The theme of the June issue of Medicine & Philosophy is disagreements among bioethicists. This is an interesting topic in its own right (see the extract from the Introduction to the issue below), plus there are a few articles that especially appealed to me. The discussion of cognitive enhancement appears to argue for a more tolerant attitude toward enhancement drugs based on an attitude of humility, plus toleration and transparency. There’s also an article that points out how we assume the art of clinical medicine is an innate skill and that, as a result, we fail to teach it.
Note that nothing is this journal is open access (and also that I have added the emphasis).
I. BIOETHICS AND DISAGREEMENT
Bioethics was born in the 20th century out of an attempt to cope with rapidly and radically developing medical technologies, especially as they arose around the time of the Second World War. Albert R. Jonsen, one of the founders of bioethics, writes in reminiscence:
New techniques, from antibiotics to transplanted and artificial organs, genetic discoveries, and reproductive manipulations, together with the research that engendered them, presented the public, scientists, doctors, and politicians with questions which had never before been asked. (Jonsen, 2000, 115; cf. Jonsen, 1998)
But more importantly, bioethics arose as well due to major cultural changes that marginalized previous approaches to moral issues in health care and that brought into question medical ethics as an enterprise grounded in the medical profession.
Philosophers, theologians, social scientists, and lawyers joined scientists and physicians in confronting what appeared to be unprecedented challenges (Jonsen, 1998; Engelhardt, 2012). Things have changed since then, in that bioethics is now a well-established field. However, there is an increasing uncertainty as to the foundations and significance of bioethics itself (Beauchamp, 2004; Cherry, 2012). But perhaps just as tellingly, in the view of some, one thing seems to remain the same. Some might complain that about 40 years since its inception, bioethicists are still arguing—and arguing about the very same things, or at least the very same kinds of things. Disagreement seems stark: in many cases philosophers, theologians, social scientists, lawyers, scientists, and physicians are departing from differing first principles. Philosopher Alasdair MacIntyre recognizes this radical state of the disagreement (MacIntyre, 1984), while arguing for a positive proposal for how to move forward (MacIntyre, 1988, 1990, 2009).1 Yet, MacIntyre does seem to be importantly right about the extent of the disagreement. In important ways, the collection of essays in …
Mark Schweda and Silke Schicktanz
The ongoing bioethical debate about organ markets rests not only on theoretical premises, but also on assumptions regarding public views of and attitudes toward organ donation that need closer socioempirical examination. Summarizing results from our previous qualitative social research in this field, this paper illustrates the ethical significance of such public moralities in two respects: On one hand, it analyzes the implicit bias of the common rhetoric of “organ scarcity” which motivates much of the commercialization debate. On the other hand, it explores the blind spots of the paradigm of “altruistic donation” which informs many arguments against commercialization. We conclude that the ethical discourse has to appreciate the social nature of organ donation as a reciprocal interaction between different parties with irreducibly different but equally relevant viewpoints. We criticize the neglect of such well-founded public considerations in certain philosophical-ethical approaches and stress the need for further systematic and comparative socioempirical studies about peoples’ actual perspectives in bioethics.
James Stacey Taylor
Schweda and Schicktanz argue that the debate over the ethics of using financial incentives to procure human transplant organs rests on socioempirical premises that need to be critically assessed. They contend that once this is achieved a completely new perspective on the debate should be adopted, with organ donation being viewed primarily as a reciprocal social interaction between donor and recipient. This paper challenges this conclusion, arguing that rather than supporting a new perspective on the debate over the commercial procurement of organs, the observations of Schweda and Schicktanz support the view that human organs should be commercialized.
Abortion critics have argued that one should err on the side of life and prohibit abortion since the status of the fetus is uncertain. David Boonin has criticized this precautionary argument, but his criticism has been ignored. The aim is to elaborate on the precautionary argument by responding to Boonin’s criticism. Boonin considers three versions of the precautionary argument—the disaster avoidance argument, the maximin argument, and the expected utility argument; yet all three are judged unsuccessful for the same reasons: they lead to unacceptable implications, they lead to conclusions that are too weak, and they undermine the integrity of moral reasoning. I respond to this criticism by arguing that one can avoid unacceptable implications by considering a criterion of realism, that the weaker conclusions are rather an advantage, and that the application of the precautionary principle makes room for considerations which maintain the integrity of moral reasoning. I also consider some criticism beyond Boonin’s objections.
Walter E. Block
There is a new sheriff in town on the abortion question. It is called evictionism. It diverges, philosophically, from both the pro-life and the pro-choice positions. It assumes that the birth of a human being starts with the fertilized egg but claims that the unwanted baby is a trespasser that may be evicted in the gentlest manner possible.
The use of cognition-enhancing drugs (CEDs) appears to be increasingly common in both academic and workplace settings. But many universities and businesses have not yet engaged with the ethical challenges raised by CED use. This paper considers criticisms of CED use with a particular focus on the Accomplishment Argument: an influential set of claims holding that enhanced work is less dignified, valuable, or authentic, and that cognitive enhancement damages our characters. While the Accomplishment Argument assumes a view of authorship based on individual credit-taking, an impersonal or collaborative view is just as possible. This paper considers the benefits of this view—including humility, a value often claimed by critics of enhancement—and argues that such a view is consistent with open CED use. It proposes an ethics of cognitive enhancement based on toleration, transparency, and humility, and it discusses how institutions and individuals can build a culture of open cognitive enhancement.
Jason Adam Wasserman
Calls for incorporating social science into patient care typically have accounted for neither the logistic constraints of medical training nor the methodological fallacies of utilizing aggregate “social facts” in clinical practice. By elucidating the different epistemic approaches of artistic and scientific practices, this paper illustrates an integrative artistic pedagogy that allows clinical practitioners to generate social scientific insights from actual patient encounters. Although there is no shortage of calls to bring social science into medicine, the more fundamental processes of thinking by which art and science proceed have not been addressed to this end. As such, the art of medical practice is conceptualized as an innate gift, and thus little is done to cultivate it. Yet doing so is more important than ever because uncertainty in diagnosing and treating chronic illnesses, the most significant contemporary mortality risks, suggests a re-expanding role for clinical judgment.
Charles D. Douglas, Ian H. Kerridge, and Rachel A. Ankeny
In an article somewhat ironically entitled “Disambiguating Clinical Intentions,” Lynn Jansen promotes an idea that should be bewildering to anyone familiar with the literature on the intention/foresight distinction. According to Jansen, “intention” has two commonsense meanings, one of which is equivalent to “foresight.” Consequently, questions about intention are “infected” with ambiguity—people cannot tell what they mean and do not know how to answer them. This hypothesis is unsupported by evidence, but Jansen states it as if it were accepted fact. In this reply, we make explicit the multiple misrepresentations she has employed to make her hypothesis seem plausible. We also point out the ways in which it defies common sense. In particular, Jansen applies her thesis only to recent empirical research on the intentions of doctors, totally ignoring the widespread confusion that her assertion would imply in everyday life, in law, and indeed in religious and philosophical writings concerning the intention/foresight distinction and the Principle of Double Effect.