VIBS

Volume 165

Robert Ginsberg
Founding Editor

Peter A. Redpath
Executive Editor

Associate Editors

G. John M. Abbarno Laura D

Mary-Rose Barral Joseph
Gerhold K. Becker Mark L
Raymond Angelo Belliotti Vincen
Kenneth A. Bryson Alan M
C. Stephen Byrum George
H. G. Callaway Jon Mil
Robert A. Delno Alan R
Rem B. Edwards Arleen
William Gay John R.
Dane R. Gordon Eddy S
J. Everet Green Tuija T
Heta Aleksandra Gylling Oscar V
Matti Hyry Anne W
Steven V. Hicks John R.
Richard T. Hull Thoma

a volume in
Values in Bioethics
ViB
Matti Hyry and Tuija Takala, Edit
 Matti Hyry, Tuija Takal
and Peter Herissone-Kelly, E

Amsterdam - New York, NY 2005

Cover Design: Studio Pollmann

The paper on which this book is printed meets the requ

9706:1994, Information and documentation - Paper for
Requirements for permanence.

ISBN: 90-420-1655-8
Editions Rodopi B.V., Amsterdam - New York, NY 2
Printed in the Netherlands
Foreword by John Harris

Preface

Introduction The Social Reality of Bioethics

MATTI HYRY, TUIJA TAKALA,
AND PETER HERISSONE-KELLY
1. What is Social Reality?
2. Classical Concerns
3. Developments
4. Facts, Ideals, and Approaches
5. Responsibility and Risk Taking
6. Educational Concerns
7. Blessed Confusion?

ONE The Case of Back-Street Abortion

HARRY LESSER
1. The Argument from Back-Street Ab
2. The First Element in the Argument:
Should Reflect Actual Positive
3. Back-Street Abortion as Unregulated
4. The Effectiveness of Laws Against A
5. The Bad Consequences of Making A
6. The Anti-Abortionists Reply

TWO Suicide, Self-Sacrifice, and the Duty to D

DORIS SCHROEDER
1. Duty to Die?
2. Suicide and Altruism
3. Suicide and Physician-Assisted Suic
4. Physician-Assisted Suicide and Altr
5. Conclusion

THREE Forget Autonomy and Give Me Freedom

MATTI HYRY
1. The Questions
2. What is Freedom?
3. Why Should Freedom be Respected?
FOUR Choosing Between Claims: Allocating P
in Surrogacy Disputes
MONIQUE JONAS
1. Introduction
2. Genetic Contributions
3. Labor
4. Contracts and Promises
5. Conclusion

FIVE The Many Wrongs of Human Reproduct

TUIJA TAKALA
1. Cloning, an Absolute Wrong?
2. What is Cloning?
3. Is Cloning Humans Against Human
4. Is Uniqueness Threatened by Human
5. Is Cloning Treating People as a Mer
6. Dangers and Other Costs
7. Cloning as Rights Satisfaction, and
Benefits of Human Reproductiv
8. Cast Shadows? Denied Ignorance? C
9. Odds and Ends
10. Surprisingly Little Wrong, But Stil

SIX The Problem of Intangibles

LOUISE IRVING
1. Introduction
2. The Case for Commerce
3. Logic Versus Intuition
4. The Tendency toward Commodifica
5. Freedom as Non-Interference
6. Universal Principles in an Unjust W
7. A Less Ethically Problematic Optio
8. Conclusion

SEVEN Mind the Gap: The Use of Empirical Ev

EVE GARRARD AND STEPHEN WIL
1. Introduction
2. The Fact-Value Gap
 9. Conclusion

EIGHT Informed Consent: Bioethical Ideal and E

ANGUS DAWSON
1. Introduction
2. What is Informed Consent?
3. Informed Consent as Bioethical Idea
4. Informed Consent: The Empirical R
5. What Should We Do Now?
6. Conclusion

NINE What Empirical Bioethics Can Learn fro

Ethics
SREN HOLM
1. Introduction
2. Bioethics and Business Ethicsthe
3. Some Concrete Illustrations
4. Conclusion

TEN On Corporate Ethical Responsibility, Sta

Strict Liability in Biotechnology
JUKKA KILPI
1. Business Ethics
2. Fundamental Issues of Philosophica
3. Toward a Rational Normative Disco
on Corporate Ethical Responsib
4. Shareholder Value versus Stakeholde
5. The Corporation as a Nexus of Cont
Responsibility toward the Mem
of the Network
6. Promise as the Foundation of a Con
7. Stakeholder Value and Strict Liabili
In Biotechnology
8. Competition and the Moral of Mark

ELEVEN Perspectivism in Risk Management

PETER LUCAS
1. Introduction
2. Economic Decision Making and Ris
 2. Moral Progress
3. Progress and Change
4. Ameliorative Change
5. Personal Moral Progress
6. Some Reflections on Mrs Gamp

THIRTEEN Healthcare and (a Kind of) Virtue Ethics

MARK SHEEHAN
1. Non-Normative Virtue Bioethics
2. Metaethics
3. Applications to Medicine and Health
4. Internal Morality and the Practice of

FOURTEEN Bioethics, Rights-Based Consequentiali

and Social Reality
PETER HERISSONE-KELLY
1. Four Aims
2. Consequentialism and Rights
3. An Unavoidable Tension Between C
and Rights?
4. Rights-Maximizing Policies, and th
of a Distinction
5. The Puzzle

About the Editors and Contributors

Index
initiative to fruitionhas very much come from
neighbors in Denmark and Finland: Matti Hyry, Tu
Holm. Although Sren has now moved a little South
called the Central West, he will remain an honorary M
of this volume are right to say that we have not
preceding volume the beginnings of an institution in
but also that we very clearly have, here in the North W
institution in European terms. Taken as a whole, the
bioethicists and medical lawyers can reasonably claim
largest and the most active centre for bioethics in Euro
The present volume addresses the social reality
could be more pressing and important at this time. Ma
questions that face humanity are related to the life sc
which those sciences may be used and abused by hum
social reality that faces us today, but the social rea
descendents, depends upon how we use the scientific a
that have been and are being developed. Indeed, how w
determine whether our descendentsboth in th
futureremain human beings, properly so called, or b
of persons that we will, in part, have created. Many cu
horror and distaste upon the prospect of changing the
humanity. In recent times Francis Fukuyama and Leon
eloquent appeals for the preservation of our speci
Jonathan Glover, myself, and Gregory Stock, have ta
approach to the desirability of what will be an
preservation of this particular species. We know tha
beings that now exist but all primates, gorillas, c
orangutans, and siamangs are descended from a comm
lived in Africa between 5,000,000 and 7,000,000 yea
ancestor had had the foresight or the power to take t
taken by Fukuyama or Kass, we would never have exis
of the preservation of humankind. As Richard Dawkin
out recently, we humans are not only apes, we are Afri
natural category which does not permit the artificial se
beings.
It is difficult to imagine a more important topic
the social reality of bioethics, the reality within which
will help to shape in the future. How we manage that
not only the nature of our lives and the shape of our so
very identity as self-conscious beings.
Sir David Alliance
Un
of England, at the universities of Central Lancashire, K
One book does not make a seriesbut two mi
beginnings of an institution.
Most chapters in this book are based on pres
Second North West Bioethics Roundtable (NorthW
Professor Sren Holm in Manchester on 3 February 2
thematically-related papers were solicited from scholar
the meeting, but whose work complements the origina
The sponsors of NorthWeb 2, and the ensuing bo

Empirical Methods in Bioethics, a project co-

Sren Holm and funded by the European Uni
Management of Living Resources research pro
Genes, Information, and Business, a pr
Professor Matti Hyry and funded by the
research program Life 2000;
Ethical and Social Aspects of Bioinformatics
by Professor Matti Hyry and funded by the
research program Systems Biology and Bioin
What Is Bioethics All About? a project co-
Takala and funded by the Helsingin S
Foundation;
Values in Bioethics, a Special Series in R
Book Series;
Centre for Social Ethics and Policy, Universi
Institute of Medicine, Law, and Bioe
Manchester;
Centre for Professional Ethics, University
and
Faculty of Health, University of Central Lanc

The organizers, and the editors of this book, acknowl

gratitude. In addition, the editors would like to thank
Neill for invaluable help with recalcitrant computers.

Matti Hyry, Tuija Takala

18 April 2004, Mancheste
This page intentionally left bla
 1. What Is Social Reality?

The title of this book presented some initial prob

authors. What is social reality? they asked. Sho
talking about the different meanings or interpretation
reality? And is there a reality, as opposed to these va
The definition of social reality in the followi
includes all the spheres of human interaction which we
somehow exist in conjunction with the physical, m
moral worlds we inhabit. It includes all the fields o
Georg Wilhelm Friedrich Hegel referred to as civi
work, commerce, and voluntary associationsbut also
and social policy that he classified in different categor
care, and scientific advances in biology and genetics,
intertwined with these realms.
Bioethics as an activity is, of course, also an
part of social reality, widely construed. Profes
legislation, and ethical studies have an impact on
policy, and also on the other manifestations of our
reality and bioethics exist in a reciprocal relationship,
frequently reflect or cause changes in the other.

2. Classical Concerns

In the first three chapters of the book, three philosophe

classical concerns in bioethics, namely those evoke
drugs. In the contexts of abortion, suicide, and canna
discuss the degree to which consequences, duties, a
should be taken into account in laws and regulations.
In chapter one, Harry Lesser examines the
abortionthe argument that terminations of pregnan
allowed, because their prohibition inflicts serious harm
to, and will, resort to the services offered by incom
abortionists. According to his analysis, those who bel
morally wrong cannot be conceptually forced to acce
the consequences in this particular case are too d
 In chapter two, Doris Schroeder scrutinizes the p
assisted self-sacrifice in the face of medical scarci
between three main categories: namely, physician-
altruistic physician-assisted suicide, and obligatory
assisted suicide. These are all theoretically feasible, bu
while the first two can in certain circumstances be
option is always immoral, since it violates the requirem
autonomy of individuals. The element of coercion
suicides implies a culturally determined duty to d
justified. The risk of coercion is also an element in
which is why vulnerable groups should not be en
themselves for the sake of others.
In chapter three, Matti Hyry studies the us
autonomy and freedom in relation to cannabis p
management. He maintains that autonomy, or self
notion is currently understood in bioethics, wo
restrictions on the use of cannabis for medicinal pur
are based on the idea that drugs like this confuse
addictionboth presumably factors that would hind
decision making. He argues, however, that different
would be reached by employing the idea of freedom
options, and defends the view that freedom instead o
respected in situations where individuals are not harmi
which render them less than autonomous in the deman

3. Developments

The next three chapters deal with developments in m

the relevance of popular claims, attitudes, and evaluat
on questions related to the assignment of parenthood
arguments for and against human reproductive cloning
feelings of disgust in the context of new medical techn
In chapter four, Monique Jonas analyzes the
genetic and surrogate parents for primary care-taking
children they jointly produce. She identifies three base
genetic connection between biological parents and th
into the childbearing process, and contracts made con
arrangement. She argues that since genetics and labo
noteworthy consequentialist arguments for the compe
 In chapter five, Tuija Takala explores the rights
reproductive cloning. The objections that she c
arguments from dignity, uniqueness, instrumentalizat
lived in the shadow of another, and the alleged right
She finds that none of these objections could justify a
if the procedure could be made safe for the children
involved. The catch, as she sees it, is that cloning
without research into it, and research into it cannot in
be accepted due to the practices being unsafe
consequently, that while there would be nothing intr
successful reproductive cloning of humans, we d
ethically acceptable means to guarantee its success.
In chapter six, Louise Irving challenges some of
and legal arguments that have been employed to defe
international organ sales. Her view is that, on the surfa
on the practice are founded almost exclusively on
disgust and indignation, which is why liberal ph
thinking forces us to the permissive conclusion. She
since these ways of thinking rely on an inadequate,
freedom and autonomy, we should question the dema
the foundation of prevailing laws, rather than the vi
hold. A more positive notion of liberty would, acco
the values supported by respect for liberty, and also i
of humanity which cannot be legitimately alienated.

4. Facts, Ideals, and Approach

In the next three chapters, the focus is on empirical f

their relationship, as well as on the ways in which w
concerning them in bioethics and neighboring fields.
topics include the gap between facts and values in b
reality of informed consent in medicine, and the lesso
empirical business ethics.
In chapter seven, Eve Garrard and Stephen
attention to the role of the natural and social sciences
They acknowledge the relevance of facts produce
inquiries, but contend that these facts, or their prod
bioethics properly conceived. Biology and medic
connections between our actions and the outcome
the reasonableness, and hence morality, of peoples res
In chapter eight, Angus Dawson questions the p
informed consent in the face of empirical reality. He co
that to be informed or valid, peoples consent to m
research programmes should ideally be based on
concerning these procedures and programmes. Thi
requirements of the principle, and unless it is met,
supposed to flow from its observance in terms of aut
remain unclear. Sociological studies seem to sugges
people do not understand or remember the things p
before they are asked to sign the relevant forms. D
difficulties involved are so pervasive that a
communication skills on the part of practitioners is no
In chapter nine, Sren Holm compares empirica
business and healthcare ethics. In the former, the em
established, and some research into the moral dim
decision making seems to aim at, and succeed in, ac
of knowledge on which further studies can be based. T
in bioethics, where almost every new project starts fro
premises. Another deficiency in empirical healthca
immorality of professionals and their activities is s
phenomenon of corruption has been the focus of seve
ethics, whereas bribing and similar practices in medi
touched. Yet it would be useful to know whether ba
practices in fact facilitate the provision of healthcare or

5. Responsibility and Risk Taki

The next two chapters are dedicated to responsibili

corporate decision making and other economic activitie
continue the discussion on the interface between b
ethics, and show how a proper grasp of the concepts
debates is in many cases essential for the understandi
as well.
In chapter ten, Jukka Kilpi sketches a
responsibility. He stresses the importance of backgroun
defines corporations as networks of contracts be
interested parties. Corporations, thus defined
responsibilities which are based on the utility and m
the assumption of strict product liability would add an
the proceedings and ensure the protection of everybody
In chapter eleven, Peter Lucas challenges th
analyses and other economic appraisal methods i
making. His challenge is based on the observati
assessments of this kind rely on a particular attitude to
undesirable consequences of our choices: namely, r
neutral agent chooses the option which is most lik
benefits, regardless of the size and nature of the
involved. Economic appraisal methods standardly assu
is the only rational approach to risk. Lucas argue
alternative strategies of risk aversion and risk pref
rational under conditions of considerable uncertainty, f
under which healthcare decisions are usually made.

6. Educational Concerns

In the three concluding chapters of the book, the auth

moral progress and character development of nurses a
the theories underlying bioethical reflection. In keepi
ethical tradition, virtues, duties, and consequences
fundamental elements of professional morality.
In chapter twelve, Simon Woods studies the na
in healthcare students and professionals. Considering t
a far-from-ideal nurse from Charles Dickenss Martin
that there are certain developments which can reasonab
moral progress in novice nurses. These include an
situation from a moral point of view, an awareness of
between a carer and the cared-for, and an ability
responses and working methods in a professional situa
can perceive in professionals to these directions ca
regarded as instances of moral progress, in spite of th
face if we set out to define more generally the esse
ethical improvement in the human race.
In chapter thirteen, Mark Sheehan delineates a
for physicians. He starts by considering the notion
develops socially and which has its own distinctive en
He argues that it is possible to build a teleological
morality on the practice of medicine by physician
relationships with their patients and apply their skill
patients defines what the virtues of medical practice are
In chapter fourteen, Peter Herissone-Kelly consi
bioethicist who hovers between a belief in the impor
and a conviction that the rights of individuals should
own sake. He constructs a non-utilitarian version of co
states that in choosing our actions and inactions we
maximize the number of people whose rights come
result. While this solution satisfies the conseque
imaginary bioethicist, it seems to fall short of respecti
own persons. However, Herissone-Kelly argues that t
impact, as people who make policy decisions have no
rights of individuals against those of other indivi
claims seem to fail when they are most needed.

7. Blessed Confusion?

Philosophically speaking, the conflicting views exp

claims made in the chapters of this book convey a
Reality, be it physical, moral, or social, is not some
granted. Its ontological status can be whatever it is, b
understanding of it will probably always be more or le
When we realize this, we can react in at leas
maintain that good and bad, right and wrong a
categories, which can only be re-negotiated through po
can insist that academic studies can shed at least s
matters. Either way, there still seem to be things to be

NOTES

1. Georg Wilhelm Friedrich Hegel, Hegel's Philosoph

M. Knox (Oxford: Oxford University Press, 1967), 182 f
 1. The Argument from Back-Street A

An important example of the use of empirical fac

occurs in what may be called the argument from
which has been used both in arguments for legali
arguments for maintaining its legality, whether on
various limitations. It is the argument that the r
abortion is that, whether or not the total number of
(which may be held to be uncertain), the decrease is
the number of unskilled and unhygienic abortions is c
the argument continues, even if we firmly believe abo
must admit that to make it altogether illegal, or v
legally, does appreciably more harm than good. It is
argument for legal abortion, but it is the only one tha
who firmly believe that abortion is morally wro
empirical fact, or set of facts, and arguing that given
empirical consequences of making abortion illegalw
to legalize it, irrespective of whether it is morally righ
As a result, the argument from back-street abo
used, and can be found quite frequently in both
discussions of the rights and wrongs of abortion, whe
possibly it was the really decisive argument in getting
the United Kingdom. This chapter will be concern
conclusive argument, with the view that this empiric
that it is a fact, and that, although this cannot be qu
preventing legal abortion is to increase back-street ab
increase unskilled and unhygienic abortionis all th
the question whether abortion should be legally availa
the argument, I will take a short passage from an acc
the Second World War, Monica Dickenss One Pair
gives her reaction to having as a patient a woman,
nearly killed by a botched abortion, and who was le
more children. I will return to this passage, but for the

Before I was a nurse I was not in favour of legal

that anything would be preferable to some of the
perpetrated outside the law. If women could see w
 The Law Should Reflect Actual Positive

The first thing to notice is that there can be up to fou

this argument, not all present in the above quotation
with each other. The existence, or potential existence,
could be seen as showing that:

to make abortion illegal is contrary to ou

opposed to our official moralizing;
it results in unregulated abortion, which is in
it is largely ineffective, because abortion
behavior, is the kind of thing the law canno
but can only drive underground;
the harm done by unskilled operators out
reducing the total number of abortions, even

It is also worth noting that the argument, with the

point, has sometimes been extended to euthanasia, wit
made that we have in effect a situation of back-street
euthanasia is regularly carried out, admittedly mostly
people, but illegally and entirely unregulated. This w
here, but I want to examine the four elements in the ar
The first element comes from the view that th
existing morality, whatever it is, and that it is a mista
widely believed not to be wrong, or to punish any cr
as excessive severity. (In early nineteenth century E
use of the death penalty had the consequence that j
convict.) This was argued, for example, by C. S. Lew
in Personal Concerns,2 Lewis says that if we ceased to
we should no doubt be both fools and villains, but
admit the fact than to have a law against murde
disregarded, and juries who acquitted murderers what
question is whether this should apply as a general pr
the effect of the separation of law and morality is to
ineffective.
Thus it might be held that there is no sens
penalties to deter crime if a consequence of their sever
to convict and criminals are not punished at all: it is
petition to have stealing from a bleaching ground rem
capital offences was made by the owners of bleachin
altering the general moral view of what is acceptab
needs to be done. Similarly, the outlawing of corpora
very mild forms, in countries such as Sweden, was a
successful move to alter general attitudes. We mig
conclude that, with regard to abortion, the pure fact, if
people in our society, including many Roman Catholi
always wrong, is not, considered in isolation, a
legalizing it, inasmuch as exactly the same argumen
racial discrimination, in earlier days at any rate. W
however, is whether one consequence of this is that an
is bound to be ineffective. This will be considered late
One point, though, that should be conside
constitutes the actual morality, the positive moralit
assuming that this should be defined by what people
encourage, whether or not this is in line with offici
with what they feel constrained to say on official occa
is evidence, but cannot define their morality, because
against our own moral standards. For example, un
century, official sexual morality held that pre-marital
actual morality held that it was wrong for women bu
point for menthere are problems with this position,
of conduct that is among other things physically imp
actual morality of the time. And it is quite arguable
abortion was largely seen as something not to be l
sometimes permissible or even necessary. Certainty is
in this area, much of the evidence is anecdotal, thoug
sources is available. Nevertheless, if the argument
crucial issue is that of effectiveness.

3. Back-Street Abortion as Unregu

Before considering effectiveness, we need to consider

the argument. This is the point that back-street abo
abortion, is necessarily unregulated, so that issues of
an abortion and how it is to be performed are dec
entirely unprincipled, depending on who a woman h
much money she can raise, and so on, with no refere
policy, or medical advisability. It is true that legal
eliminate arbitrariness, probably caused partly by the v
was at least the result of genuine disagreement on
instead of, as previously, the result of there being in p
rich and one for the poor.
So this part of the argument amounts to sayi
illegal it will still take place, but considerations of mo
not affect whether and how it is carried out: indeed p
will be excluded. The argument consequently depend
law is ineffective. Even if this can be shown, so
abortion as wrong in principle might take the view th
raise questions about the just distribution of w
distributed in the first place. If abortions ought n
restricting them arbitrarily to the well-off is no wors
on what they regard as misplaced social grounds. It m
least having the merit of reducing the overall number o

4. The Effectiveness of Laws against A

The crucial point thus appears to be effectiveness. Th

problems in deciding this issue. First, the notion its
are sometimes disobeyed. How much disobedience is n
the law as in reality non-operative, or close to non-op
is the problem of information. Although back-str
publicity of a kind in order to carry on their busines
annual statistics of the numbers of operations they
there are serious grounds for arguing that in this area t
reduce the total number of abortions carried out, has re
The argument would be that, even when abortion is
few prosecutions now and again, it is always possib
obtain an abortion, with little risk of prosecution,
sufficiently determined and able to raise the money
appears to be generally true, instead of true in some so
because of the nature of the operation, which can fairly
and because it is very hard, without an eyewitness, t
has had an abortion rather than a miscarriage. What
when abortion is illegal, is a safe and hygienic abort
in question has access to sufficient financial resources.
I would therefore suggest that there is evidenc
sense of the word, the law against abortion was not
Kingdom, and probably not elsewhere. Does it auto
the high number of legal abortions after the law cha
was responsible for some increase, although we cannot
this, given that the number of previous illegal abortion
was an increase after legalization, it is reasonable to t
law had some deterrent effect, although no doubt oth
general change in moral attitudes at that time, also pla
about the increase. So we might conclude, though n
the law had some effect, albeit a pretty small one. And
of abortion might argue that this was enough to ju
murder, the prevention of a single abortion would be
law.
Second, the convinced anti-abortionist might arg
for a society to declare itself to be against abortion
against it, regardless of effectiveness. This would
argument considered earlier, that the law should ref
instead, the argument would be that the law should g
objection to this would be that this could be justified
least in line with a social trend, so that there was a re
becoming in time both effective and acceptable, as has
two examples above, of race discrimination here and o
in Sweden and some other countries. But where the l
existing morality and the signs are that the gap is goin
case here, then maintaining a hypocritical and ineffecti
purpose. So this reply from the anti-abortionist can be
reply still holds.

5. The Bad Consequences of Making Abor

The argument that any law prohibiting abortion will b

thus a strong one, but anyone convinced that abortion
that it is morally wrong, could still reply that even a
number of abortions is worthwhile. To answer this we
the final element in the argument from back-street a
that even if there is this beneficial consequence of
outweighed by the harm done by unskilled abo
unhygienic conditions outside the law. This argumen
two slightly different ways, which are not mutually ex
In its first form the argument points to a
consequences that follow from making abortion illega
the problems caused by people being recommended un
home remedies. We should also note that one co
being illegal was that there could not be open see
whether to have a pregnancy terminated, with the res
who might under those circumstances have decide
ended up having abortions, so that the effect of ill
toward reduction of abortion. But essentially the arg
possible slight reduction in numbers, even if seen
outweighed by the sometimes permanent injuries,
mental suffering, injustice, and even deaths caused by
The other form of the argument is the one use
Dickens in the passage quoted earlier, that crimina
consequences that are so horrible that allowing abort
numbers, has to be better than allowing them to h
might be dismissed as emotive, but, I think, wrongly.
particular policy we must take account properly of
shown for example in the case of Irene, as Monica D
whose situation caused her to make these comments.
detail of Irenes case is relevant. It is irrelevant to th
that Irene had originally wanted the baby and let her
an abortion, or that the aborted fetus was brought to th
that she was put in a labor ward, surrounded by othe
now unable ever to have one of her own. All these
sorry for Irene, but not reasons for changing the l
relevant that it was the law that prevented her from h
abortion, with the result that she had a horribly bu
therefore a fair argument that the inevitable harm do
even if they are a minority among those given il
sufficient reason for not making abortion illegal, as M
It is also a live argument: what happened to Irene is
now than in the early 1940s, even in an illegal operat
and if illegal operations became widespread no doub
Termination of a pregnancy is much safer now than it
the means to make it safe would not necessarily b
operators, even if they were concerned with safety, w
guaranteed.
 The makers and enforcers of the law are
responsible for the voluntary actions of those
forces anyone either to carry out or to under
whether hygienic or unhygienic.
The calculation has not been done properly, b
reckon in the way in which legalization has
abortion and started a slippery slope that
abortion for good reasons, medical or social
on demand, and will end with infanticide.
Abortion is in itself so wicked that the r
however small, produced by criminalization,
all the bad consequences.
It is wrong to make calculations at all with re
as abortion or murder: it must simply be forb

The first of these replies does not, I think, hol

true that the legislator is not morally responsible f
disobedience to the law. But it is also true that legi
whether any particular activity should be legal or illeg
into account, as best they can, which situation is the
making any activity a crime if the consequences are
legal. They cannot ignore that it is illegality that mak
profitable, and simply say that no one is forced into it
I think, empirically refutable. It is true that the inci
probably risen since it was legalized, and that some of
being more easily available. But it is not clear that
given the previous amount of illegal abortion, or that
the general change in attitudes, are not equally importa
reasons to deny that there has been a slippery slope to
One is that the restrictions in the law are in practic
other is that there were from the start many doctors w
act in accordance with the decision of the individual
exact legal technicalitieswe have not gone from usin
limitations on when abortion is permissible, to igno
distinctions have been found unworkable from the beg
every development has been a relaxation. As the age o
earlier, so also have the restrictions on late abortio
there has been no attempt of any kind to legalize infan
On the other view, it is because there is a moral
abortion, which is not open to being overridden by uti
How do we assess these, and what does this show ab
which we started: are the empirical facts about back-str
establish that abortion, irrespective of whether it is mo
be legal? (I leave aside the possibility of legalizing it
not others, which, if what was said above is correct,
unworkable, but assume there will be some limit on
into the pregnancy at which it is allowable or normally
all this show anything about the status of empirical cla
area of healthcare ethics?
It does show one thing that, I think, is im
ineffective, or would be ineffective, and this can be s
law should not be passed, or should be repealed. Thi
the empirical evidence is sufficient to determine ac
itself is often not easy to obtain. But there is a problem
one, where there is, probably, a quite limited effec
would see the effectiveness as being too low to justify
it as outweighed by the amount of harm produced by t
not, what answer can be made? Can we appeal to rea
also contestable? Will what is reasonable to one person
an abandonment of principle?
We should also note that there is some artificiali
in isolation. The person still in favor of making abor
wish to change social institutions and values so that
single parentsand Irene would not need to go to
first place. The person in favor of legal abortion may
contraception and its availability, and the availability o
fewer people seek abortions. But in the end the
unavoidable dispute about values. Both sides agree th
in itself, is an evil: we have been considering the
abortion should be legal whether it is wrong or not, ra
of whether it is wrong or who should decide. But s
unhygienic and unskilled abortion is so much worse th
it is preferable to allow more abortion of a safer kind;
is always right to reduce the incidence of abortion, eve
My conclusion at the moment would be this. W
what laws it is right to have, and what conduct sh
empirical demonstration that a law is, or would be, i
conclusive reason against having that law. But if the
Irene. For many people this settles the matter, but fo
make a decision about values as well as an empirical
what also, I hope, emerges from this discussion is the
the empirical, of finding out, as best we can, what actu
the likely effects of the different options are. And cr
show that, even if the empirical evidence does not sett
clear obligation to discover what it is. The anti-abortio
considerations raised by cases such as Irenes shou
cannot legitimately claim that they are irrelevant.

NOTES

1. Monica Dickens, One Pair of Feet (London: Peng

2. C. S. Lewis, Personal Concerns (Glasgow: Collin
This page intentionally left bla
 Doris Schroeder

1. Duty to Die?

Most philosophical literature on suicide examines th

Is suicide morally indefensible (Thomas Aquin
Immanuel Kant, Ludwig Wittgenstein) or morally
David Hume)? How can suicide be defined (Emile Dur
suicide be marked off from other types of self-caused d
in this last question, particularly the distinction betw
hand, and self-sacrifice, with its connotations of altru
instance, Maximilian Kolbe, a Franciscan monk a
himself for a father at Auschwitz. He took the place
who was condemned to death by starvation, but event
injection on 14 August 1941. By this heroic act, Ko
own death intentionally, but he is not usually classifie
The distinction between suicide and self-sacrif
leads to my main question, namely: how does
physician-assisted suicide? Could we ever reasona
assisted self-sacrifice? Literature dealing with phys
defines the relevant pool [of people who might benef
persons who will be patients suffering from a t
intractable illness, who will be competent.2 It is thi
whom occasionally a duty to die is demanded. Ac
patients with long illnesses ought when they no long
quit this life.3 Friedrich Nietzsche believed that the
society [for whom] . . . under certain conditions it i
living.4 More recently a United States governor was
said that the elderly, irreversibly ill, who need substan
have a duty to die.5 And, perhaps most import
Professor in the Clinical Ethics Program at East Tenn
explicitly promoted a duty to die in the Hastings Cen
demand could be analyzed philosophically with the
will be the focus of this chapter.
To this end, three topics will be discussed. First,
drawn between suicide and self-sacrifice? Second
Emile Durkheim defined suicide as death resulting
from a positive or negative act of the victim himself
produce this result.7 The definition has since been c
broad.8 However, before we look at its limitations
which cases of suicide Durkheim rightly captures wi
elements needed to make sense of Durkheims defini
chain (direct or indirect), victims action (including ne
words, omissions) and foreknowledge. The followin
these elements.
James skis in the Alps in April in an area
Bergwacht due to imminently expected avalanches. H
and ignores the warning signs. The act under consider
area. Direct causal chain between act and death: A
hits James and he dies within minutes from injuries an
Indirect causal chain between act and death: An ice
and throws him into a glacier, where he dies, phys
hypothermia. Positive act: James enters the avalan
sounds of approaching avalanches. He dies. Negative
leave the avalanche area, despite the sounds of appro
dies. Foreknowledge: In all of the above permutation
avalanches can kill and he is aware that the area h
likelihoodsee avalanches within the next hour.
According to Durkheims definition, James
following would not count as suicide. No causal c
death: Before meeting an avalanche, James is hit by
fail to come off, and he dies from injuries infli
foreknowledge: James is a novice skier, unaware of the
and unable to read the warning signs. Foreknowle
certainly seem to be necessary conditions for suicide
and death), but are they sufficient conditions?
At least one feature seems to be missing from
namely the agents intention. Durkheim purposeful
concepts such as intention and motives for action whe
wanted to arrive at a scientific definition of su
demarcate his research from research in psychology.9
argued that two types of self-caused deaths both relate
eliminated from Durkheims group, namely those bas
actions as well as those forced by outsiders. According
Durkheims definition is too broad as it wrongly ca
self-deathsthe latter should not be classified as su
have been forced onto the ski slope by an armed ma
choice: either I will shoot you, or you show tha
avalanche. Given that death is more certain in the form
to take the chance.
In this chapter, I will concentrate on altruism a
fundamental difference between self-sacrifice and
element of which is altruism? Why should James not
even if he is in the avalanche area as a Bergwacht m
reasons why we might want to differentiate betw
sacrifice. First, for a considerable number of thinkers,
backgrounds, suicide has negative moral connotation
has not.12 So, we might not want to call Maximilian
1982) a suicide. Second, it is the aim of some W
define concepts as precisely as possible in order to fa
and understanding. If there is a conceptual differenc
self-sacrifice, it is worth bringing out for the sak
stimulate further debate. Third, ethicists might want
of self-sacrifice, regardless of death, and this analysis
with the concept as developed in suicide debates.
However, an alternative scenario is conceivable in wh
by Allied troops liberating Auschwitz. Would his a
morally praiseworthy, had he been awakened from ne
doctor?
For the purpose of this chapter, altruism will,
English Dictionary, be defined as the practice of dis
concern for the well-being of others. A straightforwa
suggests itself if we want to distinguish self-sacrifice
to use the doctrine of double effect. In order to clari
some examples:

As far as we know, Maximilian Kolbe want

fellow prisoner from death, and accepted
unavoidable consequence. It is reasonable to a
want to die, or that he might even have hope
my church will intervene on my behalf; p
not let an Aryan starve to death, and so on).
If James was forced by an armed maniac o
trying to avoid certain death by gun, whi
death from avalanche as a possible consequen
 main intention is to avoid death, but not
accepts as a probably unavoidable consequenc
A soldier covers a grenade with his body i
comrades. He thereby accepts almost certain
others.

One feature these examples have in common is t

is characterized by disinterested and selfless concern
others (see above) and can therefore be called a
pragmatically and straightforwardly, suicide and s
distinguished as follows: a suicide intends her own
sacrificer intends the outcome of an action, which c
altruistic, but only accepts death as an unavo
consequence. Hence, death is the main aim of a suicid
possibility in the case of the self-sacrificer.
There are borderline cases, where people using
not be able to agree, and these are of specific interes
instance, Captain Oates can be considered both a suicid
Oates was a polar explorer and a member of the Scott
during an expedition, he walked out into a blizzard at
becoming a burden to his friends (self-sacrifice). On th
have aimed for death itself (suicide), as he would have
even worse position had they assumed he could have b
get him back.
One could argue that he would not have objec
him and returned him to a hospital in his country, as
being a burden to his friends) would still be satisfied
to go to such lengths for an argument, we might a
aliens taken away their feelings of tiredness of life (Le
Zweig, Ernest Hemingway, Paul Celan, and so on, w
to live and can therefore not be called suicides.
So, at this stage we could say that Oatess dea
case, an overlap between the sets of suicides and
shows that they cannot be distinguished without gra
would call him a suicide, others a self-sacrificer.
However, applying the above definition has on
namely that it asks: does the person in question wa
Does she aim for death for deaths sake or for othe
begging the question. In my opinion, there are three
with this problem. First, we stay with a scientific
 Against using mental concepts, it could be argue
can never be established. Perhaps Socrates was a
engineered his death. Perhaps Kolbe was tired of lif
camp (although death by starvation is probably not t
for those who want to commit suicide). It is possi
impossibility of establishing primary motives should n
finding conceptual boundaries. Although we may nev
events, there is a distinctive difference between a soldi
onto a live grenade to save his comrades, and a sold
onto the grenade with the same results. So, for the rem
option three will be chosen and its limitations accepted

3. Suicide and Physician-Assisted S

Could the distinction between suicides and self-sac

debates about physician-assisted suicide? Would a
intractably sickas advocated by Colorados form
Lamm, Hardwig, Nietzsche, and Euripidesamou
sacrifice assisted by physicians? To answer this ques
define both concepts. Based on the above, suicide
death resulting directly or indirectly from a strongl
negative act of the victim herself, which she knows w
(italics added to Durkheims definition). Self-sacrif
intention to show extraordinarily selfless concern
others, and only foresight of ones own unwanted death
Physician-assisted suicide will be taken to m
suicide by physicians who provide the knowledge
which a patient can take her own life.14 The amoun
range from giving information only, to major invo
suitable equipment. For instance, the German Socie
(Deutsche Gesellschaft fr humanes Sterben) used
entitled Dignified and Responsible Death (Me
selbstverantwortliches Sterben) to members under c
leaflet gave information about prescription drugs, how
dosage would be lethal, and how to avoid complicat
(suicide and assisted suicide are legal in Germany; eu
Australias Northern Territory province briefly leg
physician-assisted suicide in 1996, one possibility fo
their life by obtaining a lethal injection after initi
be said to kill the patient. In cases of physicia
patient performs this last causal step.16
What are the main relevant differences between
assisted suicide here? (I shall concentrate on standa
cases of each, and exclude suicides that are set up to
help suicides.)

Suicide Physicia
Very private, individualistic act, Less private,
which requires only one person. act, which req
parties.
Full self-sufficiency of suicidal Partial self-suf
person given. volvement of p
Standardised, sociologically est- Reasons for
ablished reasons for suicide are sui-cide are m
17
manifold. and perceived
of dignity am
18
ill.

4. Physician-Assisted Suicide and A

Physician-assisted self-sacrifices would have to satis

conditions:

Death facilitated by physicians (providing

means by which a patient can take her own lif
Death foreseen as the direct or indirect r
negative act of the victim herself, which sh
this result.
The main intention behind the act shows
concern for the well-being of others.

A particular case study might clarify the requiremen

Center Report,19 based on fact but edited to preserve
Davidson, a twenty-eight year old gay man, w
pneumonia, having been diagnosed as suffering from A
Mr Davidson refused treatment for pneumonia suppo
his lover, arguing that he did not deserve to take up
patients often say, I just dont want to be a burde
emotionally, physically, and financially.21
At first sight, Mr Davidson might be regarded
criteria, and as agreeing with Euripides, Nietzsc
Lamms demands. His death would be facilitated by
have to stop treating him. According to R. G. Frey,22
situation whether withdrawal of treatment counts as
assisted suicide. With a firm legal right to refuse t
would speak of suicide. However, if we rely on the p
to withdraw treatment without a firm right, we ought
assisted suicide. So, death would result directly from
patient, Mr Davidson, and his doctors who know tha
this result. The intention as communicated to
extraordinarily selfless concern for the well-being of
take away medical resources).
This could be regarded as the prototypical cas
self-sacrifice (if it exists), as those who are in the
qualify for physician-assisted suicide are overwhelm
serious illness. In addition, their main altruistic contr
economic point of view, would be to save medical reso
However, there seems to be a distinctive differen
Gary Davidson and the case of Maximilian Kolbe. Kol
to achieve the beneficial outcome, Davidson needs to b
that needs to be solved is intimately bound up
completely independent of Kolbe. If Kolbe had nev
father would have died. Had Davidson never existed,
would have been bound up. The same is true of the
The pilot who stays onboard a burning plane to
populated area and the soldier who throws himself o
exist to make the good outcome happen. On the othe
needs to be absent, as does Gary Davidson, to achieve
Of course, we ought to note that the comparison
Oates only works within a system of limited me
resources freed are indeed making a difference for
affluent countries such as the United States, a situati
wishes to die in order to free medical resources sh
arise.
One could therefore argue that self-sacrifice has
conditions. In addition to the previous conditions, it
self-sacrifice that the person involved needs to be prese
satisfactorily? To answer these questions, two new
deaths have to be introduced, both based on anthro
Emile Durkheim.
According to Durkheim, suicide ... is surely
primitive peoples. But it displays peculiar character
characteristics Durkheim recorded fall into three catego

Suicides of men on the brink of old age, or o

Suicides of women upon their husbands deat
Suicides of followers pursuing their deceased

Durkheim characterizes the above types of s

altruistic suicides.24 Given our definition of altr
disinterested and selfless concern for the well-being of
whether these suicides are really altruistic. It is not e
well-being is being served when the widow of a rec
being burnt alive (suttee, voluntary widow burning
argue that children and other relatives are being subje
loss at a time when they are already grieving. Likewis
well-being is being maximized by the deaths of men
chief? Consequently, the word altruistic seems uns
these types of suicides.
However, the first group, that of old and ill me
dependency, falls into a gray area if we limit all cons
usefulness. The men in question could conceivably b
to overall well-being and to act altruistically by wan
They could also be regarded as the pre-modern eq
Davidson case. So, I shall look at the specific charac
obligatory altruistic suicides (OAS) to see whet
explain those who might follow a duty to die as dem

The act of suicide is expected from those who

is imposed by society as a duty on all thos
specific situations (widows, followers, old m
honor to acknowledge this duty, or accept los
OASs are culturally determined. A particula
particular approach to duty and death in order
of this nature. In modern Western culture,
herself upon her husbands death might be co
than altruistic, at least if she leaves behind ch
 The duty of OAS applies to specific groups o
the widow who is being burned with her husb
or any other person. The same applies to the
members of the third group (ill and old men).

Based on this brief analysis of the above ca

research, we can make two further classifications to
under consideration (if Gary Davidson is not a self-sa
be classified?). The two categories required are subse
altruistic suicide and obligatory honorable su
suicide is a suicide characterized by the practice of di
concern for the well-being of others. In contrast to self-
person wanting to commit suicide is part of the pe
second new category, obligatory honorable suic
characteristics: suicide is imposed by society as
culturally regulated; suicides are compulsory, no
suicides are restricted to certain groups. Which case
self-caused deaths fit our three categories (self-sacrif
obligatory honorable suicide)?
Physician-assisted self-sacrifice: A case of p
sacrifice could be hypothetically constructed as follo
twin daughters suffering from kidney failure becomes
her daughters. The kidney transplantation is successf
have her last kidney removed to benefit her second d
wish to die but instead wants to use dialysis to sta
survives the operation, complications of which she
were very likely to occur during her first dialysis le
hypothetical case fits all of the requirements for sel
above. So, we can answer the first of two main questio
this chapter. Is physician-assisted self-sacrifice p
theoretically possible. However, there rightly are leg
type of behavior and so, if it occurs at all, it is extr
likely case is probably in pregnancy, whenfor i
mother refuses chemotherapy for a very aggress
foreseeable result that the baby survives but the mothe
Altruistic physician-assisted suicide and o
physician-assisted suicide: The main distinguishing fa
sub-sets of suicide is the content of the main inte
action. Those committing altruistic physician-assisted
intention that is characterized by extraordinarily selfles
 In societies with vastly extended life expec
frailness and ill health in old age and serious financi
systems, thoughts of a duty to die can arise, as the e
Hardwig showed. Also, most opponents of physicia
euthanasia argue that these procedures will lessen our
and our sense of responsibility for the weak, vulnerab
way to look at this objection is to say that those raisin
society from imposing such a duty or from creatin
setting conducive to demands from Lamm and Hard
case that physician-assisted suicide is considered a du
in the climate of scarce resources and rationing, as the
Force on Life and the Law noted when claiming:

If we allow assisted suicide, then although nomi

originate from the patient, physicians will exercis
and/or persuasion that is illegitimate. This is pa
current context where there is growing concern a
care costs. It will be far less costly to give a le
care for a patient throughout the dying process.27

Two commentators on the Davidson case remar

pressure might explain his apparent altruism. Sophia V
Thornton write: In a period of scarce resources, a vu
patient who is labeled as nonproductive or deviant by
he does not deserve life-sustaining medical treatm
Levinson demands that Davidsons doctor seek further
patients family, who endorsed his decision to die too
He wants to know whether they are all afraid that M
from this crisis will create for them the burden and t
AIDS victim .29 Again, the social burden element i
this commentary. We cannot determine Gary Davidso
might have had a genuine and very strong wish to
medical resources (altruistic suicide), or he might have
coerced into his decision (obligatory honorable su
cannot be finally established, we can now answer our
set at the outset of this chapter: Is physician-assisted s
relativesaltruistic physician-assisted suicide or
physician-assisted suicidemorally desirable?
 widely accepted in rights-based liberal democr
Self-sacrificers and altruistic suicides shoul
they are: exceptional moral heroes. To tran
what they have done to obligatory honorable
fact that the former are morally outstandi
whilst the latter demands the same condu
thereby tacitly moves from supererogatory ac
duties, a move that cannot be justified.

So, self-sacrifice and altruistic suicide are c

morally praiseworthy heroism. Obligatory honorable
hand, can never be normatively endorsed. They are an
the weak.

5. Conclusion

Suicide and self-sacrifice can be distinguished as lon

concepts to play a role. Suicide can then be defin
directly or indirectly from a strongly intended positive
victim herself, which she knows will produce thi
differs from suicide in so far as death is only foreseen
the strongly intended part of the action is undertaken
selfless concern for the well-being of others. In additi
presence is essential to the beneficial outcome that is b
Exploring the question How does self-sacrific
assisted suicide? three categories were distinguished.

Physician-assisted self-sacrifice is characterize

showing extraordinarily selfless concern for
non-necessity of ones own death for t
Consequently, death is foreseen and wanted.
Altruistic physician-assisted suicide is identi
requires the suicides death as part of the desi
Obligatory honorable physician-assisted suic
culturally regulated, compulsory duties im
certain groups under certain circumstances.

To conclude: it was argued that obligatory honor

be imposed on anybody, as this would imply sacri
 NOTES

1. Terence OKeefe, Suicide and Self-Starvatio

Wrong?, ed. John Donnelly (New York, NY: Prometheus,
Strachan Donnelly, Views of Human Nature, The Concis
Ethics of New Technologies, ed. Ruth Chadwick (San
2001), p. 20.
2. Gerald Dworkin, Public Policy and Physician
thanasia and Physician-Assisted Suicide, ed. Gerald Dw
Bok (Cambridge: Cambridge University Press, 1998), p. 6
3. Quoted in Margaret Pabst Battin, Ethical Issues
Cliffs: Prentice Hall, 1982), p. 99.
4. Friedrich Nietzsche, Gtzendmmerung, Jens
und andere SchriftenWerke 3 (Kln: Knemann Verlag
357 (my own translation).
5. Pabst Battin, Ethical Issues in Suicide, p. 58.
6. John Hardwig, Is There a Duty to Die?, Hastin
(1997), pp. 3442.
7. Emile Durkheim, Suicide (London: Routledge an
44.
8. Tom Beauchamp, Suicide, Matters of Life and
(New York, NY: McGraw-Hill, 1993), pp. 73f; William T
Sacrifice, and Coercion, SuicideRight or Wrong?, ed.
9. Durkheim, Suicide, pp. 37f.
10. Tolhurst, Suicide, Self-Sacrifice, and Coercion,
11. Beauchamp, Suicide, pp. 73f.
12. Thomas Aquinas, The Catholic View, Suicide
Donnelly, pp. 4042; Pabst Battin, Ethical Issues in Suic
13. Tolhurst, Suicide, Self-Sacrifice, and Coercion,
14. Gerald Dworkin, Introduction, Euthanasia
Suicide, ed. Gerald Dworkin, R. G. Frey, and S. Bok., p. 3.
15. Ibid.
16. R. G. Frey, Distinctions in Death, Euthanasia
Suicide, ed. Dworkin et al, p. 27.
17. Durkheim, Suicide.
18. Beauchamp, Suicide, p. 109; Dworkin, Public
Assisted Suicide, p. 68.
19. Anon., If I Have AIDS, Then Let Me Die N
Report, 14:1 (1984), p. 24.
20. Ibid.
 25. Ibid., p. 219.
26. Strachan Donnelley, Views of Human N
Encyclopedia of the Ethics of New Technologies, ed. Ruth
Academic Press, 2001), p. 250.
27. New York State Task Force on Life and the Law,
Assisted Suicide and Euthanasia in the Medical Context
123.
28. Sophia Vinogradov and Joe E. Thornton, Com
AIDS, Then Let Me Die Now!, Hastings Center Report, 1
29. A. J. Rock Levinson, Commentary on If I Have
Now!, Hastings Center Report, 14:1 (1984), p. 25.
30. Immanuel Kant, Grundlegung zur Metaphysi
Felix Meiner Verlag, 1965), p. 52.
This page intentionally left bla
 Matti Hyry

1. The Questions

Suppose that I am in considerable pain. Suppose, fu

consulting medical literature, become convinced that c
to my problemsthat smoking marijuana would alle
causing disproportionate side effects. Should I, in th
cannabis to make me feel better? And would this be
my autonomy?
The standard responses link the answers to the
Some say that I should be free to make this choice be
my autonomy, while others contend that I should
because it is not in line with my autonomy. But is it
connection? I do not think so.
My claim in this chapter is that autonomy can b
in other words, that respect for the autonomy of
disrespect as regards their individual liberty. This is
claim. It is widely assumed in healthcare ethics
individuals is best protected by paying heed to
determination, or autonomy. But my claim is that th
at least, that this is not always the case. Respect for
restrictions of freedom.
I will defend my claim by answering four interre
are:

What is freedom?
Why should freedom be respected?
What is autonomy?
Why should autonomy be respected?

After these considerations, I will conclude by re

in terms of my example, and by outlining an ar
freedom to autonomy in this and similar cases.
are ruled out by clearly definable constraintswhi
internal, positive or negative.
Within this definition, nobody is perfectly f
limitations, human beings cannot fly like eagles, swim
like tigers. Due to economic constraints, most people
new car every month, and some people cannot even aff
day. Due to gaps in education, many people cannot ma
regarding their own lives. And due to social and cult
people cannot express their true opinions witho
consequences.
Healthcare professionals can respect, and promot
patients in two ways. They can try not to eliminate an
patients before the professional contact. And they can
economic, educational, and social constraints by the
and by civic participation.

3. Why Should Freedom be Respec

The answer to my second question can be found in th

liberal doctrine usually attributed to John Locke. Acco
individuals have rights. The most important of these a

the right to life;

the right to health;
the right to liberty;
the right to bodily integrity;
the right to private property; and
the right to punish those who violate other pe

These rights are, essentially, entitlements to non-inte

should not actively attempt to end our lives, corrup
property, or curtail our freedom of choice. If they do,
of these, they partly lose their original entitlements, an
punish them, or prevent them from wrongdoing by thr
The rights individuals possess are, in this mod
that people do not in the end belong to themselves, b
strict duty not to interfere with the lives, health,
individuals, because they should be left free to manage
for themselves. They should do this in the best way th
The definition of autonomy usually employed in he
traced back to the eighteenth-century philosophy of Im
the view that autonomy means personal self-determ
universal reason. People can, according to his doctrin
in the realm of rationality. If they yield to their
emotions, they reject their autonomy (and their true fre
Since desires, attitudes, and emotions are a const
Kant believed that people cannot be perfectly autono
that we have a moral duty to try to achieve this impo
from this that if other people know better than we wh
universal reason are, then we should not oppose their
It is, after all, our own autonomy (or rational self-
promoted by the intervention.

5. Why Should Autonomy be Respe

Kant thought that we should celebrate our autonomy,

thing that can distinguish us from the rest of the world
Desires, attitudes, and emotions belong to the empiric
encountered only as a predetermined sequence of cau
prearranged world of phenomena, there is no freedom
responsibility for ones actions, and hence no morality
But we yearn to be moral, and we yearn to be a
the world of things as they really are. In this world of
and morality are possible, and we must, to be mo
world by acting as autonomously as we can.
To reiterate, morality requires freedom, but freed
the empirical realm. It is only possible in the rationa
be moral, human beings must strive to be rational. An
respect for rational self-determination.

6. Practical Implications

My final question is, what would respect for free

autonomy imply in the case of prescribing cannabis t
the patient has expressed a clear preference in its favor?
prohibited, the option is not in the same way open
consultation. It can be argued that under these circum
the patient making the request is not actively restricte
But since the option remains closed, the freedom of
maximally promoted, either. (It could be further enh
legalize marijuana.)
This means that, whatever the legal situation, res
the individual would imply that requests like this sh
by health professionals or by society as a whole.
When it comes to autonomy, however, the
Respect for autonomy can, theoretically speaking, lea
respect for freedom. It can be argued that universal
correctly, would not oppose the use of (even
recreational drugs, provided there are good medical gro
But at least in the original Kantian setting, add
needed to show that this does not go against the categ
requirement that moral rules must be equally applic
similar cases. If the point of my example is the redu
then what about extending the rule to cases wh
discomfort or boredom could be relieved by the same m
The standard Kantian objection at this point wo
cannabis confuses the mind and leads to addictio
accusations, since both bafflement and chemical depe
hinder rational, self-deter-mined decision-making.
consistency, it seems that these accus-ations must be e
use of marijuana, lest people start to think that it
confuse ones mind for purely recreational reasons as w
This is why respect for autonomy in the Kantia
restrictions more probably than freedom. And this is w
in this paper: that respect for autonomy can lead to re

7. Autonomy or Freedom?

Let me conclude by presenting the possible combin

disrespect for the two principles, and by stating my o
them.
There are, from the purely conceptual point of v
which are presented schematically in the following tab
 self-determination. com

Disrespect (3) There is no universal (4) T

For Autonomy reason in ethics, and reas
individual liberty is a ove
secondary consideration. indiv
cho

Alternatives (1) and (2) are open to those who buy into
autonomy, and they are both feasible responses, al
prescribing cannabis the formulation of (2) can be di
could represent a traditional, or communitarian, resp
attitudes and their conformity to the values of the soci
be paramount. Alternative (4) is my own favorite. It i
which rejects even rational self-determination be
paternalism implicit in the Kantian view.
One way to defend the ultra-liberal view would b
to say that no one should interfere with the individual
God. This defense does not necessarily summon any p
religion, or theology. It can be taken simply to mean
is an extremely valuable thing, and that attempts, by o
cannot add anything to its value. To use a metaphor
debates, we could say that others are trying to play G
their rationality should override our choices.
It remains to be added that even within t
restrictions of liberty can be justified, and attempts t
self-determination of others can be legitimate. Rest
justified, if freely chosen actions would inflict harm
who think that recreational drugs diminish the autonom
course, make their views known, and try to persuade o
But until somebody gives me good grounds f
my view in this and in similar cases is: Forget au
freedom!

8. Discussion

This paper was presented in the Fifth Internationa

Almagro, Spain, 39 June 2002. In the ensuing disc
Sharon Sytsma: Pain can reduce autonomy so that re
by confusing and addictive substances, would be
grounds.

MH: Point taken, but is there ever autonomy in the

situations? If you are in pain, you are not autonomo
taken away with confusing drugs, you will be con
autonomous, either.

Jan Hartman: The traditional thick concept of free

the distinction between real and illusory freedom.
distinction. Can the thin concept of freedom yo
accommodate it?

MH: Yes, I think it can. John Locke makes the dist

free and feeling free in An Essay Concerning Human U
II, xxi, 10), where he cites the case of a man who volu
chatting with a long lost friend but is actually unfre
locked.

Zbigniew Zalewski: Saying that the justification of

liberty means committing the naturalistic fallacy.

Griffin Trotter: Well, yes, but saying that it does m

rationalistic or universalistic fallacy.

Rosamond Rhodes: Harry Frankfurt distinguishes bet

order desires. I can have a desire to eat cookies but als
desire to eat cookies. With regard to which of th
restricted?

MH: Whichever you choose. But it is against my free

decides to restrict the fulfillment of my first order
my second order (or higher or more rational) des

Constance Perry: But what should be done, if a pers

not want any treatment, even if the medics know that i

MH: It is possible within the ultra-liberal view to draw

occurrent confusion and permanent addiction. If a
This page intentionally left bla
 IN SURROGACY DISPU
Monique Jonas

1. Introduction

If King Solomon was faced with a perplexing dilemm

establish which of two womens claims to motherho
surely our modern day Solomons, Dame Elizabeth
British Human Fertilization and Embryology Authorit
predicaments of the first order to contend with. Som
dilemmas over parental rights are due to the fact tha
environment is characterized by so much new possibil
for instance, for five distinct individuals to make ess
one conception and pregnancy (a genetic mother, a gen
mother, and a commissioning couple), or for a perso
parent entirely unawares and with someone they have n
mistaken use of their genetic material in an IVF pre
standings about pregnancies or allocation of parenta
down, or mistakes happen at conception, the mean
ensuing disputes are not at all clear.
Although the technology involved here is new a
mas arising from its use take new forms, their content
himself. The desire to raise a child is something that
strongly, and parenthood imbues many lives with
meaning. So when more than one couple identify
own, the conflict that follows is likely to reflect
import. Conflicts over parental rights, and, more sp
resolve them, give us the opportunity, and indeed the
what it is that we consider important about parenthood
want parental responsibility to serve.
In this chapter, I propose to consider three facto
the resolution of disputes over parental responsibility
labor, and contracts or promises. Ordinarily, in our s
family group provides all the contributions necessary
surrogacy disputes and other conflicts over parental
and labor-based contributions can be split across severa
contracts regarding the care of the child may exist. H
sponsibility claim in isolation, I am going to assum
peting for parental responsibility are each able to pro
basic interests of the child in question (however those
be defined). Where one party is clearly not able to se
interests, there is an argument for placing the child wit
so, even if the first party has the stronger claim, in
interests. Although the strength of a claim to parental
be divorced from considerations of the childs interes
be at play too, and by removing concerns for the child
factors.
For the purposes of this chapter, I will use the
and parental responsibility interchangeably, on the a
seek legal status as a person with parental responsibi
the rights conferred thereby (especially the rights to co
primary care-taker of and decision-maker for the chi
focus here on conflicts arising from surrogacy agreeme
central claims will hold true for other kinds of parenta

2. Genetic Contributions

Genetics plays a major role in the allocation of paren

pre-dates the entry of the concept of genetics into the
The people who make direct genetic contributions t
child are thought of as her parents, at least in the first i
option on the assumption of parental responsibility.
right to rear those persons whom one bears, and this ri
the most extreme of circumstances. Ordinarily, this di
responsibilities works pretty well; generally the p
conceiving a child are more willing to invest the tim
upbringing than anybody else, so the practice is a happ
garden conceptions, there is no need to determine wh
awarded on the basis of genetics, or labor, or the unde
there is no conflict based on these disparate contribu
But in those instances in which these contributions
(and such instances may well multiply as a result of
ogy), the rationale for the presumption in favor of g
what is it about genetic parenthood that is so imp
genetic relationship between parent and child groun
rights?
child is born into a kind of slavery. But if one acc
theories of property ownership, then it is difficult to
approach to parental rights as well.2
And there are good reasons to avoid accepting
rights. The relationship between an owner and the t
characterized by rights rather than responsibilities. If
that I have over it are not conditional upon my ta
smother it with oil and adoration, leave it to slowly
strip its innards and transplant them into another car a
whim. We do not think that we owe anything to th
(although there are some possible exceptions to this, p
property amongst them), but we do think that pare
certain things and consider that treatment of children s
more than parental whim. Instead, it should be gove
and desire to protect, their well-being. Ownership does
late the subtle weave of rights and responsibilities
children together.
But the objection that genetic parenthood cannot
rental ownership does not rob the genetic relationshi
here. One could accept that genetic parenthood is n
(perhaps because children are not the sort of things th
owned) and still accept that whatever parental rights th
existence of a genetic relationship. What kinds of cla
this assertion?
One way of justifying the extension of parental
of genetic relationships is by appealing to the essentia
bution. If it were not for the fact that x and y con
information, z would never have existed.3 In other ca
(or group of persons) has made all the contributi
something, we think that this fact is enough to wa
special rights to the creator with regard to the thing
rights-extension need not be based upon any positive
of creation; it might instead be justified by a negative
else has a better claim, and in the absence of somethi
claim stands.
This is plausible, but problematic. In the case of
netic contribution is essential, it is not the only essen
environment for gestation, and, in the case of proble
pregnancies, the assistance of expert medical staff, ca
the creation of a new life. How are we to differentiate
tial. If we want to avoid the extension of parental
working obstetricians and IVF clinicians, we will have
of essential contribution count here, and why.
It might be possible to do this by distinguish
affecting contributions (and the claims that they c
identity affecting contributions. An obstetrician or
might have furnished the help essential to the childs
contributions were essential to the creation of the baby
on the identity of that baby. The child would have
regardless of who delivered it or who injected the ova
would not have had the same identity, however, if it
been derived from different people than it in fact was.
Another way to express this might involve a di
tion on the one hand and nurture or support on the o
that a childs conception and birth can rely upon the s
than the genetic parents, but claim that that support i
ent from the contribution entailed by actual creation.
Whilst efforts such as these may be capable of b
I suspect that they will prove to be both riddled with
tantly beside the point. There might be differences bet
creation and essential contributions of support, but ho
can such distinctions bear, and what difference do
allocation (note how the distinction looks set to brea
the IVF technician, handpicking the sperm used to fer
that the process of establishing what identity-affec
entails (and excludes) would be so problematic as to b
I think that there is another, simpler way to ide
about genetic parenthood. Genetic parents tend to c
genetic offspring, and identify their interests as bei
childrens welfare in a way that they are not with oth
children with whom they share a blood relation, su
ins). This strong identification means that genetic p
general, from the extension of parental responsibil
would, and that they have more to lose than anyone els
denied or revoked.
There are also important spin-off effects for the c
genetic parents. Because, in general, people identi
interest in their own genetic children than others, t
want the best for their children, and will more easily m
to secure their childrens interests, than other people a
only really function as justifications for given pol
policies or acts do, in fact, bring about the intended
the preferred good). So, extension of parental rights
only supported by the above claims in those cases in
hold:

genetic parents really do have deep and abidi

ing parental responsibility;
those interests lead them to strive for their ch
no other party has deeper or more abiding
those children.

In most instances, these three conditions hold true, an

cases in which they do not are very likely (in contex
conflicts and the like) to be cases in which removi
genetic parents would be an acceptable option (because
neglected or abused, or because their basic interests are
within their family home). In these cases, the link is b
parenthood and its use as a justification for parental
failure to meet one or both of the first two condition
parents do not have abiding interests in their childre
those interests, whilst present, do not lead them to str
interests). Thus, the allocation of parental responsib
genetic parenthood fails to perform its function and o
looked to. The consequentialist approach to paren
qualified importance to genetic parenthood: a general a
the genetic parents is justified, but if, in a given case,
not in fact fulfill their obligations or develop an atta
that assumption is able to be overridden.
The central problem with this justification in the
rogacy arrangements does not arise because one or
conditions is not met, but because the third does no
genetic parents are generally not the only parties w
interests in the assumption of parental responsibili
precisely because there are other parties who identify
in raising the child in question, are willing to strive
being, and earnestly seek assumption of parental resp
that we care about genetic parenthood in general also
than the genetic parents and so, in these cases, geneti
provide the solid ground for parental rights claims tha
claim from genetics loses some (but not all) of its pow
So, with regard to surrogacy disputes and other
rights, the genetic contribution grounds a claim worthy
it is not a lone contender. The force of the genetic clai
in the fact that people care more, as a rule, about chil
as their own, and identify strong interests in raising t
gacy disputes, parties other than genetic parents may c
these self-same reasons for lodging a parental rights cl
require the consideration of other factors. This explana
of the genetic relationship offers no quick fixes in con
consideration here, but it goes some way to explainin
kind that failed surrogacy agreements give rise to, are
tion of the case to be made for labor and contracts wil
in which resolution may be sought.

3. Labor

A claim very like the one considered above for geneti

basis of labor. There are two kinds of labor, or more
labor, that would be of relevance when judging claim
bility. The first is labor invested before birth, the se
afterwards. Because disputes that spring from surroga
likely to happen while the child in question is in
conflicts that occur later would be smattered with oth
as the parental relationships that the child is likely
wish to concentrate on pre-birth labor. We can assume
parental responsibility will be equally willing to labo
child after birth, given that we have specified that th
equally good upbringing in either home. So, the labo
conflict will be considered here.
Perhaps the most interesting kind of labor that t
is that which a gestating mother performs in relation t
although the claim that gestation involves labor is no
It can be held that the processes involved in, and ener
support of a fetus do not constitute labor, or at least
that we would want to attribute to the gestating wom
that, although a woman may choose to continue wi
thereby elect to support a fetus, the actual process of s
her controlher body performs the necessary funct
tutes labor, or if it does, then it is not the kind of l
tively attributable to the individual, as opposed to the
Without wishing to become embroiled in a deb
ments necessary for an act to constitute labor, I will c
can be made for gestation as labor, especially in the
gacy pregnancies. One of the factors that might be tho
from other kinds of acts is intention. Other acts that
lectual labor and physical labor of the stool-making o
for instance, differ drastically in their natures, but per
ties that unites them under the labor umbrella is that
ized, and indeed motivated, by intent to work towa
(this is why we can distinguish between an eminent
career working towards a discovery, and an idle sc
similar discovery while messing about in the school
rare pregnancies that take place entirely unbeknownst t
would fail to meet this criterion, and so might not qua
could have troubling implications), IVF and surrogac
would. In these cases, the gestating women intend th
the functions necessary to nurture and sustain fetu
considerable lengths to ensure that this happens. O
acknowledging the possibility of mounting a serious
want to include gestation in the kinds of labor that mig
As in the case of genetics, one of the reasons for
claim can be advanced on the basis of labor would
nature of that labor to the creation of the object in
labor certainly qualifies as an essential contribution. B
that hampered this approach with regard to genetics r
same simple consequentialist reasons that genetic
thought to ground rights claims strike me as applicabl
to care about the things that they create more than
benefit from recognition of their labor through the ex
certainly seems to be the case where children are
mothers, who did not (initially, at least) intend to rear
bear, often develop strong emotional ties through the
and find themselves identifying with the fetus as th
This can happen even when the surrogate is not the
child. After birth, many parents (perhaps especiall
experience the intimacy of gestation in the same way
that their sense of identification with their child deepe
the work involved in looking after them. The investm
contributions and labor are divided between disparate
can develop independently and, when disputes occu
since both labor and genetic contributions can gro
ibility, and because of what amounts to the same r
twenty-first century Solomons to negotiate between cla

4. Contracts and Promises

So far I have identified one reason to acknowledge p

people identify themselves as having a fundamental in
tion), and two pegs on which that reason may hang
and labor). When two parties present opposing claim
bility, one on the grounds of a genetic relationship wit
the grounds of the labor that they have so far invested
both claims are of equal importance to the claimant
there is little to choose between them. Some other con
introduced as an arbiter, and I wish to consider the
assume that role.
Surrogacy agreements involve a kind of contract
woman and the intended parents. This is an aspect o
find objectionablethe prospect of something as inti
conception, pregnancy, and childbirth being nudged
and contract seems like the ultimate misinterpretation
final victory for masculine market values. There ap
in the self-interest drenched world of free trade for ap
tional content of childbearing. Barbara Katz Rothma
expresses these fears. She notes that the language o
imported into our vocabulary for the creation of life:
that implies that making babies is a form of pro
transformed by work into a product.4 She also c
process of gestation with the free market values tha
Rothman and many others,6 surrogacy misreprese
childbearing, takes advantage of women in compromi
morally unacceptable fashion, and inappropriately com
making them the subject of a contract and financial exc
It is to be expected that theorists who hold thes
contracts that govern surrogacy arrangements to be of
and maintain that they can never justify the separatio
and her child. It is not my wish to challenge the mo
stances. I will take it as given that if the surrogate,
party for that matter, were misled, insufficiently in
wholly consenting at the time that the surrogacy agre
would invalidate the contract. But where an agreemen
competent, informed, and consenting individuals to t
pregnancy, I consider that this agreement has moral be
The contract or promise is no stranger to m
speaking, we consider that if we make a promise to so
consequent obligation to keep, or at least to take all re
the promise that we made. This obligation might be d
more powerful, and conflicting obligation might prese
the obligation created by the promise, or the promisee
the obligation, or circumstances might change in such
ise is invalidated or notably weakened.7 But, in the a
promises create obligations and constrict our choices.
The question to be addressed here is whether the
rogacy agreements are defeasible, and if so, what woul
The most commonly espoused justification for the
related promises relates to the unexpected bonding
mother and her child. The thought here is that the su
agreement with false beliefs about how easy it wou
emotional distance between herself and her pregnanc
never have anticipated (or, have been reasonably expe
motherly feelings that she would develop for the ba
she went into the agreement with a sincere commit
reality of the surrogate experience prevented her from
that commitment, and this constitutes valid ground
contract.
I find these claims problematic. Entering a surro
extremely serious step, involving the creation of a ch
tions of others, and what contract law refers to as relia
parties to the contract.8 In such agreements it is re
parties involved to seriously consider their particip
only to make a commitment to the process if they rega
that they can honor. Because of the level of serio
commitment should be taken as binding on the indiv
the intentions that characterized their decision to partic
that developed upon expression of those intentions,
consideration if that commitment falters.
activity and all the benefits that accompany it, disa
wider social reasons that support the enforcement of
enforcement comes at some cost to the promisor. If w
is the sort of thing that can be subject to contract, it
the rules of contract.
There is also a more localized reason to adhere
ence, to the contract, and which incorporates consider
surrogates agreement to gestate a child for the com
raise generates both expectations and, I contend, relian
prepare themselves for parenthood, the male often ma
tion (as might the female commissioner), and place th
in the agreement: hopes that are likely to have gone u
surrogacy is seldom anyones first procreative choice. T
interests also involves the cutting off of other options:
agreed to perform gestation on their behalf, they m
services of another prospective surrogate, who would
fulfill the contract. It seems to me that where expectat
consequence of the promisors actions or agreements, t
some responsibility for them, and that this is best assu
the contract.
So, for reasons of social utility, as well as fairn
of contracts should be preserved, and participants en
their participation with the utmost seriousness before
Having said that, there are certain instances in which
people from their promises and commitments on the g
proved more demanding than could reasonably have
time they were made. For instance, I would not hold m
for failing to meet me for coffee when I discover th
leaving her with no transport, and an urgent need to re
She had made a commitment that she had every reaso
fulfill, but an unforeseeable event occurred which pre
Her intentions were good, but events overtook her and
promise does not attract blame.
But there are other instances in which it could b
with the keeping of a promise or commitment should h
taken into account by its maker. When certain difficu
occur, such as would feasibly threaten an agents abili
ment, then they should be taken into account by the ag
the commitment and then defaults on it, citing these
then she might be held responsible for her failure.
without transport on Tuesday, but he still made a co
upon him having transport then, and so he let Sall
prevented from keeping his promise. It might not be J
isnt ready to pick up then, but that doesnt absolve
bility.
The same might be said of surrogacy cases. It is
rogate mother will form an emotional bond with the
that she might have difficulties in surrendering the
comes. This likelihood should be something that th
considers very seriously before entering into a surrog
she has any doubts about her ability to adhere to such
should not make it. If she does come to an agreement
couple and then finds that she cannot keep it, she
accused of failing to take the agreement seriously en
accord enough weight to the possibility that she woul
attached to the baby.
She might reply by saying that, although she k
that some women, or even most women, would beco
could not predict that this would happen to her, beca
her personality and priorities led her to believe that s
tionally unattached. She could not predict what her re
way that John could reasonably predict that he woul
on Tuesday, because he has concrete information to
mechanic has told him), while she has only psycho
estimates to make.
There is something in this. We often react to e
could never have predicted, and in ways that defy our s
the difficulties with these kinds of predictions warr
only by us as assessors after the fact, but also by pros
the people commissioning them). Prospective surrog
their considerations the chance that their prediction
surrogate pregnancy might prove mistaken, and shoul
agreement if they can be very sure that they will be a
certainty proves mistaken, we need not attribute blam
standable error to the surrogate, but the contract should
It is my view that the fact that circumstances
keeping of promises more difficult or costly that onc
absolve a promise-maker or contractor of her volun
tions. Where fate intervenes in a completely unpredicta
with an individuals promise-keeping, this ought to
surrogate mother can reasonably be expected to an
response to the pregnancy. Some women are able
landladies or pre-natal nannies rather than mothers
others simply are not.9 It strikes me that it is up to th
to accurately predict which category she would fit in
held to her contract if her prediction proves to be mista

5. Conclusion

In a parental rights dispute of this kind, someone

loser: primary parental responsibility can only be awar
and that means that at least one claimant will lose o
hold most precious: the chance of forging a tradition
with a child. In the hardest cases, the stakes are high
have to make a decision in somebodys favor, and I h
by which this might fairly be done.
According to my analysis, genetic and labor-bas
provide grounds for a parental responsibility claim be
those kinds predispose the makers of them to care abo
efforts. When labor and genetic contributions to the co
child are made by diverse parties, as in surrogacy a
come to ground opposing claims. Because they count
third consideration is required to break the tie. I hold
cements a surrogacy agreement should play that part.
The surrogates promise to the commissioners c
interests on their part: they prepared themselves for
what she undertook to do for them. If the contract is
losses that the surrogate is responsible for; whilst the
is not responsible for the surrogates loss in the same
enforced, because they never led her to believe that
different. Where surrogacy agreements, which were
informed consent, break down, fair resolution will gen
ing the contract and according parental responsibility
party.
First Treatise, sections 5254.
3. See Derek Parfit, Reasons and Persons (Oxford: C
4. Barbara Katz Rothman, Recreating Motherhood:
ogy in American Society, Beyond Baby M: Ethical Issu
Technologies, ed. Dianne M. Bartels, Reinhard Priester,
Arthur L. Caplan (Clifton, NJ: Humana Press, 1990).
5. Barbara Katz Rothman, Surrogacy: A Question o
M, ed. Bartels et al.
6. See, e.g., Elizabeth Anderson, Values in Ethics
bridge, MS: Harvard University Press, 1993); Gena Core
(New York, NY: Harper and Row, 1985); Vanessa E. Mu
Construction of the Maternal-Foetal Relationshipt
Examined, Res Publica, 7:1 (2001), pp. 1337; Liezl v
Niekerk, Interpretations, Perspectives, and Intentions
hood, Journal of Medical Ethics, 26:5 (October 2000), p
7. W. D. Ross, Foundations of Ethics (New York,
Press, 1939), p. 9; Toni Vogel Carey, How to Confuse Co
tion, Journal of Philosophy, 72:10 (1975), pp. 276
Paradox of Promising, Philosophical Review, 106:2 (Ap
8. Gillian Hadfield, An Expressive Theory of Cont
lemmas to a Reconceptualization of Rational Choice in Co
of Pennsylvania Law Review, 146:5 (June 1998), pp. 523
9. Helena Ragone, Surrogate Motherhood: Concep
Francisco, CA: Westview Press, 1994) pp. 7578; van
Interpretations, Perspectives, and Intentions in Surrogat
This page intentionally left bla
 Tuija Takala

1. Cloning, an Absolute Wrong

After the birth of the first ever cloned mammal, Doll

headlines, people all around the world rushed to conde
an absolute wrong.1 A number of laws and treaties we
in this spirit.2 Subsequent discussions in public, politi
echoed the denunciation of human cloning, although
difficult to put their fingers on the exact features
absolute wrong. At the same time, however, there wer
the possibilities that cloning humans might create.
In this chapter I will study the main arguments
man reproductive cloning. I will start with the most o
ments, namely the arguments from dignity, uniq
people as means. After these I will deal briefly wi
issues. I will show that all the mentioned counterarg
to support a total ban on human reproductive cloning
that research ethics will prevent research into huma
and, thus, effectively preclude most actual attempts t
further shown that the arguments in favor of clonin
strong either. The clones perspective on the matte
claims that cloning is wrong, because it creates a life
that it violates the (alleged) right not to know.
I will show that by employing philosophical m
it seems to be impossible to say that there is someth
se, wrong about human reproductive cloning, althoug
that are wrong . By showing in which circumstances c
than in others, these practices are further specified. It
the weakness of the arguments in favor of human clo
(albeit contingent) related to the practice should lea
there are no good reasons for investing public mon
reproductive cloning. But we should also conclude
sufficient reasons to ban human reproductive clon
outstanding safety issues can be properly addressed.
beings. While this type of cloning has also been
problematic, it is far better tolerated than the idea of
beings by similar methods (with the perhaps surpri
Catholic Church, which seems to see more problem
ing).4 In what follows I will deal mainly with issues
cloning, and mention the therapeutic alternative only
used in the debates form a close connection between th
There are roughly two ways of cloning mamm
less controversial is embryo splitting. This happe
embryo is divided into two or more, thus creating ide
times, triplets or even more. In its artificial form the
with human embryos since 1993.5 The technique that
outrage is the possibility of creating clones by nuclea
Dolly was produced. In this method the nucleus of a c
(in Dollys case a cell of an adult sheep) is transferr
egg taken from a donor, by a process know as cell fusi
on this more controversial option, although some
overlap with those raised by embryo splitting. Clon
makes possible the creation of a near-identical geneti
individual. The closest match can be achieved when th
come from the same individual. And even when they
mitochondrial DNA has its origin in the egg, while
material is derived from the transferred nucleus.

3. Is Cloning Humans Against Human

Many international protocols and treaties condemn

cloning as an act against human dignity.7 It is, how
exactly human dignity is and why it is violated b
cloning.8 As an example of how far apart different un
dignity in relation to cloning are, consider the followi

The dignity and legal rights of a clone could be g

.9

On principle, to replicate any human by technolo

the basic dignity of the uniqueness of each hu
sight.10
a mere means. I will return to these in the following se
It seems that the argument from human dignity
only in the contexts of religious ethics and official do
ingly, however, even the Christian Church is divided o
is a bearer of human dignity and what this should imp
As far as the Catholic Church is concerned, any huma
human dignity in one way or another. Therefore, t
cloning is that therapeutic cloning is at least as bad as
interpretation perhaps even worse than) reproductive cl
therapeutic cloning

would involve experimentation on embryos and

ing, although in the embryonic state] and would
sion before birtha cruel, exploitative way of tre

The view of many Protestant theologians is different

tian thinking the sacrosanct nature of very early hu
usually emphasized, and therapeutic cloning, with all i
human welfare, is seen as less problematic than reprod
I will leave the concept of dignity with the note
probably a value held dear by us all. It is a common n
we value in human life. It is a name for that somethin
problem putting our finger on. It is not the same for
not a very helpful tool in drawing lines between t
unacceptable.

4. Is Uniqueness Threatened by Human

It has been suggested that humans possess somethi

uniqueness, and that this profound right could be
The suggestion is problematic in two obvious respe
identical twins, and the fact that most cultures do not s
their inherited similarity, seems to suggest that even i
it would not be absolute, or even very highly valued
would in most cases be less of an exact genetic copy o
identical twin, because the mitochondrial DNA of clon
used, not from the nucleus transferred, and this m
genetically speaking, unique (unless, of course, the e
from the same person). Besides, a clone would also
uniqueness, although the existence of identical twins
holding this view seem to believe that the uniquenes
based on their natural or God-given origins. For i
states that [E]ven identical twins are unique [but cl
apparently follows from the fact that God gives uniqu
own making, but would deny it to man-made clo
assumption sounds almost too tempting to let go un
not pursue it further here. Leon Kass, in his turn, argu
difference between natural accidents and delibera
manipulation.16 A similar ethos can also be found
German Enquete Commission on gene technology.17
Even leaving theological elements aside, this ar
its difficulties. I cannot but think that the inner logic
be something like the following. Uniqueness is valuab
health is valuable to people. Not all people are healt
theless as worthy as human beings as those who a
something wrong about ill-health and, therefore, inten
experience ill-health is wrong. Analogically, although
worthy as other people, there is, however, something
unique genetic constitution, and, therefore, intention
genotypes is wrong. I dare say that identical twins, a
would disagree with the assumptions underlying
However, the argument from uniqueness only works
setting) if we think that there is something wrong in
genotype, that is, if we think that there is something w
But even if we held this rather discriminatory view, it
clones would be less valuable as persons. It is only if
is something less valuable about twins per se that w
value to clones, too. Since this is not the case, we sh
the light of this argument, a person born with the hel
would be as important an individual as those born thro
tional methods of reproduction.18

5. Is Cloning Treating People as a Mer

With the shortcomings of the arguments from unique

against human reproductive cloning employ the Kantia
never treat people as a mere means.19 This has also
language of instrumentalization. Those who use this l
 Humanity itself is a dignity, for man can be used
others nor even by himself) merely as a means
used at the same time as an end.21

It is debatable, however, whether cloningif use

tive purposesviolates the humanity principle any
intentional act of reproduction. I, for one, have never
would have reproduced only for the sake of the forthco
also some metaphysical problems related to the fact
deliberation, nothing of the future child exists.) And,
wish to condemn parents for wanting to have childre
critical to condemn those who wish to use cloning as a
If, however, people use reproductive cloning to
one or to recreate any other person they for some re
recreating, the accusation of going against the hum
stick. If we do not believe in simple genetic determi
persons uniqueness is a sum of different factors, ma
genetic, the idea that we could bring back someone is
in the sense that it cannot be done. If it were, howev
person created by cloning treated, not as a person
recreation of) someone else, that would indeed count a
a mere means. In these circumstances cloning would
principle. It does not, however, follow that human re
se would be a violation of the principle.22
The treating people as a mere means argument
against therapeutic cloning if we believe that early em
the sense intended in the principle.23 To use early e
benefit of others would be to treat them as a mere mea
if we do not see early embryos as human, the conde
cloning on the basis of treating the embryos as a mere
(in the sense intended by the humanity principle).

6. Dangers and Other Costs

There are a number of other practical arguments pre

reproductive cloning. First of all, the method is not
tempts to fuse a nucleus with an egg to make Dolly, th
subsequent attempts to clone animals it has become
large offspring syndrome, respiratory distress, circul
pay.
Even if a more liberal stand is taken on the mo
embryoseven if it is held that they have very little o
price of cloning in terms of human suffering seems
search leading to human cloning and every attempt to
require quite a number of donated eggs. This woul
women agreeing to undergo hormone treatments and e
of which is very pleasant, nor without risks. Info
perhaps, in the light of current medical ethics and et
this acceptable, even if questions can be asked abo
such research. Also, both the research and actual atte
human fetuses to term would require a lot of women
fetuses. Again, the needed hormonal treatments, pre
are not without risks. But if the women, of their o
participate, that is acceptable within the liberal fra
involved are autonomous agents who can give their
dures. It can be argued, though, that if the need for vo
cantly, the risk of exploitation is also likely to increa
clones themselves who do not have any say in the ma
There are a number of difficulties in dealing wi
who do not yet exist, and perhaps never will, and the d
them.25 What can be said is that attempts to clone hum
best of our knowledge, result in a large number of b
viduals.26 It is yet to be established what the great ben
reproductive cloning in the face of this outcome wou
its potential benefits in the next section.
In terms of research ethics, it might be that rese
ing cannot (ever) be justified, even if there is nothing
human cloning as such. According to the leading s
cannot be adequately tested on other mammals, becaus
differently to the practice. On the other hand, it seem
other mammals, many human clones could have leth
visible only after their birth.27 No ethics committee w
trials on cloning up to the time after birth. It is only
which experiments are allowed. It might be that hum
mere possibility, because research into it cannot be p
only hope that, with the expected risks, nobody
humans without prior research.
In addition to the direct human suffering, resea
ductive cloning can arguably cause suffering indirectly
 7. Cloning as Rights Satisfaction, and Other E
of Human Reproductive Clonin

In what follows, I will have to assume, against c

predictions, that the technique of cloning can be per
violations of accepted codes of research ethics. Oth
concerning our right to benefit from past evil deeds wo
Among the most favorably envisaged future use
tive cloning is that of helping infertile couples to h
genetic heritage. The argument for this is backed up
some call the right to reproduce, or reproductive freedo
family is, after all, one of the internationally acclaim
is argued that since everyone has the right to reprodu
ductive cloning should be funded publicly to help even
currently suffering from infertility.
The alleged right to reproduce is, however, a co
has been interpreted in numerous ways around the wor
not clear who possesses such a right.31 In many countr
in the end, the woman should have a stronger say
countries allow women to decide on abortions on the
argued, depriving men of even the bare liberty to repr
ence from others.32 And as for individuals with sever
and people who have been institutionalized, while th
is no longer condoned in the West, their reproducti
many respects severely limited.
The paragon right holders here are fertile wome
engage in traditional heterosexual penetrative sex with
to reproduce is a solid liberty right with which no
interfere. (The most notable exceptions include women
right to use contraceptives, and prohibitions concer
deception.) If there are fertility problems, or difficultie
partner, the right to reproduce is reduced into a privile
proper authorities to decide who is worthy of exercis
duce. Sometimes the privilege is granted more readily
countries with public health care systems there is a
services that are provided, paid for, or compensated by
hand and the services that have to be purchased private
the wealthy are often viewed as more likely to be ab
home for their child, and consequently are desirable ca
services too. It seems clear that the modern world ha
 It is, however, plausible to argue that because the
nonetheless, a liberty, nobody should interfere with
tempts to clone humans. And it may be unfair to pick
alternative does not fare much better in comparis
exercise of the right to reproduce by those who have
their disposal has caused, and continues to cause,
Children are born in terrible conditions, they are negle
to dangerous substances even before birth, and in m
cared for. The right to reproduce as a liberty has, how
be so important to what it means to be human that all
is accepted as a price worth paying.
Those who wish to hold on to the right to repro
ban cloning, have pointed out that cloning is not rep
intended by the right, because it is asexual.34 There ar
that can be made to this claim. The first is to ask, who
defined the conceptually acceptable modes of reprodu
argue that even if to have a child through cloning wo
right to reproduce, the unrestricted freedom of indivi
choose, unless they harm others, is usually accepte
Under this right to autonomy principle, people c
reproductive purposesif nobody is harmed in the pro
if clause are, in the light of what we now know abo
meet.
Another suggested positive outcome of human r
the possibility of avoiding certain mitochondrial disea
we inherit comes only from the mother, and if the m
drial disease, it will be passed on to her children. If
transfer could be mastered, a couple could have thei
disease-free) genetic offspring by using an egg from
involve fertilizing the womans egg with the mans s
the nucleus into an egg with healthy mitochondria, a
this egg in the womans uterus.35 This practice would
far less resistance than other types of human reproduc
not involve making a copy of another human being, an
the child would be almost entirely its genetic parent
noted, though, that mitochondrial diseases are relativ
take a long time before nuclear transfer can be done t
for this to work. Meanwhile, however, research into hu
to produce a lot of suffering, and it is by no means
future method of avoiding mitochondrial diseases wou
be like to be a clone. Would there be something wrong
It has been argued that even if clones were full
lives might still be deprived of certain important a
which would make intentional attempts to clone huma
suggested that a clone would live its life in the shado
whom it was cloned,36 and that the clone would b
ignorance.37 Some have claimed that Joel Feinberg
childs right to an open future would also carry the
bergs argument is not, however, as such, applicable to
or cloning, because it is focused on the childs open f
natural (genetically fixed) potential, and does not
futures of individuals who may, on genetic grounds, n
The idea of the life in the shadow and right to
is that although it is relatively clear that our identity a
straightforwardly determined by our genes, it is possib
tions are projected onto cloned lives by the individu
or by other people. The life in the shadow argument em
fact that others would look at clones comparing them
the ignorance argument draws mostly on the existen
clones themselves as people who have been (or who b
foretold their destiny.40
A life in the shadow of another human being wo
ish the clones possibility of living a life that is in a f
his or her life.41 Insofar as people are, even partly, pe
peoples (more original) lives, this is bad for them as
This argument shows that as long as people have a ten
mere shadows of their originals, there is something wr
another question, however, whether this observed te
cloning should be prohibited. It is debatable wheth
original on a clone is any worse than the shadow cas
parents on their children.
The idea that cloning is wrong because it produc
know too much (or believe that they know too mu
relies on the existential idea that life is about disco
wrongness of cloning, according to those who hold th
that clones are not given the chance (when they know
discover themselves, as some of the finding out has alr
original. This argument, too, draws on the assumed
lean towards genetic determinism in their view of the
clones. Leaving the existential issues on one side,
older than the clones, then the clones would have a les
about their genetic makeups than other people do. The
is, what type of a right is the right to genetic ignorance
people cannot be adequately protected against genet
casethey only need to look in the mirror or meet t
know something about their genetic makeupit wou
to genetic ignorance can only be a negative claim righ
right I mean that the right-holder has no duty to know
makeup, and that others have a duty not to inform
wishes).45 A right like this does not, however, oblig
protect her from the information. I would be tempte
does not violate the right to genetic ignorance as a
although the issue is debatable.

9. Odds and Ends

In addition to the main arguments against cloning th

there are numerous other issues that are often brough
the topic. For instance, some are worried about the i
human gene pool should cloning become a regular m
Others bring up the difficulties all this causes to f
where a mother can also be a sister and ones grandpa
genetic parents. The clones depicted in sci-fi literatu
mark on peoples views on cloning. A persistent im
involving armies of less-than-human clones marching
keep alive the notion of clones as beings that have b
evil purpose or to do a dubious or inhumane job.
It is unlikely that cloning will ever become the
duction, and even if it did, the human gene pool woul
a long time. As for the changes in family life, the
model with two parents of opposite sexes and their
has for some time now been a thing of the past. T
reasons to expect that people could not assimilate chi
source into their lives. As for the fear of eugenics, I w
new technology that, in theory, makes possible cert
would force societies to adopt eugenic policies. We alr
ogy to screen fetuses, test prospective parents, steri
unwanted pregnancies. We have the means to large-sca
not choose to use them. I would think it plausible t
distress in many people, and those anxieties, too, shou
of the costs of cloningeven if the fears could
grounded, and despite the fact that yuk reactions are
as moral arguments.46 This is especially so when there
little reason for attempting human reproductive clonin

10. Surprisingly Little Wrong, But Still . .

As far as we know, we can expect very marginal

reproductive cloning. It could be used as an alternat
and the method of nuclear transfer could be used to
drial diseases, but with no generally acknowledged p
duce and with the rarity of mitochondrial diseases, it is
should use cloning to tackle these issues. The argum
human reproductive cloning do not, at least phil
unequivocally justify an absolute condemnation of
cloning, but the cumulative effect of the contingent
practice should make us wary, to say the least.
Research leading to human reproductive cloning
trials on very early embryos, but it would require ca
term as well. With the expected risks, research propo
not gain ethical approval. Without proper research, to
ductive cloning, again with the associated risks, wou
seem that unless the outstanding safety issues on
cloning can be addressed, we cannot conduct the ne
consequently, cannot justifiably attempt human reprod
Human reproductive cloning is a high-risk, expe
even in the best-case scenario, only minor benefits.
wrong, and should not be condemned as such. Howev
seems, the safety issues cannot be resolved, and researc
would cause suffering and place the study subjects und
should not, as things now stand, be attempted. And ev
could, sometime in the future, be properly addressed,
invest public money into research with so few bene
(provided that the money could be used for more worth
 2. See, e.g., UNESCO Universal Declaration on t
Human Rights, UNESCO, 3 Dec 1997; The European Par
Cloning, 13 Mar 1997; National Bioethics Advisory C
Annual Report, Maryland, USA, March 1998, Appendix B
3. Sren Holm, A Life in the Shadow: One Reaso
Clone Humans, Cambridge Quarterly of Healthcare Eth
pp. 160162.
4. See e.g. Pontificia Acedemia Pro Vita, Reflection
Libreria Editrice Vaticana, 1997).
5. Rebecca Kolberg., Human Embryo Clonin
262:5134 (29 October 1993), pp. 652653.
6. Alan Colman, Why Human Cloning Should N
Genetic Revolution and Human Rights, ed. Justine B
University Press, 1999), p. 15.
7. See e.g. UNESCO, Universal Declaration on Hum
Rights; Council of Europe, Additional Protocol to t
Protection of Human Rights and Dignity of the Human B
Application of Biology and Medicine, on the Prohibit
Beings (with additional Explanatory Report). European
DIR/JUR (98)7; cf. United Nations, general Assembly
International Convention Against the Reproductive Clo
Report of the Sixth Committee, Draft Resolution A/C.6/57
8. See e.g. John Harris, Clones, Genes, and Huma
Revolution and Human Rights, ed. Burley, pp. 6667; cf
Look at Dignity, Cambridge Quarterly of Healthcare
714.
9. David de Pomerai, Dolly Mixtures: Retrospects
mal and Human Cloning, Journal of Genetics and Ethics
10. Donald Bruce, CloningA Step Too Far, Jo
Ethics, 4:2 (1998), p. 37.
11. Pontificia Academia Pro Vita, 1997, 15 & 14.
12. Bruce, CloningA Step Too Far; Ethical Issu
Research, Volume III: Religious Approaches (Rockville,
Advisory Commission, June 2000).
13. See e.g. UNESCO, Universal Declaration on t
Human Rights, 1997.
14. Holm, A Life in the Shadow, p. 160; Dan W. B
Beings: An Assessment of the Ethical Issues Pro and Co
Facts and Fantasies About Human Cloning, ed. Martha
Sunstein (New York: W. W. Norton, 1998), pp. 103104.
15. Bruce, CloningA Step Too Far, p. 37.
16. Leon R. Kass, Life, Liberty, and the Defence of
CA: Encounter Books, 2002), p. 154.
bryo, Unsanctifying Human Life: Essays on Ethics, ed
Blackwell, 2002), p. 186.
19. See e.g. Immanuel Kant, The Metaphysics of M
manuel Kant, Practical Philosophy, ed. Mary J. Gregor
University Press, 1996), p. 6:462, 38. Also, in the sam
Kant, The Metaphysical Principles of Virtue, 434435
20. See e.g. Hilary Putnam, Cloning People, The
Human Rights, ed. Burley, p. 9; John Harris, Goodbye
Human Cloning, Journal of Medical Ethics, 23:6 (
Clones, Genes, and Human Rights, pp. 6778.
21. Kant, The Metaphysics of Morals, p. 6:462.
22. John Harris, Is Cloning an Attack on Hum
387:6635 (19 June 1997), p. 754; K. Labib, Dont Le
Cloning Debate, Nature, 388:6637 (3 July 1997), p.
Dignity, and Ethical Revisionism, Nature, 388:6640 (24
Shapiro, Cloning, Dignity, and Ethical reasoning, Natur
1997), p. 511; John Harris, Cloning and Bioethic
389:6640 (2 October 1997), p. 433.
23. Cf., however, Immanuel Kant, The Metaphysical
434435, and Groundwork of the Metaphysics of Mora
same collection.
24. Ian Wilmut, Dolly: The Age of Biological Cont
lution and Human Rights, ed. Burley, p. 20; R. Jaenisch
Clone Humans, Science, 291:5513 (30 March 2001), p. 2
25. Cf., however, Derek Parfit, Reasons and Person
versity Press, 1984); Justine Burley and John Harris, Hum
Welfare, Journal of Medical Ethics, 25:2 (April 19
McCarthy, Persons and their Copies, Journal of Medi
1999), pp. 99100.
26. See e.g. Jaenisch and Wilmut, Dont Clone Hum
27. Ibid.
28. See Immaculada de Melo-Martn, On Cloning H
ics, 16:3 (2002), pp. 254265.
29. See e.g. Tuija Takala and Matti Hyry, Benefiti
ing, Human Embryonic Stem Cell Lines, and the Fragili
Position, Ethics of Stem Cells, ed. John Harris (Oxford: O
forthcoming).
30. United Nations, Universal Declaration of Hum
the General Assembly on 10 December 1948.
31. See e.g. Kass, Life, Liberty, and the Defence of
Deech, Cloning and Public Policy, The Genetic Revolut
ed. Burley, pp. 95100.
 35. Wilmut, Dolly: The Age of Biological Control,
36. Holm, A Life in the Shadow.
37. Hans Jonas, Biological EngineeringA Previ
says: From Ancient Creed to Technological Man (Engle
tice-Hall, 1974) 141167.
38. E.g., Brock, Cloning Human Beings: An Asses
sues Pro and Con; also de Melo-Martn, On Cloning H
Joel Feinberg, The Childs Right to an Open Future,
Fulfillment: Philosophical Essays (Princeton: Princeton U
pp. 7697.
39. See e.g. Tuija Takala, The Childs Right to an O
Genetics, Ethical Issues in the New Genetics: Are Genes U
and Michael Parker (Aldershot: Ashgate, 2003), pp. 3946
40. Holm, A Life in the Shadow; Jonas, Biologic
41. Holm A Life in the Shadow, p. 162.
42. Jonas, Biological Engineering, pp. 159163.
43. See e.g. Tuija Takala, The Right to Ignorance
13:34 (July 1999), pp. 288293; Matti Hyry and
Ignorance, Moral Obligations, and Social Duties, Jou
Philosophy, 25:1 (February 2000), pp. 107113; Matti H
Genetic Information, Rights and Autonomy, Theoretica
ics, 22:5 (September 2001), pp. 403414; Tuija Takala,
Reasonable Paternalism, Theoretical Medicine and Bio
2001), pp. 485491.
44. Cf. Feinberg, Social Philosophy; Hyry and Ta
tion, Rights, and Autonomy.
45. Hyry and Takala, Genetic Information, Rights,
46. See e.g. Jonathan Glover, Eugenics and Huma
Revolution and Human Rights, ed. Burley, pp. 101104;
and the Defence of Dignity, p. 150.
 1. Introduction

Most approaches to contemporary problems, if they ar

are justified by some manner of measurement. Bi
important, as the development of policy and regula
considerable consequences. Advances in scientific a
bring with them the problem of insufficient knowledg
a public already alarmed about the fallibility of scie
assurances. The potential good of something like s
genetic screening tends to fall under the same scien
about the genetic modification of crops and cloning in
It is difficult to know whether public outcry about s
indicates a proper area for concern, or is merely a
reactions to the new. Much of this public outcry is
factorwe do not like it, but we are not sure why.
express what the problem may be, with vague talk
against nature, and concern about the erosion of resp
and uniqueness. There does seem to be an intuitive u
are things important to personhood and human flouri
equal respect for persons. But these are often diff
therefore to quantify, so consideration of them is gene
In order for bioethics to be considered effective a
to be comprehensive in its approach to bioethical p
approach would perhaps require analysis of existi
research and theoretical concepts which would be co
usual ethical frameworks and principles. To conside
approach to problems in bioethics might look, it is
case in which widely accepted moral principles alone l
may appear to be morally counter-intuitive. I illustrate
the argument is broadly applicable to bioethical pro
case study relates to a commercial trade in kidneys
favor of allowing such a trade is said to be made thro
rather than any particular rights-based or libertarian p
philosophical argument may look as if it stands on it
ing the yuk factor as an unsubstantiated reaction. B
factor does indicate something substantive, and it may
In 1989, two British surgeons were exposed in a
buying of kidneys from Turkish nationals to treat p
United Kingdom. This caused a huge public outcry, a
form of the Human Organ Transplant Act (1989)wa
ban the practice. However, there has since been a cal
Forum for Transplant Ethics for this ban to be reviewe
to consider the following argument.1
There is very little in existing law to support p
the reaction of widespread repugnance was itself taken
ban. The law already permits persons to make extr
what they do with their bodies. For example, a pers
treatment even if death is a certain outcome. The legis
non-therapeutic sterilization and the legality of (of
surgery procedures all imply that our bodies are, in a
decide what to do with.
The concern about a commercial trade in kidney
volve exploitation of the poor, and altruistic donation
demarcation line to prevent this from happening. Th
upon the doctrine of consent, which must be inform
surgical intervention to be valid. It was assumed tha
prevents uncoerced consent. But the Forum argues, l
that this is an unsafe distinction. There is nothing to
cannot make an informed choice to sell a kidney for an
this was indeed the case for one of the Turkish na
scandal. He was raising money to pay for an opera
Also, altruistic donations may be coercive through th
tion, guilt, or obligation, and these pressures can be
perceived financial inducement. The risk to the donor
diate post-op risk of 0.05% and a 0.07% chance of so
the remaining kidney.2 This is deemed perfectly ac
donors, so arguing against kidney sales on the grounds
Finally, even if we think kidney selling is wrong, it
prohibition is warranted. The Warnock Committee R
unanimously disapproved of the practice.3 Despite thi
tion of private arrangements, involving the paym
expenses, was not warranted, on the grounds of the
and the difficulty of enforcement.
The philosophical arguments are similarly str
concern is the slippery slope argument, which ho
poverty is forcing people to sell, but that by protec
take away the only option they have left, thereby mak
mous. The second is that those likely to sell a kidne
enough to understand the risk and implications of the
answered that these concerns should be addressed by a
and counseling, and if this is impracticable then the
the hands of a guardian, as is the situation under
Forum for Transplant Ethics states that our indigna
exploited poor seems to take the curious form of w
worse off still.
Arguments in defense of the current prohibition
much less tangible. They relate to possibilities of
corruption of sensibilities if body parts are considere
that this rhetoric cannot hope to outweigh the very re
destitution. To say that commodification of the self is
a point instead of giving a reason. The Forum states th

[A]ttempts to justify the deep feelings of repu

driving force of prohibition, and feelings of repu
and healthy, no matter how strongly felt, canno
only hope of the destitute and dying.4

To summarize the Forums case: there is an ove

crease the supply of kidneys, and this can be done at
ban. There probably would not even be a ban if leg
rushed through on the wave of a scandal, as no one w
of the evidence that it was warranted. There are great s
both of cost to the health service on a micro-level (le
and in the advancement of autonomy and general w
level. We may not like it, but that is no reason for sto
the ban would reflect a commitment to autonomy
entailed by self-determination.

3. Logic versus Intuition

So there we have it: impartial logic and reason at

outcry and inconsistent legislation can be seen as k
yuk factor in operation. We may feel repugnance
commitment to liberal autonomy demands a substan
 Intuitionism is a bit of a bad word in philos
The Greeks intuitively knew there was nothing wron
knew womens brains were smaller than mens (som
that some races were inferior to others. Others are c
absolutely that homosexuality is morally wrong. S
guide to moral integrity and we must leave it behind
logic and reason.
But what if we still think that something is wron
of the public outcry, bearing in mind that this practice
banned, be just misguided? That this is a possibility w
by John Harris. However, if we think that there
intuitive in the conclusion that the poor must be free t
and that we do them a disservice by not letting th
nothing left with which to argue this point, without b
tions of flailing at logic.
But maybe there is a second-order moral questio
asks why reasoning from logic leads to conclusions t
feel are morally suspect. If it is so logically obvious a
then why is there such a tension about this issue? Is
something important?
Janet Radcliffe-Richards, writing in support of
kidneys, admits that she feels the same repugnance tow
reason has forced her to override this concern.5 The
Gaita says that philosophers who say they courageous
it compels them are often indulging in self-congra
this seems rather harsh directed against the ration
advanced by those who see a market in organs as a sol
here that needs to be elaborated. If logic and reason lea
many feel is nevertheless alarming and wrong, must
conclusion? Do we not need to examine the premises
autonomy is based on one of negative liberty, the ri
live life as you please unless your actions harm anoth
found in the private transactions of willing buyers an
sion is that prohibition is unwarranted, undesirable,
this conception of liberty that makes rationales like
logically and legally compelling and, as we can see, m
that make the inevitable conclusion one of commodific
We hold a concept of property as private prope
The right to property is inalienable (a fundamental
property itself is considered fully alienable (we must
our property, events such as bankruptcy aside). So m
right to sell, is inherent in the concept of property
things that are outside the market, are then concept
problematic. The conceptualist view of property c
things are property but not fully alienable. It can only
are just not property.7
We do think of the body as property. The norm
speaking about the body is further supported by the wa
is ours. The normative discourse used when talking
of ownership. Expressions like it is my body and
are a manner of speaking rather than an expression
They reflect the negative right to be left alone that is le
requirement of consent to be touched. But this way
creasingly market driven society gives rise to concep
including buying and selling.8
It is generally accepted that liberalism in its broa
as the absence of restrictions. In other words freedo
From this it is assumed that respect for autonomy req
to avoid stating any preferences regarding the choice
citizens. These choices may be good, bad, or arbitr
thing is that they are made by the person. This tends
tion, because freedom is defined as individual freedom
Acceptance of these tenets leads to the conclusi
my property, and no one can tell me what the good
alienable, therefore I must be allowed to sell it if I wis
these basic premises all tend toward commodification
the customary rhetoric of economic analysis, by only
quantifiable harms. This person is dying, this person
way the language of liberal democracy is becoming
the language of the free market.
are formed. A laissez faire system without directio
absurdities, and for this reason the success of the mark
not by its ability to meet the necessarily self-intereste
als, but on its ability to satisfy human needs and welfa
The freedom of non-interference is worthless w
ethical conditions required to make it valuable. Not en
of peoples choices absolves us of any responsibility t
protection. The liberal response to this is that we ca
values on others. The reluctance to interfere can be d
ingness to be paternalistic. However, as Hegel would a
value judgment therea judgment about the value of a
regardless of how that choice is reached. For Hegel,
freedom to be manipulated by the particular social
stances of the time. The acceptance of negative liber
choice of the individual as the only relevant starting
conclusions of the Forum. However, good and impor
written into the liberal ideal and it is simply wrong to
judging the desirability of peoples choices. This is
sexuality to heterosexuality, prostitutes to poets, or
nence. It is to look at the basis of the choice, espec
that it is coerced by circumstances, and determine w
the flourishing of the individual.
So, a commitment to liberal neutrality leads to
the facts, and the pervasiveness of the discourse mak
ceive of the conclusions as substantively wrong. How
premises may be flawed, then we are not compelled to
The premises exemplify a discourse that is detrime
wrong conceptions of what it is to be free. The id
choose to alienate certain things, a kidney in this
alienationthe freedom to sell anythingis an ac
freedom. If we follow this logic, then everything is up
we accept that we are driven toward these conclusi
discourse then we are entitled to say in advance, from
things important to personhood, what should be free f
acceptance of a positive conception of liberty would
ities required to foster self-development would be seen
constrain freedom.
death. India likewise has no cadaver program, and f
tional problems make long-term dialysis unsuitable
reasons for these problems that deserve a separate anal
particular problems make it an appropriate framework
analysis, being a society which, arguably, could mos
mercial trade. The argument against prohibition wil
persuasive against the backdrop of problems such as th
as the Forums talk of starving children and destitut
the argument from autonomy to support it where no
meaning of the word, exists, is flawed. Two desperat
amount to autonomy. Those with different religious
will have a different moral framework to argue from
that it is our job, in the West, to morally justify a
them.
The argument advanced by the International Foru
ics relies on legal analogies and the philosophical c
omy and informed consent. It is important to keep in
wish to keep prohibition in place, for whatever re
handedly removing the only hope of the destitute a
Forums accusation. If this were the case, then defende
not bear the moral weight of that argument. But the cl
legitimacy of a commercial trade in kidneys rests on th
problems are caused by the constraints of altruistic d
data tells us this is not necessarily the case. It is the
organ procurement that a commercial trade in kidney
against. The Forum may have reached different conc
had been taken into account.

7. A Less Ethically Problematic O

For both the United States and the United Kingdom

method would be a system of required response.
required to register their willingness or refusal to do
authority or their General Practitioner. The administrat
not thought to be particularly problematic, and all don
on a central database. This would legally protect t
organizations, stop next of kin refusals, and mai
prerogative to opt in, opt out, or delegate the choice t
expectation is that this system would evolve into one
been asked.
Furthermore, focus on an organ shortfall helps t
adequate funding resulting in a lack of facilities and s
which, according to the Royal College of Surgeons, is
is organ shortage.10 There are ways to increase the sho
do not suffer the concerns of a commercial trade. Th
from the political will and co-ordination required to
The law is committed to the formalisms of the polit
the principle of autonomy, while not being able to s
for people because of the commitment to liberal ne
tension between the rhetoric and what might perhaps b
holistic type of justice. Really the law should probab
It would accord with the language and conception of
reflect the primacy of the principles of autonomy an
not accept it because that widespread abhorrence, th
many things. It represents fears of the market encroa
mining, every area of our liveseven the inside of our
because, at heart, we know that those with the leas
They are fears because intangibles like dignity, bodily
and flourishing, which we can conceive of but ha
cannot be measured to the satisfaction of a discourse, s
It seems to be of incalculable importance to ta
knowledge and information about the social world
abstract moral principles to do all the work. We cann
terms are dictated by a particular framework of discour
erished to begin with, decide, or we get impoverish
philosophy is surely able to propose that that there i
good that demands certain inalienabilities. Acceptance
isms of a liberal market economy constrains our a
market terms. This erodes social responsibility and
unfortunate, under the guise of help, by insisting that
to make money any way they can.

8. Conclusion

To summarize: we can see how logic and analysis,

particular framework of discourse, necessitate conclus
ally counter-intuitive. The concern about a commerci
real. But it is difficult to counter the logical argumen
are not going to be forthcoming. However, issues t
spread public concern can be examined, and if they are
of something substantive, less ethically problemati
reached. This requires something more than armchair p
an engagement with social reality.
Even if the argument in favor of a commercial
tional and logical, this does not necessarily make it eth
less morally contentious options are available but
mended. The framework used by the International
Ethics was far too simple and one-dimensional to fit
widespread unease and distaste about a concern in ap
given more weightwhy swim against the tide? Bo
the horror of kidney selling is so strong because it sy
all the wrongs we feel free to ignore because of our fam
This is important. It may be, and I believe that
ienabilities are needed to engender altruism and ke
personhood such as dignity and bodily integrity. If w
bles are probably important, then ignoring them will
applied ethics, or a better social reality.

Acknowledgement

The research for this paper has been supported by the

Bioethics (EMPIRE) project, funded by the Europe
Research. I thank the commission for its support.

NOTES

1. Janet Radcliffe-Richards, A. S. Daar, R. D. Gutt

Kennedy, M. Lock, R. A. Sells, and N. Tilney for the I
Transplant Ethics, The Case for Allowing Kidney Sales,
(27 June 1998), pp. 19501952.
2. Gerald Dworkin, The Law Relating to Organ T
land, Medical Law, ed. Ian Kennedy and Andrew Grubb
3rd ed., 2000), p. 1084.
3. Baroness Warnock A Question of Life, Medica
Grubb, p. 825.
4. Radcliffe-Richards et al, The Case for Allowing K
 7. Margaret Jane Radin, Market Inalienability,
100:8 (1987), pp. 1849-1937.
8. Jim Harris Who Owns My Body, Oxford Jou
16:1 (Spring 1996), pp. 5584.
9. Peter Singer, Hegel (Oxford: Oxford University Pr
10. Royal College of Surgeons of England, Report o
Review Organ Transplantation (London: Royal College o
1999).
11. Bob Brecher, The Kidney Trade: Or, the Custo
Journal of Medical Ethics, 16:3 (September 1990), pp. 12
 Eve Garrard and Stephen Wilki

1. Introduction

Is empirical information a significant part of bioethics?

answer to this is so obviously yes that there does no
for debate. How could any branch of applied ethics be
matter what background ethical theory is endorsed, it s
world is, empirically speaking, must be relevant to
ances of the theory. But this question can be seen as
long tradition of querying the relation between the w
the world of moral-philosophical reasoning. As far ba
Plato was suggesting that the empirical world, includ
believe about it, had little to offer the philosopher,1
respectable opinion about moral matters as an ind
moral theorizing.2 More recently, a common sourc
relevance of the empirical to the moral has been loca
purportedly exists between facts and values; a gap w
said, any attempt to derive ethical conclusions from em
if we cannot derive ethical conclusions from them, the
in bioethics appears suspect.
In this chapter, we argue that even if there is a
not rule out the relevance of empirical information t
that there are quite strong arguments for thinking tha
than it is normally claimed to be, in which case there
close relationship between the empirical data and bioet
not follow from this general thought that all kinds of
to enter equally into ethical debate. We distinguish
relevant to ethics, and data that are actually part of
which of these roles is being played by any given piec
tion will be a highly context-sensitive matter. We
theory-sensitive, because data that are merely relev
account of ethics could be construed as part of ethics o
Later on, we discuss four particular sources of
science; social science research into the outcomes of ou
social science research into the behavior and attitudes
science research into public attitudes. Since, as we a
implausible moral theory, we conclude that much,
 2. The Fact-Value Gap

One of the principal reasons given for casting doub

empirical data to ethical conclusions is the claim tha
values seem to be quite different kinds of things. I
claim, facts (for example about the widespread politi
real and objectively there, so that we can make true s
whereas whatever values (for example the wrongness o
not thought to be like that. This difference is some
value gap, the metaphor of a gap being used to cap
difference in kind is a profound one that cannot easily
lar, the gap between fact and value prevents from u
statements (statements about right and wrong, good
descriptive premises. So, for example, no amount of
about intractable pain in some terminally ill patients c
infer that euthanasia is right, for the gap between the d
and the evaluative conclusion prevents any such infer
Unless we have something like a moral principle s
innocent is sometimes morally permissible, the infer
through. And this failure of inference may be thought
relevance of empirical data to any ethical conclusion
ones, since such data can never settle ethical debates.
But this further thought is open to two objection
ranted by the existence of a fact-value gap, since th
bridging the gap that will at least allow empirical evid
ethical issues, even if it cannot settle them on its own.
presence of a bridging principle about which actions ar
or even obligatory, can do this work. And second, th
fact-value gap of the traditional kind, understood as a
difference between facts and values, is itself highly deb
On the traditional account of the fact-value gap,
scribable in true statements, whereas values are sub
statements are not capable of truth or falsity at all. But
it is still possible for empirical data to play a sign
debate. If ethical statements are just expressions of
different features of the world, or are effectively prescr
on those attitudes, then we need the empirical data to
of the world are actually present. If we have the attitu
general happiness, let us say, or perhaps on the basi
scribe actions which tend to promote it, then we need
an evaluationthe data are still relevant to our moral c
However, this traditional understanding of the f
means the only one available. Those who think tha
capable of truth and falsity, so that some amount of
of the moral domain, will regard the difference betwe
more like the difference between physical facts and b
the latter are understood as a subset of the former. Va
seen as a kind of fact, so that the contrast is betwee
descriptive facts. (This view is perfectly compatible w
is-ought gap.3) The gap here is no longer so deep a
values and empirical data now turn out to be different
is open for a closer relationship between them.
There are other reasons to think that that relati
First, the existence of thick ethical concepts,4 such
or cruelty, shows that sometimes empirical and ev
intertwined that they cannot be disentangled. A judgm
courageous carries empirical and evaluative content, bu
tually separablewe cannot pick out the empirica
courageous without having a firm grasp of the kind
involved here.5 And when we are formulating our sc
separately from any considerations to do with moralit
that values are an essential part of the process. This
values such as simplicity and coherence are an ind
theory choice: we use them to select the best of a com
ries, and consequently they are inextricably involve
what the facts are.6 So values are sometimes involve
the empirical facts are, and it would not be entirely s
were also true.
There is also another important theoretical reason
empirical facts to play an important part in ethical deb
(and for some, a defining feature) of morality is th
universal about our moral judgments. If (for example
person deliberately to kill innocent civilians, then it i
relevantly similarly circumstances deliberately to k
such actions are wrong in virtue of being the deliberat
(This is to say that moral properties supervene upon
this means that in some sense the empirical facts fix t
they are a genuine part of the ethical debate. Just whi
this role, in which circumstances, is itself disputed,
on which normative ethical theory turns out to be th
to) determine the rightness of that decision. By contr
faith (or lack of it) in the treatment may not be actual
even though they may have some relevance to it (for
relevant to the speed with which the treatment should
the decision to do so should be publicly presented).
This aspect of morality, that moral features of a
present in virtue of the presence of some non-moral
non-moral properties determine the moral ones, is
argument. This is what enables us to draw an importan
empirical facts that are part of a particular ethical deb
determine the rightness (or wrongness) of what is to b
facts that are merely relevant to the debate, playing a
How this distinction is to be run will vary from c
general point, although there is no reason to think w
data at arms length when we are doing ethics, some em
more equal than others, so to speak, and we may no
entry-ticket to everything that on the face of it appears
Large claims have been made concerning the c
some kinds of empirical data, both from the natural
social sciences. Perhaps the most notable claim has be
evolutionary psychology and biology, especially con
promotes survival and reproduction. Some sociobio
that such data are enough to settle major ethical issue
for example, can be shown to promote survival and
have found a justification for engaging in altruistic b
have no reason to believe that altruistic actions are righ
ing survival and reproduction, then even if facts ab
survival and reproduction turn out to be relevant to e
not thereby have reason to think they are part of ethics
can by themselves provide a justification for altruistic
Other data from the sciences are sometimes prese
and in subsequent sections we consider some of these
the role of social science in bioethics. However, we
look at the natural sciences.

3. The Role of Natural Science

Obviously, the morality of an action or policy will oft

the facts of natural science: especially, in the case o
research ethics, even though its findings are undoubt
This is hardly surprising since, if we allowed scien
likely consequences of our actions to count as ethic
would be open and almost all research would or co
(because almost all research can, in particular circums
ethics).
Our second point about natural science (one whi
of the theoretical considerations discussed earlier) is
alone is never sufficient to settle an ethical quest
reproductive medicine case mentioned above, for exam
debate (restrictive and permissive) might agree tha
adversely affected by the use of a particular techno
disagree about whether this is sufficient to justify
because there is an underlying moral or philosophi
significance of the non-identity problem, or abo
parental autonomy.9 In cases like these, gathering
psychological evidence about the welfare of future chil
debate forwards, since what is at issue is a moral or
not an empirical one. Even if we knew everything th
about child welfare, the dispute would persist.
We conclude, then, first that natural science is no
though its results are often relevant to ethics, and seco
research alone is never sufficient to settle an ethical qu

4. Social Science: Some Prelimina

We noted earlier that research into the likely consequ

obviously relevant to ethics. As Robert Zussman pu
medical ethics is based on consequentialist claims th
well equipped to deal with.10 This is the main way i
can contribute to bioethics, since knowing what th
would be if we did x will often be a crucial part of
against doing x. To take a straightforward example,
against commercial surrogacy, claims that a pool of
be created on the model of working class prostitution
to be imported from poor countries for the purpose
gates.11
In order fully to assess Brechers moral argume
cial and economic data to confirm or falsify what he
job it is to provide empirical evidence for or against su
Does anything follow from the fact that sociolo
likely consequences of our actions is (or should be) o
Probably not, or not much. For, as we saw earlier, m
is not enough to make something part of ethics, a
science just sketched is not fundamentally different
science, because both simply deliver information ab
actions. However, several writers have expressed dis
usual account of moral reasoning according to which

social science is often seen as able to provide

philosophy attends to moral values and concep
formally valid arguments.12

Mairi Levitt describes this as the traditional view

philosophy, according to which:

sociologists are junior technicians in the bioe

than equal partners. Where bioethics is concerne
ics, setting out what ought to be done, if sociolog
they will only be useful to provide background
may select from these data, but any empirical re
subordinate to moral reasoning.13

Erica Haimes, meanwhile, talks of the over-simpl

normative and descriptive ethics (that assigns the soc
maiden role of simply providing the facts).14 So to
at this stage as not part of ethics (or as merely its
perhaps be too hasty, since there are other possibl
occupy. In the next few sections, we explore these, a
ments for the view that its role in ethics is central rathe

5. The Sociology of Ethics

In the previous section, we were thinking mainly of so

ing information about the effects on society of our a
rather different social science endeavor is the sociology
in two main forms. First, there are studies of the
 whilst there is still a legitimate case to be made
abstract formal discipline, distanced from matter
tice, it is not possible to posit the same view o
As individual and collective practitioners of the
varied in their approaches and interests, they a
sional and other social groupings and are thus su
of, and in turn influence, broader social changes a

We would not disagree with what Haimes says here,

affect and are affected by social phenomena. Howeve
whether much follows from this. For we could say
about any academic subject (or any practice). And so
not entail the view that the sociology of ethicists is
ethics. After all, in most areas, we would not say th
subject was part of that subject: for example the socio
itself physics. So, while acknowledging that it is u
know about the sociology of their subject, we doubt th
to view sociology as an integral part of ethics.
A second (stronger) reason for rejecting the soci
view is that knowing about the sociology of academic
in quite unusual cases) provide us with reasons to a
arguments. This is because the soundness of an argu
its origins. So (for example) discovering that 90% of b
male Catholics would not, in and of itself, tell us anyt
of these bioethicists arguments against procreative a
logical fact would make us suspicious of their argum
and make us subject them to more careful scrutiny
because we would suspect them of bias). But if the arg
they are sound no matter who propounds them. An
essentially the same point would be to say that to rejec
argument on sociological grounds (for example, beca
people who put it forward) would be fallaciously to
move, defined by Nigel Warburton as attacking the
with whom you are arguing rather than finding fault
ment.16
 Mozart was chosen by 8% and Elvis by 7%. A t
of the four should be cloned, and 5% said they d
those questioned chose more than one name. 10
mans should be cloned, compared with 7% of wo

The rest of our chapter looks at public attitudes resear

research into what the public thinks about ethical iss
take several forms, ranging from more or less crude qu
the one quoted above) through to more subtle ethnog
work.18 Obviously, public attitudes research can som
bioethics in the same way that natural science rese
follows we question the view that it is any more im
ethics) than natural science research, along with the
(as opposed to merely relevant to) bioethics.
In discussions about the role of public attitudes
often accuse sociologists of being relativists, while
the favor by accusing the philosophers of not being rel
this reason, well start our examination of public a
some thoughts about relativism.
The relevant relativism for our purposes is mora
cifically, metaethical relativism, which says (roughly)
true or most justified morality and that moral propos
as they are true at alljust in virtue of their confo
societys attitudes or conventions. This view shoul
guished from, and definitely is not entailed by, desc
view that there is, as a matter of fact, extensive cros
sonal diversity in moral attitudes and opinions. So
relativism, a particular practicesay, sex between adu
be wrong-for-us (for example the population of
generally have negative attitudes to such relationships
right-for-them (some other society) because in thei
adults and children is generally approved of.
Relativism of this sort has several implications
present purposes, the main one is methodological. Fo
us, what makes propositions such as x is wrong
where S is a relevant social group) is the fact that x
by most members of the relevant community, then
answer to all ethical questions just by surveying peopl
they think. So, if relativism is true, then bioethics sho
a branch of sociology. For sociologists could (in p
contrary, sociology is peripheral to ethics. Given wh
crucial to this view is the rejection of metaethical relat
place to attempt a thoroughgoing refutation, but w
outline our principal reasons for dismissing it.
One major defect in the theory is the uncri
might (majority opinion or social convention) with
really ought to do). For while public opinion shoul
into account when framing policy, there is no necessa
what society thinks about any given issue and th
matter. In other words, it is possible for society to
immoral even if there is nothing wrong with it. Or, t
(if rather clichd) examples, it would be possible for a
sex between adults and children, genocide, and tort
morally permissible, even if really such practices were
A second unattractive feature (one closely relate
relativism commits us, as ethicists, to being deeply c
conservative with respect to the present conventions an
society. This is because, if relativism were true, we c
the answers to moral questions from public opinion an
be no standpoint from which to criticize prevailing vi
This is interesting because, in conversation with
sometimes presented moral relativism as a politic
whereas in fact it is the opposite.
If we reject moral relativism then we are left wit
sociologys proper role within bioethics could be. For
to argue directly from (say) 90% of people disapprov
wrong or x should be banned, then it is not clear
care about the fact that 90% of people disapprove of x

7. Consultation Exercises

Almost all publicly funded ethics research of

commissioned by ethics committees or commis
matic that some attempt to discover what people
under consideration is part of the remit. But the
obtaining this information is seldom clear.21

A possible rationale for undertaking and taking ser

research is as part of a consultation process. A releva
 In January [2002] we commissioned two indepe
the range, safety and reliability of the techniques
sex selection, and the other on the social and ethi
relate to them. In June [2002] qualitative mark
several discussion groups was conducted into p
sex selection in the UK and to support this, w
further quantitative research on this subject.23

The purpose of this consultation document is

the public concerning under what circumstances s
avail-able to those seeking treatment and whethe
sions should be put in place to regulate it .24

The HFEAs information gathering process contain

ments.

An expert report analyzing and summarizi

search.
An expert report on the social and ethical con
Responses to a consultation document.
Specially commissioned primary empirical
science (market research) techniques, both
tative.

It is worth paying some attention to what exact

ment is (or should be). (1) appears reasonably unprob
covered by what we said earlier about the position of n
in bioethics. More or less the same goes for (2), alth
gets to count as an expert on ethical and social m
tious. (3) differs from the other elements because it i
allexcept (trivially) insofar as it is research into w
HFEA releases a consultation document on sex sele
attitudes research, because there is no reason to beli
will be representative. Indeed, the results generated
often quite unrepresentative, because they attract
pressure groups. (A good example of this problem is
zier Report on surrogacy.25)
Consultation processes, then, are not reliable gu
and professional attitudes, and filtering needs to be
distortions created not only by pressure groups, but al
process necessary? And, more generally, given that
like these do not deliver trustworthy information a
what is their real purpose?
There appear to be two realistic possibilities. O
exercises are not research tools at all, but instead par
ess. This may well be true and, if it is, then while
will have a point, their point will not have anythi
attitudes research, since consultation exercises will not
than general elections are research. A second possibili
consultation exercise is to trawl for arguments that ca
critical assessment by ethicists (and relevant others).
the HFEA has in mind when it says:

We would especially welcome more substanti

anyone who has a strong interest in this subject.
listen carefully to all the arguments put forward.

The idea appears to be that experts and informed la

arguments for assessment by the HFEA experts. If
consultation exercises then they may well have a r
minor one, because they are a source of moral ar
thereof). They provide the raw material out of whi
(and others) can fashion coherent sets of policies and p
Let us turn now to the part of the HFEAs proce
beled social science (market) research. The point of
this con-sultation is unclear, especially if we keep in
tion of moral relativism and the fact that this is suppo
a referendum on sex selection. Another way of gettin
ask: what if it turns out that 80% of people are agains
for medical reasons), but that the arguments for this
unsound? If we are doing ethics (as opposed to mere
political compromise), then the arguments (or lack the
the views of the 80%, and this might make us wond
spend money on the market research in the first place.
We conclude then that the existence of official
does not in any way bolster the position of public at
bioethics. Our reasons are first that much of what m
attitudes research within the consultation process is e
research at all, and second, for policymakers, the ar
over the views of the majority where the two come in
As we have already suggested, a valid use of public att
the handmaiden paradigm) is to discover whether a
have harmful psychological or social effects. We mig
that if 80% of adults were frightened by the prospect
cloning, then we would have a reason for banning
numbers of people would sleep easier in their beds k
of the clones had been rendered less likely by restrict
banning cloning could be justified by reference to the
causes.
On the face of it, this use of public attitudes rese
legitimate use of natural science research discussed ear
warn us about the harmful effects of our actions. How
is that some forms of psychological harm are caused b
for rational assessment. It is widely accepted, even
practice is substantially harmful to innocent third p
prima facie case for banning it. However, in order
harm principle must be restricted so that only so
allowed to count. In particular, we must exclude ps
would not have occurred were it not for the unrea
victim. In other words, it would be wrong to ban s
people were unreasonably afraid of or distressed or rep
ple, if either their moral beliefs (for example clo
dignity) or their non-moral beliefs (for example i
then the world will be overrun by Hitler replicants) we
What if, for example, a majority of the popula
repulsed by the existence of churches and by the existe
this provide a good reason to ban them? We would
definitely not, even if people really were psycholo
presence of these things. Of course, other State me
psychological harm might be warrantedmost obviou
campaign to stop people from having such unreas
impose bans would be to pander to peoples irrational
would be an unfair violation of the rights of gay pe
(We should add that not all irrational fears are unrea
termfor example, it would probably be wrong to
fear unreasonable.)
It is not hard to see how similar thoughts appl
ples, especially for our purposes public attitudes to iss
the following example of social science research, descr
 practices: psychological (in terms of worrying a
children conceived), biological (in terms of the
was used as a conceptual brake. . . a boundary
not to be traversed) and relational (the impac
nologies on wider social relationships).28

We do not doubt that Edwardss research is intere

What is more questionable, though, is its ability to
This is principally because of the reasonableness con
Edwardss ordinary people offer three possible obje
technology: the welfare of children created, concerns ab
incestuous reproductive practices), and effects on
ships. Does this tell us anything about the bioethic
For several interconnected reasons, probably not.
First, ethicists do not usually need social scienc
about the existence of moral argumentsand, as it h
cited by Edwards are precisely the kinds of things alr
by moral philosophers. It is probable then that, in m
losophers will be capable of generating the relevant arg
(which is, after all, what they do best) without relyin
research to do it for them. (We do not deny, though
small number of cases in which the ethicists are incapa
the arguments themselves.)
Second, because of the reasonableness constrain
people endorse these three objections does not matter
of ethics and policy. Either these objections are reason
they are reasonable, then this is something that bioet
discover without knowing that the objections are wid
is, without the public attitudes research. But if, like
existence of churches, the objections are unreasonabl
disregarded, or at least should not directly influence
may however influence it indirectly by prompting mo
or by providing an empirical premise in a pragmatic
example we had better not allow x, or there will be ri

9. Conclusion

During the first few sections of the chapter, we saw th

cal case for keeping empirical evidence out of ethics
argue that bioethicists should refuse to work with or
contrary, we agree with Levitt that:

Together philosophical and sociological bioe

bioethical perspective by setting an issue or pro
social, cultural, and political context.29

However, we have defended the view that the function

is what Haimes terms the handmaiden role of provid
with the view that sociology is (therefore) peripheral
bioethicslike natural science, a mere supplier of em
can be plugged in to bioethical arguments.

NOTES

1. See the allegory of the cave, Plato, The Republic,

mond-sworth: Penguin Books, 1972), VII 514a521b
2. Aristotle, Nicomachean Ethics, trans. W. D. Ross
and J. O. Urmson (Oxford: Oxford University Press, 1980)
3. See David Wiggins, Truth, Invention, and the
ceedings of the British Academy, 62 (1976), pp. 331378.
4. See Bernard Williams, Ethics and the Limits o
Fontana Press, 1985).
5. See John McDowell, Non-Cognitivism and Ru
stein: To Follow a Rule, ed. Steven H. Holtzmann and
(London, Routledge and Kegan Paul, 1981).
6. See Hilary Putnam, The Collapse of the Fact-
Collapse of the Fact-Value Dichotomy and Other Es
Harvard University Press, 2002).
7. See Richard Hare, The Language of Morals (Ox
Press, 1952).
8. Michael Ruse and Edward Wilson, Moral Philo
ence, Philosophy, 61:236 (April 1986), pp. 173192.
9. David McCarthy, Why Sex Selection Should
Medical Ethics, 27:5 (October 2001), p. 304. See also: R
Savulescu, Ethics of Using Preimplantation Genetic Dia
Cell Donor for an Existing Person, British Medical J
November 2001), p. 1242.
 12. James Lindemann Nelson, Moral Teachings from
Lessons for Bioethics from the Social Sciences and M
Center Report, 30:1 (JanuaryFebruary 2000), p. 12.
13. Mairi Levitt, Better Together? Sociological
spectives on Bioethics, Scratching the Surface of Bio
and Tuija Takala (Amsterdam: Rodopi, 2003), p. 11. See a
Problems in Clinical Practice (Manchester: Manchester U
pp. 2339; Zussman, The Contributions of Sociology to
14. Erica Haimes, What Can the Social Sciences Co
Ethics? Theoretical, Empirical, and Substantive Consider
(April 2002), p. 89.
15. Haimes, What Can the Social Sciences Contribu
ics?, pp. 923.
16 . Nigel Warburton, Thinking from A to Z (Lond
2000), p. 70.
17. Ananova (www.ananova.com), Clone Einstein
2003.
18. For a useful overview see Methods in Medical
arman and Daniel P. Sulmasy (Washington, DC: George
2001), pp. 146191.
19. Levitt, Better Together?, p. 12.
20. See Eve Garrard and Stephen Wilkinson, Doe
Theory?, Scratching the Surface of Bioethics, ed. Matti
(Amsterdam: Rodopi, 2003), pp. 3545.
21. John Harris, Introduction: The Scope and Im
Bioethics, ed. John Harris (Oxford: Oxford University Pre
22. The Human Fertilisation and Embryology Asso
lection: Choice and Responsibility in Human Reprodu
2002.
23. The HFEA, Sex Selection, p. 5.
24. The HFEA , Sex Selection, p. 6.
25. Margaret Brazier, Alastair Campbell, and Susan
Review for Health Ministers of Current Arrangements for
tion (London: The Stationery Office, 1998).
26. The HFEA, Sex Selection, p. 6 (our emphasis).
27. See Sally Sheldon and Stephen Wilkinson, Fem
and Cosmetic Surgery: Regulating Non-Therapeutic
Bioethics, 12:4 (October 1998), pp. 263285.
28. Haimes, What Can the Social Sciences Contribu
ics?, p. 103.
29. Levitt, Better Together?, p. 17.
This page intentionally left bla
 Angus Dawson

1. Introduction

It is now almost universally held that patients undergo

or participating in medical research are required to give
The trend to argue that this is so began in earnest in
thirty years ago and has now grown to encompass vir
national, and international bodies with any role in
relation to both research and clinical medicine. (For ex
Code1 and the Helsinki Declaration2 were formulated
protecting research subjects from abuse, and both d
nence to recognizable forms of informed consent. T
identify information about the nature of the research,
and details about the methodology as being of cen
policy documents by the United Kingdoms Depar
British Medical Association,4 and the General Medica
informed consent should now be considered a rou
practice as well as of research.)
However, despite this consensus about the need
there has been a series of papers, going back nearly as
the concept itself, suggesting that there are serious pro
turn this laudable ideal into reality. This research seem
are real and persistent problems in gaining an inform
least a subset of each of the groups studied. Despite th
advocacy in favor of informed consent has continued t
a review of the empirical evidence that suggests tha
consent is difficult or impossible, at least with these s
this evidence is too consistent and too important to
supporters of the concept of informed consent need to
are raised by these studies: informed consent as a bio
face up to empirical reality.

2. What is Informed Consen

Many different definitions of informed consent hav

example, Tom Beauchamp and James Childress offer
consent, and they focus only on three key criteria
information provision for the patient, non-coercion
assessment of the patient as being competent. Some
Stephen Wear,8 seem content to give up on an an
altogether and opt for a more pragmatic account inst
range of variables to be combined in different way
situation. Despite this skepticism about picking out th
sion makes clear that there is still enough common
different accounts to be sure that they are all talking ab
I will use the term informed consent in this
most widely used and understood term in relation to t
eration. I will, however, focus on the three key compo
Gert and his collaborators. We can frame these cri
follows: Is the person competent? Is the decision f
coercion? Was the relevant information provided, and
the decision? I will discuss each of these in turn. Th
describe why each issue is considered to be an essentia
consent.

A. Competence

Being competent or having capacity is a necessary ab

the relevant information about different possible i
making the decision about which option to adopt. Ex
involves, and how it is to be determined, has been s
since the publication of Allen E. Buchanan and Dan
for Others.9 Buchanan and Brock argue that competen
being related to the particular decision to be made an
of harm attached to the possible outcome of that de
riskier decisions require a greater degree of competen
been both challenged and defended in the bioethics lit
correct account of competence, it is vital that a clear
the defenders of informed consent so that the competen
be clearly distinguished. This is held to be necessary
the autonomy of the competent individuals: they will
own decisions and are presumed to be capable of giv
sent. However, clear arrangements will also have to be
making in relation to incompetent patients. This mig
about what is in an individuals best interests or a role
or proxy decision makers.11
be breached not just through attempted persuasion, b
tion or the manipulation of information to try to o
This type of influence need not be intentional, as in
well just follow from certain types of relationship
patient relationships, family relationships, and so
potential danger, the supporter of informed consen
should be taken to ensure that indirect influence does n

C. Information Provision and Underst

This is the core element in any account of informed co

tence and the ability to make a free choice might be he
for an informed consent rather than, strictly speakin
itself. However, an informed consent cannot be given
of the relevant information, and without that informa
by the patient. Information will be relevant in relation
sis, the nature and purpose of the available alternative
associated risks and benefits of each option. It is als
reference to the consequences of non-treatment. It ha
that different people have different abilities to unders
and different amounts of pre-existing knowledge to d
tion.
However, in response it has been argued that ph
methods to try to ensure that the patient has understoo
example, an opportunity might be explicitly given for
the patient could be seen on a number of different o
non-emergency situation). It is also often pointed out t
shy, over-awed, in pain, or afraid given the nature of
Can the information be given in such a way that it
Does it need to be repeated? For these reasons, the s
consent place great importance upon the need for
skills. They will argue that the ideal system would be
respond to the individual abilities and wishes of the
essentially all competent patients are assumed to gi
consent or autonomously waive their right to do so
chapter I will focus only on the issue of information g
the other two components (voluntariness and competen
to be a moral requirement. Now that we are clear ab
informed consent, we can move onto the next question
it? There are two main ethical justifications for seekin
given in the literature. The most common one is to a
self-determination, but Brock12 reminds us that it is al
a justification by appealing to the role that informe
within an account of patient well-being. I will briefly
bilities here.
Autonomy is a difficult concept to define, but ca
ized as involving the control or direction of the decis
individual by that particular individual herself. This m
both an internal (or psychological) aspect and an
aspect. The individual is autonomous in the internal
to choose what she wants, and other things, such
influence her choices. She is autonomous in the exter
able to act freely because she is not physically restrain
so on. The appeal of autonomy for the justification of
general beliefs about the rights of the individual to c
happens to her own body. It is held by the supporter
view that this is the best way of avoiding other peopl
our behalf. The classic statement of this principle is
Stuart Mills On Liberty:

[T]he only purpose for which power can be rig

any member of a civilised community, against
harm to others. His own good, either physical
cient warrant. He cannot rightfully be compelle
cause it will be better for him to do so, because
pier, because in the opinion of others, to do so w
right.13

Any attempt to interfere in such decision-mak

relevant individual runs the risk of the accusation of p
noting that although the term paternalism is often
texts, it is frequently used pejoratively as though the
act in this way were enough to explain and justify its w
reason to think this, of course, unless we wish to sti
is simply to have this particular (condemnatory) mea
an informed consent is not sought might well be pater
own, does not mean that they are wrong.14 The arg
cations of informed consent gain strong support throu
ever surveys are conducted about whether patients wan
to medical procedures, a clear majority answer that the
The standard view, then, is that informed consen
both ensuring and promoting the autonomy or self-de
patients. Much recent discussion of issues in healthc
though it is autonomy or self-determination that is
promoted within medicine, and seeking informed c
central methods by which this is to be achieved. (Th
can be strengthened by looking at some of the hist
growth of interest in informed consent. This has eme
historical events in relation to medical research, and th
protection for the rights of individuals to be informe
and the research they participate in.16) However, the
argument to this, which is that autonomy is only one
erations, and other factors such as beneficence need to
weighting in the moral judgment to be made. This vie
by the thought that any plausible moral theory (such a
many forms of consequentialism, the four principle
pluralist and want to trade off different values aga
different ones taking priority depending upon the circu
The second possible way of justifying an appeal
to look toward patient well-being. The idea here is tha
in the consent process might well increase patient
because she is going to be better informed, more inv
making, her autonomy is respected, and she is less lik
possibilities about the future are explained. Such a
broader than the appeal to autonomy. On this view
might be a component of well-being, but other facto
contribute toward the individuals good.
There appear, then, to be strong ethical argume
informed consent, as both autonomy and well-bein
moral considerations. Let us accept, at least for the pu
that the moral case in favor of informed consent is so
to these two justifications. However, it is important t
concede this, the empirical evidence, suggesting that p
when involved in the information giving and rece
informed consent process, still continues to exist.
serious enough to raise the issue of whether it is actu
informed consent in a real sense at all. Perhaps the c
 4. Informed Consent: The Empirical

We have seen that informed consent is popular amon

can be morally justified through an appeal to autonom
that it has received growing ethical and legal suppo
good reason to be cautious about the role that informe
have in relation to healthcare, even if we think it
caution arises from the implications of the empirica
gathered in relation to the effectiveness of attempts to
in practice. In the rest of this section I will outline
evidence relating to a number of different aspects o
However, before we do this I should, perhaps, enter
empirical evidence and the way that it is used in et
qualification arises from the sense that we should alwa
as provisional (as it can always be questioned or ov
and that we should note that different studies are of va
are small scale and have various methodological limita
these factors, we should always be cautious in our argu
evidence, and we should take care not to over-ge
should also resist the temptation just to ignore empiri
an issue where it is available. It is too easy to sugge
action and then just pay no attention to the fact that w
is difficult or impossible to achieve that desired end.
to note about the empirical evidence in relation to in
scale of research on this issue. (For example, in a
empirical studies published in relation to all areas of
Sugarman, R. Faden and J. Weinstein suggest that 16
of articles focused on informed consent, making this t
topic.19)
There are numerous examples of studies with im
suit of informed consent, and in this brief review
evidence in three areas. The first relates to the way
background psychological factors and the experience o
decision-making. The second relates to evidence abo
sion of significant pieces of information, and the th
about understanding the relevant information through l
processes involved in communication between indivi
into account.20 He argues that there is a need for anyo
ing informed consent to have knowledge of, and a
psychological evidence about problems in gaining
understanding. He provides a good summary of many
to how the psychological evidence bears upon the issu
I will mention just two issues here.
The first is that psychologists have established t
mation is provided to subjects influences their assess
might include the fact that people will tend to rem
evidence, or the riskiest, or that they might tend t
particular direction by the way that the information is
of such framing effects can be seen in a number of
clear relevance to this paper is the effect upon perce
where the same risks are described in terms of surviva
Similar deformations upon the assessment of risk can
have noted the way that the probability of a negat
greater weight than its severity within judgment about
The second example is that it is now well recog
pre-existing and background beliefs, attitudes, and va
decisions that she makes. This means that such th
emotional state will make a difference to her decision
forgotten that patients are, generally, in the position
because they are ill. Barrie R. Cassileth, R. V. Zup
and V. March argue that understanding is at least partl
of illness of the patient: as the illness progresses pati
This seems completely plausible. Patients should n
rational consumers with the ability to efficiently proc
detailed and complex information and then make a d
objective determination of the best outcome for them
some will be able to do this, most will not. Tom B
Childress provide a plausible warning about ignoring

Many patients cannot, in advance, adequately ap

the pain, and many ill patients reach a point
longer balance with clear judgment the threat of
fits of surgery. At this point, they find the be
whelmingly attractive, while devaluing the risks.
There is also significant evidence that various factors
comprehension of the disclosed information is likely
example discussed by Kent is to do with evidence a
ability of consent forms and information sheets.26 A
these pieces of documentation will have been reviewe
are a number of reasons why such countervailing
comprehension and recall of the information provide
clearly written. For example Gert, Culver, and Clouser
which information is given to a patient in relation
condition.27 The patient is first told that it is commo
associated with unpleasant side effects, but that it will
heart attack by 50%. Many people might be tempted
harm when presented with such odds. However, the
bility of heart attack has actually dropped from 1/200
this way it might look less rational to take the drug
provided by the work of H. J. Sutherland, G. A. Lock
F. Sem, L. Brooks, and J. E. Till,28 that suggests
interpret key words routinely associated with discussio
(e.g. usually, frequently, occasionally, and r
ways. It is sometimes argued that evidence about risks
parallels with commonly experienced everyday events
by car between two points, and so on) but this type of
into problems.29

C. Understanding and Recall of Inform

Perhaps the most worrying message to come out of th

is that a consistently large percentage of patients wil
recall crucial information presented to them in either w
part of the informing process. For example, a study
Parker, and S. P. Ramsay30 looked at the underst
written information about a resuscitation policy in a
The study suggests that written information is not
least within this type of context). Of the 401 patients
recalled being given the patient information booklet o
17% recalled reading the information about the resusc
example of such a study is that conducted by Cassilet
This study focused on 200 cancer patients who filled
day after they had opted for various forms of treatmen
to understand the purpose and nature of the procedur
the surgery.
Of course, we should note that it is not clear tha
relevant facts in relation to a consent are tested most
gating the recipients recall of what was said or read
However, the best of this literature tests comprehensi
soon after the moment of consenting, and in the absen
odological tools it is the best we have. Wear summa
this issue as follows:

[The] low levels of recall, and the absence of an

recall of even the essentials, question any o
formed consent.33

At the very least the supporter of informed consent sh

so many participants in informed consent interaction
salient details even after short periods.

5. What Should We Do Now?

The response often given to this type of evidence is th

more information as part of the process of obtain
sentas though the issue were just one of poor co
view we can be more aware of the different problem
account in practice. In some cases this might be tr
cases it looks as though a more serious remedy is req
The first is that the very number of different problem
prove difficult to respond to all of the issues and, s
concerns arise from the way that the information is pr
fact that there is a lack of information as such. The me
evidence seems to be that we need to consider more ra
One possibility, in the spirit of informed conse
use a more individual-oriented approach such as that
analysis. For example, P. Ubel and George Loewe
whilst the model of informed consent is one that
patient to be the one to choose which medical opt
values, the problem is that in many situations the r
with its own risks of harm and potential benefits) to b
there is too much information for the individual to me
use as the basis for a decision. This view is supported
colonoscopy, barium enema, and fecal occult blood tes
if

the information physicians give patients does n

choices that fit their values, then informed conse
of its moral justification. To meet the moral goal
physicians need to find a method to combine
medical facts in a way that produces superior med

Their paper is a discussion of the possible benef

cision-making tools (such as decision analysis) as an
with the need to decide which medical option is most
their values. It also usefully discusses some so-cal
(such as regret, fear, and hope), which, it is argued,
into decision analysis. Decision analysis might well
vidual attempting to weigh different options before
about which one is best. However, given the complex
can hardly provide a solution to the problem of poor
information relevant to healthcare decision making.
The empirical evidence in relation to informed co
cernible impact on the way that bioethicists and po
proached the issue of informed consent. The consensu
should insist upon it. This seems odd given the cons
emerging from the published empirical studies. It m
tions can be introduced into the process of gaining inf
all the possible problems can be overcome. If this is th
reasonable to assume that the supporters of informed
the issues raised to ensure the best possible chance o
After all, if it is the case that informed consent is
surely we have an obligation to try as hard as we ca
seems to be little evidence of this having occurred,
simply to suggest that doctors undertake more train
skills. Even if there were evidence of the empirica
seriously and addressed in practice, problems in g
consent are likely to remain. This is because of the d
cal nature of some of the issues uncovered by the empi
Another option is to carry on with the presen
though we are getting true informed consent. Such
defensible if we have evidence that people want us to
does no harm. However, an alternative response woul
 6. Conclusion

Informed consent is an issue with a high profile. It

position in the bioethics literature of the last thirty yea
seen as essential in both a clinical and a research con
such as the National Health Service in the United K
high profile, it is important to acknowledge and take
research of relevance to this issue. Even such a sup
informed consent as Wear is forced to conclude that
effects such as enhanced compliance, coping, and a
of anxiety and anticipated pain, seem to clearly deriv
sent, the overall aim of producing the informed pat
has just not materialized.36
It is clear from the review of the evidence abo
needs to be conducted to explore the potential problem
ing of information given as part of the process of
consent. In the light of the evidence, as things stand a
good grounds for thinking that it does not make s
weight on gaining an informed consent. While it m
informed consent can survive as a requirement, it mig
revised as a practice. We must certainly accept the lim
and at the very least explore ways to improve the
almost universal insistence upon giving an informed
research contexts does not seem appropriate given the
of this bioethical ideal with empirical reality.

NOTES

1. Informed Consent in Medical Research, ed. Len D

(London: BMJ Books, 2001), pp. 34.
2. www.wma.net/e/
3. www.doh.gov.uk/consent
4. www.bma.org.uk/ap.nsf/Content/consenttk2
5. www.gmc-uk.org/standards/default.htm
6. Tom Beauchamp and James Childress, Principle
(Oxford: Oxford University Press, 5th ed., 2001), pp. 79
Surrogate Decision Making (Cambridge: Cambridge Univ
10. Mark R. Wicclair, Patient Decision-Making
Bioethics, 5:2 (1991), pp. 91104; Dan W. Brock, Decisi
and Risk, Bioethics, 5:2 (1991), pp. 105112; Becky Cox
Consent (Washington, DC: Georgetown University Press
Related Standards of Competence: Continuing the Debat
Standards of Competence, Bioethics, 13:2 (1999), pp.
clair, The Continuing Debate Over Risk-Related Stan
Bioethics, 13: 2 (1999), pp. 149153.; Tom Buller,
Relativity, Bioethics, 15:2 (2001), pp. 93109.
11. Lord Chancellors Department, Making Decisi
Proposals for Making Decisions on Behalf of Mental
(London: The Stationery Office, 1999); Angus Dawson
General Practice and Ethics: Uncertainty and Respons
Dowrick and Lucy Frith (London: Routledge, 1999).
12. Dan W. Brock, Informed Consent, Health Ca
tion, ed. Donald van de Veer and Tom Regan (Philadelp
Press, 1987), pp. 98126.
13. John Stuart Mill, On Liberty (Mineola, NY: Dov
14. Paternalism, ed. Rolf Sartorius (Minneapolis: U
Press, 1983).
15. R. J. Alfidi, Informed Consent: A Study of Pat
of the American Medical Association, 216:8 (1971), p
Strull, B. Lo, and G. Charles, Do Patients Want to Part
sion-Making?, Journal of the American Medical Assoc
pp. 29902994.
16. Informed Consent, ed. Doyal and Tobias; Pre
mittee, The Human Radiation Experiments (Oxford: O
1996).
17. Jeremy Sugarman, D. McCrory, D. Powell, A. Kra
sell, Empirical Research on Informed Consent, Hastin
Supplement, S1-S42 (1999).
18. Jeremy Sugarman, R. Faden, and J. Weinstein,
Research in Medical Ethics, Methods in Medical Ethics
and Daniel P. Sulmasy (Washington, DC: Georgetown U
pp. 1930; Wear, Informed Consent, chapter 3.
19. Sugarman et al, A Decade of Empirical Researc
23.
20. Gerry Kent, (1996) Shared Understandings for
Relevance of Psychological Research on the Provision
Science and Medicine, 43:10 (1996), p.1518.
21. A. Tversky and D. Kahneman, The Framing of
chology of Choice, Science, 211:4481 (1981), pp. 453
 23. K. Hopper, P. Houts, M. McCauslin, Y. Matthew
tients Attitudes Towards Informed Consent for Intrav
Investigative Radiology, 27:5 (1992), pp. 362366; J. F
and D. J. Mazur, Verbal Expressions of Probability in In
tion, Medical Decision Making, 11:4 (1991), pp. 27328
24. B. R. Cassileth, R. V. Zupkis, K. Sutton-Smith, a
Consent: Why are Its Goals Imperfectly Realized?, N
Medicine, 302:16 (1980), pp. 896900.
25. Beauchamp and Childress, Principles of Biomed
26. Kent, Shared Understandings for Informed Con
27. Gert et al., Bioethics, p.165.
28. H. J. Sutherland, G. A. Lockwood, D. L. Tritchler,
J. Till, Communicating Probabilistic Information to C
Noise on the Line?, Social Science and Medicine, 32:6
29. S. Lichtenstein, P. Slovic, B. Fischoff, M. Layma
ging Frequency of Lethal Events, Journal of Exper
(1978), pp. 5578.
30. E. M. Taylor, S. Parker, and M. P. Ramsay, Patie
standing of Written Information About a Resuscitation
(1998), pp. 6476.
31. Cassileth et al., Informed Consent.
32. Beauchamp and Childress, Principles of Biom
110.
33. Wear, Informed Consent, p. 53
34. P. Ubel and G. Loewenstein, The Role of D
formed Consent: Choosing between Intuition and System
and Medicine, 44:5 (1997), pp. 647656.
35. Ibid., p. 648.
36. Wear, Informed Consent, p. 55.
This page intentionally left bla
 Sren Holm

1. Introduction

Bioethics and business ethics are related fields. They

as applied ethics, and are both concerned with ethica
within a set of socially important practices (healthcar
tively). They both attempt to make claims that are su
for practitioners in the fields of interest, and they bo
standard set of ethical theories developed in moral
early days of applied philosophy (the principlist app
popular in both fields). In both fields there has also
increase in the number of empirical studies performed.
business ethics is older than the empirical trend i
probably be explained by the different environme
disciplines developed, and the concomitant differ
academic merit (pure philosophy not being high
schools). In business ethics, the proportion of empi
have stabilized at around 3040% of the papers p
journal, the Journal of Business Ethics,1 whereas i
increasing.
This chapter builds on an analysis of the empir
fields with regard to:

The questions asked.

The theoretical frameworks.
The methodology.
The actual conduct of the study.
The conclusions drawn.

It is uncontroversial that many of our ethical argu

cal premises of different kinds. We often need to know
world in which the moral agent is supposed to act
general characteristics of moral agents, something ab
action imposed by nature, culture or institutions, and
we can effectively influence decision-making and actio
the basic ethical analysis, and when we move on t
legislation or institutional arrangements.
Another is that as the ethical questions considered be
becomes more difficult to find answers to the empiri
disciplines. Some of the empirical premises neede
whether euthanasia should be legalized may never
enough outside the context of this specific ethica
subjects of study by sociologists, and so on.
But if empirical studies are to be valuable cont
they have to ask relevant questions, use suitable metho
conducted. They also ideally have to build on, or at
studies, so that over time a coherent body of work is d

2. Bioethics and Business Ethicsthe Mai

Since this chapter is written for a readership presum

state of bioethics, I will here focus on empirical bus
difference between empirical bioethics and empirical b
whereas empirical bioethics is almost exclusively expl
in nature, in empirical business ethics it is possibl
studies that are either experimental or have some clear
hypothesis that is being investigated. This is by no
type of research is dominant in business ethics, bu
common than in bioethics.
A full survey of the methodology of both fields w
be as depressing as the systematic analysis published
A. M. Gibson in 1990 of the methodology of ninety-f
ethics studies published from 1961 to 1989.2 They f
weaknesses in almost all of the areas of methodology
from choice of study population and data analysis. A
business ethics literature is that many studies use stu
population because these are easily available and can be
answer, ensuring large samples and high response
problematic, since students lack the experience of re
empirical bioethics appears to be in a better position, w
of studies actually studying the practitioners at the coa
This methodological criticism does not entail t
papers to be found if we look carefully. What can b
large numbers in the business ethics literature are
investigate what relevant people think, believe, feel,
try to link this with some meaningful background va
ethical awareness and ethical decision-making, twenty-
the influence of a persons moral philosophical or
making (an interesting finding here appears to be tha
use both deontological and consequentialist approache
to resolve all types of business ethical problems; satis
of problems here is measured by the respondents self
studies studying the effect of Codes of Ethics, fifteen
rewards and sanctions, and eighteen looking at the
tional culture and climate.3 It would be impossible t
reasonably coherent body of work in bioethics.
Another important field of study in business eth
allel in bioethics, is large-scale studies of the oft
ethically questionable practices. There is, for instanc
program looking at how corruption in general, and the
bribery in particular, have negative macro-economic ef
where corruption is widespread. The results of thi
corruption in business is not only immoral, but that i
to be economically counterproductive at the societal
the case that corruption is the grease that lets the ec
The research shows that it is more like the sand that s
working.
Similar work is lacking in bioethics with regard
ethically problematic behaviors in healthcare practic
people to continue to put forward arguments along
might be ethically bad, but it is still pragmatically use

3. Some Concrete Illustrations

Let me further illustrate the strengths and weaknesses

business ethics with two recent studies. Most of us
people are more ethically aware they will also make
eventually perform better acts (or if we do not believe
at least prone to say things like that when we try to
losophy of medicine teaching.) But this is clearly a
hypothesis, although it needs some specification befor
A Norwegian study published in 2001 tests tw
from this main hypothesis.4 It tests whether strong
tively affect moral reasoning, and whether good mo
tially influences policy-decisions and action-decisi
wrong, or we need to think again about the relati
reasoning and action.
A study from the United States published in 20
relationship between ethical sensitivity and moral reas
Most models for ethical decision-making have the reco
tion of an ethical problem as their first step, and cogn
identified problem as their second step. It is therefor
gate whether these two constructs are separate or wheth
Most writers assume that they are connected and th
sensitivity also display better reasoning. In order to st
ers studied the direct relationship between sensitivity a
the relationship of each of the constructs with a ra
structs: relativism, empathy, deontological orientatio
tion, and Machiavellianism. A hypothesis was put f
direction of each of these relationships. In the stu
whereas all hypotheses concerning ethical reasoning we
findings, none of the hypotheses concerning ethical se
rated, and the authors are forced to conclude that eth
with the empirical evidence, continues to sugges
between the constructs exists in spite of the strong
association between them.5
What these two studies share is primarily a comm
hypothesis-driven research process, and a willingness t
work already done in the field. Let us imagine that som
going to write a new review of empirical studies asse
making in business. Because the two studies we ha
theory-based, such a review can not only mention the
can also discuss these results in relation to other stud
theories.
These studies are far from perfect. In both cases w
instruments used to measure the central constructs.
versions of James Rests DIT-test to measure develop
ing,6 and this test is for many tainted by belonging to
of cognitive moral development theory. But both stu
conducted with a utilitarian, virtue theoretical, or c
moral reasoning instead (or perhaps a mega-instrumen
different constructs of moral reasoning).
that euthanasia should be legalized, to studies inv
reasons are, and whether these reasons can be connecte
moral constructs. Is there a difference between people
and a consequentialist orientation? Is there a differen
have participated in ethics courses and those who have
ence between paternalists and non-paternalists?
We also need to be more careful in planning our
that they can be compared with studies of the same top
researchers. Although important insight and knowled
the single, excellent research project, there are in most
to be found in the accumulation of knowledge w
research builds on prior research, and does not try to
logical wheel in every new project.

NOTES

1. Denis Collins, The Quest to Improve the Hum

1500 Articles Published in Journal of Business Ethics
Ethics, 26:1 (July 2000), pp. 173.
2. Donna M. Randall and Annetta M. Gibson, Me
Ethics Research: A Review and Critical Assessment, Jou
9:6 (June 1990), pp. 457471.
3. Terry W. Loe, Linda Ferrell, and Phylis Mansfield
cal Studies Assessing Ethical Decision Making in Busin
ness Ethics, 25:3 (June 2000), pp. 185204.
4. Einar Marnburg, The Questionable Use of Moral
Studies of Business Ethics: Discussion and Empirical
Business Ethics, 32:4 (August 2001), pp. 275283.
5. John R. Sparks and J. P. Merenski, Recognit
Ethical Sensitivity and Reformulated Cognitive Moral D
nation and Evidence of Nomological Validity, Teachi
(Winter 2000), pp. 359377.
6. Moral Development: Advances in Research and
(New York, NY: Praeger, 1986).
This page intentionally left bla
 AND STRICT LIABILITY
BIOTECHNOLOGY
Jukka Kilpi

1. Business Ethics

The ethical responsibility of the corporation consists

duty to obey the law. Ethical responsibility is found
within the spheres of morals and ethics. Normative eth
phy, analyses values, defines general principles on w
and applies rational arguments to point out which valu
Applied ethics, as the name of the discipline su
normative ethics that explores conflicts of values in
human action. Medical ethics and bioethics are exam
well-known domains of applied ethics. Business
established area of applied ethics. Since the 1980s it ha
ent of the academic curriculum and research, initially i
America and more recently in Europe. Lately, bu
become a more common item on the agenda of large co
lar, multinational corporations include ethical steering
as integral parts of their quality and management sys
regulators are drafting legislation that will make ethi
for public companies in the same way as environment
been introduced to company reports.
In spite of this development it is still common f
be regarded as an oxymoron. How can business have
ethics? Business is about making money, and must
suspicious, must it not? This pessimistic view is sur
even by those whose life and career concentrates on do
To see business and morals as alien, or even opp
a serious and unfortunate aberrationbut one with
Aristotle, for instance, considered money-making as
dirty activity, as his discussion in Book I of The Polit

Money-making then, as we have said, is of two

necessary and acceptable, which we may call adm
the commercial, which depends on exchange, i
 The mission of virtue ethicists is to introduce
business in order to counter-balance the egoistic greed
ing that activity. Virtue ethics emphasizes, in the spiri
essence of human nature is altruistic promotion of oth
therefore, altruism also has to be the final goal of bus
corporate ethical responsibility should dampen econom
profit, competition, and the promotion of individual in
However, if we employ the tools of academic
search of business practices and values, the hollowness
ethics taking business as immoral or amoral is soon
atic analysis of values and their conflicts in business s
at the major traditions of philosophical ethics. They re
different levels.

2. Fundamental Issues of Philosophic

Three different levels of fundamental philosophical iss

fied in ethics:

Metaethics: Can we rank values by means o

sis? Are values truth-apt or not?
Normative ethics: What values and moral p
and right ones and what establishes their good
Applied ethics: Values and principles applied

In philosophical research and argumentation these

connected. An answer to the metaethical issues has an
of the normative account, and so also to the practi
values. From the point of view of a philosophical theo
not irrelevant when a view of the ethical responsibilit
formulated. This suggests that we should start the
ethical responsibility by summing up the answers ma
philosophy give to the fundamental metaethical proble
of values.
The oldest defense of the objectivity of values is
do objectively exist in an ontological sense. Hence the
natural rights philosophy: values exist in the worl
ties, like trees, or animals, or human beings. Two e
Perceiving them immediately is possible only with th
and belief is not sufficient for an argument supportin
the absence of empirical evidence for independen
values, natural law or natural rights do not carry en
establish corporate ethical responsibility.
Utilitarianism, initiated by David Hume, was th
reply to natural law philosophy. Utilitarianism takes th
satisfaction of interests as the key to rightness and goo
convincing moral theory that still exercises a strong in
The most serious criticism against utilitarianism is t
used to justify otherwise unfounded harm imposed up
increases the happiness of the many. In other words, u
support to actions that we see as offending some pe
inadequate theory, as it is incapable of giving an i
status we actually do give them in our intuitions and
ments.
An alternative to utilitarianism is deontological
duty. Its centerpiece is the intrinsic value of rights and
moral principles promulgating them. Immanuel Kan
most prominent deontological ethicist. He called the h
the categorical imperative. Its contents echo the a
morals: always treat a person as you would wish oth
in a similar situation.
Kant derived his theory from his account of hu
mous and rational beings. Our autonomy and rationa
that makes us capable of respecting moral principles,
foundation of the objectivity of values. Even so, va
objective existence outside the realm of human reaso
natural law philosophers, while at the same time
objectivism.
From the point of view of modern ethics, subjec
tion to twentieth century empiricism, and its offsprin
The most distinguished Finnish philosopher of all tim
gained his reputation from research purporting to d
values are truth-apt.3 According to von Wright and h
values are conventions and practices grown out of
They can be analyzed and the inherent logic of va
assessed but, ultimately, disputes over the rightness
irresolvable.
for the truth-aptness of values.
In addition to these positive impacts, analytic ph
blurring the field of normative philosophy. Some ph
adopted the basically subjectivist metaethical idea o
have felt that participation in the normative debate is t
ity. Since they do not think that rational knowledg
tained, they have thrown themselves into normative d
ing their subjective opinions and preferences. The valu
have sometimes been backed less by normative argum
by their personal credentials as philosophers gained i
tive ethics.
The result has been that the subjectivism associa
cal philosophy has infused normative debate on m
vagueness and irrationality. This applies to business
ethics, already mentioned above, is a good example: b
adopt virtues without a proper analysis of what busin
out a rational justification of the virtues glorified.
Another major problem with virtue ethics is its
lenge: if the criterion of a virtue and, consequentl
ethically responsible corporation, is that it altruisticall
of other persons, the solution is too simple and sin
ethics does not offer rational arguments for altruistic e
person who does not share the virtuous Aristotelian vi
essence is not given any reason to adopt altruism and a
It has been common to accommodate Aristo
metaethical camp, and quite rightly so, as his teleo
emphasis on human nature and its perfection in virt
have included him among the subjectivists because
methodological character of his account of human n
relies too much on moral insight instead of argument,
psychology for moral theory in stating his views.5 T
the truth or goodness of the virtues he stipulates as the
perfection and moral goodness are founded on his
instead of on argument and analysis. Although a met
an ontological sense, Aristotle is an epistemologica
subjectivist in the way that he establishes ethically val
This basically subjectivist method is carried on b
ethicists who take Aristotle as their ultimate autho
license to beg the question for virtues they advocate. T
as Jonathan Jacobs has recently noted, virtue-centered
 quality of teleology is unbelievable. This is one
moral theory has taken over and subordinated o
We can talk of virtues as dispositions to act for
as actualizations of objective excellences.6

3. Toward a Rational Normative Dis

on Corporate Ethical Responsibi

What makes normative ethics challenging is the prov

ments that systematically purport to show why those
change their thinking and values. The arguments ev
sometimes it is right to use compulsion, for instance
force those who disagree on a principle nevertheless to
Applied to corporate ethical responsibility this me
provide arguments which show that the corporation, a
act on its behalf, have to bear ethical responsibility e
legitimately, are motivated by profit and the satisfactio
Economics and anthropology take humans as ra
endeavor to satisfy their interests.7 This does not exc
to pay respect to moral principles or choose an altruist
it is reasonable to build moral and ethical responsi
human nature that matches, as this one does, the pa
normative theory is seriously weakened as rational p
some other idea of human nature. It is also more li
theory that rests on an unrealistic view of mankind wi
difficulties when put into practice.
In this spirit, a quick evaluation of the major tra
cal ethics suggests that the most promising theorie
corporate ethical responsibility are utilitarianism and
The utilitarian fundamentals are straightforward and pr
has to bear ethical responsibility if its consequence
measure of usefulness may be, for instance, happines
tion of interests.
Utilitarianism is a strong basis for corporate eth
it is not a comprehensive theory. For instance, it leave
to what economic or distributive system is bestal
competitive markets are hard to ignore when the sati
assessed. It can be concluded, however, that a utilitar
the maximization of profits the only issue for which
to achieve the satisfaction of some other individual
utilitarianism into conflict with deontological ethic
which is rights founded on personal autonomy an
generate corporate ethical responsibility in the deonto
the one hand, autonomous persons have the right
freedom to do business, whilst on the other hand they
freedom only through actions that respect the rights o
rate world, this translates into an ethical responsibi
rights of other agents.
In conclusion, ethics offers rival theories about
moral responsibility. Fundamentally, these rival theo
views of the human being as a moral agent. Utilitarian
ethics put the emphasis on the individual and his or
while virtue ethics focuses on social bonds and altrui
In order better to assess corporate ethical responsibilit
deeper into the concept of moral agency, and examine
corporation is in the web of interests, rights, and ends.

4. Shareholder Value versus Stakehold

The ability to act intentionally is a necessary conditio

ing an ethically sensible status of moral agency. In ot
is not capable of intentions and of guiding her actions
she cannot influence her course of action, and cannot b
sible for it either. The other side of the coin is tha
intentions is a moral person who bears responsibility f
question whether the corporation is ethically respo
question of whether the corporation is a person.
Nobel prize winning economist Milton Friedman
sonhood some decades ago in his classic article, The
of Business is to Increase its Profits.8 Friedmans co
maximization exhausts the social responsibility of
corporation as an aggregate of the individuals who o
moral responsibility, except maybe a general duty t
from the purpose for which it has been set up, that pur
making of profit. The corporation is not a person an
general ethical responsibility.
Friedmans view has been the target of strong cr
losopher Peter French has advocated a completely op
 Frenchs argument has received wide recognitio
subjected to crushing criticism. French builds his th
fact that we ascribe intentions, and therefore personho
our language. This to French, in a Davidsonian vein,
the existence of a corporate mind independent of an
minds. Frenchs critics focus on this and claim that w
ties to entities without assuming that the ascribed pr
entities in any ontological sense. Therefore, linguis
create moral persons or moral agents.
Thomas Donaldson, Kenneth Goodpaster, and
renowned American business ethicists who have
theories that recognize our ascriptions of responsibi
corporations; establish corporate agency and social
short of granting the corporation a fully independent p
to these philosophers, it is rational to project ethic
corporations, as not all corporate actions are reducible
als. However, these projections do not make cor
persons, but give them what Patricia Werhane calls se
personhood, which is sufficient to make corporation
for their actions. Therefore, in addition to shareholde
tion has to pay respect to the interests of all of its stak
thought is now known as stakeholder value philosop
considerable ground in ethics, business, and politics,
Friedmanite shareholder value approach.

5. The Corporation as a Nexus of Co

Responsibility toward the Members of th

So it is a widely held view in contemporary business e

tion is not an independent moral person but, even so,
for the promotion of its stakeholders interests and w
stakeholder is taken to cover everybody associated
with the corporate web. What is the nature of this br
responsibility? Is it related to altruism, like virtue eth
be justified without giving up the idea of human being
als who strive to satisfy their own interests? Much o
contemporary business ethics revolves around this que
science would weaken an ethical theory.
In applying the paradigm of self-interested ratio
tion, we should note that forty years ago when Milto
lished his classic paper making shareholder intere
business ethics, economics and jurisprudence took th
aggregate of self-interested individuals. However, m
nomics11 and jurisprudence12 have proceeded towar
corporation as a nexus of contracts. If we, accordingl
of the ethical responsibility of the corporation from its
a contractual network, it looks more obvious that t
parties of the web are ethically meaningful. Among t
holders, employees, management, directors, custo
authorities, state, and financiers, to mention just a few
examples. We are led to the conclusion that stakehold
not only widely supported in contemporary normativ
patible with modern sciences paradigm as to human a
This compatibilityor open architecture to use
Technology business jargonis a good indication t
ethically responsible not only to its shareholders for it
stakeholders.

6. Promise as the Foundation of a Co

Why does the corporations responsibility to all its

ethical flavor? Since we are dealing with contracts, w
bility not be sufficient? These questions may be ta
jurisprudence, which widely accepts the view that c
promises.13 This makes ethics unavoidable. Promisin
with ethics: promises carry a moral obligation to keep
Next, then, we may ask upon what the morall
promises is based? The answers given to this questi
their association with one or another major tradition
The most interesting theories of promising are the util
ing the usefulness of promise-keeping, deontolog
promises to the autonomous will and moral agency of
tual thinking explaining promises as conventions
Without examining these theories in any further detail
none of the theories challenges, prima facie, the mor
ises should be kept. This unanimity, not so freque
ethically responsible to all its stakeholders.

7. Stakeholder Value and Strict Liability in

What are the bioethical implications of the corporation

sibility? In this chapter I hope to point out some of the
modification (GM) in agriculture.
One of the key disputes in the debate on legis
with GM is whether strict legal liability should be im
turers of GM products, such as seeds.14 Strict liability
manufacturer to be negligent in order to be liable f
only be necessary that the product be defective and d
does not make strict liability a compensation auto
burden of proof of the claimant as compared to, for ins
on the basis of negligence.
In law, strict liability is closely associated with g
ity: that is, liability for manufactured goods and, mor
and intangibles. In most jurisdictions, products liabili
strict liabilityeither in written law or in common la
case with GM. In common law countries there have
cases of GM damages for a legal standpoint to have be
elsewhere, most notably in Europe, only Austria an
liability legal regimes applying to GM.
The New Zealand Royal Commission on Gen
produced a report that contains extensive coverage of t
and legislation on GM. The report concludes that
adequate measures to handle the liability issue. This
option that strict liability will prevail, but will leave it
verdicts. However, the fundamental reason why the
advocate written law imposing strict liability is evide
use of strict liability would be a barrier to innovation a
reasoning has taken the upper hand in the United Sta
officially recognized as an environmental hazard. As
become more risky for potential claimants to take GM
for damages, as the claimants would have to establis
ousness of GM in order to be successful. This is in
policy adopted in Europe. In the European Unions
Environmental Liability, GM is subject to a special
for a wide range of strict liability areas.16
damages they cause; but to what extent responsible?
or should the manufacturer consider GM products a
and exercise appropriate caution before entering the ma
Here we have no need to go into the largely unre
hazardousness of GM products. As philosophers, we
less contested propositions, like a product is a pro
other words, modern law includes under the concept
manufactured goods, but also a wide array of serv
Against this background it is quite hard to justify th
agricultural product is not a product. Therefore, we
reason to treat GM products differently from other pro
strict liability regime.
Stakeholder value is a forceful ethical argument e
lation between the manufacturer of goods and the cu
those goods. Law already widely recognizes that this
strict liability, which means that it is the manufactur
that the products do not carry an unreasonable risk. F
of stakeholder ethics, nothing suggests that the situati
in the case of GM products.
New Zealand Law Commissions reason for not a
ity in written law reveals that tougher financial liabil
cost and risks of GM research, making companies mo
launch new GM products. From the viewpoint of s
outcome from strict liability sounds like a most de
improve corporate deliberation, and most probably
products sold. At the same time it would be in accord
market economy by leaving the risk assessment to co
with the chance that they make money if they choose
their judgment falters.
I conclude by suggesting that the above line of
to other fields of bioethics and medical ethics as well.
be even more loaded with passions and emotions,
structure of ethical problems carries many similarities
artificial insemination or human cloning. The first is
the second is at least in a start-up phase of its busines
to say that human cloning should be made legal. The
of reasons that it should not. But what could, at lea
stakeholder value business ethics is that strict liabili
producers of cloning or in vitro fertilization service
produce a human being, the service provider should,
same.
Stakeholder value philosophy shows that issue
solved by examining businessinherently very
bioethics it backs strict products liability, which in m
of production is already a broadly applied and acce
efficient market controls against potentially hazardou
affecting markets basic dynamics. If financial gain is
ogy or medicine, the best deterrent against unethical
financial liability instead of prohibition.

8. Competition and the Moral of Ma

The outcome of a philosophical analysis of corporate e

that even if we begin with the viewshared by eco
and jurisprudenceof the corporation as a contractua
self-interested individuals, designed to advance tho
being, we can show that this corporate medium is a b
sibilities, rights, and duties.
It is not necessary to introduce ethics into busine
nal to business itself, for instance from the idealistic a
the virtuous self propounded by virtue ethics. Busine
with ethics. Trust, honesty, and equality of opportuni
tions of good businessand even more, they are neces
well-functioning, competitive market. This fact has en
of stakeholder philosophy, Thomas Donaldson, to
advantage of nations, analogous to Harvard econo
famous idea of the competitive advantage of nations ba
innovate.17 An example supporting Donaldsons t
advantage provided by ethics could be the global succe
other lesser-known Finnish companies. Without und
of Finns in technology and commerce, it can be sugge
streaks are partly founded on high standards in bus
known as reliable, uncorrupted business partners, and
partners and clients.
However, the ethics of a competitive market
deeper than mere ethical business practices and the res
all stakeholders. Markets entail freedom of action that
a fundamental trait of human nature; efficiency that
amount of welfare out of given limited resources;
 To sum up, business contains, both on the mac
tive market economy and on the micro-level as a
elements which most ethical theories would assess
desirable. Against this background it is a hollow claim
adopt an altruistic ethical standard from outside th
itself. The claim is also paradoxical because it goe
fundamental logics and benefits of a competitive mark
monopolies would have the best resources for altruist
competing in an efficient market have very low margin
The fundamental social function of business is t
of goods and services. In carrying out this function,
rational self-interestedness of individuals to service
Corporate ethical responsibility facilitates this process
for the legal framework erected by democratic govern
implementing income redistributionand respect fo
stakeholders of the corporation.
The corporation may take heed of its ethical res
nization by implementing a wide array of means and p
improvements in corporate governance, channels to
between stakeholder groups, codes of ethics, training
All these measures, and many others aiming at the
routine in thousands of companies, especially in the U
concrete expressions of the fact that business ethics
the contrary, good business is infused by ethics, and
area of philosophy dealing with values of business a
related to values.18

NOTES

1. Aristotle, The Politics, trans. T. A. Sinclair (Bu

Books, 1979), p. 46. See also Norman Barry, Business Eth
Press Ltd), 1998.
2. James Gordley, The Philosophical Origins of Mo
(New York, NY: Oxford University Press, 1991).
3. G. H. von Wright, The Varieties of Goodness (L
Kegan Paul, 1963).
4. See Michael Smith, The Moral Problem (Oxford:
5. See The Ethics of Aristotle. The Nicomachean
Thomson (Aylesbury: Penguin Books, 1976), pp. 21922
Macmillan, 1993), pp. 162167.
9. Peter A. French, The Corporation as a Moral Pers
Philosophical Reader, ed. T. I. White (New York, NY:
167187.
10. See, for instance Thomas Donaldson, Constru
for Business, Business Ethics, ed. T. I. White, pp. 16718
ter, Business Ethics and Stakeholder Analysis, Business
pp. 205223; Patricia Werhane, Persons, Rights, and Co
Cliffs, NJ: Prentice-Hall, 1985).
11. E. F. Fama, Agency Problems and the Theory o
Political Economy, 88:2 (1980), pp. 288307.
12. D. Millon, Theories of the Corporation, Duke L
201262.
13. C. Fried, Contract as Promise (Cambridge, M
Press, 1981).
14. See D. L. Kershen, An Agricultural Law Researc
ity Issues in Agricultural Biotechnology, http://www.na
15. Royal Commission on Genetic M
www.gmcommission.
govt.nz, p. 328.
16. Kershen, An Agricultural Law Research Article,
17. Thomas Donaldson, The Ethical Wealth of Na
ness Ethics, 31 (2001), pp. 2536.
18. I am indebted to Matti Hyry and Peter Herisso
ments on earlier drafts of this paper.
This page intentionally left bla
 1. Introduction

The debate concerning the use of economic appraisal

benefit analysis (CBA) in healthcare decision making h
several decades.1 Arguing in favor of the use of such
have pointed out that they represent a straightforw
healthcare workers can fulfill their ethical obligation
resources are used with maximum efficiency.2 Opp
economic appraisal methods has tended to take one o
has been argued that something in the economic a
decision making is essentially incompatible with trad
Second, attention has focused on difficulties confronti
methods in practice: for example, the difficulty o
measures of health. The use of non-monetary measure
Quality Adjusted Life Year (QALY) has excited part
In the midst of all this, comparatively little at
been paid to the question of the general defensibility o
CBA-inspired methods as decision making guides i
Indeed, we might easily be forgiven for thinking tha
essentially problem free, and that any difficulties a
more from the conditions of its use than from anyth
present paper aims to challenge such a view. I shall
having to do with the ineradicable uncertainty afflicti
sion making, economic appraisal methods such as
unsuitable in a wide range of healthcare contexts. The
the use of economic appraisal methods in contexts of
we shall see, from the apparent plausibility of the as
risk management essentially involves the maximiz
utility. But the latter assumption is by no means as s
appear.
The main piece of evidence I shall cite against
existence of the insurance industryor, more preci
insurance agreements that may be rationally entered in
parties. The existence of such agreements, I will ar
management is an inherently perspectival (or, if yo
affair: there may be a multitude of equally rational pe
risk, and the perspective according to which the ration
odsfor example, to questions of resource allocatio
sound, the argument will also have broader applic
rational risk management essentially involves the ma
net utility is also held by many ethical consequentia
wise have little in common with the proponents of e
least because of the sheer variety of ways in whi
stoodfor example as preference satisfaction, interes
fare in the economists sensethe satisfaction of
through market choices). While my explicit focus
thenthe question of the defensibility of the use
methods in healthcare contexts subject to signif
argument also has implications for the general defensib
ist decision making in contexts of uncertainty.

2. Economic Decision Making and Risk

In practice, all healthcare decision making involves

tainty. Healthcare institutions, medical procedures,
being as they inevitably are, we can never be entirely s
at the culmination of any decision making process a
will subsequently be realized in practice. Strictly sp
working in the realm of probabilities, rather than certa
as easy to overstate the extent of our uncertainty as to
circumstances the extent of any relevant uncertainty
may perhaps be legitimately ignored. But in many ot
be the case. In this chapter I shall be concerned to h
arise in connection with the use of economic appraisal
(and its derivatives) in contexts marked by signifi
specify more precisely which types of contexts are
uncertainty goes beyond the scope of this chapter. I
assumption that such cases exist, and that they form a
of the total range of contexts in which healthcare decis
argue that economic methods are unsuitable in cases
uncertainty, and that their use in such cases will onl
not obstruct, more properly deliberative decision maki
Economic decision making methods evaluate t
options in any given decision making context acc
contributions they promise to make to aggregate lev
measured in terms of the satisfaction of individual pref
fending the general legitimacy of such approaches, the
appeal to their alleged rationality: [A] rational soc
which the benefits to society (i.e. the sum of people
costs.6
In order to maximize expected utility in context
tainty however, such economic decision making met
an attitude of strict risk neutrality. Economists conce
tive analytics of risk standardly distinguish three diff
under the headings of risk aversion, risk neutral
ence.7 We can bring out the distinctive characters
considering how representatives of each would tend to
bird in the hand is worth two in the bush.
Other things being equal (and assuming for pre
mogeneity and general desirability of members of th
would expect a risk neutral individual to agree that
worth two in the bush where and only where the odds
bird from the bush are 0.5. If the odds of retrieval of th
were significantly greater than 0.5, then a risk neutra
inclined to take a chance on the two in the bush, rather
in hand. On the other hand, where the odds of retrieva
cantly less than 0.5 a risk neutral individual would
hand. Risk averse individuals by contrast would tend t
hand even for odds of retrieval of the birds in the bu
than 0.5. Despite the fact that, at odds of retrieval of
mizing expected net utility would be best served by re
hand for a chance at the two in the bush, the risk av
prefer to pass up this opportunity, and cling to the s
the bird in the hand. Risk preferring individuals would
from risk neutrality in the opposite direction. A risk
would be prepared to relinquish the bird in the hand f
in the bush even at odds of retrieval for each of signifi
It follows that both risk averse and risk prefe
regularly make decisions that fail to maximize expe
averse individuals failing to capitalize on good oppor
utility, risk preferring individuals rashly risking secu
risk neutral individual at least) would appear to be a
add to those assets.
Given that both risk aversion and risk preferen
behavior that fails to maximize expected net utility, it
siasts for economic decision making methods must,
 3. Risk Neutrality and Rational

The thought that an attitude of risk neutrality is ess

management might seem to receive support from exam
casino operator, whose guiding principle is to accept
balance of the odds and the sums at stake come out
Such a principle combines prudence with respect to e
appropriate boldness where opportunities exist to incre
adherence to the principle might well see the casino op
bad luck. Imagine a case in which a customer hits a
edly betting successfully, against all the odds. In a ca
operator is virtually assured of a profit in the long run
doggedly on taking the customers bets. Indeed, in
well contrast the (perhaps) irrational emotional state
proves unable to leave the table during her winning
confidence of the casino owner in the face of short
long run, if the odds are right, I cannot lose.
In the light of such examples it may be tempting
tral conduct as our paradigm of rational risk manage
ever, would be a mistake. It simply is not the case th
risk neutrality is the key to rational risk managemen
the position of a casino operator. Suppose a customer
casino and place a massive bet, at long odds, such that
casino would be bankrupted. Should the casino operato
may well say No. Even in a case in which the bet i
customers point of viewthat is, where the ratios
payout, in the light of the odds, are such that only a
ual would willingly place such a betthe possibility o
the casino will still be there. And in such circums
path, and the path of prudence, may well diverge. Whi
the rational response for the casino operator may look
bet, she must also take into account the potential
quences of losing, unlikely though losing may be. A
attitude in this case may well be a luxury the casino
Instead, the prudent course might well be to pass up w
ple a good opportunity to turn a profit, on the ba
should the customer win are, from the casinos perspe
contemplate.
reliable guide. The rational response to some risks
aversion.
Equally, the casino operator may sometimes rat
attitude of risk neutrality in the opposite direction: t
There is, for example, no obvious reason why the casin
play the national lottery. The odds against a win migh
the prize is fabulous, and the ticket price is (for m
Despite the fact that, the odds against success being
national lottery is of a type that, generally speaking,
individual would willingly make, there remains, for
obviously irrational in playing the national lottery
opportunity to stake an insignificant amount on a ch
lions, albeit at extremely long odds, risk preference
sense than risk neutrality.
On closer inspection then, the case of the casino
there is a connection between risk neutrality and ration
is a more complicated connection than might have at
casino operator, risk neutrality only makes sense wit
these limits will be determined by such contextual fa
the financial reserves available. There will be many c
gling concern will (rationally) adopt an attitude of
well-resourced competitor would (rationally) have take
However, perhaps the best illustration of the li
equates rational risk management with the maintenance
neutrality, and thus with the maximization of expect
vided by the insurance industry. The barroom econom
equates rational risk management with the maintenance
neutrality, and on that basis argues that it is irrationa
(since we are always likely to pay out more in premium
in payouts), will be a familiar figure to many. Her
promises to be the most profitable course is not alw
course. When, for example, I insure my home again
what I cannot afford to replace. Consequently, I ha
grounds for risk aversion in this case. Statistically s
good bet that my house will not burn down. Neverth
bet from my point of view. Just as the casino operator
in situations in which it will not make sense to take w
possible perspectives, looks like a good bet, so in ou
cases in which the chances of loss are extremely low
of losing are catastrophic; and in these cases an attitud
does it follow that it is irrational of my insurer to tak
on my behalf? Not necessarily. A vast proportion of m
up in my house. For my insurer, on the other hand,
represents a drop in the ocean of her total assets. The r
house burning down is therefore a risk with respect to
to remain sanguine. My insurer can rationally mainta
neutrality in cases in which the rational response f
aversion, and it is this difference of perspective that e
both parties can rationally enter into the insurance co
rationally take on exposure to a risk that the insuree
tion from.
It is important to note that in such cases it is
both parties to the contract will agree on every quantif
in question. In the case I have mentioned, my insurer a
(though we need not) on the value of my house, th
premium, and the odds of my house being destroy
insurer will rationally take on exposure to a risk that I
tion from does not necessarily reflect a difference in
nature of the risk. The crucial difference, which serv
for both parties to rationally enter into the cont
thatwith her vast financial reservesthe insurer is i
to maintain an attitude of risk neutrality in cases in wh

4. Perspectivism and Risk

In recent years a good deal of attention has been paid t

risk is objectiveby which is usually meant som
precise and impartial quantification, or subjective
meant something like fundamentally dependent on
filters.8 What the insurance example reveals howeve
whether risk is objective or subjective does not repre
framing of the issues. The insurance example shows
agement is a thoroughly perspectival (or again, if yo
affair. Even when all the quantifiable facts concernin
there remains the question whether those exposed to
view their risk exposure with equanimity, or would be
risk protection, and equally whether some of those no
might be well advised to take on more risk exposure
assumptions regarding the quantifiability of risks:
produce reliable (monetary or non-monetary) measures
benefits, and to establish with reasonable accuracy
alternative outcomes will occur; that there is no sing
riskthat risk neutrality, risk aversion and even ris
represent a rational response to a specific risk
stancesindicates that the objectivist account tells o
(The insurance example also has the merit of showing
be a rational response to risk exposure in many more m
casino example might suggest.)
Moreover, just what the objectivist account leave
dispensable part of the story, for decision making pur
and risk preference are rational responses to risk in so
apparent justification for the indiscriminate use of econ
methods in risk contexts collapses. As we have seen,
ods appears legitimate only where they are allied to an
neutrality. The claim is that such methods represen
decision making because they maximize expected net
also seen, there are a huge number of mundane cases
maximizing expected net utility does not represent th
management. In these cases, economic methods wi
intrinsic link to the risk neutral perspectivefrom
divorced without losing touch with their legitimizing
unreliable guide to rational decision making. It appe
the most trivial cases the question whether the goal o
utility is appropriate to a given decision making conte
rily answered without considering the host of contex
entail that an attitude of risk aversion (or risk prefere
rational response.
There are several means by which decision maki
designed to take account of the contextual factors I hav
I can only gesture briefly here. Perhaps the most
amongst these means lies between those that hinge on
expert inquiry into the context in question, and those
degrees, and by varying methods, to build some lay
process. The false promise of economic methods rested
they appear to offer a short cut to rational risk mana
exclude a crucial segment of the data that rational risk
upon: contextual information regarding who is exp
important the items at risk are to them (such impor
decision dilemmas in healthcare and elsewhere that
actual and potential personal catastrophes, whose econ
The proper response to such cases is not simply to pro
an accurate economic value on the cost of these cat
may well be true), but to insist in addition that econ
tell us what we really need to know: whether the cost
which those affected can afford to pay.
It is not unthinkable that an expert-driven appr
risk, which found a way to take the contextual fact
properly into account, would qualify as a satisfactory a
economic methods. What is most obviously wrong wi
methods in risk contexts is not that they are expert-
attempt to base decision making on inappropriate sh
appears likely that the most politically acceptable alt
economic methods will display limited dependence
and provide significant scope for lay involvement.
precisely, we should take account of the various c
jointly determine whether a given potential cost is on
group of individuals can rationally accept exposure
unreasonable to suggest that the individuals involve
directly. Having accepted the principle of direct lay i
several routes lie open to us. These range from s
methods, to the host of techniques associated with d
procedures. My own predilections and commitments w
the second class of alternatives. Be that as it may,
chapter has been firstly that of showing that econo
methods are not a universally reliable guide to rational
secondly that of indicating where their primary shortco

NOTES

1. See e.g. J. A. Gray, Choosing Priorities, Journ

(June 1979), pp. 7374; Gavin Mooney, Economics, Me
(Hemel Hempstead: Harvester, 2nd ed., 1992). For an ov
see Tom L. Beauchamp and James F. Childress Principle
(Oxford: Oxford University Press, 5th ed., 2001), pp.
perspective from economics see Paul McCrone, Understa
ics (London: Kogan Page, 1998), Introduction. For a cri
 4. See ibid., pp. 250272.
5. See McCrone, Understanding Health Economics,
6. David Pearce, Cost-Benefit Analysis (London: Ma
p. 3.
7. See e.g. Jack Hirshleifer and John Riley, The A
and Information (Cambridge: Cambridge University Pres
8. For a useful summary of views see Sheila Jasan
Risk, Environmental Values, 8:2 (May 1999), pp. 1355
This page intentionally left bla
 1. Introduction

In this chapter I will make an argument, albeit a rather

support of moral progress. Having tested various ver
at various times and with quite diverse audiences, and
stubborn degree of objection to this claim, I can on
response in the reader. There are in fact two sorts of
argument, and most audiences give a grudging acc
claim that we can at least make sense of the possibi
but respond with an almost universal rejection of the
have undergone moral progress. I would not be surpri
similar reaction. This seems all the more reasonable g
this in the post-Bosnia, post-Rwanda, post-11 Sept
midst of the second Gulf War. Our inhumanity to eac
myopathy are daily flashed across the world courtesy o
coverage the modern media provide. The reasons I wo
persisting with this paper can be established by takin
Cartesian reflection. What, you should ask yourself, a
denying either of the claims I make? I would suggest
are not only deeply counterintuitive, but also profoun
is of course an alternative viewnamely, that it is n
false, but my defense of the claims that is inadequat
conclusion you will have to consider the argumentss

2. Moral Progress

As an applied philosopher working in the field of b

time is spent teaching ethics to health workers. It s
would be a task of Sisyphean pointlessness if there
possibility of moral progress. The very reason f
healthcare workers is not merely to acquaint them wi
history of philosophy, but to enable them to recogniz
to their work, and, by incorporating practical mor
process of making clinical judgments, to make better
I believe that this is not too grandiose a claimindi
better doctors, nurses, and therapists, and perhaps even
say something about the metaphysics of progress.
In order to understand moral progress, we need a
that is adequate to the task. One conception of progr
change. And to understand change we need an unders
parameters by which a thing may be judged to hav
physical arguments are complex, and this short chapt
the detailed discussion required, so I shall use the o
my argument at a more intuitive level.

3. Progress and Change

Take the progress of a train along a track as an exampl

way of describing the trains progress is in terms of
relative to stationary objects over time. So one set of
progress consists of the different spatio-temporal co-or
question, which are useful in this case for measurin
along the track. The trains progress can therefore be r
the difference between our observations of the train a
tion 1 (p1) compared to the observations at t2 and p2. O
account of progress may have an analogy in terms of
consider the temporal aspect: that progress is a functio
However, in terms of moral progress this seems inad
temporal co-ordinates may apply, since it takes at lea
to make a comparison possible, what are the moral equ
co-ordinates? There are of course some possible candid
claim that at t1 slavery is widely practiced, while at t2
practiced seems to have the same form as our account
The problem with this example is that we are unable
putative moral progress and the mere reporting of a
which may be a non-moral difference or even a rep
without some further account of why this is moral
report of a mere change. A possible solution to co
progress is a form of teleological change, so that pr
relative to the goal or end aimed at. Applying the teleo
train example seems to give a more meaningful acco
gress if we consider that progress as more purposeful
position, so that, for example, the progress of the tra
to the station to which it is traveling.
we would already need to know the goodto know
the first placein order to make the judgment tha
progress. But the nature of the good is the very th
disputes. A skeptic might observe that any candidate f
be radically underdetermined by the different and comp
good offered by different agents. This kind of teleolog
sibly demanding if it requires that we have infalli
good before we are able to work out our progress i
moral problems. This is not the account of moral pro
although I do believe that a form of teleological accoun
The account I have in mind is not one that enta
on the grand scale, but is rather an account of mo
process of practical moral reasoning, and the objec
relation to the goals of morality. What are the goals o
sistent with my account above, I do not believe th
approaching an exhaustive account of such goals or e
mean that we have no account at all. Human exper
with knowledge enough to begin to shade in, and sha
detail, some of the general concepts, such as flouris
that otherwise sound good but seem empty. There is
drawn, analogy here with knowledge in the context o
The lack of a Grand Unifying Theory, or our lack of
of matter, does not undermine the ability of the natu
good enough explanations of the physical world,
endeavors to seek such a theory, or pursue such know
and important enterprises. I do not believe that mor
cerned with uncovering new moral facts, but that it
deepening and enriching of our moral understanding.
To claim that there are such goals and goods as
ity does not require us to give a substantive accoun
since the process of shading in the detail of such
rejecting or accepting different accounts of them, is its
our understanding is deepened and enriched. Charles
moral postulates as hypergoods, i.e., goods which ar
bly more important than others but provide the standp
must be weighed, judged, decided about.2 The proces
tion is one by which it is possible to come to the jud
of action or anotherone conjectured account of the
superior. It is a process repeated and echoed at many l
introspections to more collective deliberations, a pro
underpin wider social institutions. This is not to
inevitable, but minimally, as Thomas Nagel commen
with somethings having become established as obv
out from there.4
An example of this point of departure approach
tered view regarding the set of entities to which no
apply. This has been irreversibly expanded from a
women were unquestionably excluded, to the positi
unquestionably included, or at least the presumpti
continue to exclude women need to argue their case ag
ary is now set.
Although the boundaries of equal respect have be
rection to the point where contraction is almost inco
ries are not immutable. The frontiers of contempo
characterized by disputes as to whether the boundarie
way that constitutes a superior set of discriminations
notions of equal respect can be meaningfully expand
animals on the one hand, and contracted to exclude th
on the other.5
The process of this discourse echoes Charles T
ranking of different goods based on the epistemic
solution: We are convinced that a certain view is sup
lived a transition which we understand as error-reduc
temic gain.6

4. Ameliorative Change

The idea that a necessary component of moral progre

improving has led Stan Godlovitch to reject teleologi
for moral progress, in favor of an account of ameliorati
suggests that we can judge such progress with the b
evaluationthings look better from here considering
from.7 Retrospective evaluation is of course only on
that contributes to the general idea of moral progress.
moral status of slavery at different times, for example,
than a simple observation on the practice of slavery
claim for moral progress. This is because a report th
widely practiced leaves open the question of the mor
this observation is also a claim for moral progress, t
ity, and the moral status of persons, to name but
moral progress is therefore not only evident in retrosp
in the very possibility of moral argument itself.
So the idea that ameliorative change can only be
fit of hindsight is not the whole story. A judgmen
judgment that one moral claim is better than anoth
comparison over time but could equally, and inde
standing competing moral claims side by side. This
judgments of moral progress are entirely abstract af
alone, for we must have knowledge of human harm
substance to our moral concepts. A number of differe
when making the judgment that one moral claim is
another. One of these is moral relevancea good ju
sensitive to whether different properties are morally re
has been made in moral discourse by showing that
species are not morally relevant in the way they wer
when deciding between the different interests of com
groups. Another example concerns judgments regardin
fit of our moral concepts, or what I call moral exte
can be judged in terms of the way in which a mo
extended to become more inclusiveless discrimina
more discriminating in anotheras I have suggested
equal respect.
This marks the end of the preamble. I now turn t
proach, in which I first present an account of person
then go on to argue that this account is a useful, and i
for understanding moral progress in general.

5. Personal Moral Progress

My account of personal moral progress relies upon

experiment, and therefore requires some participation
following section is an extract from Charles Dickens
zlewit.8 I suggest that for the first task in this practical
enjoy this extract. For readers who are not familiar wit
following points will set the scene. Mrs Gamp, refer
nurse, has been hired, with her colleague Mrs Prig,
John Doe patient, a young man, identity unknown,
fever. The reader enters the scene at the point where M
 the patient and his overhearing them when
point easily.
Oh! she said aloud, hes quiet, but his w
matter wot you say.
Anythin to tell afore you goes, my dear?
ting her bundle down inside the door, and lookin
partner.

Mrs Prig merely comments on the quality of the f

carers and adds as an afterthought:

The physic and them things is on the drawers

Mrs Prig, cursorily. He took his last slime drau
chair ant soft enough. Youll want his piller.
Mrs Gamp thanked her for these hints, and
good night, held the door open until she had di
end of the gallery. Having thus performed the ho
her safely off, she shut it, locked it on the insid
walked round the screen, and entered on her o
chamber.

The first thing Mrs Gamp does is to examine the a

view to her own comfort before turning to examine the

Mrs Gamp solaced herself with a pinch of snuff

him with her head inclined a little sideways, a
gaze upon a doubtful work of art. By degrees, a
of one branch of her calling took possession of t
ing down, she pinned his wandering arms agains
he would look if laid out as a dead man. Her fing
his limbs in that last marble attitude. Ah! sai
away from the bed, hed make a lovely corpse.
She now proceeded to unpack her bundle;
the aid of a fire-box on the drawers; filled a sma
nary to refreshing herself with a cup of tea in th
laid what she called a little bit of fire, for t
purpose; and also set forth a small tea-board, t
wanting for her comfortable enjoyment. These pr
long, that when they were brought to a conclusio
think about supper; so she rang the bell and orde
 and never mind ones self as long as one can do a
She moralised in the same vein until her
then administered the patients medicine, by t
clutching his windpipe to make him gasp, and i
down his throat. I amost forgot the piller, I dec
drawing it away. There! Now hes comfortable a
I must try to make myself as much so as I can.
With this view, she went about the constru
neous bed in the easy-chair, with the addition of
her feet.

The next morning Mrs Gamp reports to the doctor and

Well! said the doctor, we must keep him quie

give him his draughts regularly; and see that he
Thats all!
And as long as Mrs Prig and me waits upo
that, said Mrs Gamp.
I suppose, observed Mrs Prig, when they
tor out, theres nothin new?
Nothin at all, my dear, said Mrs Gamp.
his talk from making up a lot of names; elsew
him.
Oh, I shant mind him, Mrs Prig return
else to think of.

6. Some Reflections on Mrs Gam

Not every reader will find the exploits of Mrs Gamp

my experience most people cannot help but laugh at t
believe that the irony of the piece, amusing or not, is
ing question, however, is why such a piece of prose wo
straying too far into the realm of literary criticism, I
reasonable account of the ironic effect in terms of th
world as revealed in the text against our own experie
The text clashes with our moral sensibilities; and this
clash merely in taste. The irony works because there
tion concerning the right moral starting point in such
that between healthcare worker and patient.
then, because we already know, or at least have exp
ought to follow in terms of behavior when a perso
towards another.
But what is the right moral starting point for such
some way to establishing the parameters here if we c
example in a different context. Imagine for exampl
responsible for educating novice healthcare workers an
candidate student for your education and training pro
that we can begin with some quite concrete ideas abou
Mrs Gamp to grasp in order for her to progress as a
implying that part of the assessment of progress fo
worker necessarily includes an evaluation of the stu
progress. I do not mean to suggest that novice health
profession as moral deviants and are somehow conv
virtue by the training program. Rather, I am suggest
ness of such programs to attend to ethics education
about where, in terms of moral development, the stud
end of the program, but with a clear idea of what th
program ought to be. With reference to my earlier re
such programs usually do have a teleological schem
terms of the aims and objectives of the program, or
ioral criteria the student must demonstrate in order to b
Mrs Gamp is of course a convenient device, an o
ture, through which to make explicit the parameters i
personal moral progress; however, noting this fact doe
validity of the example. The following schema capture
parameters on which the progress of a student on suc
tion might be based.

Mapping the moral domainacquainting th

ens.
Developing a sense of moral relevance.
Self-scrutiny or moral reflectionchallengin
ing of moral concepts.

Using Mrs Gamp as the subject, I shall now give s

three specimen categories identified in the above schem
healthcare worker. However, mapping the moral doma
workers requires the establishment of some clear pa
Understanding and assimilating such givens woul
progress for the student. Of course, the givens may al
of departure for still further progress, although this ra
do not wish to consider here. I will, however, say so
below.
Progress construed in terms of outcomes for
identified as, for example, observable behaviors in th
the sickroom. For example, we would expect the health
certain orientation, demonstrate a particular phenome
which shows her to perceive the very room as having a
salience. The focus of the healthcare workers attentio
toward the person who is the patient. The objects in
regarded as means to serve the interests of the patient a
regards the room and its contents, as potential veh
comfort. The irony of the exchange between Mrs Pri
example, is that it inverts the expected priorities, focu
quality of the food and amenities for the carer rathe
Others have commented upon this sense of moral sal
the relationship between health worker and patient. S

When you meet the patient you meet another hum

nerable, who trusts you, and whose life you can
cant way. This creates a specific responsibility to
ing, which can be difficult to understand for out
ertheless plays a significant role in the deliberat
fessionals. In their minds it is related to the po
the respect they have to show.9

Nurse theorists have described this relationship as on

However it is characterized, the relationship between
patient ought to be a moral relationship which stands
between strangers meeting on the street, or that betwe
assistant. To understand the moral nature of the relatio
the implicit set of priorities that form the parameters o
for example, that there may be some sacrifice of pers
ences by the healthcare worker in favor of the comfort
patient. These are at least the starting premises of such
from a fundamental grasp of the distinction between
and the multitude of possible relationships, with th
which are possible between one person and another
believes that she has fulfilled her duty by sitting wit
and ensuring that he received his medication. This,
because she is not able to distinguish between the me
care-taking and taking carewhat Per Nortvedt d
the-other.11
We might begin to be convinced that Mrs Gamp
gress if we witnessed her ability to recognize the di
and cared for, and saw her incorporating such diffe
ways, into her routine of care. The development of a
care would demonstrate a deepening of Mrs Gamps
and such changes in behavior would be evidence o
progress.

C. Self-Scrutiny or Capacity for Moral R

Closely tied to this deepening moral sense and evolvin

a morally appropriate way towards her patients, wo
evolving capacity for reflexivity. By reflexivity, I
engage in a process of reflection, making oneself a
involved in making a judgment and turning such judg
the purpose of reinforcing or revising those proces
capacity, which the student might be required, and oug
explicit in an accessible way.
In my account of personal moral progress throu
sional education, I have tried to give a flavor rather tha
what the process might consist in. It is clearly not a c
However, I believe that we would judge our student
undergone a process of personal moral developmen
period of education she was able to demonstrate, bot
her actions and in how she consistently behaved, that s
values upon which healthcare is premised. There ar
standing questions. How can we be sure of the validity
that formed the premises of the educators? How can w
to which students have to progress, are themselves
As with other areas of knowledge, it is more reasona
the skeptic than with her.12
tive with not a shred of irony about them. Even less c
that this was a textbook example of good nursing ca
that the premises of healthcare ethics are not themselve
course they are, and so ought they to be. Naked patern
challenged as the single foundation for the relatio
worker and patient. But the understanding of the con
helped to oust paternalism is undergoing a further tra
to enrich it and render it more subtle, more sensitive
tions in which healthcare is practiced.
The idea that we have gained moral knowledge,
have established some moral baselines as our starting
point I believe hold not only for my example of person
more generally. Godlovitch characterizes such progres
A ratchet is a mechanism incorporated into some
backwards slippage, and thus technology provides a u
of moral progress: the slippage test. On this basis h
no more revert to an internalized acceptance of racial
than we could to a pre-Copernican cosmology. Put
developments in moral thinking do seem nigh-on irre
what might be calledin a term that would b
modernistscentral tenets of morality.

NOTES

1. Keith Michael Baker, Condorcet: From Natura

Mathematics (Chicago, IL: University of Chicago Press, 1
2. Charles Taylor, Sources of the Self (Cambridge:
Press), p. 63.
3. Michele Moody-Adams, The Idea of Moral Prog
30:3 (July 1999), pp. 168185.
4. Thomas Nagel, The View From Nowhere (New Yo
sity Press, 1986).
5. Peter Singer, Rethinking Life and Death (New Yo
sity Press, 1994).
6. Taylor, Sources of the Self, p. 72.
7. Stan Godlovitch, Morally We Roll Along: (Op
Moral Progress, Journal of Applied Philosophy, 15:3 (1
8. Charles Dickens, Martin Chuzzlewit (Oxford: O
1998), pp. 345358.
of Nursing Ethics, Nursing Ethics, 5:5 (September 1998)
12. Ronald Dworkin, Objectivity and Truth: Youd
losophy and Public Affairs, 25:2 (Spring 1996), pp. 871
13. Godlovitch, Morally We Roll Along.
 Mark Sheehan

1. Non-Normative Virtue Bioeth

My aim here is to sketch the beginnings of what I t

approach to bioethics. It is an approach that arises fro
particular position in metaethics to ethical issues in m
In what follows I will give a (very) brief account of
highlight the most salient aspects for its application.
the chapter I will consider how in general terms this
might be effectively applied to the realm of medicine
hope we will see, it results in a kind of virtue bioethic
One way of saying what is distinctive about vir
ence to the question that is taken as the starting poin
Virtue theory, as I will understand it, has as its focu
kind of person should I be? as opposed to the ques
do? What makes the approach that I want to sugge
approach is not much more than its connection with
the latter question.
Starting with, as it were, an agent-based question
should I be?) rather than the act-based question (Wha
lead the theorist in one of two ways. First, by analy
sons character, we might be able to elicit some help
ought to be done in certain kinds of situations. This
content to the claim that the right thing to do in a
virtuous person would do in that situation. If we can
what characteristics the virtuous person possesses (tha
the thought goes, we will have a better idea of what
idea is that by focusing on the first question, we w
answer the second.
Alternatively, we might think that beginning
question leads us away from an answer to the act-ba
once we have decided that the right thing to do in a g
the virtuous person would do in that situation, there is
said that will enable us to determine what ought to
second route leads us to focus on what it is that th
dowhat abilities and capacities does the virtuou
facilitates right moral judgment? Importantly, this que
account from normative virtue ethicsthe first path ab
ethics, like all normative theories, in the end, tells us
My approach here is a metaethical one, and so it do
thisat least for the most part. Instead it makes claim
things, the nature of ethics, and more specifically abo
ity possessed by the virtuous agent. I say for the m
there will be some substantive normative claims t
generate, but its primary aim is not to generate such c
provide a systematic set of formulae for their generatio

2. Metaethics

The theoretical position I will discuss here traces its ro

style approaches, to Aristotles Nicomachean Ethi
Aristotle he has very little to say in the Nicomachean
tive content. Indeed, as David Wiggins has put it, ev
permitted to take refuge in the notion of aisthesis, or s
And in aisthesis, as Aristotle says, explanations
Aristotle does spend some time dealing with character
the virtues, in the end the exercise of virtue depends o
judgment: [T]he temperate man craves for the things h
and when he ought; and this is what rational principle
There are two aspects of this theoretical positio
out here. The first is the kind of perceptual capacity o
tion that is possessed by the virtuous agent. John Mc

A kind person can be relied on to behave kindly

situation requires. Moreover, his reliably kind be
come of a blind, non-rational habit or instinct
tion requires a certain sort of behaviour is (one w
reason for behaving in that way, on each of the
it must be something of which, on each of the re
aware. A kind person has a reliable sensitivity
quirement that situations impose on behaviour.
reliable sensitivity are cases of knowledge T
might say, a sort of perceptual capacity.3

This perceptual capacity is the core of the approach. I

tivity, aided and influenced by reflection and deliber
 In urging behaviour one takes to be morally requ
saying things like this: You dont know what
is shy and sensitive. Conveying what a circum
loaded sense, is getting someone to see it in the s
virtuous person would see it. In the attempt to do
trivances similar to those one exploits in other
to back up the injunction See it like this: hel
cases, descriptions with carefully chosen terms
emphasis, and the like.4

In the attempt to get a person to see matters arightt

justify a particular claimone exploits a variety
variety is not to be underestimated. It includes c
deontic considerations, logic, emotion, character, and
term, conceptual analysis. In short, it includes the ful
tive strategies and the complex conceptual apparatus
language.
So, the key thought behind this approach is th
has a special perceptual ability. This enables our virt
nize, read, or interpret situations well. The recognizin
amount to determining what ought to be done in th
course this says nothing of the kind of justificatio
support the deliverances of this sensitivity. In no
theorists of particular persuasions each have their own
So, for example, the utilitarian might justify her jud
the utilitarian calculus of expected utility. With this
related to it being a metaethical approach), there is
strategythere is no definitive set of rules to follo
employ. Instead, all considerations and all justificato
able and, before the fact, equally relevant. Again, in
about which justificatory strategy is conclusive in a p
on the case and on the ability of the judge to see what
I want now to mention two of the more standard
proach, if only to put them aside. First, we migh
relativism and moral truth. How is this even vaguely a
can there be a fact of the matter about what ought to
fixed justificatory strategy for assessing truth, and ju
rest or depend upon the agents perception? This
difficult problem faced by this account and so, natural
 Second, it might be complained that we really
to tell us what ought to be doneAt least norma
that!but this metaethical approach shies away fro
that is of use. The response here is to make an anti-no
that searching for the one, true normative theory is a m
should, in the face of the way in which our moral l
This claim depends on the distinctiveness of partic
inadequacy of rules and principles to cover this di
independently of a particular sensitivity concerning
McDowell puts it:

If one attempted to reduce ones conception of wh

set of rules, then, however subtle and thoughtfu
up the code, cases would inevitably turn up in w
plication of the rules would strike one as wrong
because one had changed ones mind; rather, one
was not susceptible of capture in any universal fo

This is not to say that rules, generalizations, outcom

like play no role or are of no consequence. They featu
and only as called for by the situation itself.

3. Applications to Medicine and Hea

As things stand one would be justified in thinkin

approach could provide very little in the way of assista
with ethical issues in healthcare. Indeed, the interest
arise in healthcare are all normative onesthose abo
is silent. How then, could an approach such as this p
factory in the realm of healthcare? The answer come
practical terms, by developing and encouraging what
moral seriousness, and second (more theoretically
examination of the idea of a practice as it applies to
cine. Each of these will be discussed briefly below.
First, this approach, given its Aristotelian root
emphasis on education, reflection, and experience. Thi
perception-sensitivity pointswe develop the p
question precisely through some combination of the
context, who is to decide what ought to be done, and t
 For to such persons, as to the incontinent, know
but to those who desire and act in accordance w
knowledge about such matters will be of great be

It might be thought, however, that this appeal

tions or moral seriousness is merely a toothless
knows that education, reflection, and experience ar
ethicist would deny it. But if this is the limit, if edu
experience are all that ethics and ethicists can provid
quite deeply. Many, perhaps most, members of the hea
used to the methodology of science. Science provide
problems. The same is often expected of ethics. On th
nature of ethics is such that the kind of guidance ofte
rules or algorithms that will yield solutionscannot b
good deal more to be said on these matters. Howev
stress here is that this approach does have signifi
healthcare and, in particular, for the relationship b
ethics. Ethics (as a discipline) provides a distinctive k
tion about the patterns and forms of moral argumentat
A second way in which the theoretical position o
tion can be applied to healthcare is by exploring the id
utilizing it in the case of the practice of medicine.
between virtue theory and the idea of a practice as a
from the work of Alasdair MacIntyre and, in partic
There he defines a practice as:

any coherent and complex form of socially estab

man activity through which goods internal to th
realized in the course of trying to achieve those
which are appropriate to, and partially derivative
ity, with the result that human powers to achiev
man conceptions of the ends and goods involved
tended.8

So, bricklaying is not a practice but architecture i

skilfully is not a practice but the game of football is. P
a practice but farming is.
Much of this definition is not particularly rele
here, concerned as it is with MacIntyres general theor
 considers them as qualities contributing to a w
which relates them to the pursuit of a good for h
ception of which can only be elaborated and poss
ing social tradition.9

In all of this, no human quality is to be accounted a

fies the conditions specified at each of the three stages
To further explain his idea of a practice MacInty
the example of the practice of playing chess. If we wan
ing child to play chess we might initially require so
(candy), but we would hope that there will

come a time when the child will find in those g

in the achievement of a certain highly particular k
strategic imagination, and competitive intensity
for trying to excel in whatever way the game o

MacIntyre is not as clear as he might be about the

goods internal to a practice and the practice itself.
define the relation negatively, in terms of external goo

There are always alternative ways of achieving

their achievement is never to be had only by eng
lar kind of practice.12

There is a little more to the connection between

and virtue theory than the MacIntyrean one. Virtu
teleological. That is, the virtues, it is normally h
required for the Good Life, where the Good Life is to
goal, or end, or point of human life. Given this, it
clear why practices are useful units of analysis fo
MacIntyre. Practices, characterized in part by the goo
them, can readily be seen as component parts of hum
component parts can, with varying degrees of ease, be
rest and examined. Of course, the rest of MacIntyres s
capture the way in which the vast array of practices
might participate are to be combined to make sense o
society. In any case, for our purposes here the unit of t
with a smaller, more limited group of human intera
makes the specification and investigation of normat
tive and metaethical levels. By reflecting on the practic
place in it, the individual has an additional justificat
process of decision-making. But also, it will I think
that the point of the practice of medicine and what g
provide us with internal grounds for the obligations of
in it.
When we do turn to the application of this ide
immediately confronted by a problem of scope. What
practice? Healthcare might be taken to be not one bu
tices. Alternatively, it seems perhaps extreme to dis
within healthcare too finelyby distinguishing, say,
rics from the practice of gynecology. Certainly, in a
count these issues would need to be addressed, but
chapter it is not unreasonable to allow a degree of ab
mind, I will primarily be concerned in what follows
and, consequently, with the practice of clinical med
many hats. I will not be considering the physician as
cian as citizen. The ethical issues that arise in the c
distinct from those in clinical medicine. Similarly,
political issues involved in medicine very often impi
cine, the ethical issues surrounding rationing and d
instance) are also distinct. This is not meant to im
overlap or that the distinctions are always and ever
medicine is, I think, quite readily seen as a practice
and it is one that perhaps unjustly (given the variety o
receives much attention (consider here discussions o
relationship).
It is important to be a little clearer about the rela
considerations concerning the idea of a practice and th
of the previous section. If this account of a practice
used to inform the individuals understanding of his
values then, naturally, the strategy is being used as a m
or reasoning. Given my metaethical position, the use
form of moral reasoning stands on an equal footing w
reasoning. That is, my claim is not that the normat
from using this method to determine ones obligation
over any other method. In this respect, my brief discus
medicine below is not intended to violate the non-no
the metaethical position of the first section. So, the th
have given an account of the practice of medicine, w
 4. Internal Morality and the Practice of

These general thoughts about applying a virtue theor

cine and healthcare have recently received some atten
the Journal of Medicine and Philosophy was dedicate
the internal morality of medicine. Central to the ide
ity of medicine is the MacIntyrean account of a prac
internal to a practice.13 The internal morality step is o
medicine because, it is thought, medicine constitutes
internal goods. These internal goods provide us with t
morality of medicine: a morality, for healthcare profe
the internal goods of the practice. In this last section
the way in which this discussion utilizes and so appli
a practice to medicine and healthcare. We will see th
idea of a practice there are a number of temptations tha
avoid. The chapter will conclude with a few gene
practice of medicine and the way in which this kind o
proceed.

A. Mistaken Views of Practice

Perhaps the most significant danger in applying the id

particular case is that we focus too heavily on the
practice. Edmund Pellegrino, in his paper on the inte
cine is I think guilty of this, as are Robert Veatch a
Pellegrino writes that the practice of medicine

exists because being ill and being healed are un

ences, not because society has created medicine
than social construct, the nature of medicine, its
tues, are defined by the ends of medicine itself, a
cally internal from the outset.15

So it looks as though the goods of medicine come fro

cine, and that the goods internal to the practice of me
the goods or ends of medicine.
There are two general dangers that this account
should be careful not to assume that the relationship b
medicine and the nature of medicine is clear. The nat
that different people, in different cultures and in differ
appropriate medicine differently. The underlying conce
the goods and goals of the science of medicine are b
with the goods internal to the practice of medicine.
The second danger involved in applying MacInty
tice to medicine is that we will focus too hard on the
practice, and not on other normative features internal t
note, in this context, that MacIntyres definition of a
standards of excellence appropriate to particular pract
goods internal to them. It is also easy to miss the o
tyres definition of a practicethe fact that a practice i
set of activities that involves particular kinds of relatio
lar sets of circumstances. Indeed, a good case can be
the physician-patient relationship is of a unique sort. I
ing, then, if there were unique obligations and respon
to both sides of it.

B. Internal Morality and the Practice of M

There is one final danger associated with using the

explicate morality within medicine. This danger inv
failing to distinguish between various senses of the
While it does apply in cases like Pellegrinos acco
background, and as I have suggested, there are more pr
case.
A useful way to bring this danger out is with r
public. In Book One, Socrates uses the physician
discussion with Thrasymachus regarding the nature o
ple, he considers the science of medicine to be an art,
the stronger and the patient to be the weaker. He also
the strict and the popular senses of a word. Thus the
sense is not someone who can be mistaken about
physician in the strict sense one who makes money o
claims that any physician in so far as he is a physici
the advantage ... of the patient.16 The methodology
and, arguably, the point of the discussion as a whole
and understanding what it is to be a physician in the
come to see that the true physician seeks the advanta
is, by investigating what it means to be a physician
might become clearer about the way in which a physic
the concept of a physician. (I do not mean to imply th
intended the distinction to be drawn, though I think th
reading of Book One that draws the distinction in som
So the physician in the strict sense cannot be mi
money, and seeks the advantage of the patient. It
distinguish between the concept of a physician and the
roughly and for our purposes here, the former is tied
guage in a way that the latter is not.
In the context of the practice of medicine, it is th
practice with which we are concerned. The final dan
investigating the practice of medicine then, is faili
strict sense of the practice of medicine from the practic
contexts on the one hand, and some notion of the ide
on the other. To a large extent, the difference between
a difference in methodological approach. If we wishe
practice of medicine we would conduct an empirical s
into the ideal practice of medicine, naturally, takes us
normative ethical theorypresumably detailing how p
involves giving substance to a conception of the ideal
Since our focus is on something more like the
of medicine, our investigation would utilize the re
analysis. In such a study, the relationship between th
tice in a particular contextthe way medicine is prac
of the practice of medicine is importantly normativ
of the concept will enable us to criticize particular inst
various ways, and it will contribute to accounts of th
important way. Much more needs to be said about the
in particular, about the one favored herehowever t
project. It is important to notice how this approach li
cal approach described above. This linguistic strateg
available only to this approach, but is essentially a m
so is particularly germane to a metaethical approach.
The Socratic example of medicine involved a thre
tween the science of medicine, the physician, and
roughly understand the science of medicine to involve
of knowledge, given by science, concerning the hu
physician is ideally someone who possesses this know
to apply it. The patient, by and large, does not possess
or the skill to apply it, and yet she has needs or defic
can be met or remedied. The practice of medicine wi
informing those motivations and expectations. It seem
motivated to visit physicians by what they understand
the relevance of the physicians skill to those need
given this, that the physician will endeavour to meet t
say, also, that physicians can expect that patients w
tions and expectations about their needs and the physic
Of course the relationship generally is affected by the d
between the physician and the patient. Quite clearly
advances in medicine, there will be things that cann
physician (or by any physician). Similarly, there will
which medicine will have nothing to say.
The idea is that by giving an account of the pra
derstood broadly as I have suggested above, we can i
relationships and goals that are constitutive of, or
volved in, the practice. These relationships are forme
have general kinds of expectations, motivations, an
means to be a physician in the strict senseunde
component of the practiceis tied to the practice a
turn, is understood in terms of the relationships and g
tive of the practice. This kind of approach avoids the
other attempts to apply the idea of a practice to h
assume that a practice is defined or constituted by th
The resulting account would not involve recourse
principles or normative theory, and in this sense it
bioethics. It would of course be intimately related to th
informing it, and in this sense it would be a kind of v

NOTES

1. David Wiggins, Deliberation and Practical R

Truth, ed. David Wiggins (Oxford: Clarendon Press, 3rd e
2. Aristotle, Nicomachean Ethics, trans. David Ros
son and J. L. Ackrill (Oxford: Oxford University Press, 1
3. John McDowell, Mind, Value, and Reality (Lond
Press, 1998) p. 51.
4. McDowell, Mind, Value, and Reality, p. 85.
5. David Wiggins, Moral Cognitivism, Moral Rela
Moral Beliefs, Proceedings of the Aristotelian Society, 9
 10. Ibid., p. 275.
11. Ibid., p. 187.
12. Ibid., p. 187.
13. Robert M. Veatch and Franklin G. Miller, T
Medicine: An Introduction, Journal of Medicine and P
pp. 555556.
14. Robert M. Veatch, The Impossibility of a Mo
cine, Journal of Medicine and Philosophy, 26:6 (2001
Beauchamp, Internal and External Standards for Medica
Medicine and Philosophy, 26:6 (2001), pp. 601619.
15. Edmund D. Pellegrino, The Internal Morality
Paradigm for the Ethics of the Helping and Healing P
Medicine and Philosophy, 26:6 (2001), p. 563.
16. Plato, The Republic, trans. Robin Waterfield (O
sity Press, 1998), 342d36.
 REALITY
Peter Herissone-Kelly

1. Four Aims

I have four aims in this chapter. First, I want to s

utilitarian rights-based consequentialist approach to p
an approach that attempts to give rights their proper pl
attributing to them an independent, non-derivative va
examine an objection to such an approach, an objectio
can never be properly accommodated within a conse
The thought that I will develop here is that consequen
much we tinker with it, can never be harmonized wi
upon which the notion of a right depends, and so
point of rights. Third, I will suggest that perhaps
though it may be, is of little relevance to many of th
bioethics. This is because consequentialist and no
proaches to rights appear to collapse into each othe
sorts of questions of policy with which much of bio
will point out how unsatisfactory, and how much o
appears that the way of thinking of persons that unde
them of rights tends of necessity to disappear precise
it.
The first two aims will involve a fairly substan
general moral theory, while the third and fourth will
into the realm of bioethics. The detour is necessary if w
correct destination.

2. Consequentialism and Righ

Imagine a callow young philosopher eager to develop

bioethics. She is convinced, rightly or wrongly (thou
bly), that bioethics requires moral theory, and she fin
consequentialist intuitions. She recognizes that her m
theoryand here, she would certainly have lots
bioethicistsis utilitarianism, but something worries
 Of course, she is aware that a utilitarianism of
more than ready to offer utilitarian justifications of the
it is worth noting that all versions of utilitarianism ba
theory presented to first year undergraduates are soph
unease remains.
Her disquiet might be explained in the following
fications of rights necessarily afford them a subordin
value dependent on their contribution to general ha
varieties of utilitarianism, preference satisfaction.
intuition might be that this is just not good enough
independent, non-derivative value.
The utilitarian may attempt to counter the fledg
ries by asking what difference it makes to believe this
tarian calculations deliver the answer she desires: so
end up being respected. But quite apart from the fa
want to get clear about what sorts of value (derivative
various elements of her moral theory have, this sug
appear very soothing. If she genuinely thinksagain
quentialist leaningsthat rights have a non-derivative
anism that makes them subordinate to preference satis
present the appearance of a rogue theory. That is, it mi
invariably recommend actions that respect rights, but
the possibility that it will throw up what from her pe
answer. Rights could be trampled on at any moment, i
out to maximize preference satisfaction.
What is the bioethicist do in this imagined situat
robustly consequentialist, but she also has a com
derivative status of rights, and that commitment is
deontological in character. The alternative, it seems to
a non-utilitarian consequentialism that confers an ind
value on rights. Of course, many would call this a vari
ism (a utilitarianism that admits a plurality of indep
axiology, or theory of the good). Anne Maclean wo
utilitarianism.1 While I think it more useful to call
quentialism, and to reserve the term utilitarianism
consequentialism that posits either happiness or prefere
sole independent good, I am ultimately unconcern
What I am concerned to do is to outline, and look a
consequentialism that is prepared to regard rights a
derivative value.
right or wrong in virtue of their consequences, or
consequentialism is the view that acts are right or w
kind of acts they are. By itself, this distinction is,
been quick to point out, less than helpful.2 One the
consequentialist too believes that an action is right or
kind of act it is: if it is the kind of act that has good co
a right act. On the other hand, the non-consequentiali
needs to take into account its consequences: as the p
has forcefully shown us, what sort of act A is, is in
outcome.3 For example, A is not an act of killing un
quences is that someone dies.
It would seem that a more satisfactory way of d
is that adopted by, amongst others, Philip Pettit.4
whilst a consequentialist and a non-consequentialist th
all in their accounts of the good, where they must dif
tion between them liesis in their accounts of the
theory Ts account (or theory) of the right tells us w
relation to the values that make up Ts account (or th
according to this way of drawing the distinction, we co
tialist and a non-consequentialist theory that both h
realizing exactly the same values, or goods. Where the
the way that they thought those values ought to be rea
A consequentialist theory is one with an accoun
us that we ought to maximize value. That is, in cons
to do, we should opt for that course of action that w
value in the world. So, in the case of a rights-ba
maximizing the value of rights will involve makin
peoples rights as possible are respected. At least,
rough characterization of what it will involve. I will a
precise characterization below.
A non-consequentialist theorys account of the
tell us to honor values in our own actions. Where
values in question, this will mean making sure that w
through our own actions. Crucially, such a theory
rights-based consequentialism will allow: it will no
somebodys rights in order to ensure that more people
At least that is the claim, very roughly put. I will hav
later.
What it means to say that our fledgling bioethi
quentialist intuitions, then, is that she feels that what
introduction of rights into a moral theorys account of
renders that theory non-consequentialist. This is beca
other moral goods, such as the fair distribution of re
concept of right as one intuitively understands it, and
independent definition of the good.5 For Rawls,
goodsgoods that can be characterized as such indepe
cation of what is rightcan feature in an account of
quentialist theory.
I do not want to become embroiled in the issue
right about this. I simply want to look at the prospects
us that rights are amongst the goods to be maximize
such a theory as a species of consequentialism, secure
at least some philosophers would categorize it as such.
Perhaps the most important question to be asked
the outset is this: precisely what is it that the theory
Earlier, in my rough characterization, I said that ma
rights will involve making sure that as many peoples
respected. This is clearly nowhere near precise enough
of qualifications need to be added. Presumably, the
consequentialist would not think it right to ensure th
exercise a relatively trivial right, if to do so would in
one other persons right to life. So, we clearly need so
rights in order of importance, and some way of w
people need to benefit from having a right lower d
respected to justify one persons having a more im
And the answer to this question will obviously not r
all pairs of rights selected: for a particularly important
case that no amount of people benefiting from a lesser
could ever justify Rs violation.
And the complexity does not end there. It might
people have more right to have their rights respecte
example, an average, law-abiding citizen might have
right to life respected than would a genocidal despot. I
claim sounds wrong, then perhaps it would be more
certain circumstances people, through their actions, c
important rights.
to maximize respected rights, whilst acknowledging t
in doing so. In other words, I just want to assume
qualifications, whatever they are, are taken as read in
mizing the value of rights will involve making sure
rights as possible are respected. I will also sideste
whether what ought to be maximized is the number
the number of people with respected rights, and will a
option is the more plausible.
Clearly, as a means to achieving this end, a righ
ism will also be concerned to maximize the number
rights. Bioethics is, of course, concerned with giv
problems encountered in medicine, bioscientific resea
So, it frequently suggests what policies ought to be ad
hospital trusts, governments, and so on. This is not it
may not even be its primary use, but it is perhaps th
most practical value, and it is certainly that which is
social reality. In such applications of bioethical me
rights-based consequentialist will be to produce the po
maximum number of people with respected rights, fro
people who are users of the trusts services, who fall u
protection, and so on. That being the case, the perso
lates or implements a rights-based consequentialist po
secondarily, be concerned to maximize, say, the nu
trust who respect its users rights.
In outline, then, a rights-based non-ultilitarian
be one that affords rights an independent valuea val
ent upon the contribution that respecting rights will m
tion of some other value (such as, in the case of ut
satisfaction). It will identify the right act or policy a
range of possible acts or policies, which will maximiz
qualifications, the numbers of people with respected
turn to an important objection to theories of this sort.

3. An Unavoidable Tension Between Consequent

There is much that is attractive about the theory sketch

possessed of an independent value, surely it can only
that that value is maximized: that as many people
rights respected. However, it might be argued that to t
objection lies an intuition that it is quite hard to art
degree of precision, but which all the same has eno
intuition that, in viewing someone as a bearer of righ
as essentially a separate, independent individual
herself, in a much used phrasewho as such is not
be reduced to the status of a variable in calculatio
maximize some good or other.
This intuition, of course, informs one of the st
elled at utilitarianism by rights-theorists: the critici
individuals rights cannot legitimately be overridden i
good. Indeed, it may seem that to have a right is, at l
legitimate claim not to have certain of ones interests o
An individuals rights cannot be sacrificed, for instan
so would lead to greater overall preference satisfaction
tion of some comparatively trivial preferences being m
This intuition, then, tells against utilitarianism
drove our imaginary fledgling bioethicist, introduced i
that theory. And it will also tell against a non-utilit
that gives rights an independent value, but that fails to
of its hierarchy of goods. To see what I mean by this,
gives both rights and happiness a non-derivative valu
have a value that is either lower than or equal to that
In such a theory, five units of happiness will be seen
value than four units of a right being respected, and co
ness will consequently have the capacity to override
viduals rights. Indeed, they will also possess this ca
places rights at the top of its hierarchy of goods, but
aggregate happiness expected from a given action cou
to justify rights being violated.
However, it is perfectly possible to construct a r
tialism in which rights are regarded as invariably ab
goods. We can stipulate that it is a theory of this s
bioethicist finds most attractive. In such a theory, ca
ought to be done would only ever pit an individua
rights of others. Clearly, as mentioned above, amon
viduals may possess, there will be assumed to exis
chyplainly some rights are more important than othe
ing rights-claims of the same level in the hierarchy
theory like this, we will simply have to make sure t
possible have their rights respected. And, indeed, it
circumstances is to maximize them. To put the poi
seems that all we can do to honor rights in our
circumstances (the non-consequentialist requiremen
number of people whose rights are respected (the righ
ist requirement). So it looks like the conse
consequentialist theories collapse into each other when
claims appear on the horizon (at least where the comp
same level of importance).
It feels, though, as if the non-consequentialist s
object to this. The rights-theorists objection to conseq
is that it clashes with the view of persons that under
them of rights. That view, as we have seen, is of perso
individuals, worlds entire unto themselves. The
persons ought not to be regarded as mere variables in c
would maximize value, and we could argue that this
when the value to be maximized is the number of pe
respected. Possessing rights legitimately exempts us
calculations.
It seems correct to say that the reason there is a
tion of maximization of value on the one hand, and th
the other, is that while the first relies on what we c
conception of value, the second depends on a radically
of persons. And it still might seem that we can
aggregative view of a person, in order legitimately to e
of hersinterests protected by rightsfrom being
directly comparable interests of a greater number of
famous quotation of Rawls, all consequentialism, an
ian variety, does not take seriously the distinctio
Perhaps the concept of a given right as something
equally with all others is able to help explicate this th
Suppose that the only way a particular agent A c
of ten people (call them B 1B10) is by failing to prot
person C. R is the same right in all eleven people.
ought to do, A needs to consider that Cs right R is
of B1B10. The non-consequentialist of course agr
presenting the matter, but insists that A will go wro
the equality that holds between C and, say, B1 mean
possess one unit of an aggregateable property that mi
1, so that B 1B10 collectively possess units with a
words, the non-consequentialist will say that the way i
decide whose right we ought to protect in a CR-c
because such cases will always be equivalent to a conf
claims. As such, they will place us as agents in a pos
that of Buridans Ass (a donkey placed at an equal d
of hay, and consequently unable to decide which b
consequentialist will need to take another tack if she i
intact.
The most promising tack, it seems to me, is this
that, whatever else a right might be, it is a legitim
treated in a certain way, or not to be treated in a certai
things done for us, or not have certain things done to
reference here to the actions of othersno-one can hav
simply to happen to her, or not to happen to her;
claims on the doings of others. This is why they im
obligations to do or not to do certain things.
Bearing that point in mind, imagine now that y
person, and that failure to violate some right R of t
involve failure to protect the same right R of ten othe
do? Well, whatever you do, you will be doing to that
you. If you violate a right of hers, it is pretty clear th
her as a means of protecting the rights of ten others. B
at persons that conceives of each as a world entire unto
own distinct value, will condemn this way of acting
reason to complain about the way you have treated h
treat her as the separate, individually valuable being sh
Kantian sense, treated her as a means only, and not as
But what of the other ten people caught up in
Will it not be the case that you have also treated them
protect the one persons rights? Well, on one unders
have treated them badly, since you will not have treate
all. Nothing has been done to them, at least not by
from your perspective, something has happened to
case, it is, strictly speaking, inaccurate to say that an
been violated; instead, it is just the case that somethin
them. This is a version of a point made by Thomas
acknowledges, it involves commitment to a princi
clearly related to, if not identical with, the doctrine of d
This, then, appears to be the most plausible way
aggregationism intuition. But is it really convincing?
in our imagined situation, not to have done someth
problemsthose that demand an answer that can infor
significantly irrelevant.

4. Rights-Maximizing Policies, and the Collaps

What is the social benefit of work in bioethics? Wh

with social reality? The answer to these questions, a
this chapter, would appear to be that it can guide the fo
It is to be hoped, that is, that it can produce answers to
policies governments, health services, and so on, o
policy-makers, qua policy-makers, do not find them
position described in my one-to-ten example. The
presented with one person with a particular right, a per
moral foreground, while others with conflicting rights
sight in the moral background. Indeed, they are no
presented with anyone. But what they do in makin
potentially huge numbers of people, among whom th
ing rights. For example, they may have to constru
distribution of scarce resources, resources to which all
have an equal right. It seems to me that in CR-circu
the policy maker has no choice but to maximize the nu
rights are respected. What else can she do? There
alternative at the vantage point from which she is fo
siona vantage point where all those affected by her
in the moral foreground, where all are having som
Some recommended course of action is necessary, and
other basis for it than aggregative calculation.
It is highly significant that, when all are in th
this way, it does not much matter whether the pol
described as maximizing the number of people whose
whether the policy maker is described as honoring rig
That is, it seems that the only way in which she is a
her own action is by maximizing the number of pe
respected. So, again the non-consequentialist and righ
ist approaches collapse into each other, and this time
background distinction is available to prevent that col
that they produce the same answers, but that they be
tinguishable from each other.
that we do not, when making or recommending such
able to stick rigorously to our preferred moral theory
want still maintain that we are either conse
consequentialists even herethe consequentialist can
ing rights in her action because that involves maximiz
the non-consequentialist can say that she is maximizin
because that is the way, in this situation, to honor th
Instead, the dissatisfaction arises because the claim tha
rests upon a radically non-aggregative conception of
correct.
To claim a right is to claim, so far as the inte
right is concerned, legitimate exemption from being c
a variable in aggregative calculations that aim at the m
Now, since in CR-circumstances the perspective of
maker can only lead to rights being honored through
whose rights are respected being maximized, it seems
curiously blind to what is essentially involved in the
might say that theories that aim only to maximize v
include rights in their list of the values to be maximiz
of rights can be included in their accounts of the goo
only way of honoring rights in the formation of polici
mize them, and since to seek to maximize rights is t
right essentially is, it would appear to be impossible
in the formulation of policies.
I suppose we might just want to bite the bullet a
case. We could say that the policy-maker is not a
respected rights at all in CR-circumstances, but is in
mizing the goods to which those rights entitle pe
redescription might make her actions sound a little l
admitted that those goods are tremendously importan
important that people have rights to them.
Would this be a satisfactory route to take? I do n
If a right is a legitimate claim not to be featured in c
would maximize some good or other (including the
respected), then it would appear that its true useful
when people are making such calculations. Ideally, the
has a right in such situations ought to act as a brak
which ensures that she is not treated as a mere
maximizing equation. And such a brake is needed in
as much as it is in circumstances in which rights co
consequentialism and non-consequentialism collapse
drawn becomes most important.

NOTES

1. Anne Maclean, The Elimination of Morality:

arianism and Bioethics (London: Routledge, 1993).
2. E.g. Roger Crisp, Ethics in the Modern World, N
The Interviews, Julian Baggini and Jeremy Stangroom, ed
2002), pp. 3132.
3. Thomas Nagel, Moral Luck, Mortal Questions
bridge University Press, 1979)
4. Philip Pettit, Consequentialism, A Companion
ed. (Oxford: Blackwell Publishers, 1991), pp. 230240.
5. John Rawls, A Theory of Justice (Oxford: O
1999), p. 22.
6. Ibid., p. 24.
7. Thomas Nagel, Autonomy and Deontology, Co
Critics, Samuel Scheffler, ed. (Oxford: Oxford University
172.
8. See Samuel Scheffler, Introduction, Consequen
Samuel Scheffler, ed. (New York, NY: Oxford University P
This page intentionally left bla
collection is one in a series he is writing looking
empirical evidence for different ethical arguments ab
He has also written about these issues in relation to res

Eve Garrard is Senior Lecturer in Ethics and Philos

Professional Ethics at Keele University. Before movin
for several years for the Open University, and ha
teaching philosophy to adult beginning students. Mu
now to healthcare (and other) professionals. Her re
moral theory and applied ethics, including bioethics,
issues arising out of the Holocaust. She has recentl
the nature of evil and forgiveness.

Matti Hyry is Head of the Centre for Professional E

Moral Philosophy at the University of Central Lan
philosophy and bioethics in various Finnish Universit
ordinated research projects in bioethics at the Universi
been a permanent adviser on bioethics to the Finnish
Development Center for Welfare and Health since 199
in the work of legislative committees at the Finnish
and Health. His publications include Critical Stud
Medical Ethics (1990), Liberal Utilitarianism and
2002), Playing God: Essays on Bioethics (2001),
bioethics and general philosophy in academic journals

Peter Herissone-Kelly is Lecturer in Professional Et

Professional Ethics at the University of Central Lanc
B.A. in Philosophy from Bolton Institute, a B.Phil. i
University of Oxford, and a background in phi
metaphysics. He is currently working on a Ph.D. thes
on Rational Agency.

Sren Holm is Professorial Fellow in Bioethics at C

Professor of Medical Ethics at the University of Oslo
medicine, philosophy and healthcare ethics, and two d
a former member of the Danish Council of Ethics, wh
Government and Parliament on bioethical issues.
bio-banking. Her main interest is in the relationship
language.

Monique Jonas is a Lecturer in Ethics at Keele Univer

interests include ethical problems in decision making
theory and bioethics, and the relationship between eth
She has co-edited a volume of essays on the role of
bioethics and the regulation of biotechnologies with S

Jukka Kilpi is Docent of Business Ethics at the Univer

and Visiting Fellow at the Centre for Professional
Central Lancashire, UK. He is also CEO of the F
finance consulting company Kapai Oy, and an Asso
Institute of Australia. Dr Kilpi's book The Ethics of Ba
in Routledge's Professional Ethics series. He has num
and journals including the Encyclopedia of Applied
Journal of Philosophy, Public Affairs Quarterly an
Ethics.

Harry Lesser is a Senior Lecturer in Philosophy

Manchester. He is author of several articles in the fie
some being in journals and some being contributions
the collection Ageing, Autonomy, and Resources (A
particular interests, in both teaching and research,
psychiatry, and in issues concerning ageing and the e
working on papers on personal identity and dementia,
quality of life in old age. He is also editing a collec
Justice and Ageing, to be published by Rodopi.

Peter Lucas is Lecturer in Bioethics at the Centre fo

the University of Central Lancashire, UK. His rese
virtue ethics, risk and the public understandin
phenomenological continental philosophy, and cri
previously contributed articles to Environmental E
Values and Philosophy of the Social Sciences.

Doris Schroeder was educated in Germany and the

postgraduate level in economics/management and ph
worked as a Lecturer in Philosophy at Lancaster Un
holds the post of Senior Lecturer in Philosophy at t
Mark Sheehan is a Lecturer in Philosophy and appli
for Professional Ethics at Keele University. His main r
metaethics, metabioethics, research ethics, and reso
His most recent publications include a pair of articles
in primary care for the British Journal of General Pr
the social reality of health in a volume on di
healthcare.

Tuija Takala is Docent in Practical Philosophy

Helsinki, Finland and Lecturer in Bioethics at the Uni
She has taught philosophy at the Universities of He
Finland. Her research interests include political ph
ethics, particularly bioethics. Her publications inclu
Sensibility: Philosophical Studies on the Ethics of M
(2000), Scratching the Surface of Bioethics (edited wi
and articles in Bioethics, Cambridge Quarterly o
Journal of Medical Ethics, The Journal of Medicine
Theoretical Medicine and Bioethics.

Stephen Wilkinson is Senior Lecturer in Ethics and Ph

for Professional Ethics at Keele University. His
addressed topics including the allocation of health serv
savior siblings, separating conjoined twins, and the na
A paper on this last topic won the Philosophical Q
Essay Prize in 1999. He has recently completed a
commercializing the human body (Bodies for Sale, R
Program Director of Keeles new professional doctor
the D.Med.Eth, as well as of its long-standing M.A.
Law.

Simon Woods is a Senior Lecturer at the Policy, Eth

Research Institute (PEALS), University of Newcastle
Director of Learning and works closely with the Life
of the six national Genetics Knowledge Parks recently
He is also a Fellow of the Institute of Medicine Law
University of Manchester, is qualified as a nurse, and
doctoral degrees in Philosophy. He has conducte
conceptual research, and has published widely in health
This page intentionally left bla
actual morality, 89 therapeuti
ad hominem argument, 83 Clouser, K.
After Virtue (Macintyre), 153 Codes of Et
altruis(m)(t)(tic), 2, 1720, coercion, 2,
2328, 68, 73, 75, 80, 114, Cohn, Felici
116119, 123124 commodific
analytic philosophy, 115116 Condorcet, M
anthropology, 108, 117, 120, consent, 58,
123 93103
applied ethics, 75, 77, 107108, informed c
113114 93103
Aquinas, St. Thomas, 17, 115 consequentia
Aristotle, 77, 113114, 116, 45, 81, 9
150, 153 161167
Augustine of Hippo, Saint, 17 rights-bas
Auschwitz, 17, 19 contract(s),
autonomy, 14, 3137, 58, 60, 4650, 7
6971, 7374, 83, 94, corporal pun
9698, 115, 118120, 123, corporate et
147 4, 1131
parental a., 81 cost-benefit
127128
Beauchamp, Tom L., 19, 93, 99, Culver, Cha
101, 156
Brazier Report, 86 Davidson, G
Brecher, Bob, 75, 81 Dawson, An
British Medical Association Deciding for
(BMA), 93 and Broc
Brock, Dan W., 94, 96 deontolog(ic
Brooks, L., 100 115, 117
Bruce, Donald, 56 Department
Buchanan, Allen E., 94 Dickens, Ch
Buridans Ass, 168 147
business ethics, 34, 107111, Dickens, Mo
113114, 116, 119120, dignity, 3, 2
122124 7475, 8
Butler-Sloss, Dame Elizabeth, 39 DNA, 5455
Dolly the Sh
cannabis, 12, 31, 3335 Donaldson,
Cassileth, Barrie R., 99100 Durkheim, E
Celan, Paul, 20 2425
Center to Improve Care of the
Dying, The, 23 Economics,
Childress, James, 93, 99, 101 Einstein, Al
embryo(s), 5
euthanasia, 8, 78, 108, 111 (HFEA),
Human Orga
fact-value gap, 7779 humanity pr
Faden, R., 98 Hume, Davi
Feinberg, Joel, 61
framing effects, 99 inalienabilit
Frankfurt, Harry, 36 7475
freedom, 23, 3137, 5960, intangible(s
7172, 118, 123 internal goo
French, Peter, 118119 Internationa
Frey, R. G., 23 Transpla
Friedman, Milton, 118, 120 6869, 7
intracytopla
Gaita, Raymond, 70 injection
Garrard, Eve, 3 intuitionism
General Medical Council (GMC), in-vitro ferti
93 42, 444
genetic determinism, 57, 61 Irving, Loui
genetic ignorance, 3, 62
genetic(ally modified) Jacobs, Jona
(modification) (GM), 67, Jesus Christ
121122 Jonas, Moni
genetics, 12, 40, 4445 Journal of B
German Enquete Commission, Journal of M
56 Philosop
German Society for Humane justice, 10, 7
Dying, 21
Gert, Bernard, 94, 100 Kant(ianism
Gibson, A. M., 108 5657, 1
God, 32, 35, 5456, 115 Kass, Leon,
Godlovitch, Stan, 140, 147 Kent, G., 99
Goodpaster, Kenneth, 119 Kilpi, Jukka
Kolbe, Maxi
Haimes, Erica, 8283, 88, 90 23, 25
Hardwig, John, 17, 21, 23, 26
harm, 1, 78, 1112, 14, 35, 37, labor, 2, 12,
60, 70, 88, 94, 96, 100102, 50
115, 141 Lamm, Rich
Harris, John, 70 Lesser, Harry
Hartman, Jan, 36 Levinson, A
Hastings Center Report, The, 17, Levitt, Mair
22 Lewis, C. S.,
Hyry, Matti, 2 liberty, 3, 3
Hegel, Georg, 1, 72 7072, 1
Helsinki Declaration, 93 Locke, John
Macintyre, Alasdair, 153157 paternalism,
Maclean, Anne, 162 Pellegrino,
March, V., 99 Perry, Const
marijuana, 31, 34 Personal Co
Martin Chuzzlewit (Dickens), 5, perspectivis
141 Pettit, Philip
McDowell, John, 150152 Plato(nic)(ni
metaethic(al)(s), 6, 8485, 157158
114116, 149152, 155, Politics (Ar
158159 Porter, Mich
Mill, John Stuart, 96 positive mo
moral luck, 163 pregnancy, 1
moral progress, 5, 137147 pre-implanta
moral theor(ies)(y), 47, 77, 97, diagnosi
115117, 137, 152, Presley, Elv
161162, 164, 170 principle(s),
Mozart, Wolfgang Amadeus, 84 87, 97, 1
Mrs Gamp, 5, 141146 promise(s),
murder, 8, 11, 13 128129
psychology,
Nagel, Thomas, 140, 168 public attitu
National Health Service (NHS),
103 Quality Adju
National Kidney Foundation, 74 (QALY),
natural law, 114115
Nazi(s)(ism), 19 racial discri
New York State Task Force on Radcliffe-Ri
Life and the Law, 26 Ramsay, S. P
New Zealand Royal Commission Randall, D. M
on Genetic Modification, rationality, 3
121 120, 12
Nicomachean Ethics (Aristotle), Rawls, John
150 relativis(m)(
Nietzsche, Friedrich, 17, 21, 87, 110,
2324 Republic (P
Nokia, 123 Rest, James,
normative ethics, 82, 113114, Rhodes, Ros
116117, 151 rights, 3, 6,
Nortvedt, Per, 146 5859, 6
Nuremberg Code, 93 114115
parental r.
Oates, Captain L. E. G., 20. 23 r. maximi
On Liberty (Mill), 96 161171
One Pair of Feet (Dickens), 7 r. to repro
organ sales, 3
 r.-prefer(ence)(ring), 129131, Thornton, Jo
133 Thrasymach
Roman Catholic(ism)(s), 9 Till, J. E., 10
Rothman, Barbara Kate, 46 Tolhurst, W
Royal College of Surgeons Tritchler, D.
(RCS), 74 Trotter, Grif

Schroeder, Doris, 2 Ubel, P., 101

self-interest, 5, 46 uniqueness,
self-sacrifice, 2, 1728 United State
physician-assisted s., 2, 1718, for Orga
2223, 2527 utilitarian(is
Sem, F., 100 117118
Seneca, 17
sex selection, 86 Veatch, Rob
Sex Selection: Choice and virtue ethics
Responsibility in Human virtue theor
Reproduction (HFEA), 86 110, 149
sexual morality, 9 von Wright,
Sheehan, Mark, 5
Singer, Peter, 72 Warburton,
slippery slope argument(s), 82 Warnock, B
social reality, 1, 75, 169 Warnock Co
sociobiolog(ical)(ists)(y), 80 Surrogac
Socrates, 21, 157158 Weinstein, J
Solomon, 39 Werhane, Pa
stakeholder value, 118123 Wiggins, Da
strict liability, 121122 Wilkinson,
Sugarman, Jeremy, 98 Wittgenstein
suicide, 12, 1728 Woods, Sim
obligatory altrusitic s., 24
physician-assisted s., 2, 1718, Zalewski, Zb
2123, 2528 Zupkis, R. U
supererogat(ion)(ory), 25, 2728 Zussman, R
surrogacy, 2, 3950, 81, 86 Zweig, Stefa
Sutherland, H. J., 100
suttee, 24
Sutton-Smith, K., 99
Sytsma, Sharon, 36

Takala, Tuija, 3
Taylor, Charles, 139140
Taylor, E. M., 100
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Contemporary Continental Philosophy of Religion. A v
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Central European Pragmatist Forum, Volume One. A v
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Mythos and Logos: How to Regain the Love of Wisdom.
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Reconstruction: The Central European Pragmatist Foru
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Welch. A volume in Philosophy in Spain

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159. Robert Ginsberg, The Aesthetics of Ruins

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Jewish Thinkers. Translated from the Spanish by Anne D
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Policy on Local and Global Levels. A volume in Philoso

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