Читать книгу This Is Bioethics - Udo Schüklenk, Ruth F. Chadwick - Страница 8

1.1 Imagine you were running a medical non‐governmental organization (NGO) established to preserve the lives of poverty‐stricken people in resource poor countries. Your NGO is also usually among the first to provide emergency assistance in case natural emergencies such as tsunamis strike. However, you did notice that agencies evaluating your efficiency¹ give you a below‐average ranking. That is a worry to your fundraising staff, mostly because you rely on donations and such ratings are said to impact eventually negatively, on your capacity to raise cash. You investigate what the problem is, and it turns out that the ratings agency is critical of your policy of responding mostly in cases of high‐impact disasters such as earthquakes, floods or civil wars, because they invariably require a highly resource intensive intervention. The agency’s verdict is that, on the same capital outlay, you could preserve more lives in developing countries if you aimed at establishing medium‐ to long‐term health delivery solutions, including setting up primary health care facilities, beginning vaccination programs, and other such relatively low‐cost means. Chartering private jets to fly emergency teams in response to disaster also preserves lives deserving to be rescued, the ratings agency says, but it demonstrably results in a substantially lower number of lives preserved than you could preserve if you dropped such actions in favor of working toward better health care delivery infrastructure in the countries you usually serve.

1.2 So, if your objective is to preserve lives in developing countries, the ratings agency might be correct in saying that you only preserve a suboptimal number of lives. You could do better. Should you change your policy though? After all, what the ratings agency proposes implies, if you were to act on it, is that those in most dire need, say those living in war‐torn countries with minimal health care infrastructure, should be toward the bottom end of your list of priorities, because assisting such people would cost more – per life preserved – to succeed. All other things being equal, more lives could be preserved if the NGO focused on preserving not those most in need but perhaps those whose lives are also threatened but who could be helped with the deployment of fewer resources. Should we only care about the number of lives preserved then, or do other factors matter, too, such as for instance that some people, possibly due to no fault of their own, live in particularly abysmal conditions? Should we factor in the amount of resources required to nurse such people back to a life that would permit them to live independently? Should the age of the to‐be‐rescued matter? Should it matter whether they have a family dependent on their support? Questions such as these are fundamentally ethical questions. And this chapter is about ethics, it is about right and wrong, good and bad, and how we can go about judging alternative courses of action that might be available to us.

1.3 What are the fundamental purposes of ethics then? Unsurprisingly, one of the purposes of ethics is to offer us clear action guidance when we are faced with a particular ethical problem. Of course, action guidance alone is not sufficient, or else an ethicist telling us what we ought to do is not much different to what a preacher or a taxi driver, engineer or medical doctor could tell us. Anyone can admonish us to do this or do that when faced with an ethically challenging situation. All of us almost certainly would have a view on what the NGO chief should be doing. In fact, most of us would probably happily add our two cents worth of opinion when asked what we think the NGO chief should do, policy wise. Thinking about what she ought to do engages with ethics. That takes us to the second objective of ethics. It is to do with the normative justification for the advice given. The preacher’s advice would derive its authority from the claim that she knows what a higher authority (say a God) wants us to do. Of course, many people today are atheists² or agnostics³, and many of those who are not atheists hold a large number of different deities dear to their hearts, all with competing action guidance derived from their respective sources of godly wisdom. For all we know, the taxi driver and engineer might just reply that that is how they feel, or possibly even think, about the problem at hand. Let us leave aside, for a moment, that in ancient Greece there were no taxi drivers or engineers as we understand them today. During those times their approach to ethics would have led to them being labeled as Sophists⁴, that is a group of philosophers who subscribe to the view that there are no objectively right or wrong answers to ethical questions, and that answers to ethical questions are at best reflective of someone’s subjective, strongly held beliefs or feelings. What gave way to the birth of modern ethics were philosophers like Plato⁵ and his teacher Socrates who both believed that we can actually give right or wrong answers to questions about what is ethically good or bad. We will return to their take on ethics in a moment. How might the medical doctor in our example respond to the ratings agency’s ethical challenge? Trying to do better than the Sophists of the world, she could refer to guidance documents issued, for instance by her national medical association’s ethics people⁶, or those issued by the World Medical Association⁷, a worldwide umbrella organization of national medical associations, or possibly the World Health Organization⁸. But what if these organizations have actually omitted to address the problem at hand in their guidance documents? And, even if they haven’t, quotes from a document don’t constitute an ethical justification. What if the document quoted got it wrong? It turns out, we have good reason to be skeptical about famous historical medical guidance documents such as the Hippocratic Oath⁹. Robert M. Veatch explains why the Hippocratic Oath isn’t a document medical professionals ought to aspire to. According to Veatch just about everything is wrong about it, from its pledge to questionable Greek deities to a cultish understanding of medicine as a secretive practice to practical guidance that prioritizes individual patient interest always over the greater good of the society (Veatch 2012a, 10–29). To put it in Veatch’s own words, ‘the Oath is so controversial and so offensive that it can no longer stand alongside religious and secular alternatives. […] The Hippocratic Oath is unacceptable to any thinking person. It should offend the patient and challenge the health care professional to look elsewhere for moral authority’ (Veatch 2012a, 1). Veatch tells us, somewhat reassuringly, that the Oath today is used in so many variations in the world’s medical schools that sometimes only fragments of the original document seem to remain (Veatch 2012b).

1.4 Be mindful that even if we agreed with the content of the Hippocratic Oath or a modern version of it, and even if they actually provided us with guidance for the problem under consideration, we would again have to take it on authority that we should go about the NGO’s problem in one particular way and not in another, unless there is an ethical justification provided why we should do what it admonishes us to do. Given that in our scenario almost certainly a lot of people would disagree with whatever it is that is being proposed, policy wise, it is important that we get our justification right. Here is where ethics’ second purpose comes in: In addition to providing us with action guidance, it must also provide us with a reasoned justification for the guidance given.

1.5 As we will discover, there exist a fair amount of competing ethical theories, some more influential than others, that succeed with varying degrees of success both on the action guidance as well as on the action justification fronts. How should we decide then, which one, or which set of them to adopt for our own purposes? Is it ok to use one set of theories for one type of problem and another set of theories for another type of problem? Couldn’t we choose virtue ethics for decision‐making at the hospital bedside, but decide to go with utilitarianism for matters of resource allocation decision‐making? But why should we do that, as opposed to just the opposite? Could there be a meta‐theory telling us which theoretical approach to deploy under what circumstances? Or must we determine which theory is the right one and try to abide by its guidance as best as we can, even if some of that guidance is turning out to be deeply counter‐intuitive? Well, these are questions about the nature of ethics; they ask whether there can be a true ethics, whether ethical statements must be of a particular kind, whether they can be objectively true or false, or whether they ultimately boil down to statements expressing our feelings. These and other questions are typically analyzed by meta‐ethicists. They don’t create ethical theories, rather they create theories about ethics. There are also legitimate questions about the extent to which ethical theories truly lend themselves to be ‘applied’ in some sense or another to problems such as the one mentioned at the beginning of this chapter. We will not engage in this sort of theorizing about ethics in this chapter, with the exception of a few paragraphs on ethical relativism. The reason for this is that the discussions driving meta‐ethics are quite technical in nature, and by and large there is no obviously correct solution to many of its controversies. Even in the absence of final answers to many of these questions, however, it is still quite possible to undertake ethical analyses. As we will see throughout this book, some arguments are more plausible than others; certain types of argument, such as for instance slippery‐slope based arguments, are almost always flawed, and so on and so forth. However, you can easily read up on meta‐ethical theories elsewhere. (McMillan 2018) A wonderful source of superb on‐line Open Access content, written usually by the some of the best philosophers around, is the Stanford Encyclopedia of Philosophy. Check, for instance its entry on Theory and Bioethics¹⁰ (or Singer 1991, Part VI: The Nature of Ethics).

1.6 Bioethics is specifically concerned with normative issues in the biomedical and life sciences. Bioethicists hail these days from many different disciplines, including theology, law, medicine, sociology and many others. Think of typical problems bioethicists analyze in their research: Should we permit editing of the human genome? Is it acceptable to use sentient animals in clinical research? Is abortion wrong? Should we decriminalize assisted dying in some form or shape?

1.7 Theologians will be able to tell us what a respective religion would make of the problem at hand. Legal experts could tell us what the law currently says with regard to any of these issues; they might even bravely venture into an analysis suggesting that the law ought to be changed, if they find it to be a violation of their country’s constitutional values. Health care professionals should be able to enlighten us with regard to what their professional values have to contribute to these difficult questions. Sociologists do what sociologists do best, they will ask other people, say taxi drivers, philosophy students, or a representative sample of a given group of people, what their take is on these questions. None of these discipline‐specific responses is capable of enlightening us in a moral or ethical sense. The problems flagged earlier can all be read as asking fundamental ethical questions, namely: Is it ethical to alter the human genome? Is it moral to use sentient animals for clinical research purposes? Is abortion immoral? Is the criminalization of assisted dying ethically defensible? Bioethics relies first and foremost on ethics to sustain reasonable defensible answers to these questions. However, it is not the type of ethics that many armchair philosophers would recognize as traditional philosophical ethics. There can be no doubt that bioethical reasoning is not as deep or watertight as, for instance, meta‐ethical reasoning aims to be. Rather, with few notable exceptions, it aims to use the normative frameworks, that we will be looking at, as a rough guide indicative of where, say a utilitarian analysis would lead us when we consider the morality of abortion and infanticide. These frameworks are also useful as tools of critical analysis. They offer us some pretty good guidance and guidance justification on the types of criteria that we might apply when we go about asking, for instance whether abortion is a morally good or bad thing. They could even help us taking a considered ethical stance on markers of fetal development that are frequently argued over by activists and legislators alike. Say, does the moment of conception confer moral standing on the developing human? Or, does the capacity to feel anything matter? Does it matter whether an embryo would be capable of surviving outside the pregnant woman’s womb? These are the types of questions that ethical theories can indeed shed new light on.

1.8 Before we try to get a quick overview of major ethical theories that exert today a significant influence in bioethics, let us briefly address a few other preliminary issues, namely, that of the place of religion in ethics, the relationship between the law and ethics, the challenge ethical relativism poses particularly in the context of bioethics, and the not completely irrelevant question of why we should bother being ethical to begin with.