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CHAPTER 1

Moral Reasoning in Bioethics

Second, it would be difficult to imagine moral issues more important— more closely gathered around the line between life and death, health and illness, pain and relief, hope and despair— than those addressed by bioethics. Whatever our view of these questions, there is little doubt that they matter immensely. Whatever answers we give will surely have weight, however they fall.

Third, as a systematic study of such ques­ tions, bioethics holds out the possibility of an­ swers. The answers may or may not be to our liking; they may confirm or confute our precon­ ceived notions; they may take us far or not far enough. But, as the following pages will show, the trail has more light than shadow— and thinking critically and carefully about the prob­ lems can help us see our way forward.

ethics and bioethics

Morality is about people’s moral judgments, principles, rules, standards, and theories— all of which help direct conduct, mark out moral prac­ tices, and provide the yardsticks for measuring moral worth. We use morality to refer gener­ ally to these aspects of our lives (as in “Morality is essential”) or more specifically to the beliefs or practices of particular groups or persons (as in “American morality” or “Kant’s morality”). Moral, of course, pertains to morality as just defined, though it is also sometimes employed as a synonym for right or good, just as immoral is often meant to be equivalent to wrong or bad. Ethics, as used in this text, is not synonymous with morality. Ethics is the study of morality using the tools and methods of philosophy. Philosophy is a discipline that systematically examines life’s

Any serious and rewarding exploration of bio­ ethics is bound to be a challenging journey. What makes the trip worthwhile? As you might expect, this entire text is a long answer to that question. You therefore may not fully appreciate the trek until you have already hiked far along the trail. The short answer comes in three parts.

First, bioethics— like ethics, its parent disci­ pline— is about morality, and morality is about life. Morality is part of the unavoidable, bitter­ sweet drama of being persons who think and feel and choose. Morality concerns beliefs regarding morally right and wrong actions and morally good and bad persons or character. Whether we like it or not, we seem confronted continually with the necessity to deliberate about right and wrong, to judge someone morally good or bad, to agree or disagree with the moral pronounce­ ments of others, to accept or reject the moral outlook of our culture or community, and even to doubt or affirm the existence or nature of moral concepts themselves. Moral issues are thus inescapable— including (or especially) those that are the focus of bioethics. In the twenty­first century, few can remain entirely untouched by the pressing moral questions of fair distribution of health care resources, abortion and infanti­ cide, euthanasia and assisted suicide, exploitative research on children and populations in devel­ oping countries, human cloning and genetic en­ gineering, assisted reproduction and surrogate parenting, prevention and treatment of HIV/ AIDS, the confidentiality and consent of patients, the refusal of medical treatment on religious grounds, experimentation on human embryos and fetuses, and the just allocation of scarce life­ saving organs.

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4 PART 1: PRINCIPLES AND THEORIES

some or all of these as proper guides for our ac­ tions and judgments. In normative ethics, we ask questions like these: What moral principles, if any, should inform our moral judgments? What role should virtues play in our lives? Is the principle of autonomy justified? Are there any exceptions to the moral principle of “do not kill”? How should we resolve conflicts between moral norms? Is contractarianism a good moral theory? Is utilitarianism a better theory?

A branch that deals with much deeper ethical issues is metaethics. Metaethics is the study of the meaning and justification of basic moral be­ liefs. In normative ethics we might ask whether an action is right or whether a person is good, but in metaethics we would more likely ask what it means for an action to be right or for a person to be good. For example, does right mean has the best consequences, or produces the most happi- ness, or commanded by God? It is the business of metaethics to explore these and other equally fundamental questions: What, if anything, is the difference between moral and nonmoral be­ liefs? Are there such things as moral facts? If so, what sort of things are they, and how can they be known? Can moral statements be true or false— or are they just expressions of emotions or attitudes without any truth value? Can moral norms be justified or proven?

The third main branch is applied ethics, the use of moral norms and concepts to resolve practical moral issues. Here, the usual challenge is to employ moral principles, theories, argu­ ments, or analyses to try to answer moral ques­ tions that confront people every day. Many such questions relate to a particular professional field such as law, business, or journalism, so we have specialized subfields of applied ethics like legal ethics, business ethics, and journalistic ethics. Probably the largest and most energetic subfield is bioethics.

Bioethics is applied ethics focused on health care, medical science, and medical technology. (Biomedical ethics is often used as a synonym, and medical ethics is a related but narrower term used most often to refer to ethical problems in

big questions through critical reasoning, logical argument, and careful reflection. Thus ethics— also known as moral philosophy— is a reasoned way of delving into the meaning and import of moral concepts and issues and of evaluating the merits of moral judgments and standards. (As with morality and moral, we may use ethics to say such things as “Kant’s ethics” or may use ethical or unethical to mean right or wrong, good or bad.) Ethics seeks to know whether an action is right or wrong, what moral standards should guide our conduct, whether moral prin­ ciples can be justified, what moral virtues are worth cultivating and why, what ultimate ends people should pursue in life, whether there are good reasons for accepting a particular moral theory, and what the meaning is of such notions as right, wrong, good, and bad. Whenever we try to reason carefully about such things, we enter the realm of ethics: We do ethics.

Science offers another way to study morality, and we must carefully distinguish this approach from that of moral philosophy. Descriptive ethics is the study of morality using the meth­ odology of science. Its purpose is to investigate the empirical facts of morality— the actual be­ liefs, behaviors, and practices that constitute people’s moral experience. Those who carry out these inquiries (usually anthropologists, sociol­ ogists, historians, and psychologists) want to know, among other things, what moral beliefs a person or group has, what caused the subjects to have them, and how the beliefs influence behav­ ior or social interaction. Very generally, the dif­ ference between ethics and descriptive ethics is this: In ethics we ask, as Socrates did, How ought we to live? In descriptive ethics we ask, How do we in fact live?

Ethics is a big subject, so we should not be surprised that it has three main branches, each dealing with more or less separate but related sets of ethical questions. Normative ethics is the search for, and justification of, moral standards, or norms. Most often the standards are moral principles, rules, virtues, and theories, and the lofty aim of this branch is to establish rationally

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Chapter 1: Moral Reasoning in Bioethics 5

about art; norms of etiquette about polite social behavior; grammatical norms about correct use of language; prudential norms about what is in one’s interests; and legal norms about lawful and unlawful acts. But moral norms differ from these nonmoral kinds. Some of the features they are thought to possess include the following.

Normative Dominance. In our moral practice, moral norms are presumed to dominate other kinds of norms, to take precedence over them. Philosophers call this characteristic of moral norms overridingness because moral consider­ ations so often seem to override other factors. A maxim of prudence, for example, may suggest that you should steal if you can avoid getting caught, but a moral prohibition against stealing would overrule such a principle. An aesthetic (or pragmatic) norm implying that homeless people should be thrown in jail for blocking the view of a beautiful public mural would have to yield to moral principles demanding more humane treat­ ment of the homeless. A law mandating brutal actions against a minority group would conflict with moral principles of justice and would there­ fore be deemed illegitimate. We usually think that immoral laws are defective, that they need to be changed, or that, in rare cases, they should be defied through acts of civil disobedience.

Universality. Moral norms (but not exclusively moral norms) have universality: Moral princi­ ples or judgments apply in all relevantly similar situations. If it is wrong for you to tell a lie in a particular circumstance, then it is wrong for everyone in relevantly similar circumstances to tell a lie. Logic demands this sort of consistency. It makes no sense to say that Maria’s doing action A in circumstances C is morally wrong, but John’s doing A in circumstances relevantly similar to C is morally right. Universality, how­ ever, is not unique to moral norms; it’s a charac­ teristic of all normative spheres.

Impartiality. Implicit in moral norms is the notion of impartiality— the idea that everyone

medical practice.) Ranging far and wide, bio­ ethics seeks answers to a vast array of tough ethical questions: Is abortion ever morally per­ missible? Is a woman justified in having an abor­ tion if prenatal genetic testing reveals that her fetus has a developmental defect? Should people be allowed to select embryos by the embryos’ sex or other genetic characteristics? Should human embryos be used in medical research? Should human cloning be prohibited? Should physicians, nurses, physicians’ assistants, and other health care professionals always be truthful with patients whatever the consequences? Should severely im­ paired newborns be given life­prolonging treat­ ment or be allowed to die? Should people in persistent vegetative states be removed from life support? Should physicians help terminally ill patients commit suicide? Is it morally right to con­ duct medical research on patients without their consent if the research would save lives? Should human stem­cell research be banned? How should we decide who gets life­saving organ trans­ plants when usable organs are scarce and many patients who do not get transplants will die? Should animals be used in biomedical research?

The ethical and technical scope of bioethics is wide. Bioethical questions and deliberations now fall to nonexpert and expert alike— to pa­ tients, families, and others as well as to philoso­ phers, health care professionals, lawyers, judges, scientists, clergy, and public policy specialists. Though the heart of bioethics is moral philoso­ phy, fully informed bioethics cannot be done without a good understanding of the relevant nonmoral facts and issues, especially the medi­ cal, scientific, technological, and legal ones.

ethics and the moral life

Morality then is a normative, or evaluative, enter­ prise. It concerns moral norms or standards that help us decide the rightness of actions, judge the goodness of persons or character, and prescribe the form of moral conduct. There are, of course, other sorts of norms we apply in life— nonmoral norms. Aesthetic norms help us make value judg ments

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6 PART 1: PRINCIPLES AND THEORIES

the moral life— is to do moral reasoning. If our moral judgments are to have any weight at all, if they are to be anything more than mere per­ sonal taste or knee­jerk emotional response, they must be backed by the best of reasons. They must be the result of careful reflection in which we arrive at good reasons for accepting them, reasons that could be acknowledged as such by any other reasoning persons.

Both logic and our commonsense moral ex­ perience demand that the thorough sifting of reasons constitutes the main work of our moral deliberations— regardless of our particular moral outlook or theory. We would think it odd, per­ haps even perverse, if someone asserted that physician­assisted suicide is always morally wrong— and then said she has no reasons at all for believing such a judgment but just does. What­ ever our views on physician­assisted suicide, we would be justified in ignoring her judgment, for we would have no way to distinguish it from personal whim or wishful thinking. Likewise she herself (if she genuinely had no good reasons for her assertion) would be in the same boat, adrift with a firm opinion moored to nothing solid.

Our feelings, of course, are also part of our moral experience. When we ponder a moral issue we care about (abortion, for example), we may feel anger, sadness, disgust, fear, irritation, or sympathy. Such strong emotions are normal and often useful, helping us empathize with others, deepening our understanding of human suffering, and sharpening our insight into the consequences of our moral decisions. But our feelings can mislead us by reflecting not moral truth but our own psychological needs, our own personal or cultural biases, or our concern for personal advantage. Throughout history, some people’s feelings led them to conclude that women should be burned for witchcraft, that whole races should be exterminated, that black men should be lynched, and that adherents of a different religion were evil. Critical reasoning can help restrain such terrible impulses. It can help us put our feelings in proper perspective and achieve a measure of impartiality. Most of

should be considered equal, that everyone’s inter­ ests should count the same. From the perspective of morality, no person is any better than any other. Everyone should be treated the same unless there is a morally relevant difference between persons. We probably would be completely baf­ fled if someone seriously said something like “murder is wrong . . . except when committed by myself,” when there was no morally relevant dif­ ference between that person and the rest of the world. If we took such a statement seriously at all, we would likely not only reject it but also would not even consider it a bona fide moral statement.

The requirement of moral impartiality pro­ hibits discrimination against people merely be­ cause they are different— different in ways that are not morally relevant. Two people can be dif­ ferent in many ways: skin color, weight, gender, income, age, occupation, and so forth. But these are not differences relevant to the way they should be treated as persons. On the other hand, if there are morally relevant differences between people, then we may have good reasons to treat them differently, and this treatment would not be a violation of impartiality. This is how phi­ losopher James Rachels explains the point:

The requirement of impartiality, then, is at bottom nothing more than a proscription against arbitrariness in dealing with people. It is a rule that forbids us from treating one person differ­ ently from another when there is no good reason to do so. But if this explains what is wrong with racism, it also explains why, in some special kinds of cases, it is not racist to treat people dif­ ferently. Suppose a film director was making a movie about the life of Martin Luther King, Jr. He would have a perfectly good reason for ruling out Tom Cruise for the starring role. Obviously, such casting would make no sense. Because there would be a good reason for it, the director’s “dis­ crimination” would not be arbitrary and so would not be open to criticism.1

Reasonableness. To participate in morality— to engage in the essential, unavoidable practices of

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Chapter 1: Moral Reasoning in Bioethics 7

purports to explain right actions, or make judg­ ments about right or wrong actions.

Moral values, on the other hand, generally concern those things that we judge to be morally good, bad, praiseworthy, or blameworthy. Nor­ mally we use such words to describe persons (as in “He is a good person” or “She is to blame for hurting them”), their character (“He is virtu­ ous”; “She is honest”), or their motives (“She did wrong but did not mean to”). Note that we also attribute nonmoral value to things. If we say that a book or bicycle or vacation is good, we mean good in a nonmoral sense. Such things in them­ selves cannot have moral value.

Strictly speaking, only actions are morally right or wrong, but persons are morally good or bad (or some degree of goodness or badness). With this distinction we can acknowledge a

all, it can guide us to moral judgments that are trustworthy because they are supported by the best of reasons.

The moral life, then, is about grappling with a distinctive class of norms marked by normative dominance, universality, impartiality, and rea­ sonableness. As we saw earlier, these norms can include moral principles, rules, theories, and judgments. We should notice that we commonly apply these norms to two distinct spheres of our moral experience— to both moral obligations and moral values.

Moral obligations concern our duty, what we are obligated to do. That is, obligations are about conduct, how we ought or ought not to behave. In this sphere, we talk primarily about actions. We may look to moral principles or rules to guide our actions, or study a moral theory that

IN DEPTH

MORALITY AND THE LAW

Some people confuse morality with the law, or iden- tify the one with the other, but the two are distinct though they may often coincide. Laws are norms enacted or enforced by the state to protect or pro- mote the public good. They specify which actions are legally right or wrong. But these same actions can also be judged morally right or wrong, and these two kinds of judgments will not necessarily agree. Lying to a friend about a personal matter, deliberately trying to destroy yourself through reckless living, or failing to save a drowning child (when you easily could have) may be immoral— but not illegal. Racial bias, discrimination based on gender or sexual orien- tation, slavery, spousal rape, and unequal treatment of minority groups are immoral— but, depending on the society, they may not be illegal.

Much of the time, however, morality and the law overlap. Often what is immoral also turns out to be illegal. This is usually the case when immoral actions cause substantial harm to others, whether physical

or economic. Thus murder and embezzlement are both immoral and illegal, backed by social disapproval and severe sanctions imposed by law. Controversy often arises when an action is not obviously or seri- ously harmful but is considered immoral by some who want the practice prohibited by law. The conten- tious notion at work is that something may be made illegal solely on the grounds that it is immoral, re- gardless of any physical or economic harm involved. This view of the law is known as legal moralism, and it sometimes underlies debates about the legalization of abortion, euthanasia, reproductive technology, con traception, and other practices.

Many issues in bioethics have both a moral and legal dimension, and it is important not to confuse the two. Sometimes the question at hand is a moral one (whether, for example, euthanasia is ever morally permissible); whether a practice should be legal or illegal then is beside the point. Sometimes the ques- tion is about legality. And sometimes the discussion concerns both. A person may consider physician- assisted suicide morally acceptable but argue that it should nevertheless be illegal because allowing the practice to become widespread would harm both patients and the medical profession.

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8 PART 1: PRINCIPLES AND THEORIES

simple fact of the moral life: A good person can do something wrong, and a bad person can do something right. A Gandhi can tell a lie, and a Hitler can save a drowning man.

In addition, we may judge an action right or wrong depending on the motive behind it. If John knocks a stranger down in the street to pre­ vent her from being hit by a car, we would deem his action right (and might judge him a good person). But if he knocks her down because he dislikes the color of her skin, we would believe his action wrong (and likely think him evil).

The general meaning of right and wrong seems clear to just about everyone. But we should be careful to differentiate degrees of meaning in these moral terms. Right can mean either “obliga­ tory” or “permissible.” An obligatory action is one that would be wrong not to perform. We are obli­ gated or required to do it. A permissible action is one that is permitted. It is not wrong to perform it. Wrong means “prohibited.” A prohibited action is one that would be wrong to perform. We are obli­ gated or required not to do it. A supererogatory action is one that is “above and beyond” our duty. It is praiseworthy— a good thing to do— but not required. Giving all your possessions to the poor is generally considered a supererogatory act.

moral principles in bioethics

As noted earlier, the main work of bioethics is trying to solve bioethical problems using the potent resources and methods of moral phi­ losophy, which include, at a minimum, critical reasoning, logical argument, and conceptual analysis. Many, perhaps most, moral philoso­ phers would be quick to point out that beyond these tools of reason we also have the consider­ able help of moral principles. (The same could be said about moral theories, which we explore in the next chapter.) Certainly to be useful, moral principles must be interpreted, often filled out with specifics, and balanced with other moral concerns. But both in everyday life and in bio­ ethics, moral principles are widely thought to be indispensable to moral decision­making.

We can see appeals to moral principles in countless cases. Confronted by a pain­racked, terminally ill patient who demands to have his life ended, his physician refuses to comply, rely­ ing on the principle that “it is wrong to inten­ tionally take a life.” Another physician makes a different choice in similar circumstances, insist­ ing that the relevant principle is “ending the suf­ fering of a hopelessly ill patient is morally permissible.” An infant is born anencephalic (without a brain); it will never have a conscious life and will die in a few days. The parents decide to donate the infant’s organs to other children so they might live, which involves taking the organs right away before they deteriorate. A critic of the parents’ decision argues that “it is unethical to kill in order to save.” But someone else appeals to the principle “save as many chil­ dren as possible.”2 In such ways moral principles help guide our actions and inform our judg­ ments about right and wrong, good and evil.

As discussed in Chapter 2, moral principles are often drawn from a moral theory, which is a moral standard on the most general level. The principles are derived from or supported by the theory. Many times we simply appeal directly to a plausible moral principle without thinking much about its theoretical underpinnings.

Philosophers make a distinction between ab­ solute and prima facie principles (or duties). An absolute principle applies without exceptions. An absolute principle that we should not lie de­ mands that we never lie regardless of the cir­ cumstances or the consequences. In contrast, a prima facie principle applies in all cases unless an exception is warranted. Exceptions are justi­ fied when the principle conflicts with other principles and is thereby overridden. W. D. Ross is given credit for drawing this distinction in his 1930 book The Right and the Good.3 It is essen­ tial to his account of ethics, which has a core of several moral principles or duties, any of which might come into conflict.

Physicians have a prima facie duty to be truth­ ful to their patients as well as a prima facie duty to promote their welfare. But if these duties come

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Chapter 1: Moral Reasoning in Bioethics 9

their consent, treating competent patients against their will, physically restraining or confining pa­ tients for no medical reason— such practices con­ stitute obvious violations of personal autonomy.

Not all restrictions on autonomy, however, are of the physical kind. Autonomy involves the capacity to make personal choices, but choices cannot be considered entirely autonomous unless they are fully informed. When we make decisions in ignorance— without relevant information or blinded by misinformation— our autonomy is diminished just as surely as if someone physi­ cally manipulated us. If this is correct, then we have a plausible explanation of why lying is generally prohibited: Lying is wrong because it undermines personal autonomy. Enshrined in bioethics and in the law, then, is the precept of informed consent, which demands that patients be allowed to freely consent to or decline treat­ ments and that they receive the information they need to make informed judgments about them.

In many ways, autonomy is a delicate thing, easily compromised and readily thwarted. Often a person’s autonomy is severely undermined not by other people but by nature, nurture, or his or her own actions. Some drug addicts and alcohol­ ics, people with serious psychiatric illness, and those with severe mental impairment are thought to have drastically diminished autonomy (or to be essentially nonautonomous). Bioethical ques­ tions then arise about what is permissible to do to them and who will represent their interests or make decisions regarding their care. Infants and children are also not fully autonomous, and the same sorts of questions are forced on parents, guardians, and health care workers.

Like all the other major principles discussed here, respect for autonomy is thought to be prima facie. It can sometimes be overridden by considerations that seem more important or compelling— considerations that philosophers and other thinkers have formulated as princi­ ples of autonomy restriction. The principles are articulated in various ways, are applied widely to all sorts of social and moral issues, and are themselves the subject of debate. Chief among

in conflict— if, for example, telling a patient the truth about his condition would somehow result in his death— a physician might decide that the duty of truthfulness should yield to the weight­ ier duty to do good for the patient.

Moral principles are many and varied, but in bioethics the following have traditionally been extremely influential and particularly relevant to the kinds of moral issues that arise in health care, medical research, and biotechnology. In fact, many— perhaps most— of the thorniest issues in bioethics arise from conflicts among these basic principles. In one formulation or another, each one has been integral to major moral theories, providing evidence that the principles capture something essential in our moral expe­ rience. The principles are (1) autonomy, (2) non­ maleficence, (3) beneficence, (4) utility, and (5) justice.4

Autonomy Autonomy refers to a person’s rational capacity for self­governance or self­determination— the ability to direct one’s own life and choose for oneself. The principle of autonomy insists on full respect for autonomy. One way to express the prin­ ciple is: Autonomous persons should be allowed to exercise their capacity for self-determination. According to one major ethical tradition, autono­ mous persons have intrinsic worth precisely because they have the power to make rational decisions and moral choices. They therefore must be treated with respect, which means not violating their autonomy by ignoring or thwarting their ability to choose their own paths and make their own judgments.

The principle of respect for autonomy places severe restraints on what can be done to an autonomous person. There are exceptions, but in general we are not permitted to violate people’s autonomy just because we disagree with their decisions, or because society might benefit, or because the violation is for their own good. We cannot legitimately impair someone’s autonomy without strong justification for doing so. Con­ ducting medical experiments on patients without