Arthur L. Caplan, Guest Editor
Arien Mack, Journal Editor
The time seems ripe for an examination of both the appropriateness of applied work in philosophy and an analysis of the substantive contribution philosophers, theologians, and humanistically minded social scientists and lawyers have made to the resolution of practical problems. The subject area which has attracted the interest of the greatest number of philosophers and others interested in the application of philosophical methods and skills to public affairs and policy is what has come to be known as bioethics.
Philosophy seems to have been paroled from the ivory tower. How can we best use it once it is loose? How shall we avoid the various kinds of trouble which gave reason for locking it up in the first place? This seems to be part of the wider question: how are we to apply our thinking to reality? How can we close the gap which so often opens between theory and practice? One of the jobs of philosophy is to find and formulate the rules which underlie sense, the inarticulate patterns by which it works, and to try and deal with their conflicts.
The study of genetic engineering has shown a singular talent for attracting public approbation as well as exciting public fears. But it is not our increasing though still primitive ability to read the genetic language that stirs public hopes and fears; it is rather our new-found skill at editing. This is the fearsome wizardry of genetic engineering. An important part of the discussions that should take place is consideration of ethical issues.
As long as the creations of technology are inanimate objects, as has always been the case hitherto, it is still “man” who has to activate them, and who chooses to bring about their further development by means of new invention, even though this choice is largely deprived of its options and pushed in the single direction of going ahead. However, this will not be the case if the creations of technology are living creatures.
When confronted with complex ethical questions, it is tempting to look for a simple answer; and in this case, a simple answer seems to be available: that all human life is of equal worth. On this view, the life of a Down’s syndrome baby is no less valuable than the life of a normal baby. Since all human life is of equal worth, it is as wrong to let a Down’s syndrome baby die, when it could be kept alive, as it would be to let any other human beings die when they could be kept alive. This simple answer gains support from two quite distinct sources. One is the traditional doctrine of the sanctity of human life; the other is the belief in human rights.
In this essay I shall consider an argument that is often made in discussions of methods of influencing people’s behavior. This argument states that control of one person by another is constantly taking place, but in an implicit and unconscious fashion, and that it would be preferable for control to take place on a systematic and explicit basis.
The concept of competency is generally thought to be a continental divide of sorts in the ethics and public policy of medicine. Patients on one side of the watershed of competency get to make treatment decisions, while those on the other side do not. Brief experience with competency determinations, however, reveals that law, ethics, and medicine are less neat and more complicated than the sure ridge line of the continental divide. Competency appears to be a binary concept, but on closer examination its binariness dissolves and vanishes, or remains tufted and turreted, hardly the clear guiding line for action expected.
Spurred by the hopes evoked by medicine’s power and by the fears about how that power might be used, the gay community has sparked an important debate that will test the capacity of American society to respond effectively and humanely to an unfolding tragedy. To this point the confluence of political and social forces that has emerged in the public encounter with AIDS has permitted a sympathetic hearing of the moral concerns that have been central to bioethics. Whether the social crisis that will be created if the spread of AIDS continues unabated will provide so hospitable a setting for those liberal values within which privacy and voluntarism are so important is far from certain.
The need to allocate scarce resources is an ongoing feature of the health-care system. Whether the resources in limited supply are organs, slots in a dialysis unit, blood, or highly trained medical and nursing personnel, the problem of selecting an appropriate means of distribution is a fundamental one. There is, however, evidence of a growing confusion concerning the need to allocate medical resources in a fair manner and the need to embark on rationing schemes. This confusion begins at a conceptual level, and is deepened by an uncritical acceptance of the assumptions about waste and overexpenditures on health care. The first steps in any philosophical inquiry are to clear up conceptual confusions and to critically examine the assumptions on which arguments rest.
Control over the information and images, the values and views, the signs and symbols conveyed to the public is a generally sensitive issue. Industries, political institutions, professional groups, and aspiring individuals all want to manage the messages that enter the cultural arena. Modern physicians, often working on the border between advanced research and medical practice, are no exception. As academics they have traditionally shunned publicity. Today, however, they employ sophisticated public relations techniques and communication controls to manage the news. The press is receptive to their efforts. Promising therapeutic advances and dramatic medical interventions are front-page news. The difficult ethical choices brought about by the increasingly sophisticated technical possibilities are of broad public interest.
A banality of societies bewildered by moral questions is that ethics produces no answers and is at best a weak guide to much of anything. That is sometimes said of biomedical ethics. But at one level it has produced any number of useful “answers” and helpfully clarified many difficult issues. These range from new insights into and widespread agreement on the definition of death, protection of human research subjects, informed consent, and patients’ rights to fruitful discussions of prenatal diagnosis, in vitro fertilization, termination of treatment, and hospital ethics committees. If brilliant formulations and innovative conceptualizations have been rare, that is hardly a situation unique to bioethics.