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The Journal of Medicine and Philosophy is celebrating thirty years of publication. Over that period, medical ethics has evolved, in part because of the impact of branches of philosophy other than ethics.
I. INTRODUCTION
In 2006, the Journal of Medicine and Philosophy celebrates its thirtieth anniversary. It was founded by the Institute of Society, Ethics and the Life Sciences.
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The Journal of Medicine and Philosophy was founded in 1976, when medical ethics was still commonly referred to as "medical ethics" and philosophy of medicine was still a branch of philosophy focusing on conceptual and metaphysical issues.
The first two volumes of The Journal of Medicine and Philosophy reveal the orientation. The first medical ethical topic appeared in the last issue of the second volume.
The Journal of Biomedical Ethics provides a thirty-year history of the gradual penetration of philosophy of medicine and other specialties in philosophy into discussion of biomedical ethics, eventually resulting in a reconceptualization of medicine's philosophical underpinnings.
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II. THE EARLY YEARS
The early years of biomedical ethics were devoted to exciting debates over topics of social and ethical controversy. Historians debate the dating of the origins of contemporary medical ethics, which is now often called biomedical ethics or just bioethics. I have dated the current generation of biomedical ethics somewhat later, from the large cluster of events in the two to three years on either side of 1970, including the first heart transplant, the first brain-oriented definition of death, and the first critical legal informed consent cases.
In the window centering on about 1970, traditional medical ethics changed into an interdisciplinary field involving
theologians, philosophers, lawyers, social scientists, and historians as well as physicians and other health professionals. This change was the real beginning of the current generation of medical ethics.
In the early years of the Journal, medical ethics and philosophy of medicine were thought of as separate entities. The dominant focus of the journal was on aspects of philosophy without direct or obvious ethics content, such as metaethics, philosophy of mind, philosophy of science, philosophy of biology, and epistemology.
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III. INFORMED CONSENT
Informed consent was the first standard bioethics topic to find significant representation in the Journal. It was the theme of the final issue of volume 2 and was isolated from the mainstream of Western philosophical thought.
The consent doctrine was born in the early 1970s when philosophers and lawyers introduced the consequence-
oriented Hippocratists to Immanuel Kant and the liberal rights tradition of Locke, Hobbes, Rousseau, Mill, and the American founding fathers.
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IV. THE DEFINITION OF DEATH DEBATE
A second topical confrontation between traditional medicine and philosophy focused on the definition of death debate. A group of Harvard scholars proposed a brain-oriented definition of death that would make a new group of patients dead at a time when their organs could be procured.
The debates following the initial Harvard Report drew on the field of philosophy of mind, mind-body theory, and personal identity and personhood theory. Randy Schiffer's article was the first entry in the Journal in this area.
V. MENTAL HEALTH, PSYCHIATRY, AND THE ETHICS OF BEHAVIOR CONTROL
In the 1970s, physicians were using surgical techniques to control human behavior, electroshock to treat depression, and drugs to control hyperactive children.
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Philosophical work was needed to clarify controversies in the fields of mind-body relations and mental health, and to determine whether medicine was an appropriate means for addressing the problems.
VI. ABORTION AND BIRTH TECHNOLOGIES
A fourth topic of ethical controversy in medicine centers on the moral status of the embryo and fetus. Traditional ethical analysis leaves us without guidance, and various philosophical fields have made efforts to provide that guidance.
The Journal has not succeeded more than any other venues of debate, but it has made several contributions.
VII. PHILOSOPHY’S IMPACT ON OTHER ETHICAL TOPICS
Many ethical topics in biomedical ethics deal more straightforwardly with classical issues of normative ethics, but some also require other branches of philosophy. One of the early contributors was Hans Jonas (1969, 1974), and important developments drew on the field of philosophy of science.
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The question of uncertainty in medical science has been the focus of many articles and thematic issues in JMP.
The Journal has contributed to the study of rights in biomedical ethics, and the introduction of the concept of rights in medical ethics was pushed through by those with interests in political and legal philosophy.
A final example of the first level of impact of philosophy on medicine brings us more up to date. Philosophers and linguistic analysts have helped to sort out the problem of "futile care" for clinicians.
The work of the first three decades of the Journal has penetrated biomedical ethics to the point that the field is no longer merely the application of the discipline of ethics to medicine.
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VIII. PHILOSOPHY OF MEDICINE’S RADICAL IMPACT ON MEDICINE
The Journal of Medicine and Philosophy played a significant role in many important changes in medical ethics, but it also marked several significant movements that changed medicine itself.
The twentieth century was the high point in modern medicine, when physicians were expected to be able to rely on modern science to determine what was best for patients. However, by the end of the century, this understanding of modern medicine had become the victim of philosophical challenges.
IX. GENERALIZATION OF EXPERTISE: ESTABLISHING A FACT/VALUE DISTINCTION FOR MEDICAL PRACTICE
The first step in changing the paradigm for the practice of medicine came in the early 1970s when religious and philosophical ethicists brought their fact/value distinction to medicine. This forced reluctant physicians to step aside and surrender claims to authority.
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A separation between fact and value was similarly drawn in other controversial areas of medicine. Just because we could technically abort a fetus, did not mean it was morally licit.
The implications of this standard fact/value distinction for a division of health professional labor began to be recognized.
Philosophers claiming that physicians could not claim special expertise in making moral evaluations of medical procedures accidentally left the impression that physicians had to take time out from their usual operating mode
to solicit a moral evaluation from the patient, the community, or experts in moral wisdom.
X. UNIVERSALIZING THE SEPARATION OF FACT AND VALUE
Scholars have realized that every medical decision involves the imposition of a value judgment upon some set of medical facts, no matter how trivial and seemingly devoid of value judgment.
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The theme of my "Doctor Does not Know Best" essay was that evaluation of medical options is inevitably subjective. Knowing all the facts of medical science cannot lead to a conclusion that an intervention will be beneficial.
The source of determination of benefit is different from the source of determination of outcome predictions. Doctors cannot know whether an intervention will be counted by the patient as a benefit, and therefore cannot determine what is best for the patient.
Part of the problem is that a physician can only provide an opinion regarding the medical good of a patient. If the
physician proposes to maximize medical welfare, the patient might dissent on the grounds that maximizing the one component would have to come at the expense of other goods.
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The Journal has helped advance the recognition of the uniqueness of patient perspectives in judging benefit and
harm by including accounts of diverse religious and cultural perspectives on medical decision-making.
XI. A MORE COMPLEX THEORY OF THE RELATION OF FACT, VALUE, AND CONCEPT
While the early essays in this journal relied on a fact/value dichotomy, most philosophers realized that this was too easy and that there were conceptual and moral difficulties with the simple reliance on the health professional
as a source of ideally value-free facts.
Philosophers knew that the patient model of decision-making could not survive scrutiny because it relied on a simple view of the patient with unlimited authority to make the value choices.
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Philosophers challenged the notion that scientists could provide accounts of facts devoid of conceptual and evaluative commitments. The implications for medical science were soon realized, and conceptual and evaluative commitments must necessarily be incorporated into every piece of medical research.
Modern science had always acknowledged that scientific accounts would contain biases, but post-modern science was beginning to acknowledge that even factual accounts physicians receive from the medical literature
and present to their patients will necessarily carry the imprint of a worldview or "thought collective".
By the end of the century, the Journal of Philosophy of Science and Medicine was addressing issues of underdetermination, incommensurability, and post-Kuhnian accounts of incommensurable world views. This opened the door to a postmodern medicine.
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XII. CONCLUSION
The Journal of Medicine and Philosophy has been at the center of a radical reshaping of bioethics in the past thirty years, stemming in part from the application of contemporary philosophy of science to the medical field.
In addition to the Journal of Medicine and Philosophy, The Hastings Center Report, the Journal of Medical Ethics, and the Journal of Bioethics, there are several newer journals in the field, including Theoretical Medicine and Bioethics, the Journal of Clinical Ethics, and the Kennedy Institute of Ethics Journal. The American Journal of Bioethics is loosely associated with the University of Pennsylvania's Center for Bioethics, and features a heavy emphasis on electronic interchange between lead article authors and large numbers of collegial commentators.
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CLARIFYING APPEALS TO DIGNITY IN MEDICAL ETHICS FROM AN HISTORICAL PERSPECTIVE
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Over the past few decades, the concept of dignity has deeply pervaded medical ethics. An historical perspective
on dignity shows that it can occur in a relational, an unconditional, a subjective and a Kantian form, and that it is not yet time to dispose of dignity in medical ethics.
Since the Second World War, physicians have been asked to act with dignity and to respect human dignity. In the 1990s, patients started to claim that healthcare workers should respect their dignity.
World Medical Association, 1948, International Code of Medical Ethics, 1949, Declaration of Helsinki, 1964, STR 6.131, PO Box 85500, 3508 GA Utrecht, Netherlands, e-mail: r.vandergraaf@umcutrecht.nl, telephone 00 31 88 756 8640, Fax 00 31 88 756 8099.
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In recent years, human dignity has been argued to be compromised by germ-line interventions and commodification of human body parts.
Several international guidelines on bioethics regard human dignity as one of the most important principles in bioethics, and the principle of human dignity and human rights is also a prominent position in Canada's Tri-
Council Policy Statement.
Despite the concept of human dignity being embedded in medical ethics, some bioethicists prefer to eliminate it.
The task for ethicists is to clarify vague appeals to human dignity and to consider what its normative strength in medical ethics is.
Recently, some scholars have accepted the challenge of evaluating human dignity as a theoretical concept in bioethics. However, little attention has been paid to the question of how historical meanings of dignity can clarify
the current meaning of dignity in medical ethics.
The terminally ill are entitled to dignity, according to the United Nations Educational, Scientific and Cultural Organization (UNESCO).
Human Dignity is a useful concept but a useless concept according to some authors. L.R. Kass, D. Beyleveld, R. Brownsword, R.E. Ashcroft and K. Bayertz argue that human dignity is a philosophical origin and scientific erosion of an idea.
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Würde and vrdighed, the Roman and Germanic words for dignity, have been embedded in various historical and
cultural contexts.
By studying historical texts that mention dignity we can learn whether current appeals to dignity relate to one concept, and whether the appeals to dignity have an historical core.
We think that close reading of historical texts can provide new ways to interpret our modern concept of dignity.
We think that historical analyses of dignity should be complemented with theoretical analyses, and that both should be conducted at the same time. We aim to define continuities in the concept of dignity in order to gain more conceptual clarity.
METHODS
We studied historical texts that explicitly mention the term (human) dignity. We concentrated on terms that are etymologically related to the terms for this concept in modern documents, and studied the texts in the original language to minimize interpretational bias.
24 C. Trinkaus, 2003, and M.J. Meyer, 2001, both write about the Renaissance idea of the dignity of man. Würde is a term used in philosophy and science theory. It is also used in history and theology, and can be found
in several dictionaries and encyclopedias, such as N. Roughley's Würde (1996) and E. Starke's Menschenwürde (1992).
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We included texts on respect for dignity from Roman writers from Antiquity, Christian writers from the Middle Ages, Italian humanists from the Renaissance, philosophers from the Age of Reason, and modern authors.
ROMAN AUTHORS FROM ANTIQUITY
Cicero writes that to maintain dignity, a Roman must have loyal feelings towards the state and have these feelings approved by good men. Once dignity is attributed to a Roman, they receive immediate respect from others.
A fourth feature of dignity is that the subject of dignity should live up to it. Roman statesmen should retire from political office with maintenance of dignity, and should be scrupulous in their religious observances and in obeying the authority of the senate, the laws, and the like.
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In Roman times, relational dignity was restricted to individuals, but in On Duties Cicero writes that human beings
have dignity because they are able to learn and contemplate, unlike the animals. Therefore, we call this form of dignity unconditional dignity.
CHRISTIAN WRITERS FROM THE MIDDLE AGES
In the writings of Christians from the Middle Ages, human beings have dignity because they possess characteristics that distinguish them from other creatures in the universe. Hence, according to Christian authors,
man should live up to the dignity that he has received from God.
Although it is embedded in man's nature to be dignified, Adam's fall from paradise has resulted in a loss of dignity according to some Christian writers. However, Christ has restored man's dignity.
Pope Leo the Great's Sermo (Sermon), Rupertus Tuitiensis' In genesim (On Genesis), and Alcuin's De dignitate conditiones humanae (On the Dignity of the Human Condition) are all important documents.
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ITALIAN HUMANISTS FROM THE RENAISSANCE
During the Renaissance, the Italian humanists wrote about the dignity of the human condition, which they grounded in Christian aspects, as well as secular aspects.
At the end of the Renaissance, a humanist named Giovanni Pico della Mirandola publishes 900 theses and invites scholars for a disputation. The disputation never takes place, but two years after Pico's death, his oration
is published and receives the title On the dignity of man.
After creating all creatures, God began to think about man, Adam, but had no archetype according to which he could create him. So God mandated that man should have in common whatever belonged to every other being, and placed man in the middle of the world.
Man's dignity is based on freedom, and it is morally preferable if he does justice to this value. Therefore, people are free to choose what dignity means to them, but they should try to make most of it.
PHILOSOPHERS FROM THE AGE OF REASON
Reference works mention only a few places where dignity is based on the rational nature of man. Blaise Pascal writes that thinking is man's whole dignity, Samuel von Pufendorf writes that man has a very great dignity because he possesses an immortal soul, and is very skilful in various arts.
G. Pico della Mirandola, B. Pascal and S. von Pufendorf wrote on the dignity of man, and the law of nature and nations, respectively.
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According to Kondylis, man's fallen nature (misery) and man's special place in the universe (dignity) remain important themes in this period, and relational dignity is still much used.
At the end of the Age of Reason, a new form of dignity appeared in the writings of Immanuel Kant. Kantian dignity excludes beings who lack the capacity for autonomous action and requires them to treat themselves and others as an end at the same time.
RESPECT FOR DIGNITY AND THE SPHERE OF RIGHTS IN MODERN TIMES
From Modern Times onwards we do not encounter new forms of dignity, but an increasing emphasis on respect for dignity and a close relation between unconditional dignity and (human) rights. The phrase 'respect for dignity'
occurs in many constitutions, declarations and guidelines.
THE FRAMEWORK AND ITS USEFULNESS IN MEDICAL ETHICS
Relational dignity differs from the other forms of dignity in that it applies only to specific people. The other forms of dignity apply to human beings in general, though with restrictions, and Kantian dignity only excludes beings insofar as they lack the capacity for autonomous action.
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The framework might raise five questions, but we think that the different forms of dignity have at least four aspects in common. They are the special status of man, the beauty of the body, being the image of God, man's rational nature, and autonomy. A lack of recognition by others can infringe dignity, as can a mediocre performance by a Roman official or the idea of man's fallen nature. Unconditional dignity is vulnerable as long as respect for it is not grounded in constitutions or guidelines. Although people might use different terms or phrases for dignity, they all have four aspects continuously in common. Being explicit about the specific meaning of dignity will prevent dignity from becoming a conversation-stopper in moral debate.
The concept of dignity is frequently used in discussions about euthanasia and physician-assisted suicide. Harvey Max Chochinov et al. found that a loss of dignity was closely associated with certain types of distress often seen among the terminally ill, and that dignity can be enhanced, even in the terminal phase of a disease.
A number of studies have been conducted on the topic of dignity in dying, and several models for palliative care have been developed.
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Velleman and Chochinov both consider dignity as an essential value that can be lost, but should be done justice
to as much as possible. However, the validity of their appeals to dignity should be evaluated in relation to the form of dignity they use.
Our analysis of dignity complements theoretical analyses of dignity, like that of Kass90 and of Beyleveld and Brownsword91 mentioned above. We think that four different forms of dignity can be distinguished in modern ethical debate, and that it is more helpful to distinguish between these forms.
Some might ask whether the historical forms of dignity that are distinguished in the framework are useful, but we
think that at least two of them currently make sense as medical ethical norms. Unconditional and subjective dignity are unlikely to be useful, and we need a secular essential human characteristic.
Pico's subjective dignity is too religious to be useful in medical ethics, and relational dignity can be made sense of in medical ethics. Physicians who act with dignity can be compared to high officials in the Roman society.
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Kantian dignity is something over and above the medical ethical principle of respect for autonomy, since it is based on autonomy. It differs from the usual interpretation of respect for autonomy, which is about autonomous choice and decision-making.
Kantian dignity requires that a person live autonomously, respect the dignity in others, and make informed, and hence autonomous, choices. This is no part of the medical ethical principle of respect for autonomy.
Kantian dignity differs from respect for autonomy in research ethics in that respect for autonomy requires that the researcher adequately inform his or her participants and that their functioning as autonomous beings is not impeded by the proposed research project.
We think that relational and Kantian dignity can be made useful in medical ethics, but the status of these two forms of dignity in medical ethics is still unclear. Furthermore, we have to discuss whether the dignity of human beings can be protected by human rights.
Dr. Johannes J.M. van Delden is professor of Medical Ethics at the Julius center for Health Sciences and Primary Care, University Medical center, Utrecht. He believes the marriage between bioethics and philosophical ethical theory is troubled.
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I assume that the connection between bioethics and philosophical ethical theory is contingent and fragde, and that it is often unclear how the theory is to be brought to bear on dilemmatic problems, public policy, moral controversies, and moral conflict.
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No moral philosopher has developed a detailed program or method of practical ethics supported by a general ethical theory, nor has any developed a fine-grained conception of notions such as "practical ethics" and "practical method".
I will use the term "ethical theory" to refer to normative philosophical theories of the moral life and philosophical accounts of the methods of ethics. I will not discuss the value of philosophical argument as a resource for the treatment of specific issues in bioethics.
My concerns are with the types of theory and method that have been under discussion in bioethics in the last quarter-century. I leave it open whether (2) or (3) can be successfully addressed without addressing (11).
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I will question philosophy's success in all three areas, laying emphasis on its failure to connect theory to practice. I will focus on three areas of the intersection between bioethics and ethical theory: Cultural Relativity and Moral Universality, Moral Justification, and Conceptual Analysis.
Prior to the early 1970s, medical ethics was not connected to philosophical ethical theory. However, in the late 1970s and early 1980s, the idea that medical ethics could be given universal, principled moral foundations and practical methods of inquiry emerged.
In the late 1980s, approaches to bioethics that invoked universal principles began to be vigorously challenged. These approaches included case-based approaches, rights-based approaches, virtue-based approaches, feminist approaches, and assorted attempts to show that one approach is superior to others.
After fifteen years of theory-conflict, bioethics is no longer profiting from these discussions, and they have little to do with clinical and research practices.
The theory part of bioethics will vanish soon, because it serves no useful purpose. What is enduring is how to handle the original hope for universal principles, rights, or virtues, and how to make such norms relevant for practice.
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A crosscultural perspective on medical ethics is needed that recognizes that cultur shapes the content of ethical precepts, the form of ethical precepts, and the way ethical conflict is handled.
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Christakis supports a contextualist view of medical ethics, and Leigh Turner agrees that mainstream ethical theory is an impoverished expression of our society's cultural traditin.
~~d phftosophers on the
Philosophers in bioethics often condemn a specific cultural practice without rebutting it through a careful analysis or a general theory. This leads to a style of moral reasoning that drastically overestimates the ability of bioethicists to "resolve" moral issues.
Turner and Christakis dismiss mainstream ethical theory and believe that cultural anthropology is better positioned to address questions of cultural conflict, transcultural bioethics, and shared principle. However, there is much to be learned from their reservations about ethical theory.
Ruth Macklin's Against Relativism: Cultural Dimity and the Search for Ethical Universals in Medicines8 argues that we can consistently deny universality to some justified mod norms, while claiming universality for others.
Macklin's book is the most thorough treatment of relativism in bioethics by a universalist. However, Macklin does
not defend her universalism through ethical theory, and her book displays experience with and practical wisdom about many problems in bioethics.
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Macklin never makes any arguments for where her principles come from or why they should be considered universal, but she claims that there is plenty of room for moral rules to vary among cultures and individuals.
Sulmasy's criticisms of Macklin's book capture my sense of deficiencies in the use and nonuse of ethical theory in bioethics. He sees in her book a failure to engage the arguments of the opposition and an absence of a theory to support central conclusions.
The lack of a serviceable literature on moral justification is important because philosophers often fail to reach down to problems of practice.
Philosophers are experts on the theory of justification, but it is unclear how they conceive of it and how they attempt to just@ their claims in the literature of ethical theory as it has been used in bioethics.
Norman Daniels argues that moral principles, theoretical postulates, and moral judgments about particular situations should be rendered as coherent as possible using Rawls's celebrated account of "reflective equilibrirn."
Rawls calls this process of justification in ethics "narrow reflective equilibrium". To answer the question of why we should accept certain principles, we must widen the circle of justificatory beliefs and bring to bear the broadest evidence and critical scrutiny we can.
Daniels' theory of reflective equilibrium is sweet reason, but is it more than common knowledge? Is reflective equilibrium a theory that can be brought to bear on practice?
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Daniels' success in bioethics seems detached from his theory of justification. It is unclear how the method of reflective equilibrium connects to practical problems, how one would know whether it has been used, and how it might be used by others in bioethics.
Daniels' work is not easy to see how his philosophical accomplishments are connected to practical problems of bioethics.
Some moral philosophers in bioethics imply that practice has no close confederation with theory, while others cite Alasdair MacIntyre's conception of a moral practice as a cooperative arrangement in pursuit of goods that are internal to a structured communal life.
Physicians accept a set of moral values that define the core nature of medical practice and indicate the virtues proper to physicians.
Brody and Miller argue that medical niorality's prohibition of physician-assisted suicide should be reevaluated because "so many things have changed since the time of Hippocrates."
Brody and Miller propose that physician-assisted death may be justifiable in terms of the internal morality of medicine, but that mml standards will sometimes be needed.
Brody and Miller make no attempt to justify legalizing physician-assisted death beyond a vague statement that "those who live in modern society who are inevitably influenced by societal values as they interpret the medical ethics."
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Brody and Miller's approach is characteristic of much current literature by philosophers in bioethics, which ignores ethical theory when it seems relevant and instead grounds its claims in institutional standards, societal values, paradigm cases, narratives, etc.
I turn now to the third of the three areas I said that I would investigate, which is conceptual analysis. The appropriate criteria for defining and classifying an act as an informed consent must be identified, and this work is ongoing and incomplete.
Though informed consent has received extensive attention in bioethics, many other concepts have not. In particular, the concept of autonomy has not yet undergone systematic and intense scrutiny in medical ethics.
The literature agrees that autonomy, respect for autonomy, and rights of autonomy are different concepts, whereas "autonomy" and "autonomous person" are not obviously moral notions. However, the distinction between the metaphysical concept of autonomy and the moral concept of autonomy has fostered confusing views.
Contemporary literature in bioethics contains no theory of autonomy that spells out its nature, its moral implications, its limits, how respect for autonomy differs from respect for persons, and the like. Gerald Dworkin's theory of autonomy is the most detailed.
This theory has many problems, such as the fact that a reflective acceptance of a first-order desire can be
caused by and assured by the strength of a first-order desire. A supplementary theory is needed to protect against such a case.
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Dworkin's theory of autonomy has not been carefully assessed or used in bioethics. Its implications for practice are unclear and untested, and Dworkin himself does not appear to use the theory in his writings on applied topics of bioethics.
The concepts of Killing and Letting Me
The distinction between killing and letting die has been raised in the literature of bioethics, and physician-
assisted suicide has been the primary concern.
Despite a remarkable convergence of opinion on the subject of euthanasia, assisted suicide, and the like, no one has yet produced a cogent analysis of the distinction between killing and letting die as itfinctions in medicine.
Letting patients die is no less important than killing. It occurs under two circumstances: cessation of medical technology because it is useless and cessation of medical technology because it has been validly refmed.
In the medical context, letting die is tied to acceptable acts, whereas killing is tied to unacceptable acts. The value-neutrality of "killing" and "letting die" found in ordinary moral discourse is not present in medical morality.
Philosophical literature focuses on cases differing only in that one is a killing and the other is a letting die, but largely evades the central context in which the distinction arises in bioethics - real encounters between doctors and patients. Philosophical analysis of killing and letting die is limited to medical practice, and therefore is not relevant outside of the philosophy classroom.
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The controversies I have discussed largely arose in philosophy and have been perpetuated using philosophical discourse. The more the issues have been refined, the less serviceable and influential ethical theory has become in bioethics.
In 1974 Samuel Gorovitz and I drove from Washington, DC to Haverford College to discuss whether bioethics had a future in philosophy. We reflected on how developments in biomedicine present a treasurechest of fundamentally philosophical issues that should be handled by the methods of moral philosophy.
For fifteen years it looked like Gomvitz would be proved right: bioethics did seem a natural for philosophers. However, the literature of an Subject ofkeamh, J. V. Brady and A. R. Jonsen, Ethics and Regulation of Clinical Research, and Deviance and Decency proved him wrong. D. DeGrazia, J. Arras, and R. M. Veatch discuss theories, cases, and specified principlism in bioethics. K. D. Clouser and B. Gert, "A Critique of Principhm," Social Science and Medicine 35 (1992): 1079-91, quotation from 1079, 1089. R. MacMin, Against Relativism: Cultural Dimity, 467-69.
Interdisciplinary bioethics has shifted in the last fifteen years toward levels of with law, ment guidelines, and international guidelines, marginalizing ethical theory.
There are various ways to use mod philosophy to defend both relativism and anti-relativism, including a compelling philosophical defense of "objectivity" and a more concrete approach to practical ethics.
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Daniels discusses reflective equilibrium in the first part of his book, but not in the second part, where he mentions it only in the title of chapter 16, and never develops it.
The book Reflective Equilibrium discusses how the idea of reflective equilibrium offers a model for practical moral problems, but I cannot find actual examples of its use.
Brody and Miller, "The Intd Morality of Medicine: Explication and Application to Managed Care", 393-97.
D. Dennett, J. Feinberg and B. Baum Levenbook, M. A. Warren, and Gerhold K. Becker discuss the moral status of persons and the ethics of abortion.
G. Dworkin's Theory and Practice of Autonomy is the most interesting book in bioethics on autonomy.
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No such work has yet been put forward in bioethics, but some beginnings are available in ethical theory. H. G. Frankfurt's early work on pets and freedom of the will provides an account of autonomy, even if it involves some arative modification.
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Steven Latham is the deputy director of the Yale interdisciplinary Center for Bioethics. He will talk about a number of topics in bioethics and then open up the floor for questions. Yale's interdisciplinary Center for Bioethics is located on Prospect Street far away on campus from the medical school but it's healthy for everyone to walk back and forth. I'm 1:35 going to talk about many topics including human embryonic stem cells, both cesarean sections, childhood vaccinations, adulthood post-traumatic stress disorder, obesity, patient decision aids and end-of-life physician assisted suicide and beyond. Human embryonic stem cells are human cells that have been removed from an embryo in vitro in a petri dish and are pluripotent which means that they can grow up to become any kind of cell in a human body. Human embryonic stem cells are immortal in the sense that they don't shrink or go through cellular aging as they multiply and divide, and you can make a thousand dishes full of them from a single human embryonic stem cell. Human embryonic stem cells are useful for testing drugs, and if we're going to see a therapeutic result from human embryonic stem cells in the short term it'll be because of drug production. Tissue generation as the therapy for cellular disease is the thing that gets most publicity you can take a human embryonic stem cell that has a genetic disease.
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If we can coax an embryonic stem cell forward into becoming a pancreatic cell, we could create cures for diabetes, Parkinson's, and a number of other diseases that occur at the cellular failure kind of level. However, our bodies reject these replacement cells. Combining human embryonic stem cell research with cloning may be able to resolve the issue of resolving genetically tailor-made replacement cells for people with cellular based diseases, although it's many years hence.
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You can make human embryonic stem cell lines from unfertilized eggs by parthenogenesis, but the eggs can't become infants because they don't have enough genetic material. President Obama announced the NIH funding scheme for doing research with stem cells and said that the research would only be funded if the stem cell lines were developed from leftover embryos from fertility clinics.
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There are more than 400,000 excess embryos in the United States right now in freezers, and the Obama NIH will fund research on stem cell lines that are created from those leftover embryos. President Obama is permitting federal money to be used as long as the embryos come from these fertility clinics, but he won't fund any research on lines that were created in the lab or on partha notes or cloning lines.
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The NIH published funding rules that prohibit the destruction of embryos created through parthenogenesis or through cloning. This is because there is less agreement about the idea of creating an embryo and then destroying it for research purposes. The Obama administration has just decided not to go there, but the state of New York has just decided to approve of paying women for their eggs, so the overall situation is that we have incredibly liberal research laws, but the question is where do you go to get funding for it.
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The federal government has restrictions on funding research that involves mixing the genetic material of humans and animals, but there are scientists who do want to mix them, but they want to mix them at the cellular
level to see what happens. The u.s. c-section rate is the highest of any developed country and the expression to
posh to push has found its way into the British press.
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Brazil is ahead of us with a higher rate of c-sections, but the w-h-o estimates that 15% is the healthiest rate for natural childbirth and not doing excessive surgery, so we're really high and one answer is that women are demanding c-sections because they can be scheduled. The medical literature has referred to non-medically indicated c-sections as cesarean sections on maternal demand or cesarean sections on maternal request. C-
sections happen more on Fridays, and go up when reimbursement for procedures is higher than reimbursement
for natural birth. Physicians sometimes perform c-sections because they're afraid of malpractice 18:01 and there
are certain practices that seem to habitually recommend c-sections more often than others 18:20 but we don't know what proportion of these are that result from maternal request. Andrew Wakefield published an article in The Lancet Journal that claimed to find a link between the onset of autism and the triple measles mumps rubella
vaccination that was then being given. Numerous researchers have attempted to duplicate this research without
success.
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Andrew Wakefield lost his medical license in the UK because he committed fraud in connection with the publication of this article and also failed to disclose before he even did the article that he was in pay for some plaintiffs attorneys who represented parents with autism who were trying to blame drug companies for their children's autism. The vaccination rates in the UK plummeted to something in the 60s and in parts of London even hit below 50% vaccination rate because parents were afraid of giving their children autism.
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In the UK, vaccination fervor has reduced a little bit and the vaccination rates are starting to rise, and Jenny McCarthy has been talking about vaccinations and autism connections. In the US, there is wide variability on how far we should respect people who don't want vaccinations. In the states where it's easy to get out of the vaccine program, vaccination rates have reduced recently because of the autism scare, but now we know that the vaccine for human papillomavirus (HPV) causes cervical cancer. A couple of states tried to add the HPV vaccination to the mandatory school vaccine program, but the parents went ballistic. Many parents then withdrawn their children from the vaccine program, and then we have months. 24:43 about how to balance individual liberty and public health, and 24:57 about post-traumatic stress disorder. We have a report earlier this year that incidents of PTSD are skyrocketing, and the prevalence is also up, and the rates are actually higher among rape and abuse victims than they are among people returning from the battlefield.
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Women are more apt to get symptoms of PTSD than men, and the definition of PTSD is in flux. Some people say that secondhand trauma can cause post-traumatic stress disorder and that patients who have seen videos of people leaping out of windows on 9/11 can also suffer from PTSD. Some people think that the definition of PTSD needs to be wider, but others worry about criterion creep. One way to prevent PTSD is by giving people beta blockers before an anticipated traumatic experience, but is that good medicine? Some ways people worry about diminishing the emotional impact on the battlefield might reduce soldiers guilt, enhance commanders willingness to send their troops into more stressful situations, and undermine something we think as important. The emotional content of an event is part of what makes someone's personality, but we don't want people walking around with PTSD. There are problems with using animal studies in PTSD research because animal brains aren't a good model for human brains, animal rights activists look at this as cruelty, and there is no treatment for PTSD, so you just stigmatize people without actually conferring any benefit. The next topic is obesity and we don't really understand why people are becoming obese there are genetic components, environmental components, patterns of eating our food are not very good for us, and so on. There's some speculation that the microbes that live in our guts have a lot to do with how we deal with food, and that they may
even be the relationship between some causes of disease and the way we handle our food.
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obesity and antibiotics have killed helpful bacteria in our guts, we don't really understand all the causes of obesity, and we blame the victim. But we can use interventions to control people's cigarette smoking habits. The
Obama health plan includes calorie labeling for all fast-food chains if you own more than six fast-food stores you
have to provide calorie laving and the fast food industry wanted it because they saw it coming at the state level. As part of health reform, we'll tax foods that are bad for us, regulate the content of foods, and establish tort liabilities for people who produce foods that are bad for us.
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We can try to create a massive social repositioning around the issue of obesity by tort liability, enacting mandatory salads, and getting food companies to reform their products to meet a market that is starting to care more than before about problems related to obesity and food-related health. A pilot program to educate physicians in the use of patient decision aids is probably in the Obama health care plan to help patients make better decisions about their health care. Patient decision aids are being pushed because they tend to save costs
because if you tell patients what the options are they tend to choose the less aggressive interventions and that means it's a cost saving thing but maybe they don't save costs. Because they're paid for by insurance companies, decision aids may be biased to save costs. However, the information they contain is designed to get
patients to make good choices, so can we make better ones?
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In the UK, if you help a terminally ill loved one to commit suicide by taking them to Switzerland where it's mostly legal or helping them get a lethal dosage of pills, you will not be prosecuted for assisted suicide. The Washington State assisted suicide program has been in place for a year and 36 people have taken lethal pills to
end their lives under the Washington plan Oregon is steady at around 50 or 55 people per year committing suicide at the end of a difficult round of disease.
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There are a lot of steps you have to go through before you're allowed to get the lethal pills in Oregon and now in
Washington, but the Oregon Death with Dignity Act is a good example of what can go wrong if you allow people to kill themselves. PAS Ethics Issues include whether suicide is intrinsically wrong, whether physicians should be involved in helping people dodge terrible end-of-life illness and symptoms, and whether physician-assisted suicide will be used in lieu of good end-of-life care for minorities, less educated populations, or patients without family support.
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In Oregon, most people who use the program are pretty well educated, have some family support, and are married. They are also mostly majority white patients, not minorities, and have two doctors who have already diagnosed them terminal. A scientist called Craig Venter made the first living cellular Examples of synthetic biology last week by splicing together bits of DNA from the lab and put them into the husk of an enucleated microorganism. The organism took off and started reproducing.
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It's the first time you can say that a life-form's DNA was laboratory manufactured from spare parts. There have been a lot of projects in synthetic biology where we take out little bits of cells and put in other things to try to make the cells metabolize differently, to try to make them like to eat things we would like to have eaten, like oil. The BioBricks technology is about manufacturing novel life-forms that have never been seen in the lab for various kinds of applications including medical applications new drugs living medicines.
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Microbes can be genetically tailored to create biofuels, pesticides, and new food additives, using synthetic biology. You could create creatures that metabolize oil and clean up the environment or that absorb greenhouse gases and explore interesting pure biological processes. 46:01 questions about how cells work and how DNA works, 46:07 ethics issues, 46:14 novel cellular phones, the forms that do bad things to us. People are worried about things escaping from the lab and becoming hazardous creatures, some people worry about social dislocation in the developing world, and some people worry that it's hubristic to make novel life forms. Yale Bioethics has projects going on involving every topic I've talked to you about today, a couple of our members are on the state stem cell committee and on the Yale escrow, we have a working group on HPV vaccine risk, a working group on post-traumatic stress disorder, and more.
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Please come to our website which is yale.edu slash bioethics to ask questions and to comment on the discussion. 49:01 I'll repeat the question, are you worried that our technology is ahead of our ethics? There was a newspaper story last year about two people who couldn't get married because it emerged that they were in fact products of the same father sperm donor. Now clinics are shipping the donated sperm across the country to
avoid children being born of parents they don't know. A couple who were infertile got an egg donor mom and sperm donor dad, and the embryo was implanted in a surrogate.
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The California Court got this case in the California Court with eight parents to choose from, but the appellate court said no the contracting couple who set this process in motion has financial responsibility for this child and is the parent. The mother who had carried the child's term adopted the child, but what do you say to that child about who are mommy and daddy? I think we're moving in the direction of complete openness, and I think people will start to do this.
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The US military is funding a great deal of research into this and I believe that beta blockers are used immediately post-trauma to retry to reduce the effects of trauma, but I'm not sure whether they have an active program of giving beta blockers to troops when they return home. There is a lot of study on human subjects being done on beta blockers and there is not much question about beta blockers working the debate is about how widely they should be accepted. There's a lot of ethical debate about whether or not to use stress and anxiety pills prophylactically, because it might lead us down a path where we are undermining people's self-
control. If a couple splits up and mom wants to implant a frozen embryo, and dad doesn't want to have children with her, all six states in the US have said dad's desire not to have children Trumps mom's desire to have a biologically related child. In cases where mama's had a hysterectomy or cancer therapy that's left her infertile, the courts have gone with the men, but in Israel the courts went with the woman who wanted the child. Medical tourism is a wide variety of things including getting organs from South and Central America, India, and Switzerland, and getting them implanted by Western trained physicians who get paid a fee for this. It's bad for several reasons, including being potentially exploitative and terrible.
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Companies are offering patients the opportunity to have a surgery done in India with American trained physicians because the total cost is so much smaller than here. The surgery costs about one third as much as here. There are rules about the creation and handling of biohazards, there are regulations to prevent lab escapes of potentially hazardous material, but there isn't yet any kind of special code around the project of synthetic biology.