Bioethics and the problem of pluralism

Social Philosophy and Policy

Volumn 19, Issue 2, 2002, Pages 1-28

  Ainslie, Donald C ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

ANALYTICAL APPROACH; ARTICLE; BENEFICENCE; BIOETHICS; BIOETHICS AND PROFESSIONAL ETHICS; CONSENSUS; CULTURAL ANTHROPOLOGY; ETHICAL THEORY; ETHICIST; ETHICS; FREEDOM; HUMAN; HUMAN RELATION; MORALITY; PATERNALISM; PERSONAL AUTONOMY; PHILOSOPHICAL APPROACH; POLICY; PROFESSIONAL STANDARD; SOCIAL JUSTICE; SOCIAL PSYCHOLOGY;

ANALYTICAL APPROACH; BIOETHICS AND PROFESSIONAL ETHICS; PHILOSOPHICAL APPROACH;

BENEFICENCE; BIOETHICAL ISSUES; BIOETHICS; CONSENSUS; CULTURAL DIVERSITY; ETHICAL ANALYSIS; ETHICAL THEORY; ETHICISTS; FREEDOM; HUMANS; MORALS; PATERNALISM; PERSONAL AUTONOMY; PRINCIPLE-BASED ETHICS; PROFESSIONAL ROLE; PROFESSIONAL-PATIENT RELATIONS; PUBLIC POLICY; SOCIAL JUSTICE; SOCIAL VALUES;

EID: 0037514515     PISSN: 02650525     EISSN: None     Source Type: Journal    
DOI: 10.1017/S0265052502192016     Document Type: Article

References (108)

1. John Rawls, Political Liberalism (New York: Columbia University Press, 1993), xvi-xviii. Note, then, that Rawls distinguishes between the fact of pluralism and the fact of reasonable pluralism (xvii). The former points only to the fact that people disagree about morality, sometimes quite radically. The latter points to those cases where these disagreements are reasonable, in a special sense noted here (see Section V below).
2. Ibid., 257-88.
3. Ibid., 11-15.
4. Ibid., 10.
5. John Rawls, A Theory of Justice (Cambridge, MA: Harvard University Press, 1971), 60-65, 302-3.
6. Tom Beauchamp and James F. Childress, Principles of Biomedical Ethics, eds. 1-5 (New York: Oxford University Press, 1979, 1983, 1989, 1994, 2001). Note that the label "principlism" was first used as a term of disparagement (see K. Danner Clouser and Bernard Gert, "A Critique of Principlism," Journal of Medicine and Philosophy 15, no. 2 [1990]: 219-36), but Beauchamp and Childress have since adopted it for themselves.
7. Tom Beauchamp and James F. Childress, Principles of Biomedical Ethics, eds. 1-5 (New York: Oxford University Press, 1979, 1983, 1989, 1994, 2001). Note that the label "principlism" was first used as a term of disparagement (see K. Danner Clouser and Bernard Gert, "A Critique of Principlism," Journal of Medicine and Philosophy 15, no. 2 [1990]: 219-36), but Beauchamp and Childress have since adopted it for themselves.
8. They themselves disagree on this matter. See Beauchamp and Childress, Principles of Biomedical Ethics, 40 (1st ed.), 40 (2d ed.), 44 (3d ed.), 110 (4th ed.), 376 (5th ed.).
9. They themselves disagree on this matter. See Beauchamp and Childress, Principles of Biomedical Ethics, 40 (1st ed.), 40 (2d ed.), 44 (3d ed.), 110 (4th ed.), 376 (5th ed.).
10. They themselves disagree on this matter. See Beauchamp and Childress, Principles of Biomedical Ethics, 40 (1st ed.), 40 (2d ed.), 44 (3d ed.), 110 (4th ed.), 376 (5th ed.).
11. They themselves disagree on this matter. See Beauchamp and Childress, Principles of Biomedical Ethics, 40 (1st ed.), 40 (2d ed.), 44 (3d ed.), 110 (4th ed.), 376 (5th ed.).
12. They themselves disagree on this matter. See Beauchamp and Childress, Principles of Biomedical Ethics, 40 (1st ed.), 40 (2d ed.), 44 (3d ed.), 110 (4th ed.), 376 (5th ed.).
13. Ibid., 40 (1st ed.), 41 (2d ed.), 44-47 (3d ed.), 109-11 (4th ed.), 376-77 (5th ed.).
14. Ibid., 40 (1st ed.), 41 (2d ed.), 44-47 (3d ed.), 109-11 (4th ed.), 376-77 (5th ed.).
15. Ibid., 40 (1st ed.), 41 (2d ed.), 44-47 (3d ed.), 109-11 (4th ed.), 376-77 (5th ed.).
16. Ibid., 40 (1st ed.), 41 (2d ed.), 44-47 (3d ed.), 109-11 (4th ed.), 376-77 (5th ed.).
17. Ibid., 40 (1st ed.), 41 (2d ed.), 44-47 (3d ed.), 109-11 (4th ed.), 376-77 (5th ed.).
18. Even if health professionals willingly follow her request to have her husband make her decisions for her, she is still required to make this request, and in that sense she is still being forced to have her autonomy respected against her wishes.
19. Note that I do not mean for all of the examples in this paragraph to be reasonable comprehensive doctrines in Rawls's sense. Part of what Beauchamp and Childress lack, I will argue, is a way to give a principled distinction between moral views we can tolerate and those we can reasonably restrict.
20. Beauchamp and Childress, Principles of Biomedical Ethics, 41 (1st ed.), 42-43 (2d ed.), 46-47 (3d ed.).
21. Beauchamp and Childress, Principles of Biomedical Ethics, 41 (1st ed.), 42-43 (2d ed.), 46-47 (3d ed.).
22. Beauchamp and Childress, Principles of Biomedical Ethics, 41 (1st ed.), 42-43 (2d ed.), 46-47 (3d ed.).
23. Ibid., 100-109 (4th ed.), 401-8 (5th ed.). For Ross, see W. D. Ross, The Right and the Good (Oxford: Clarendon Press, 1930); and W. D. Ross, The Foundations of Ethics (Oxford: Clarendon Press, 1939). For Frankena, see William Frankena, Ethics, 2d ed. (Englewood Cliffs, NJ: Prentice-Hall, 1973); and William Frankena, Thinking about Morality (Ann Arbor: University of Michigan Press, 1980).
24. Ibid., 100-109 (4th ed.), 401-8 (5th ed.). For Ross, see W. D. Ross, The Right and the Good (Oxford: Clarendon Press, 1930); and W. D. Ross, The Foundations of Ethics (Oxford: Clarendon Press, 1939). For Frankena, see William Frankena, Ethics, 2d ed. (Englewood Cliffs, NJ: Prentice-Hall, 1973); and William Frankena, Thinking about Morality (Ann Arbor: University of Michigan Press, 1980).
25. Ibid., 100-109 (4th ed.), 401-8 (5th ed.). For Ross, see W. D. Ross, The Right and the Good (Oxford: Clarendon Press, 1930); and W. D. Ross, The Foundations of Ethics (Oxford: Clarendon Press, 1939). For Frankena, see William Frankena, Ethics, 2d ed. (Englewood Cliffs, NJ: Prentice-Hall, 1973); and William Frankena, Thinking about Morality (Ann Arbor: University of Michigan Press, 1980).
26. Ibid., 100-109 (4th ed.), 401-8 (5th ed.). For Ross, see W. D. Ross, The Right and the Good (Oxford: Clarendon Press, 1930); and W. D. Ross, The Foundations of Ethics (Oxford: Clarendon Press, 1939). For Frankena, see William Frankena, Ethics, 2d ed. (Englewood Cliffs, NJ: Prentice-Hall, 1973); and William Frankena, Thinking about Morality (Ann Arbor: University of Michigan Press, 1980).
27. Ibid., 100-109 (4th ed.), 401-8 (5th ed.). For Ross, see W. D. Ross, The Right and the Good (Oxford: Clarendon Press, 1930); and W. D. Ross, The Foundations of Ethics (Oxford: Clarendon Press, 1939). For Frankena, see William Frankena, Ethics, 2d ed. (Englewood Cliffs, NJ: Prentice-Hall, 1973); and William Frankena, Thinking about Morality (Ann Arbor: University of Michigan Press, 1980).
28. Ibid., 100-109 (4th ed.), 401-8 (5th ed.). For Ross, see W. D. Ross, The Right and the Good (Oxford: Clarendon Press, 1930); and W. D. Ross, The Foundations of Ethics (Oxford: Clarendon Press, 1939). For Frankena, see William Frankena, Ethics, 2d ed. (Englewood Cliffs, NJ: Prentice-Hall, 1973); and William Frankena, Thinking about Morality (Ann Arbor: University of Michigan Press, 1980).
29. Beauchamp and Childress, Principles of Biomedical Ethics, 100 (4th ed.). In the fifth edition, Beauchamp and Childress define "common morality" as "the set of norms that all morally serious people share"; see page 3 of that edition.
30. Ibid., 100 (4th ed.), 403 (5th ed.).
31. Ibid., 100 (4th ed.), 403 (5th ed.).
32. Rawls says: "[A] plurality of reasonable yet incompatible comprehensive doctrines is the normal result of the exercise of human reason within the framework of the free institutions of a constitutional democratic regime" (Rawls, Political Liberalism, xvi).
33. Bioethical theory and methodology have received an enormous amount of attention recently; see the selected bibliography compiled in Pat Milmoe McCarrick, "Principles and Theory in Bioethics," Kennedy Institute of Ethics Journal 5, no. 3 (1995): 279-86. See also the large collection of essays focusing on Beauchamp and Childress's approach, Ranaan Gillon, ed., Principles of Health Care Ethics (New York: John Wiley and Sons, 1994).
34. Bioethical theory and methodology have received an enormous amount of attention recently; see the selected bibliography compiled in Pat Milmoe McCarrick, "Principles and Theory in Bioethics," Kennedy Institute of Ethics Journal 5, no. 3 (1995): 279-86. See also the large collection of essays focusing on Beauchamp and Childress's approach, Ranaan Gillon, ed., Principles of Health Care Ethics (New York: John Wiley and Sons, 1994).
35. Clouser and Gert, "A Critique of Principlism." See also Bernard Gert, Charles M. Culver, and K. Danner Clouser, Bioethics: A Return to Fundamentals (New York: Oxford University Press, 1997).
36. Clouser and Gert, "A Critique of Principlism." See also Bernard Gert, Charles M. Culver, and K. Danner Clouser, Bioethics: A Return to Fundamentals (New York: Oxford University Press, 1997).
37. Albert R. Jonsen and Stephen Toulmin, The Abuse of Casuistry (Berkeley: University of California Press, 1988), 18.
38. Beauchamp and Childress, Principles of Biomedical Ethics, 28-37 (4th ed.), 15-23 (5th ed.).
39. Beauchamp and Childress, Principles of Biomedical Ethics, 28-37 (4th ed.), 15-23 (5th ed.).
40. Ibid., 20-28 (4th ed.), 397-401 (5th ed.). See also Norman Daniels's discussion of reflective equilibrium and bioethics in Norman Daniels, "Wide Reflective Equilibrium in Practice," in L. W. Sumner and Joseph Boyle, eds., Philosophical Perspectives on Bioethics (Toronto: University of Toronto Press, 1996), 96-114; and Norman Daniels et al., "Method-ology," in Allen Buchanan et al., From Chance to Choice: Genetics and Justice (Cambridge: Cambridge University Press, 2000), 371-82.
41. Ibid., 20-28 (4th ed.), 397-401 (5th ed.). See also Norman Daniels's discussion of reflective equilibrium and bioethics in Norman Daniels, "Wide Reflective Equilibrium in Practice," in L. W. Sumner and Joseph Boyle, eds., Philosophical Perspectives on Bioethics (Toronto: University of Toronto Press, 1996), 96-114; and Norman Daniels et al., "Method-ology," in Allen Buchanan et al., From Chance to Choice: Genetics and Justice (Cambridge: Cambridge University Press, 2000), 371-82.
42. Ibid., 20-28 (4th ed.), 397-401 (5th ed.). See also Norman Daniels's discussion of reflective equilibrium and bioethics in Norman Daniels, "Wide Reflective Equilibrium in Practice," in L. W. Sumner and Joseph Boyle, eds., Philosophical Perspectives on Bioethics (Toronto: University of Toronto Press, 1996), 96-114; and Norman Daniels et al., "Method-ology," in Allen Buchanan et al., From Chance to Choice: Genetics and Justice (Cambridge: Cambridge University Press, 2000), 371-82.
43. Ibid., 20-28 (4th ed.), 397-401 (5th ed.). See also Norman Daniels's discussion of reflective equilibrium and bioethics in Norman Daniels, "Wide Reflective Equilibrium in Practice," in L. W. Sumner and Joseph Boyle, eds., Philosophical Perspectives on Bioethics (Toronto: University of Toronto Press, 1996), 96-114; and Norman Daniels et al., "Method-ology," in Allen Buchanan et al., From Chance to Choice: Genetics and Justice (Cambridge: Cambridge University Press, 2000), 371-82.
44. Beauchamp and Childress, Principles of Biomedical Ethics, 48 (2d ed.).
45. Albert Jonsen, "Casuistry: An Alternative or Complement to Principles?" Kennedy Institute of Ethics Journal 5, no. 3 (1995): 237-51.
46. H. Tristram Engelhardt, Jr., The Foundations of Bioethics, eds. 1-2 (New York: Oxford University Press, 1986, 1996).
47. Gerald Dworkin, The Theory and Practice of Autonomy (Cambridge: Cambridge University Press, 1988). Note that, although Dworkin is not specifically concerned with coming up with a theory for bioethics, he does rely on it in his discussions of informed consent and proxy consent.
48. Ibid., 20; see also 108.
49. Ibid., 29.
50. Ibid., 29-32, 111-12.
51. Ibid., 31-32.
52. Ibid., 114-15.
53. Ibid., 113.
54. Ibid., 10, 115.
55. Ibid., 112.
56. Ibid., 26.
57. Engelhardt, The Foundations of Bioethics, xi (2d ed.).
58. Ibid., 67-84. Engelhardt admits that this is a mere relabeling of the principle of autonomy from his argument of the first edition; see ibid., xi (2d ed.).
59. Ibid., 67-84. Engelhardt admits that this is a mere relabeling of the principle of autonomy from his argument of the first edition; see ibid., xi (2d ed.).
60. At times, Engelhardt wants to say that patients and health professionals are by definition strangers (ibid., 295-96), but he also allows that they can be moral friends-even to the extent that health-care institutions can be structured to serve a community the members of which share a moral outlook (ibid., 290, 313, 357 [2d ed.]).
61. At times, Engelhardt wants to say that patients and health professionals are by definition strangers (ibid., 295-96), but he also allows that they can be moral friends-even to the extent that health-care institutions can be structured to serve a community the members of which share a moral outlook (ibid., 290, 313, 357 [2d ed.]).
62. Beauchamp seems to deny this when he says that his and Childress's "set of principles was developed specifically for biomedical ethics and was never presented as a comprehensive ethical theory" (Tom Beauchamp, "Principlism and Its Alleged Competitors," Kennedy Institute of Ethics Journal 5, no. 3 [1995]: 182). While it is true that their principles were never presented as a comprehensive theory, they did treat them as an approximation to such a theory independently of their connection with bioethics. As I noted in Section II, they held that this is why their principles were the appropriate tools for addressing the pressing nature of the policy problems connected with bioethics.
63. Rawls, Political Liberalism, 184.
64. Ibid., 281-85. See also Rawls, A Theory of Justice, 8-9, 245-46.
65. Ibid., 281-85. See also Rawls, A Theory of Justice, 8-9, 245-46.
66. Rawls, A Theory of Justice, 17-22. See also Rawls, Political Liberalism, 22-28.
67. Rawls, A Theory of Justice, 17-22. See also Rawls, Political Liberalism, 22-28.
68. Rawls, Political Liberalism, 20-21, 185-86.
69. Norman Daniels uses a Rawlsian strategy to confront the problem of whether justice could require a state to offer its citizens health care when they reasonably differ on the moral importance of bodily health. His solution is to draw an analogy with Rawls's principle of fair equality of opportunity. Just as the state must guarantee that offices and positions are open to all who have the relevant skills and talents, it should also aim to preserve people's access to the range of life-plans that would be open to them were they to be healthy throughout their lives; see Norman Daniels, Just Health Care (Cambridge: Cambridge University Press, 1985), 19-58. Even though Daniels's argument draws only on the version of Rawls's theory in A Theory of Justice - before Rawls acknowledged the significance of the fact of reasonable pluralism and the need for a political conception of justice - Rawls supports Daniels's approach at Political Liberalism, 184.
70. Norman Daniels uses a Rawlsian strategy to confront the problem of whether justice could require a state to offer its citizens health care when they reasonably differ on the moral importance of bodily health. His solution is to draw an analogy with Rawls's principle of fair equality of opportunity. Just as the state must guarantee that offices and positions are open to all who have the relevant skills and talents, it should also aim to preserve people's access to the range of life-plans that would be open to them were they to be healthy throughout their lives; see Norman Daniels, Just Health Care (Cambridge: Cambridge University Press, 1985), 19-58. Even though Daniels's argument draws only on the version of Rawls's theory in A Theory of Justice - before Rawls acknowledged the significance of the fact of reasonable pluralism and the need for a political conception of justice - Rawls supports Daniels's approach at Political Liberalism, 184.
71. As Rawls points out when discussing the problem of abortion, "[r]easonable political conceptions of justice do not always lead to the same conclusion," in which case deciding by a vote might be the best means to settle issues of public policy (John Rawls, "The Idea of Public Reason Revisited," University of Chicago Law Review 64, no. 3 [1997]: 798).
72. Rawls, Political Liberalism, 58-66.
73. Rawls points out, however, that the mere fact that people hold an unreasonable doctrine does not legitimate the state's limiting their freedom. For they might also hold that they are required to follow the law even when it supports what they see to be immoral kinds of behavior. It is only when people who are pursuing their unreasonable moral doctrine actively interfere with others that the state should step in to protect the victims of their activities; see Rawls, A Theory of Justice, 216-21.
74. See Robert Veatch, "Models for Ethical Medicine in a Revolutionary Age," Hastings Center Report 2, no. 3 (1972): 5-7, for a discussion of models of the physician-patient relationship that endorses, as I do in what follows, a contractual model that includes certain constraints on what health professionals can offer in establishing the contract.
75. See Dworkin, The Theory and Practice of Autonomy, 113-14, for a similar account of the special place of the body.
76. Some comprehensive doctrines do allow for the possibility of reincarnation Nonetheless, even on these views, one's body for a given lifetime is irreplaceable.
77. Political philosophy acknowledges the special status of the body in its treatment of punishment, which ultimately involves a bodily intervention of some sort, such as medication, amputation, the physical restriction of movement, or the infliction of pain; even the payment of a fine must be enforceable by bodily measures, and a bodily measure must be supplied as an alternative for those lacking monetary resources. Now, if citizens were allowed to decide for themselves on which occasions such bodily interventions were warranted, the one receiving the punishment could reasonably complain that he or she was being treated unfairly. Thus, the state should instead set up a monopoly on bodily interventions-a legal and penal system-that is fair to all, one that those in the original position would recognize as needed, given the evident necessity of an enforcement mechanism for the preservation of society. Accordingly, the political conception of the person, which Liberalism, 29-35), must include as a complement a political conception of the body. Each person is entitled to integrate the status of embodiment into her comprehensive doctrine in any reasonable fashion, but the state preserves a right to bodily access (when mandated by a suitably constituted system of justice) in order to enforce the norms that make society possible. Note that the issue of punishment takes us beyond ideal theory, where there is an assumption of full compliance (Rawls, A Theory of Justice, 145, but see also ibid., 240-41). Thus, the body plays a role in extending ideal theory in two respects: in accounting for responses to injustice and in accounting for natural limitations such as disease and disability.
78. Political philosophy acknowledges the special status of the body in its treatment of punishment, which ultimately involves a bodily intervention of some sort, such as medication, amputation, the physical restriction of movement, or the infliction of pain; even the payment of a fine must be enforceable by bodily measures, and a bodily measure must be supplied as an alternative for those lacking monetary resources. Now, if citizens were allowed to decide for themselves on which occasions such bodily interventions were warranted, the one receiving the punishment could reasonably complain that he or she was being treated unfairly. Thus, the state should instead set up a monopoly on bodily interventions-a legal and penal system-that is fair to all, one that those in the original position would recognize as needed, given the evident necessity of an enforcement mechanism for the preservation of society. Accordingly, the political conception of the person, which Liberalism, 29-35), must include as a complement a political conception of the body. Each person is entitled to integrate the status of embodiment into her comprehensive doctrine in any reasonable fashion, but the state preserves a right to bodily access (when mandated by a suitably constituted system of justice) in order to enforce the norms that make society possible. Note that the issue of punishment takes us beyond ideal theory, where there is an assumption of full compliance (Rawls, A Theory of Justice, 145, but see also ibid., 240-41). Thus, the body plays a role in extending ideal theory in two respects: in accounting for responses to injustice and in accounting for natural limitations such as disease and disability.
79. Political philosophy acknowledges the special status of the body in its treatment of punishment, which ultimately involves a bodily intervention of some sort, such as medication, amputation, the physical restriction of movement, or the infliction of pain; even the payment of a fine must be enforceable by bodily measures, and a bodily measure must be supplied as an alternative for those lacking monetary resources. Now, if citizens were allowed to decide for themselves on which occasions such bodily interventions were warranted, the one receiving the punishment could reasonably complain that he or she was being treated unfairly. Thus, the state should instead set up a monopoly on bodily interventions-a legal and penal system-that is fair to all, one that those in the original position would recognize as needed, given the evident necessity of an enforcement mechanism for the preservation of society. Accordingly, the political conception of the person, which Liberalism, 29-35), must include as a complement a political conception of the body. Each person is entitled to integrate the status of embodiment into her comprehensive doctrine in any reasonable fashion, but the state preserves a right to bodily access (when mandated by a suitably constituted system of justice) in order to enforce the norms that make society possible. Note that the issue of punishment takes us beyond ideal theory, where there is an assumption of full compliance (Rawls, A Theory of Justice, 145, but see also ibid., 240-41). Thus, the body plays a role in extending ideal theory in two respects: in accounting for responses to injustice and in accounting for natural limitations such as disease and disability.
80. See Rawls, Political Liberalism, 30.
81. The institutional complexity of modern medicine makes this point readily apparent. A hospital, for example, cannot tailor its procedures to meet the exact requirements of each individual who enters it; instead, the institution aims to promote beneficent and nonmaleficent care, leaving patients the right to make the final choices about their care within those constraints.
82. The German rationalists, from Baron Christian von Wolff onward, constitute one tradition of moral thought that has recognized the need for a bioethics of everyday life, that is, for a consideration of the moral questions posed by our biological natures. See, for example, Kant's discussion of "man's duty to himself as an animal being," where he rejects such things as castration (to improve one's singing career), selling one's hair, gluttony, and nonreproductive sexual activities, in Immanuel Kant, The Metaphysics of Morals, trans. Mary Gregor (Cambridge: Cambridge University Press, 1991), 218-24. Engelhardt sometimes sounds as if he means by his "bioethics of moral friends" - bioethics for those who share comprehensive doctrines-what I call the bioethics of everyday life; see Engelhardt, The Foundations of Bioethics, 14, 74-75 (2d ed.). But sometimes he restricts all kinds of bioethics to the policy-oriented questions, as when he says that "moral visions give rise to content-full bioethics and offer substantive guidance about how one should properly act as patient, physician, nurse, or citizen framing health care policy. This volume does not address these moralities and the bioethics they support. It does not explore the particular content-full morality that ought to shape the bioethics and guide the health care policy through which moral friends can collaborate" (ibid., 102).
83. The German rationalists, from Baron Christian von Wolff onward, constitute one tradition of moral thought that has recognized the need for a bioethics of everyday life, that is, for a consideration of the moral questions posed by our biological natures. See, for example, Kant's discussion of "man's duty to himself as an animal being," where he rejects such things as castration (to improve one's singing career), selling one's hair, gluttony, and nonreproductive sexual activities, in Immanuel Kant, The Metaphysics of Morals, trans. Mary Gregor (Cambridge: Cambridge University Press, 1991), 218-24. Engelhardt sometimes sounds as if he means by his "bioethics of moral friends" -bioethics for those who share comprehensive doctrines-what I call the bioethics of everyday life; see Engelhardt, The Foundations of Bioethics, 14, 74-75 (2d ed.). But sometimes he restricts all kinds of bioethics to the policy-oriented questions, as when he says that "moral visions give rise to content-full bioethics and offer substantive guidance about how one should properly act as patient, physician, nurse, or citizen framing health care policy. This volume does not address these moralities and the bioethics they support. It does not explore the particular content-full morality that ought to shape the bioethics and guide the health care policy through which moral friends can collaborate" (ibid., 102).
84. The German rationalists, from Baron Christian von Wolff onward, constitute one tradition of moral thought that has recognized the need for a bioethics of everyday life, that is, for a consideration of the moral questions posed by our biological natures. See, for example, Kant's discussion of "man's duty to himself as an animal being," where he rejects such things as castration (to improve one's singing career), selling one's hair, gluttony, and nonreproductive sexual activities, in Immanuel Kant, The Metaphysics of Morals, trans. Mary Gregor (Cambridge: Cambridge University Press, 1991), 218-24. Engelhardt sometimes sounds as if he means by his "bioethics of moral friends" - bioethics for those who share comprehensive doctrines-what I call the bioethics of everyday life; see Engelhardt, The Foundations of Bioethics, 14, 74-75 (2d ed.). But sometimes he restricts all kinds of bioethics to the policy-oriented questions, as when he says that "moral visions give rise to content-full bioethics and offer substantive guidance about how one should properly act as patient, physician, nurse, or citizen framing health care policy. This volume does not address these moralities and the bioethics they support. It does not explore the particular content-full morality that ought to shape the bioethics and guide the health care policy through which moral friends can collaborate" (ibid., 102).
85. Beauchamp and Childress, Principles of Biomedical Ethics, 3 (4th ed.) (emphasis added).
86. Engelhardt, The Foundations of Bioethics, 9 (1st ed.).
87. Thomas Murray, The Worth of a Child (Berkeley: University of California Press, 1996).
88. Laura Purdy, "Genetics and Reproductive Risk: Can Having Children Be Immoral?" in Laura Purdy, Reproducing Persons: Issues in Feminist Bioethics (Ithaca, NY: Cornell University Press, 1996), 39-49.
89. John Hardwig, "Is There a Duty to Die?" Hastings Center Report 27, no. 2 (1997): 34-42.
90. Rosalind Hursthouse, "Virtue Theory and Abortion," Philosophy and Public Affairs 20, no. 3 (1991): 223-46; Rosalind Hursthouse, Beginning Lives (Oxford: Basil Blackwell, 1987).
91. Rosalind Hursthouse, "Virtue Theory and Abortion," Philosophy and Public Affairs 20, no. 3 (1991): 223-46; Rosalind Hursthouse, Beginning Lives (Oxford: Basil Blackwell, 1987).
92. The same problem can afflict clinical bioethicists. As Bette-Jane Crigger points out, the practice of ethics consultation sometimes "holds peril insofar as it may . . . work toward imposing a particular, content-laden vision of what the dominant culture perceives to be morally most significant and most appropriate-for example, valuing the autonomy of individual patients over the interests of others" (Bette-Jane Crigger, "Negotiating the Moral Order: Paradoxes of Ethics Consultation," Kennedy Institute of Ethics Journal 5, no. 2 [1995]: 90).
93. See Lisa Parker, "Social Justice, Federal Paternalism, and Feminism: Breast Implantation in the Cultural Context of Female Beauty," Kennedy Institute of Ethics Journal 3, no. 1 (1993): 57-76. For genetic counseling as another case where comprehensive values might have infiltrated treatments of bioethical policy, see Abby Lippman, "Prenatal Genetic Testing and Screening: Constructing Needs and Reinforcing Inequities," American Journal of Law and Medicine 17, nos. 1-2 (1991): 15-50; and Angus Clarke, "Is Non-Directive Genetic Counselling Possible?" The Lancet 338, no. 8773 (1991): 998-1001.
94. See Lisa Parker, "Social Justice, Federal Paternalism, and Feminism: Breast Implantation in the Cultural Context of Female Beauty," Kennedy Institute of Ethics Journal 3, no. 1 (1993): 57-76. For genetic counseling as another case where comprehensive values might have infiltrated treatments of bioethical policy, see Abby Lippman, "Prenatal Genetic Testing and Screening: Constructing Needs and Reinforcing Inequities," American Journal of Law and Medicine 17, nos. 1-2 (1991): 15-50; and Angus Clarke, "Is Non-Directive Genetic Counselling Possible?" The Lancet 338, no. 8773 (1991): 998-1001.
95. See Lisa Parker, "Social Justice, Federal Paternalism, and Feminism: Breast Implantation in the Cultural Context of Female Beauty," Kennedy Institute of Ethics Journal 3, no. 1 (1993): 57-76. For genetic counseling as another case where comprehensive values might have infiltrated treatments of bioethical policy, see Abby Lippman, "Prenatal Genetic Testing and Screening: Constructing Needs and Reinforcing Inequities," American Journal of Law and Medicine 17, nos. 1-2 (1991): 15-50; and Angus Clarke, "Is Non-Directive Genetic Counselling Possible?" The Lancet 338, no. 8773 (1991): 998-1001.
96. See Sandra D. Lane and Robert A. Rubinstein, "Judging the Other: Responding to Traditional Female Genital Surgeries," Hastings Center Report 26, no. 3 (1996): 31-40.
97. See Donald C. Ainslie, "Questioning Bioethics: AIDS, Sexual Ethics, and the Duty to Warn," Hastings Center Report 29, no. 5 (1999): 26-35.
98. Lane and Rubinstein, "Judging the Other"; Ainslie, "Questioning Bioethics."
99. Lane and Rubinstein, "Judging the Other"; Ainslie, "Questioning Bioethics."
100. Rawls would call this a case of "reasoning from conjecture," in that the bioethicists conjecture about the comprehensive doctrine of their interlocutors in order to show to them how certain features of public policy can be seen as reasonable on their own terms; see Rawls, "The Idea of Public Reason Revisited," 783, 786-87.
101. Rawls, Political Liberalism, 133-72.
102. An example of what I have in mind is Ronald Dworkin's treatment of abortion and euthanasia in Ronald Dworkin, Life's Dominion: An Argument about Abortion, Euthanasia, and Individual Freedom (New York: Knopf, 1993), where he tries to show that people with deep disagreements about the morality of abortion can nonetheless accept a liberal abortion policy.
103. Dan Brock also recognizes the need for an overlapping consensus in order for bioethical policy to be stable in Dan Brock, "Public Moral Discourse," in Sumner and Boyle, eds., Philosophical Perspectives on Bioethics, 293-94. My argument that bioethics needs an overlapping consensus helps to reveal further how my Rawlsian version of liberalism in bioethics differs from Engelhardt's liberal bioethics. For he explicitly rejects the overlapping consensus for three reasons; see Engelhardt, The Foundations of Bioethics, 59-64 (2d ed.). First, he thinks that Rawls's principles, such as fair equality of opportunity, are not such as to achieve a consensus. All that is needed is for individuals to recognize that, since the state is a union of strangers, it must rely on the principle of permission. Second, Engelhardt worries that what appears to be an overlapping consensus may actually be citizens' acquiescing to whatever powers control the state. Third, he suggests that Rawls's claim that comprehensive doctrines in the overlapping consensus must be reasonable serves an ideological function, ruling certain moral outlooks out of court on the basis of controversial moral commitments. None of these criticisms seems to me to hit the mark. Engelhardt's first point seems in fact to support Rawls; for when individuals recognize from within their own comprehensive doctrines the appropriateness of a conception of justice that is fair to all, those doctrines fall within the overlapping consensus. Rawls and Engelhardt differ on what the appropriate such conception would be, and how it would be justified, but Engelhardt seems at this point to acknowledge that citizens need to see the moral appropriateness of the conception of justice for themselves. Engelhardt's friends/strangers distinction gets him in trouble here, as it blinds him to the need for our substantive moral outlooks (which he identifies as relevant only when we are among friends) to endorse the political arrangement if the state is to be stable. Engelhardt's second point seems to treat Rawls's overlapping consensus as if it were an empirical notion rather than a normative one. For the appearance of a consensus that he worries about is not the existence of one as Rawls understands it. If people are merely acquiescing to a political arrangement out of pragmatic concerns, it counts as a mere modus vivendi, the stability of which would be undermined whenever the power balances in society shift. Engelhardt's third complaint, about reasonableness, also seems to be based on a misunderstanding. He takes reasonableness to be a substantive notion, committing Rawls to a particular moral outlook. But, in fact, reasonableness for Rawls only points to a willingness to live with others on terms that are acceptable to all; it is thus a formal notion rather than a substantive one.
104. Dan Brock also recognizes the need for an overlapping consensus in order for bioethical policy to be stable in Dan Brock, "Public Moral Discourse," in Sumner and Boyle, eds., Philosophical Perspectives on Bioethics, 293-94. My argument that bioethics needs an overlapping consensus helps to reveal further how my Rawlsian version of liberalism in bioethics differs from Engelhardt's liberal bioethics. For he explicitly rejects the overlapping consensus for three reasons; see Engelhardt, The Foundations of Bioethics, 59-64 (2d ed.). First, he thinks that Rawls's principles, such as fair equality of opportunity, are not such as to achieve a consensus. All that is needed is for individuals to recognize that, since the state is a union of strangers, it must rely on the principle of permission. Second, Engelhardt worries that what appears to be an overlapping consensus may actually be citizens' acquiescing to whatever powers control the state. Third, he suggests that Rawls's claim that comprehensive doctrines in the overlapping consensus must be reasonable serves an ideological function, ruling certain moral outlooks out of court on the basis of controversial moral commitments. None of these criticisms seems to me to hit the mark. Engelhardt's first point seems in fact to support Rawls; for when individuals recognize from within their own comprehensive doctrines the appropriateness of a conception of justice that is fair to all, those doctrines fall within the overlapping consensus. Rawls and Engelhardt differ on what the appropriate such conception would be, and how it would be justified, but Engelhardt seems at this point to acknowledge that citizens need to see the moral appropriateness of the conception of justice for themselves. Engelhardt's friends/strangers distinction gets him in trouble here, as it blinds him to the need for our substantive moral outlooks (which he identifies as relevant only when we are among friends) to endorse the political arrangement if the state is to be stable. Engelhardt's second point seems to treat Rawls's overlapping consensus as if it were an empirical notion rather than a normative one. For the appearance of a consensus that he worries about is not the existence of one as Rawls understands it. If people are merely acquiescing to a political arrangement out of pragmatic concerns, it counts as a mere modus vivendi, the stability of which would be undermined whenever the power balances in society shift. Engelhardt's third complaint, about reasonableness, also seems to be based on a misunderstanding. He takes reasonableness to be a substantive notion, committing Rawls to a particular moral outlook. But, in fact, reasonableness for Rawls only points to a willingness to live with others on terms that are acceptable to all; it is thus a formal notion rather than a substantive one.
105. After several studies had shown that there is significant resistance among physicians to taking seriously the revolution bioethics has tried to bring about in physician-patient interactions, the massive Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatment (SUPPORT) was undertaken in an attempt to clarify how physicians treat extremely ill patients. It found that physicians frequently respond inappropriately to dying patients' requests not to be resuscitated or to cease treatments. Moreover, an experimental intervention designed by the researchers to rectify this problem was found to have no impact on this or other related aspects of care for the dying. See Alfred Connors et al., "A Controlled Trial to Improve Care for Seriously Ill Hospitalized Patients," Journal of the American Medical Association 274, no. 20 (1995): 1591-98. For a series of discussions of the meaning of the SUPPORT study, see the various essays in Hastings Center Report 25, no. 6, "Dying Well in the Hospital: The Lessons of SUPPORT" special supplement (1995).
106. After several studies had shown that there is significant resistance among physicians to taking seriously the revolution bioethics has tried to bring about in physician-patient interactions, the massive Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatment (SUPPORT) was undertaken in an attempt to clarify how physicians treat extremely ill patients. It found that physicians frequently respond inappropriately to dying patients' requests not to be resuscitated or to cease treatments. Moreover, an experimental intervention designed by the researchers to rectify this problem was found to have no impact on this or other related aspects of care for the dying. See Alfred Connors et al., "A Controlled Trial to Improve Care for Seriously Ill Hospitalized Patients," Journal of the American Medical Association 274, no. 20 (1995): 1591-98. For a series of discussions of the meaning of the SUPPORT study, see the various essays in Hastings Center Report 25, no. 6, "Dying Well in the Hospital: The Lessons of SUPPORT" special supplement (1995).
107. I do not mean to suggest that all health professionals hold this comprehensive doctrine. Some might treat their work as mere work-highly remunerative and intellectually challenging, but with no special moral content.
108. It is true that health professionals have had the opportunity to integrate into their comprehensive doctrines whatever moral insight they have gleaned from their experience with treating disease. And this means that they will be more prepared than will most patients to confront whatever moral challenges their illnesses pose. But the fact of reasonable pluralism applies here, too, in that different health professionals will make sense of their experiences in diverse ways. No one health professional's moral views, then, should be privileged in the construction of health policies, even if the collective insight of health-care providers (and of others with first-hand experience with disease, such as the disabled, survivors of various conditions, or family caregivers) can be an extremely useful resource for bioethicists in both their policy endeavors and their explorations of the bioethics of everyday life.