Marine Care Wars: How Market Ideology and Corporate Power Are Biological Laboratory in Woods Hole, Massachusetts. Killing Americans (2012). An MBL-ASU/HPS collaboration includes the Jean Kazez, Ph.D., is Adjunct Assistant Professor of Embryo Project (embryo.mbl.edu), HPS Repository, Philosophy at Southern Methodist University. She is and Digital HPS Consortium. She is (co)editor of a the author of Animalkind: What We Owe to Animals dozen books and author of three, including Whose (2010) and The Weight of Things: Philosophy and the View of Life? Embryos, Cloning, and Stem Cells with Good Life (2007), both published by Wiley-Blackwell. Harvard University Press. David Koepsell, Ph.D., earned his law degree Bertha Alvarez Manninen, Ph.D., is an associate and Ph.D. in philosophy from the University at professor of philosophy at Arizona State University’s Buffalo. He teaches ethics in the Philosophy Section, West campus. Her primary area of research is bioethics Faculty of Values and Technology, Delft University with an emphasis on the moral status of embryos and of Technology, The Netherlands. He has published fetuses. Other interests include philosophy of religion, widely on the philosophy of intellectual property, ancient philosophy, social and political philosophy, applied ethics, , and civil rights (see http:// and philosophy and film. davidkoepsell.com). Don Marquis, Ph.D., is Professor of Philosophy at John Lachs, Ph.D., is Centennial Professor of Philo­ The University of Kansas. His essay “Why Abortion is sophy at Vanderbilt University. His latest book, Stoic Immoral” was published in The Journal of Philosophy in Pragmatism (Indiana University Press), has just appeared. 1989 and has been reprinted over 90 times. Patrick Lee, Ph.D., holds the John N. and Jamie D. Daryl Pullman, Ph.D., is a professor of medical ethics McAleer Chair of Bioethics, and is the Director of in the Faculty of Medicine, at Memorial University in the Institute of Bioethics, at Franciscan University of Newfoundland and Labrador, Canada. He has pub- Steubenville. He has published widely on bioethics, lished widely on issues in clinical and research ethics. including written articles and books on bioethics, Laura Purdy, Ph.D., is Professor Emerita of including Body-Self Dualism in Contemporary Ethics and Philosophy at Wells College. Her research has focused Politics (with Robert P. George, 2007), Abortion and primarily on issues in reproduction and family. Unborn Human Life (2010). Jeffrey Reiman, Ph.D., is the William Fraser Stephen E. Levick, M.D., is a clinical assistant pro- McDowell Professor of Philosophy at American fessor of psychiatry at the University of Pennsylvania University in Washington, DC. He is the author of In School of Medicine, where he supervises psycho- Defense of Political Philosophy (Harper & Row, 1972), therapy, and has his own private practice nearby. His Justice and Modern Moral Philosophy (1990), Critical book, Clone Being: Exploring the Psychological and Social Moral Liberalism: Theory and Practice (1997), The Death Dimensions (2004), was described by cloning pioneer, Penalty: For and Against (with Louis Pojman, 1998), Ian Wilmut, as “the first framework for detailed anal- Abortion and the Ways We Value Human Life (1999), ysis of the ethical, psychological, and social conse- The Rich Get Richer and the Poor Get Prison: Ideology, quences of human reproductive cloning.” He employs Class, and Criminal Justice (with Paul Leighton, 2012), arguments generated from that framework as both As Free and As Just as Possible: The Theory of Marxian xii Notes on Contributors Liberalism (Wiley-Blackwell, 2012), and more than scholar with the Cato Institute. He received his Ph.D. 120 articles in philosophy and criminal justice jour- in economics from New York University in 2000. His nals and anthologies. research in applied game theory, economic analysis of law, and economic methodology has appeared in the Lawrence M. Sung, J.D., Ph.D., is a Partner with the Journal of Legal Studies, UCLA Law Review, Journal of law firm of Baker & Hostetler LLP in the Washington, Economic Behavior and Organization, and other schol- DC office, specializing in biotechnology, pharmaceu- arly journals. His current research interests include tical, and medical device patent litigation, counseling, healthcare and paternalistic legislation. and technology transfer. Dr Sung is also a professor and the Director of the Intellectual Property Law William J. Winslade, J.D., Ph.D., Ph.D., is James Program at the University of Maryland School of Wade Rockwell Professor of Philosophy of Medicine, Law in Baltimore, MD. He may be contacted at Professor of Preventive Medicine and Community [email protected] or [email protected]. Health, and Professor of Psychiatry and Behavioral Sciences, and is a member of the Institute for the Christopher Tollefsen, Ph.D., is Professor of Medical Humanities at the University of Texas Medical Philosophy at the University of South Carolina; he Branch, Galveston, Texas. He is also Distinguished has twice been a visiting fellow in the James Madison Visiting Professor of Law at the University of Houston Program at Princeton University. He has published Health Law and Policy Institute. Philosophic, legal, over 60 articles, book chapters, and reviews on and psychoanalytic ideas are applied in his work to ­bioethics and natural law ethics, and is the author, the study of human values in science, medicine, tech- co-author, or editor of five recent books, including nology, and law. His book Confronting Traumatic Brain Biomedical Research and Beyond: Expanding the Ethics of Injury: Devastation, Hope and Healing was published in Inquiry (2012) and, with Robert P. George, Embryo: A 1998. He has co-authored three other books: Clinical Defense of Human Life (2011). He has recently com- Ethics: A Practical Approach to Ethical Decisions in Clinical pleted a book manuscript, provisionally titled Truth, Medicine, Sixth Edition (2006), written for health pro- Lies, and the Natural Law: Why Lying for a Good Cause fessionals; The Insanity Plea: The Uses and Abuses of The is Always Wrong. Tollefsen sits on the editorial board of Insanity Defense (1983), written for a general audience; a number of journals and is the editor of the Springer and Choosing Life and Death (1986), written for patients book series, Catholic Studies in Bioethics. and their families as well as health professionals about Jamie Carlin Watson, Ph.D., is Assistant Professor of medical–moral–legal–technological topics such as Philosophy at Young Harris College (Young Harris, kidney dialysis, organ transplantation, treatment or GA). With Robert Arp, he is the author of Critical non-treatment of damaged newborns, termination Thinking: An Introduction to Reasoning Well (2011), of life support, genetic screening and counseling, and Philosophy DeMYSTiFied (2011), and What’s Good healthcare costs and policies. In addition, he has writ- on TV: Understanding Ethics Through Television (Wiley- ten numerous scholarly articles and essays for general Blackwell, 2011). He is currently working with Peter readers on topics such as privacy and confidentiality, Fosl and Galen Foresman on The Critical Thinker’s human rights, death and dying, and legal and eth- Toolkit (Wiley-Blackwell). ical aspects of mental-health practice. He is currently working on a book with Stacey Tovino, J.D., Ph.D., Glen Whitman, Ph.D., is a professor of economics at tentatively titled The Birth Life and Death of the Brain: California State University, Northridge and an adjunct Legal and Ethical Perspectives.

Notes on Contributors xiii Acknowledgments

Art wants to acknowledge the support of the New complete this book. Rob acknowledges the support of York University Langone Medical Center and its Dean, Jeff Dean at Wiley-Blackwell, who believed in the Robert Grossman, in giving him the opportunity to project in the first place. General Introduction

Who Is This Book for? Bioethics: Bridge to the Future (Potter, 1971). He subse- quently wrote Global Bioethics: Building on the Leopold This book features chapters written by contemporary Legacy, and in 1995 co-authored the article, “Global scholars doing work in the central topics of the branch Bioethics: Converting Sustainable Development to of applied ethics known as bioethics. The chapters are Global Survival” (Potter, 1971, 1988; Potter & Potter, presented in a debate style with yes and no responses— 1995). For both Jahr and Potter, what they referred to often qualified—to core contemporary quandaries in as “bioethics” would be considered today to be the the field. The book is intended to provoke discussion related branch of applied ethics known as environ- and debate for students in ethics, bioethics, and med- mental ethics. This area of ethics explores our relation- ical ethics classrooms in high school, college, and ship to the natural world, our duties to preserve and professional school. protect nature, and whether morality extends beyond humans to animals, other living things, and the entire biosphere itself (Attfield, 2003; Keller, 2010). What Is Bioethics? Bioethics, while keenly aware of the ways in which health is shaped by climate and the environment, The English word “bioethics” comes from two Greek is focused today mainly on humans and the issues words: bios (βίος) meaning “life” and ethikos (ἠθικός) that emerge in conducting biomedical and clinical meaning “displaying moral character.” In 1927, Fritz research, healthcare, and the policies that ought to Jahr used the term in an article, “Bio-Ethik: Eine govern medicine, nursing, allied health, and the related Umschau über die ethischen Beziehungen des biomedical sciences (Caplan, 1992b, 1994, 1997, 1998, Menschen zu Tier und Pflanze,” which can be trans- 2009; Jonsen et al., 2011). So, while the name “bio- lated as “Bio-Ethics: A Review of the Ethical ethics” derives from scholars seeking to create envi- Relationships of Humans to Animals and Plants” (Jahr, ronmental ethics, the history of bioethics is actually 1927; Sass, 2007; Goldim, 2009). In that article, Jahr rooted in medical ethics, a branch of applied ethics wanted to extend a “bioethical imperative” to all concerned with the practice of medicine and health- forms of life, arguing that we ought to treat other care (Ramsey, 1970; Katz, 1984; Veatch, 1989, 2011; humans and living things with respect as ends in and Pellegrino, 2008; Kuhse & Singer, 2009; Pence, 2010). of themselves (Kant, 1785/1998). In 1971, Van Given the close connection between bioethics and Rensselaer Potter also used the term in his book, medical ethics, some refer to the discipline as biomedical­

Contemporary Debates in Bioethics, First Edition. Edited by Arthur L. Caplan and Robert Arp. © 2014 John Wiley & Sons, Inc. Published 2014 by John Wiley & Sons, Inc. ethics (Beauchamp & Childress, 1979/2009; also ●● The Blackwell Guide to Medical Ethics, edited by Glannon, 2004; Mappes & DeGrazia, 2005). Leslie Francis, Anita Silvers, and Rosamond Rhodes (Blackwell, 2007); ●● The Penn Center Guide to Bioethics, edited by Vardit The Canon of Bioethics Ravitsky, Autumn Fiester, and Arthur L. Caplan (Springer, 2009); Bioethics has a subject matter and specific questions ●● Case Studies in Bioethics, edited by Robert Veatch, that it has developed near the end of the twentieth Amy Haddad, and Dan English (Oxford University century, and the topics that comprise this subject Press, 2009); matter include: ●● The Ethics of Research Biobanking, edited by Jan ●● abortion; Helge Solbakk, Soren Holm, and Bjorn Hofmann ●● contraception; (Springer, 2009); ●● cloning; ●● Trust and Integrity in Biomedical Research: The Case of ●● genetic engineering and enhancement; Financial Conflicts of Interest, edited by Thomas Murray ●● patenting genes and organisms; and Josephine Johnston (Johns Hopkins, 2010); ●● markets for human organs and tissues; ●● Progress in Bioethics: Science, Policy, and Politics, edited by ●● physician-assisted suicide; Jonathan Moreno and Sam Berger (MIT Press, 2010); ●● stem-cell research and therapies; ●● The Oxford Textbook of Clinical Research Ethics, ●● defining death; edited by Ezekiel Emanuel, Christine Grady, ●● in vitro fertilization and reproductive technologies; Robert Crouch, Reidar Lie, Franklin Miller, and ●● animal experimentation; David Wendler (Oxford University Press, 2011); ●● clinical trials; ●● A Companion to Bioethics, edited by Helga Kuhse ●● patients’ rights and informed consent; and Peter Singer (Wiley-Blackwell, 2011); ●● codes of ethics for healthcare professionals; ●● Global Justice and Bioethics, edited by Joseph Millum ●● psychosurgery and engineering the human brain; and Ezekiel Emanuel (Oxford University Press, 2012); ●● healthcare access and reform; ●● Also see the books in the Basic Bioethics series, ●● allocation and rationing of scarce medical resources. edited by Glenn McGee and Art Caplan (MIT Press, 1999 to present). Most of these topics are debated by the contributors to this book. Each core topic is described further in Journals: the introductions to each section, including relevant reading material. The reader should consult various ●● Bioethics; other resources in bioethics to get a sense of the scope ●● The Hastings Center Report; and breadth of view on the core topics such as: ●● Journal of Medical Ethics; ●● Journal of Medicine and Philosophy; Edited books and encyclopedias: ●● American Journal of Bioethics; ●● ●● Encyclopedia of Bioethics, edited by Warren Reich Kennedy Institute of Ethics Journal; (Macmillan, 1995); ●● Theoretical Medicine and Bioethics; ●● ●● Medical Ethics: Applying Theories and Principles to the Cambridge Quarterly of Healthcare Ethics; Patient Encounter, edited by Matt Weinberg and ●● Journal of Clinical Ethics. Arthur L. Caplan (Humanity Books, 2000); Bioethics centers maintain websites with useful ●● Encyclopedia of Bioethics, edited by Stephen Post information, including: (Macmillan, 2003); ●● Bioethics: An Anthology, edited by Helga Kuhse and ●● Columbia University Center for Bioethics: Peter Singer (Wiley-Blackwell, 2006); {{ http://www.bioethicscolumbia.org/ ●● The Oxford Companion to Bioethics, edited by Bonnie ●● The Hastings Center: Steinbock (Oxford University Press, 2007); {{ http://www.thehastingscenter.org/

2 Arthur L. Caplan and Robert Arp ●● Kennedy Institute of Ethics at Georgetown Code was devised and codified in response to the University: systematic abuse of human subjects in research. The {{ http://kennedyinstitute.georgetown.edu/ Code, which was in reality the decision in one of the ●● The University of Pennsylvania Center for trials of German doctors, includes basic biomedical Bioethics: principles related to human experimentation (clinical {{ http://www.bioethics.upenn.edu/ research) such as absence of coercion in recruiting ●● The Ethox Centre at the University of Oxford: subjects, the necessity of informed consent, non- {{ http://www.publichealth.ox.ac.uk/ethox/ maleficence toward participants in experiments, and ●● Centre for Human Bioethics at Monash the correct formulation of a scientific protocol University: (Weindling, 2004; Schmidt & Frewer, 2007; NIH, {{ http://arts.monash.edu.au/bioethics/ 2011a). ●● MacLean Center for Clinical Medical Ethics at It would seem that anyone who lived during the the University of Chicago middle of the twentieth century and was made aware {{ http://medicine.uchicago.edu/centers/ of the Nazi human experimentation would sympa- ethics/library.html thize with the Jewish slogan that refers to the atroc- ●● The Centre for Bioethics of the Clinical Research ities of the Holocaust and murder fueled by racism at the Institute of Montreal: and anti-Semitism: Never Again! However, the US and {{ http://www.ircm.qc.ca/Pages/IRCMDefault. the world were shocked to hear in 1972 that, for 40 aspx?PFLG=1036&lan=1036 years, an experiment monitoring the effects of syphilis ●● Berman Institute of Bioethics at Johns Hopkins upon poor, rural, and illiterate African-American University: men—who, having been lied to by researchers, thought {{ http://www.bioethicsinstitute.org/ they were being treated for the disease but in fact ●● The Brocher Foundation: were not—had been conducted by the US Public {{ http://www.brocher.ch/en/publications-1/ Health Service and Centers for Disease Control and Prevention. The Tuskegee Syphilis Experiment—so named because Tuskegee Institute was a willing Motivations for Topics in Bioethics ­participant—began as an observational study in 1932 with 600 African-American men, 399 with syphilis The core topics of bioethics oftentimes emerged as a and 201 without the disease. In 1972, when the study result of the moral outcry elicited by some highly pub- became known through whistle-blowing in the licized practice, event, or series of events in biomedi- media, 74 of the 600 men were still alive. Concerning cine or clinical research that actually (or potentially) the original 399 men with syphilis, 28 died of syphilis, harmed people, animals, or even the biosphere. In this and 100 died of syphilis-related complications, while respect, the topics in bioethics are no different than any 40 of their wives were infected with syphilis, and 19 ethical topic that has emerged in the course of human of their children were born with syphilis (Jones, 1992; history (Cavalier et al., 1989; MacIntyre, 1998). Reverby, 2009). What makes this experiment all the For example, the Nazi experimentation on humans more insidious is the fact that, by 1945, penicillin was that took place between 1939 and 1945, where peo- being mass-produced in the US to treat diseases like ple were subjected to various hazardous and horrific syphilis, and the infected men in the experiment experiments often designed to assist in the advance- easily could have been treated after 1945; and many ment of military medicine and the physician-directed lives would have been saved as well as much pain and racial euthanasia campaigns of the Nazis, raised many suffering avoided (Katz & Warren, 2011). questions about the ethics of those involved (Caplan, In response to the Tuskegee Syphilis Experiment as 1992a; Conot, 1993; Annas & Grodin, 1995; Lifton, well as increased public awareness of other unethical 2000; Spitz, 2005). During and after the Nuremberg experiments conducted in the US and in other coun- trials (1946–1949), where numerous Nazis were tried tries (Beecher, 1966), in 1974 the National Research for a variety of atrocious crimes, the Nuremberg Act (Pub. L. 93-348) of the US established the

General Introduction 3 National Commission for the Protection of Human with inventing the first kidney-dialysis machine (he Subjects of Biomedical and Behavioral Research also helped invent the artificial heart and heart–lung (1974–1978), and in 1979 the Commission issued a machine, as well as invented an artificial eye and ear, landmark document for biomedicine or clinical and the intra-aortic balloon pump), it was Belding research called, “The Belmont Report: Ethical Scribner who improved upon Kolff’s machine and Principles and Guidelines for the Protection of opened the first center devoted to dialysis, the Seattle Human Subjects of Research.” It was named “The Artificial Kidney Center, in 1962 (Pietzman, 2007; Belmont Report” for the Smithsonian Institution’s Brown, 2009). Since there were a limited number of Belmont Conference Center (Elkridge, MD) where machines in the center and many more patients who the Commission met in February of 1976 when first needed dialysis in order to live, ethical questions drafting the report (Childress et al., 2005; NIH, related to who should receive dialysis emerged imme- 2011b). The Belmont Report affirmed all of the basic diately (Jonsen, 2000, pp. 104–106; also Katz & bioethical principles found in the Nuremberg Code, Capron, 1982; Emanuel, 1991; Elger et al., 2008). as well as articulated other principles, including the Harvard medical researchers, Philip Drinker and principle of justice whereby “equals ought to be Louis Agassiz Shaw, invented the “iron lung” in 1927 treated equally.” The report called for peer review of to assist or restart breathing in individuals; but even all studies to insure that the risk/benefit ratio involved with John Emerson’s improvements on the mechanism made moral sense and that the informed consent of in 1931, iron lungs were big, bulky, and expensive to subjects was adequate. Unfortunately, there are operate. Simple, hand-operated, bag valve mask venti- numerous cases of unethical human experimentation lators began to be used by doctors and others in 1953; documented in the US and other countries but they suffered from the obvious problem of having throughout the twentieth century, and these cases to be constantly squeezed by someone (Gorman, 1979; form the basis for a central topic in bioethics (Moreno, Laurie, 2002; Ambu, 2011). In 1971, Siemens intro- 2000; Dresser, 2001; Goliszek, 2003; Guerrini, 2003; duced the medical world to a small, fairly quiet the papers in Hawkins & Emanuel, 2008). electronic ventilator—the SERVO 900—and various Scandal was not the only driver of bioethics. models soon became a staple in ERs, then in ambu- Controversy plays a key role in the development of lances, too (Maquet Critical Care, 2001, 2005). The the field as well. Although abortion has been practiced electronic ventilator now could be used to assist by numerous cultures throughout human history and someone in their breathing, potentially indefinitely, even can be traced to a Chinese medical text from the and this occurred regularly for people in comas. The reign of Shen Nung (2737–2696 bce), and although it extended use of a ventilator (usually in combination is true that, by 1970, scholars had already been with a feeding tube) has been the source of much debating the abortion issue as a result of increased rec- debate, and cases of people in persistent vegetative ognition of women’s reproductive rights, improve- states requiring ventilators and feeding tubes—such as ment in abortion technology, many ER instances of the widely publicized cases of Karen Ann Quinlan, bungled backroom abortions, and the American who lived with a feeding tube in a persistent vegetative Medical Association’s call to decriminalize abortion in state from 1975 to 1985, and Terri Schiavo, who lived the US (Noonan, 1970; Thomson, 1971; Warren, with a feeding tube in a persistent vegetative state from 1973), it was the landmark decision by the US 1990 to 2005—cause people to think about the extent Supreme Court to disallow many state and federal to which these biomedical technologies are ethically restrictions on abortion in Roe v. Wade (410 US 113) appropriate or not (Armstrong & Colen, 1988; in 1973 that brought bioethical attention to the Buchanan & Brock, 1990; Caplan et al., 2006). abortion issue (Jonsen, 1998; Joffe, 2009). And with By the end of the twentieth century, women were that attention, another topic in bioethics was giving birth to so-called “designer babies,” which is a solidified. negative term really, but refers to babies who have Technological innovation has also driven the emer- been born after having their embryos screened for gence of bioethics. Although Willem Kolff is credited ­genetic diseases through methods of pre-implantation

4 Arthur L. Caplan and Robert Arp genetic diagnosis (PGD). PGD requires in vitro ­contemporary bioethics. He was a medical doctor with ­fertilization (IVF) techniques to obtain the embryos a specialty in pathology who claimed to have assisted for the screening, and IVF itself is its own bioethical over 130 people with their own suicides. He invented topic surrounded by arguments and controversy and used the Thanatron (named after the Greek god (Cook-Deegan, 1996; Buchanan et al., 2000; Skloot, that personifies death, Thanatos), a device that allowed 2010). In 1990, Debbie Edwards gave birth to twin one to push a button that released deadly potassium girls in Hammersmith Hospital in London after hav- chloride into one’s body intravenously, and the ing been implanted with female embryos that had Mercitron, a device that employed a gas mask that been screened by Drs Alan Handyside and Norman could be filled with carbon monoxide to let people kill Winston utilizing methods of PGD. Given Edwards’ themselves (Kevorkian, 1988; Roscoe et al., 2000; medical history, there would have been a 50% chance Dowbiggin, 2003; Nicol & Wylie, 2005; Schoifet, 2011). that a baby boy would have developed brain damage The Hippocratic Oath is something that every and die young, so she turned to Handyside, Winston, medical school student knows about. The oath specif- and PGD to ensure that she would give birth to a ically asks the new doctor to promise ἐπὶ δηλήσeι δὲ baby girl (Maugh, 1990; Handyside et al., 1992). One καὶ ἀδικίῃ eἴρξeιν, “to refrain from doing harm” can imagine screening embryos so as to “design” the (AMA, 2001, 2004; Magner, 2005). So, when kind of child we want—affecting intelligence, height, Kevorkian assisted in the suicide of Janet Adkins in eye color, looks, etc.—so it is easy to see how the 1990 with the Thanatron—his first assisted suicide— moniker has been applied (see the papers in Savelescu many utilized the ethical obligation to “refrain from & Bostrom, 2009; Harris, 2007). doing harm” to condemn his actions (Kass, 1989; PGD has also been used to screen embryos when a Hartmann and & Meyerson, 1998; Somerville, 2001). mother wants to give birth to a child who can act as a Morally, it is one thing to assist in a suicide by “savior sibling” by providing a cell transplant to a providing the person who wishes to do so with sibling who suffers from a disease like anemia or leu- instruction and a device that they may activate on kemia. In 2000, a young girl named Molly Nash their own. It is ethically different if someone adminis- received stem cells from the umbilical cord of her ters a lethal injection seeking to kill a person. newborn brother (whose tissue type had been Kevorkian killed a severely disabled man, Thomas screened as an embryo), and the stem cells were suc- Youk, on September 17, 1998, and taped his behavior cessful in treating Nash’s Fanconi anemia (Wolf et al., for later broadcast on national television. His involve- 2003; Marcotty, 2010). ment in homicide resulted in a second-degree murder Still more fascinating, at the American Society for conviction and over 8 years of prison time (Johnson, Reproductive Medicine’s 2007 annual meeting, it was 1999). Still, many argue that Kevorkian’s lethal injec- announced that researchers used a virus to add a gene, tion was a sympathetic action, along the lines of the a green fluorescent protein, to an embryo left over Scottish doctor, John Gregory’s, claim—made in the from assisted reproduction (Zaninovic et al., 2007; beginning of the nineteenth century—that a doctor, CellNEWS, 2008). Many take this to be the first doc- like any other human being, needs to have a “sensi- umented case of genetic modification of a human bility of heart which makes us feel for the distresses of embryo. The kind of genetic engineering of the traits our fellow creatures, and which, of consequence, in these examples fits squarely as a key topic in the incites in us the most powerful manner to relieve realm of bioethics, as a question like, “Are doctors and them” (Gregory, 1817, p. 22). scientists justified in playing god or altering the course The 1972 play and 1981 movie by the same name, of nature with respect to living things, especially Whose Life is It Anyway?, is a fictional story about a human beings?” becomes front and center (see the man who becomes paralyzed from the neck down papers in Magnus et al., 2002). after a car accident and wants to end his own life, and Dr Jack Kevorkian died on June 3, 2011 at the he offers several arguments in favor of his position, age of 83. His actions caused the controversial topic including the “I have a right to do with my body what of ­physician-assisted suicide to be part and parcel of I want to” argument (also see Berg et al., 2001; Annas,

General Introduction 5 2004, 2011). This popular story was solidly planted in realms of professions, institutions, and public policy the American psyche when Dr Kevorkian assisted in generate ethical problems and dilemmas that are in Adkins’ suicide in 1990 and, not only did fiction need of solutions and resolutions (McGee, 1999; become reality, but a bioethical “hot-button” topic Cohen & Wellman, 2005; LaFollette, 2006). became fodder for discussion, dialogue, and debate. Figure 0.1 represents a partial taxonomic classification In this introduction, we could speak about the moti- of bioethics, and we are aware that there are many vations for all of the topics in bioethics, but because of other philosophical disciplines and sub-disciplines not space limitations, we are unable to do so. Bioethics has shown, as well as that it is possible to classify the disci- a varied and complex history that would take several pline of Western philosophy by historical time periods lifetimes to ingest completely, but a great place to start or major movements. Also, note that the figure attempts is with Albert Jonsen’s The Birth of Bioethics (Jonsen, to represent the idea that bioethics could also be called 1998) and Vincent Barry’s Bioethics in a Cultural Context: biomedical ethics, and that medical ethics could be Philosophy, Religion, History, Politics (Barry, 2012). considered a species of bio(medical)ethics.

The Classification of Bioethics A Philosophical Discipline

Concerning its classification within the general disci- Although doctors, nurses, clinicians, lawyers, biologists, pline of Western philosophy, bioethics is usually envi- theologians, and other researchers make valuable con- sioned as a branch of applied or practical ethics, along tributions to it, bioethics is first and foremost a with environmental ethics, business ethics, legal ethics, philosophical discipline concerned with “issues that engineering ethics, and cyberethics (there are others). emerge in conducting biomedical and clinical research, Applied ethics, metaethics, and normative ethics are healthcare, and the policies that ought to govern med- branches of ethics or moral philosophy, and ethics, icine, nursing, allied health, and the related biomedical political philosophy, metaphysics, epistemology, and sciences,” as we noted in the definition of bioethics logic are understood to be the classical branches of above. And we also saw that bioethics is a branch of Western philosophy (Copleston, 1994; Jones, 1997; applied ethics, which is a branch of ethics, itself a Solomon, 2005). Metaethics deals with issues such as branch of Western philosophy; thus, if the classification the nature of moral knowledge, the proper grounds is correct, the basic features, properties, and character- for justifying moral claims, the metaphysical/ istics of Western philosophy should be present in bio- ontological status of moral norms and entities, and ethics. This means that the principles of correct cultural and ethical relativism (Bok, 2002; Jacobs, reasoning and logic trumpeted and championed by the 2002; Miller, 2003; for a discussion of relativism in philosopher—including the formation of sound or relation to bioethics, see Macklin, 1999). Normative cogent arguments, complete with objective evidence ethics deals primarily with the development, investiga- that any rational person could assent to—should not tion, and critique of various ethical/moral theories only act as the primary tool utilized in discussing the such as religious-based deontology, ethical egoism, topics in bioethics, but also provide thinkers with a Kantian deontology, utilitarianism, natural rights level playing field, so to speak, where ideas and argu- theory, and (Kagan, 1997; Fieser, 1999; ments can be respectfully explained, analyzed, debated, Pojman, 2005; Kamm, 2006; for application of nor- evaluated, and critiqued. Anyone, regardless of ide- mative ethical theories specifically to bioethics, see ology, world view, or perspective, is welcome to play Pellegrino & Thomasma, 1981; Powers & Faden, on the field, provided they play by the rules of correct 2006; Veatch, 2011). As the name suggests, applied ethics reasoning and logic. Beauchamp and Childress is primarily concerned with the application of eth- (1979/2009) affirm this philosophical approach in the ical/moral theory to practice insofar as the actions first chapter of their famous work in bioethics, Principles and interactions of humans (as well as the interactions of Biomedical Ethics, as does H. Tristram Engelhardt of humans with animals and the biosphere) in the (1986/1996) in the first two chapters of his book, The

6 Arthur L. Caplan and Robert Arp Western philosophy

Political Ethics Metaphysics Epistemology Logic philosophy

Normative Applied Metaethics ethics ethics

– Nature of moral – Development, – Application of knowledge investigation, and Business moral theory to – Proper grounds critique of moral ethics practice for moral claims theories, e.g.: – Realm of actual – Metaphysical professions, – Egoism status of moral institutions, and – Deontology Environmental norms and public policy – Utilitarianism ethics entities – Solving real – Natural rights – Cultural and ethical problems – Virtue ethics ethical relativism Legal and dilemmas ethics

Cyberethics

Engineering ethics Bio (medical) ethics

Medical ethics

Figure 0.1 Bioethics classified

Foundations of Bioethics. Of course, as Dan Brock (1993, ethics—abortion, suicide, stem-cell research, the allo- pp. 414–416) notes in the final pages of his book, Life cation of scarce vital organs, and socialized medicine, and Death: Philosophical Essays in Biomedical Ethics, phi- for example, are “hot-button” issues for most losophers have a bad reputation as being “unrealistic, Americans (see Steinbock, 1996; Caplan & Coelho, head in the clouds, ivory tower academics;” however, 1998; Meisel & Cerminara, 2004; Angell, 2005; as Brock also notes, philosophers have made important Callahan & Wasunna, 2006; George & Tollefsen, 2008; contributions to bioethics and the public policies gen- Callahan, 2009). While it is important to be sensitive erated from this important discipline. to these emotions, the bottom line is that reason motivated by a sincere desire to find common moral ground ought to drive bioethical reflection and Dealing with Hot-Button Issues discussion. One of the authors in this book, Jeffrey Reiman, puts the point a little differently in his The topics discussed in bioethics are some of the most chapter defending abortion: “People’s moral beliefs emotionally charged of all of the disciplines in applied may be influenced by emotions, affections, and fears,

General Introduction 7 which may distort people’s judgment so that they Beecher, H. (1966). Ethics and clinical research. New England believe what is not rationally grounded … We want Journal of Medicine, 274, 1354–1360. an answer (to a moral question) that we have good Berg, J., Applebaum, P., Lidz, C., & Parker, L. (2001). Informed reason to believe is true; and we must recognize that consent: Legal theory and clinical practice. Princeton, NJ: what people actually believe may be false.” The reader Princeton University Press. Bok, S. (2002). Common values. Columbia, MO: University will see that the chapters of this book have been writ- of Missouri Press. ten by philosophers and other thinkers who engage in Brock, D. (1993). Life and death: Philosophical essays in biomed- the debates adhering to the principles of correct ical ethics. Cambridge: Cambridge University Press. reasoning and logic—or, at least they attempt to Brown, D. (2009). Doctor invented kidney dialysis machine, adhere to them, and are called out by an interlocutor artificial organs. The Washington Post. February 13. Retrieved when they violate a principle. from: http://www.washingtonpost.com/wp-dyn/content/ We hope that students and scholars of bioethics alike article/2009/02/12/AR2009021203610.html will benefit from the material in this book. Best in your Buchanan, A., & Brock, D. (1990). Deciding for others: The reading, research, reflection, thinking, and bioethical ethics of surrogate decision making. Cambridge: Cambridge decision-making.—Art Caplan and Robert Arp University Press. Buchanan, A., Brock, D., Daniels, N., & Wikler, D. (2000). From chance to choice: Genetics and justice. Cambridge: Cambridge University Press. References Callahan, D. (2009). Taming the beloved beast: How medical technology costs are destroying our health care system. Princeton, AMA (American Medical Association). (2001). Principles of NJ: Princeton University Press. medical ethics. Retrieved from: http://www.ama-assn. Callahan, D., & Wasunna, A. (2006). Medicine and the market: org/ama/pub/physician-resources/medical-ethics/code- Equity v. choice. Baltimore, MD: Johns Hopkins University medical-ethics/principles-medical-ethics.page? Press. AMA (American Medical Association). (2004). Code of Caplan, A. (Ed.). (1992a). When medicine went mad: Bioethics medical ethics: Current opinions with annotations of the and the Holocaust. Totowa, NJ: Humana Press. Council on Ethical and Judicial Affairs. Retrieved from: Caplan, A. (1992b). If I were a rich man could I buy a pancreas? http://www.ama-assn.org/go/ceja and other essays on the ethics of health care. Indianapolis: Ambu. (2011). Ambu’s history. Retrieved from: http://www. Indiana University Press. ambu.co.uk/uk/about_ambu_ltd/ambu´s_history.aspx Caplan, A. (1994). Moral matters: Ethical issues in medicine and Angell, M. (2005). The truth about drug companies: How they the life sciences. Hoboken, NJ: John Wiley & Sons. deceive us and what to do about it. New York: Random Caplan, A. (1997). Due consideration: Controversy in the age of House. medical miracles. Hoboken, NJ: John Wiley & Sons. Annas, G. (2004). The rights of patients: The authoritative ACLU Caplan, A. (1998). Am I my brother’s keeper? The ethical frontiers guide to the rights of patients. Carbondale, IL: Southern of biomedicine. Indianapolis: Indiana University Press. Illinois University Press. Caplan, A. (2009). Smart mice, not-so-smart people: An inter- Annas, G. (2011). Worst case bioethics: Death, disaster, and public esting and amusing guide to bioethics. New York: Rowman & health. Oxford: Oxford University Press. Littlefield. Annas, G., & Grodin, M. (Eds.). (1995). The Nazi doctors and Caplan, A., & Coelho, D. (Eds.). (1998). The ethics of organ trans- the Nuremberg code: Human rights in human experimentation. plants: The current debate. Amherst, NY: Prometheus Books. Oxford: Oxford University Press. Caplan, A., McCartney, J., & Sisti, D. (Eds.). (2006). The case Armstrong, P., & Colen, B. (1988). From Quinlan to Jobes: of Terri Schiavo: Ethics at the end of life. Amherst, NY: The courts and the PVS patient. The Hastings Center Prometheus Books. Report, 18(1), 37–40. Cavalier, R., Gouinlock, J., & Sterba, J. (Eds.). (1989). Ethics Attfield, R. (2003). Environmental ethics: An overview for the in the history of Western philosophy. New York: Palgrave twenty-first century. Cambridge: Polity Press. Macmillan. Barry, V. (2012). Bioethics in a cultural context: Philosophy, reli- CellNEWS (2008). Genetically modified human embryo gion, history, politics. Belmont, CA: Wadsworth. stirs controversy. CellNEWS. May 27. Retrieved from: Beauchamp, T., & Childress, J. (1979/2009). Principles of bio- http://cellnews-blog.blogspot.com/2008/05/­ medical ethics. Oxford: Oxford University Press. genetically-modified-human-embryo-stirs.html

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General Introduction 11

Part 1 Are There Universal Ethical Principles That Should Govern the Conduct of Medicine and Research Worldwide?

Introduction

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

Contemporary Debates in Bioethics, First Edition. Edited by Arthur L. Caplan and Robert Arp. © 2014 John Wiley & Sons, Inc. Published 2014 by John Wiley & Sons, Inc. contradictory medical and biomedical practices ­arguments against FGM appeal to Kant and/or Mill, worldwide that can be pointed to as examples of the in one form or another (Nussbaum, 1999; Cohen fact that there seem not to be universal ethical prin- et al., 1999; Wallis, 2005; Bikoo, 2007; Burkhardt ciples governing these practices (Young, 2006; and Nathaniel, 2008; cf. Lander, 1999). The Unschuld, 2009; Caplan, 2010). principles emerging from these theories were affirmed A cultural anthropologist, sociologist, psychologist, in the Nuremberg Code (1946–1949), The Belmont or any other researcher can look at medical and Report (1979), and Tom Beauchamp and James ­biomedical practices worldwide and note descriptively Childress’ famous work, Principles of Biomedical Ethics that it is the case that there are not universal ethical (NIH, 2011a, 2011b; Beauchamp and Childress, principles governing these practices. Although, we 1979/2009), which has become a standard reference must be cautious here since many thinkers who have work for medical and other bioethical decisions. Given argued for one version or another of soft universalism the wide rational appeal and application of these have attempted to show that there are in fact a handful ­principles to multiple practical issues—bioethical or of universal ethical principles in existence, but that ­otherwise—along with their success in application in these principles make themselves manifest in culturally terms of conflict resolution and just policy making in grounded ways, giving the mere appearance of being numerous countries, it can be argued that they are the relative (Foot, 1979/2002; Nussbaum, 1993; Walzer, types of universal ethical principles that should govern 1994; Bok, 2002; Miller, 2002). In any event, the bio- the conduct of medicine and research worldwide. ethician (and any other thinker, for that matter), as phi- In fact, in the first chapter of this section Daryl losopher, can look at medical and biomedical practices Pullman affirms what he calls the principle of respect worldwide and question whether prescr­ iptively there for human dignity, which he argues is present most should be universal ethical principles governing these clearly in Kant’s moral philosophy and acts as the practices. Consider FGM again. The number of good foundation for any moral decision. Thus, it is arguments against FGM that appeal to (ostensibly) Pullman’s ­contention that not only is a respect for universalizable principles of autonomy, beneficence, human dignity ­actually at work universally in moral and nonmaleficence would seem to suggest that prac- decision-making (descriptively), but also that it titioners of FGM either are unaware of these princi- should be at work ­universally in moral decision-mak- ples, knowingly disregarding them, or may be pressured ing (prescriptively) (also see Walzer, 1994; Macklin, into disregarding them due to cultural or religious 1999; Bok, 2002). “Our concept of morality is pred- factors (Nussbaum, 1999; Cohen, Howard, and icated on the assumption of the intrinsic moral Nussbaum, 1999; Gruenbaum, 2001). In other words, worth or dignity of humanity,” Pullman notes, and it can be argued that these ethical principles (and laws the “essence of morality is to guard, protect, and emerging from them) should be guiding medical prac- advance this fundamental value.” To bolster his posi- tice worldwide such that FGM stops occurring alto- tion, Pullman appeals to a well-known strategy that gether, no matter what the culture or social situation. has been used against proponents of ethical rela- ’s (1724–1804) deontological moral tivism who think that it is not possible for one group, theory, with its emphasis upon autonomy, respect society, or culture to criticize morally the actions of for persons, and blind justice, as well as John Stuart another group, society, or culture (see Harman, Mill’s (1806–1873) utilitarian moral theory, with its 1975/2000, 1984/2000, 1996), namely, without at emphasis upon bringing about the most nonharmful least the principle of respect for human dignity, there (and hence, pleasurable) and beneficial conse­quences to is “no way to measure moral progress or regress, and a person (or sentient being) affected by an action, have no basis for judging the actions of other nations, acted as the basis for practical moral ­decision-making social groups, or even individuals as either morally since the theories were formulated in the eighteenth praiseworthy or blameworthy.” and nineteenth centuries (Kant, 1785/1998; Mill, “It might seem surprising to demand of ethical 1861/2001; Korsgaard, 1996; Baron, 1999; Hooker, principles that they be universal, given that most 2000). And many of the standard philosophical moral decision-making will concern those fairly close

14 Introduction