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The right of Stephen Holland to be identified as Author of this Work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.

First published in 2003 by Polity Press in association with Blackwell Publishing Ltd

This edition published in 2017 by Polity Press

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ISBN-13: 978-0-7456-9059-9

ISBN-13: 978-0-7456-9060-5 (pb)

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Library of Congress Cataloging-in-Publication Data

Names: Holland, Stephen (Stephen Michael), 1963- author.

Title: Bioethics : a philosophical introduction / Stephen Holland.

Description: Second edition. | Malden, MA : Polity, 2017. | Includes bibliographical references and index.

Subjects: LCSH: Medical ethics. | Bioethics.

Classification: LCC R724 .H586 2017 (print) | LCC R724 (ebook) | DDC 174/.2–dc23

LC record available at https://lccn.loc.gov/2016018446

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Introduction

The aim of this book is to introduce bioethics by discussing some contemporary issues in a philosophical way. ‘Bioethics’ can refer to any ethical challenges presented by advances in the biological sciences, but here the subject is taken to be more restricted, in two ways. First, the focus tends to be on issues directly related to health and medicine; so, for example, the controversy surrounding genetically modified crops is discussed only in passing. Second, the book tends to concentrate on ethical challenges due to quite striking biomedical advances, such as those in genetics (though this isn't hard and fast, because traditional medical ethical issues, such as advance care planning and euthanasia, are also discussed). To introduce how the book is organized, take an example of a now well-established bioethical procedure, in vitro fertilization (IVF).

One way of debating the ethics of IVF might be called ‘journalistic’. This would involve describing IVF and debating its pros and cons. But in doing this some deeper questions would inevitably arise. For example, a major objection to IVF is that it produces embryos that are destroyed, and this is said to be morally objectionable because of the moral status of the embryo. This leads to further questions: what is ‘moral status’, and does the embryo really have it; if so, why? The objection to IVF here is that the embryo is destroyed; why is this bad, or wrong? Presumably because it ends a (very short) human life: so is it always wrong to kill a human being? Why is it wrong? Are there circumstances in which it is permissible to kill a human being outright, or otherwise foreshorten their life? In continuing the ‘journalistic’ debate, it would emerge that IVF selects between ‘possible people’, as when, for example, genetically defective embryos are discarded from an IVF programme in order to avoid genetic disease. This raises identity questions: who does and should get born, and what makes us who we are? Finally, in debating IVF another familiar argument would be encountered – namely, that it is an ‘unnatural’ procedure or ‘interferes with nature’. This is an intriguing and popular kind of argument; is there really anything in it, and, if so, what?

So, discussing IVF in this ‘journalistic’ way naturally leads to deeper questions. In particular, questions of four kinds emerge: about moral status; life, death and killing; personal identity; and interfering with nature. Each of these deeper questions arises in numerous bioethical discussions other than the one about IVF. For example, the moral status of animals is crucial to the current controversy surrounding xenotransplantation. The value of human life, and death and killing, are central to the euthanasia debate. Identity questions arise in various disputes: a worry about advance care plans, such as advance decisions to refuse treatment, for example, is that they shouldn't be invoked because the author and the patient are literally different people. And it's not just IVF that is sometimes called ‘unnatural’: genetic enhancement techniques and cloning are, too. Also, an aim of this book is to discuss bioethics in a philosophically informed way, and each of these deeper questions is philosophically rich in itself. So there's an exciting opportunity here to bring together diverse bioethical issues that share common, philosophically interesting, foundations.

To this end, the book comprises four parts, each of which considers one of the four themes mentioned: moral status; life, death and killing; personal identity; and the normativity of the natural. To look further at these let's first consider moral status. All bioethical problems involve entities that have moral status. For example, one of the main reasons IVF, abortion, animal experimentation and organ transplantation are morally problematic is that embryos, foetuses, animals, and cadavers and body parts of dead patients seem to have moral stature. If it weren't for the moral status of these entities, there would be no – or, at least, much less – moral controversy. Some bioethical issues actually turn, at least largely, on the moral status of relevant entities. The two chapters in Part I discuss two contemporary bioethical disputes, over stem cell therapy and xenotransplantation, respectively, via the notion of moral status. Numerous kinds of entities are relevant because they stand to be affected by these biomedical innovations, including embryos, patients, human non-persons and non-human animals. Whether, to what extent, and on what grounds each of these has moral status – and the implications of this for the moral permissibility of these biomedical innovations – are discussed.

The second theme concerns life, death and killing. Part II discusses general principles that might inform cases in which the life of a patient could be, but is not, preserved or lengthened. Three such principles are considered. First, the sense in which life is valuable might be thought to inform the ethics of life-ending; but it is argued in chapter 3 that there is an important intuitive distinction between valuing life ‘in itself’ and valuing only life of sufficient quality. Despite attempts to reconcile these two accounts of life's value, the clash keeps recurring. Chapter 4 addresses a second principle, based on the definition and diagnosis of death. The shift from cardiorespiratory to brain-related definitions of death is important to this, as is the dispute over whole versus higher-brain criteria of death. But there is deep irreconcilability here because our concept of death is so rich and complex that there are bound to be cases where we don't know whether a patient is dead or alive. Chapter 5 focuses on a third life-ending principle. We have a moral preference for passive as opposed to active euthanasia. This is underpinned by the moral distinction between killing and letting die, but it seems that, although killing and letting die are morally distinct, this is only one of a myriad of factors that make a moral difference in specific cases of life-ending. Hence, Part II concludes on the sceptical note that none of the life-ending principles considered is as useful as might have been hoped.

The third theme is personal identity. A useful, down-to-earth way to introduce this is as the ‘someone else problem’ (DeGrazia 1999b). Three ‘someone else problems’ are discussed in part III. Chapter 6 addresses pre-implantation genetic intervention. Suppose a fertilized human ovum is genetically modified in a very radical way to avoid genetic-based disease or disability. Is the person who comes into existence different from the one who would have done so otherwise? If so, the intervention does not improve the life of an individual; rather, the genetic modification substitutes a disabled individual with a healthier alternative. This would alter the ethics of the procedure because it would no longer count as a therapy. Chapter 7 focuses on advance care planning, such as advance decisions stating that the author refuses a certain treatment were they to become incompetent to consent. Advance decisions should be made by someone for themselves, but some medical conditions drastically alter people. Suppose, for example, the author of an advance decision develops Alzheimer's disease and undergoes major psychological changes. Is the patient still the author? If not, then presumably it is morally impermissible to invoke the advance decision when deciding on treatment. This theme is pursued in chapter 8 by focusing on a particular case study. Brain-injured patients in the ‘minimally conscious state’ evince only fleeting and intermittent awareness of themselves and their environment. Should such patients be allowed to die? In particular, should an advance decision be invoked or is the minimally conscious patient someone other than the person who made the advance decision?

The final theme is interfering with nature. As mentioned above, new reproductive technologies such as IVF, and feasible practices based on genetics – such as genetic enhancement and cloning – are often greeted with the complaint that they are ‘unnatural’. This is initially puzzling. After all, we've been interfering with nature to our (overall) benefit throughout history. Also, there are some apparently obvious and powerful rejoinders to any arguments based on ‘the natural’. Part IV develops a way of making sense of this appeal to nature, suggested by a philosopher, Richard Norman. The key idea is that ‘nature’ provides some background conditions against which we can make significant choices and live meaningful lives. The ‘argument from nature’ is an expression of anxiety in the face of a threat – in the form of biomedical innovations – to some of that background. Part IV comprises three chapters, each of which applies Norman's line of thought to a biotechnology, namely, managing reproduction, genetic enhancement and human cloning, respectively.

A further comment by way of introducing the book is that, at various points in the following discussions, an explicit appeal is made to our ‘intuitions’: for example, in the claim that we share the ‘intuition’ that animals matter, morally speaking. This use of ‘intuition’ is not philosophically loaded – not a commitment to some form of ethical intuitionism – but simply refers to typical, not particularly philosophical, responses and judgements that people tend to have and make. On the other hand, this is not meant to endorse the attitude that whatever we happen to think about a bioethical problem is morally correct. Rather, in the kinds of matters that make up contemporary bioethics, in the end we often find ourselves in the somewhat disconcerting position of relying on our shared and familiar responses and judgements about things. But there is plenty of philosophy to do before we get to such a point, in terms of clarifying problems, prioritizing relevant considerations, and discussing and dispensing with dubious options. And, of course, things might be turned on their head, in that philosophical reflection might reveal intuitions to be untenable and in need of revision.

A grasp of normative moral theory is required to address practical ethical problems. It is assumed here that readers will be familiar with normative moral theories because it isn't practicable to introduce and discuss these in this book. (There are plenty of excellent introductions to normative theory, including Kuhse and Singer 1998; Rachels and Rachels 2012; Timmons 2012.) Nonetheless, there is one important theoretical point that forms the conclusion to the book. Generally speaking, biomedical policy tends to be informed by utilitarianism, and it is tempting to emphasize utility in bioethical discourse. But the four themes around which this book is organized are deontological, not consequentialist. The moral status of a relevant entity, principles concerning life, death and killing analysed in part II, that a treatment compromises personal identity, and whether a biomedical innovation is ‘against nature’, are all putative deontological, as opposed to consequentialist, constraints on medical acts, practices and policies.

Finally, this is the second edition of the book that appeared in 2003. Much has moved on in the decade-and-a-half since the first edition, in both bioethics and the author's thinking on these matters. This is reflected in the ways the book has changed. All the chapters are updated in the light of developments in biomedicine, philosophical bioethics and societal changes to legislation and policy. Some chapters – notably, chapters 1 and 4 – have been completely rewritten to reflect better the author's current views on these matters. And there are new discussions of topics that became prominent since the publication of the first edition, such as the minimally conscious state (chapter 8) which was established as a diagnostic category in 2002. But it is striking and pleasing that, for all the developments in this fast-changing field, the themes of the book remain fixed points on the shifting landscape of the subject: moral status, personal identity, life and death, and the argument from nature continue to be central concerns in bioethics.

Copyright page

Dedication

Introduction

Part I
Moral Status

Introduction to Part I