BCC Ethics Tuskegee Study Karen Ann Quinlan & Global Violence Discussion

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Read and give your opinion in writing of the following cases. Your opinion must be at least be a well formed paragraph.

Page 69. Tuskegee Study

Page 70 Death of Karen Ann Quinlan

Page 71. Surrogate Mother

Page 86-87. Drugs Devices and Disclosures

Page 89. Steve Jobs Liver Transplant

Page 116. Unmarried in Saudi Arabia

Page 120 Egyptian Doctor

Page 132 Global Violence Against Women

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Bioethics in a Cultural Context Philosophy, Religion, History, Politics VINCENT BARRY Professor Emeritus of Philosophy, Bakersfield College Australia Brazil Japan Korea Mexico Singapore Spain United Kingdom United States This is an electronic version of the print textbook. Due to electronic rights restrictions, some third party content may be suppressed. Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. The publisher reserves the right to remove content from this title at any time if subsequent rights restrictions require it. For valuable information on pricing, previous editions, changes to current editions, and alternate formats, please visit www.cengage.com/highered to search by ISBN#, author, title, or keyword for materials in your areas of interest. Bioethics in a Cultural Context: Philosophy, Religion, History, Politics Vincent Barry Publisher/Executive Editor: Clark Baxter Senior Sponsoring Editor: Joann Kozyrev Editorial Assistant: Marri Straton Assistant Editor: Joshua Duncan Media Editor: Kimberly Apfelbaum Marketing Manager: Mark T. Haynes Marketing Communications Manager: Laura Localio Content Project Management: PreMediaGlobal © 2012 Wadsworth, Cengage Learning No part of this work covered by the copyright herein may be reproduced, transmitted, stored, or used in any form or by any means graphic, electronic, or mechanical, including but not limited to photocopying, recording, scanning, digitizing, taping, Web distribution, information networks, or information storage and retrieval systems, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without the prior written permission of the publisher. For product information and technology assistance, contact us at Cengage Learning Customer & Sales Support, 1-800-354-9706. For permission to use material from this text or product, submit all requests online at www.cengage.com/permissions. Further permissions questions can be e-mailed to permissionrequest@cengage.com Art Director: Jennifer Wahi Print Buyer: Mary Beth Hennebury Marketing Coordinator: Joshua Hendrick Cover Designer: Kate Scheible Cover Image: Shutterstock 3602589 Dandelion Compositor: PreMediaGlobal Library of Congress Control Number: 2010935861 ISBN-13: 978-0-495-81408-5 ISBN-10: 0-495-81408-3 Wadsworth 20 Channel Center Street Boston, MA 02210 USA Cengage Learning products are represented in Canada by Nelson Education, Ltd. Cengage Learning is a leading provider of customized learning solutions with office locations around the globe, including Singapore, the United Kingdom, Australia, Mexico, Brazil, and Japan. Locate your local office at international.cengage.com/region. For your course and learning solutions, visit academic.cengage.com Purchase any of our products at your local college store or at our preferred online store www.cengagebrain.com. Printed in the United States of America 1 2 3 4 5 6 7 14 13 12 11 10 To Jen-Li Rose at 12, keep that breathless charm Contents PREFACE xx Introduction: Bioethics, Schiavo, and Cultural Politics Bioethics 2 Ethics 2 Normative Ethics Metaethics 2 3 BIOETHICS ACROSS CULTURES Canada’s Terri Schiavo 4 Making Sense of Moral Conflict Issues 5 5 BIOETHICS ACROSS CULTURES Religion and HIV/AIDS in Africa 6 Adversaries 6 About This Book 9 CASES AND CONTROVERSIES Reproductive Flashpoints Refusal Legislation 10 Religion and Terminal Care References PART I 9 11 11 Two Enduring Traditions 13 Introduction: Sacred and Secular Foundations iv 13 1 CONTENTS Chapter 1 Medieval Religion and Enlightenment Science 15 Welcome To Technopia 15 The Medieval Church 16 The Authority of the Bible 17 The Biblical Account of Creation 17 Human Nature 17 The Relationship and the Covenant The Problem of Evil 18 The Augustinian Theodicy 17 18 The Doctrines of the Fall and Depravity 19 Moral Failure and Illness 19 Bi-level Conception of Sin 20 Medicine and the Supernatural Illness as Salvific 21 20 Role of Government and Law 21 Enlightenment Science 21 BIOETHICS ACROSS CULTURES Buddhism, Health, and Disease Scientific Method 24 Rene Descartes 24 22 The Emergent Scientific Medicine Mechanism 25 25 BIOETHICS ACROSS CULTURES Islamic Science 26 Implications for Religion Deism 27 Anthropic Mechanism 27 28 Personhood as Consciousness The Problem of Evil 29 Conclusions 28 29 CASES AND CONTROVERSIES What Doctors Think about Religion and Health Faith Flags 31 Criticism of Science and Its Method 31 The Life and Death of Jane Tomlinson References 32 32 30 v vi CONTENTS 2 Religious and Secular Ethics Divine Command Theory Scriptural Basis 36 Natural Law 35 36 36 The Doctrine of Double Effect Secular Natural Law 38 37 Legal and Moral Rights 38 Social Contract Theory 39 Kant’s Thought and Ethics 41 Philosophy’s “Copernican Revolution” 41 God, Morality, and the Problem of Evil Moral Choice 42 The Categorical Imperative 41 42 Social Interests 43 Moral Rights 43 Utilitarianism 44 Utility Principle 45 Moral Rights and the Harm Principle 45 BIOETHICS ACROSS CULTURES Bentham in Bhutan 46 Social Interests 47 Preference Satisfaction Conclusions 47 47 BIOETHICS ACROSS CULTURES Spain Extends Rights to Apes 48 CASES AND CONTROVERSIES The Jodie and Mary Twins’ Tragedy Life vs. Law 50 51 Crossing the Border to Sell Blood 51 Is Vaccinating Part of the Social Contract? References PART II 53 Origins and Context of Bioethics 3 55 Introduction: Triumph of Secularism 55 The Birth of Bioethics 57 The Emergent Patient Consciousness 57 52 CONTENTS BIOETHICS ACROSS CULTURES Africa Still Waiting for “The Sanitary Revolution” The New Frontier of Medicine 58 New Technology and Treatments 59 Advances in Reproductive Technologies Scientific Research 59 60 BIOETHICS ACROSS CULTURES Globalization of Clinical Research Court Decisions 61 61 Law at the Beginning of Life 62 Law at the End of Life 62 The Pioneers and Their Mind-Set The Theologians The Philosophers 63 63 64 Points of Difference 65 Common Ground 65 Utility and Autonomy 66 Faith in Rationality 66 A National Religious Identity The “Jeffersonian Compromise” Conclusions 68 66 67 CASES AND CONTROVERSIES The Tuskegee Study The Death of Karen Ann Quinlan 70 Surrogate Mother Elizabeth Kane 71 References 4 69 72 The Basic Principles of Bioethics Hippocratic Paternalism 74 The Belmont Principles 75 BIOETHICS ACROSS CULTURES Transcultural Human Rights Autonomy 77 Moral Limits 78 Secular and Religious Appeal Nonmaleficence 79 BIOETHICS ACROSS CULTURES Cross-Cultural Care Beneficence 81 76 81 79 74 58 vii viii CONTENTS BIOETHICS ACROSS CULTURES Traditional Medicine for the Hmong Justice 84 Conclusions 83 86 CASES AND CONTROVERSIES Drugs, Devices, and Disclosure 86 Medical Workers Involved in C.I.A. Interrogations The Steven Jobs Liver Transplant References 5 88 89 90 Applications 93 A Patient’s Bill of Rights Truthtelling 93 94 BIOETHICS ACROSS CULTURES East Asian Autonomy 95 Informed Consent 96 Deliberation 96 Voluntariness 97 BIOETHICS ACROSS CULTURES A Japanese Woman with Aggressive Leukemia 98 Kinds of Informed Consent 98 Advance Directives 99 Participation in Medical Research 100 BIOETHICS ACROSS CULTURES A Slow Dying in Nigeria Privacy and Confidentiality 101 102 DNA: The Genetic Fingerprint 103 BIOETHICS ACROSS CULTURES Baseball’s Genetic Testing in Latin America Conclusions 104 105 CASES AND CONTROVERSIES The Merenstein Case of Informed Consent 106 Jaffee v. Redmond (1996): Safeguarding Patient Communication 106 Jesse Gelsinger: The First Gene Therapy Death References 109 108 CONTENTS 6 Beyond Principlism I: Autonomy Under Attack 111 Feeling Betrayed by Principlism 111 The Critique of Autonomy 113 Patient Autonomy as Impoverishing Bioethics 113 Patient Autonomy Disallows Conscientious Objection 113 BIOETHICS ACROSS CULTURES Unmarried and Pregnant in Saudi Arabia 116 Autonomy As Overriding Professional Judgment 117 Suggested Offsetting Principles 117 The Ecological Principle 117 The Vital Institution Principle The Theonomy Principle 118 119 BIOETHICS ACROSS CULTURES Egyptian Doctor’s Honesty Backfires Participated Theonomy 120 121 CASES AND CONTROVERSIES When Plan B Doesn’t Work Guarded about Gardasil 122 122 Benitez v. North Coast Women’s Care Medical Group References 7 125 Beyond Principlism II: Alternative Perspectives Virtue Theory 127 Feminist Ethics of Care Justice 128 128 BIOETHICS ACROSS CULTURES Buddhist Virtue Care 124 129 129 The Emergence of Feminist Bioethics BIOETHICS ACROSS CULTURES Global Violence Against Women 130 132 Existential and Spiritual Dimensions of Illness Narratives 135 Narrative Theology and Ethics 136 BIOETHICS ACROSS CULTURES Bioethics in the Twenty-first Century Conclusions 139 138 133 127 ix x CONTENTS CASES AND CONTROVERSIES Forever Small: The Ashley Treatment 139 Dax Cowart: Burn Victim Wants to Die Gatekeepers Without Empathy References PART III 140 141 142 Issues at the Beginning of Life 145 Introduction: Headlines for Reproductive Ethics References 148 8 145 Conceptual Matters in Abortion and Reproductive Technology 149 Banning Abortion in South Dakota 149 Developmental Sequence of Human Life 150 First Trimester 151 Second Trimester 151 Third Trimester 151 The Ontological Status of the Unborn The Meaning of Human Life 152 152 The Meaning of Personhood 153 When Ontological Status is Attained 154 Hominization and Ensoulment 155 BIOETHICS ACROSS CULTURES Jewish Beliefs about Personhood Moral Status of The Unborn Religious Views 156 156 156 BIOETHICS ACROSS CULTURES Islamic Understanding of Fetal Development Secular Views 157 Scientific Views about when Life Begins The Genetic View 158 The Embryological View 158 159 The Neurological View 159 Additional Views 159 BIOETHICS ACROSS CULTURES Buddhism, Personhood, and Abortion Conclusions 161 160 157 CONTENTS CASES AND CONTROVERSIES The Language of Embryology 161 Is Commander Data a Person? 162 Fetal Life and Personhood References 9 163 163 The Abortion Debate I: Pre-Roe The Murder of Dr. George Tiller A Brief History 168 166 166 Life Matters Most: The Conservative Religious View 169 Religious Natural Law and the Principle of Double Effect 170 BIOETHICS ACROSS CULTURES Early Induction in Ontario Scriptural Teachings 171 171 The Mobilization of Pro-Choice Consciousness 173 BIOETHICS ACROSS CULTURES Abortions in Kenya 174 Philosophical Analyses of Abortion 175 BIOETHICS ACROSS CULTURES A Young Muslim Woman with a Complicated Pregnancy Religious Social Teaching and Activism 178 CASES AND CONTROVERSIES Sherri Finkbine and the Thalidomide Tragedy Grisworld v. Connecticut (1965) The Pre-Roe “Bad Old Days” References 179 180 182 182 10 The Abortion Debate II: Roe and Beyond Choice Matters Most: The Roe Decision The Religious Liberty Principle 185 Privacy 187 Roe and Cultural Conflict 188 Current Religious Sentiment 189 BIOETHICS ACROSS CULTURES Outrage in Brazil 190 Choice Under Attack 192 Culture of Life 192 BIOETHICS ACROSS CULTURES Mexico Legislates Personhood 193 The Creation of the Fetal Citizen 193 185 185 178 xi xii CONTENTS BIOETHICS ACROSS CULTURES Abortion Around the World Conclusions 196 197 CASES AND CONTROVERSIES Gonzales v. Carhart (2007) The South Dakota Script 200 Redefining Pregnancy References 199 201 202 11 The Assisted Reproduction Debate I: Principled Considerations 205 Test-Tube Babies 205 Assisted Reproductive Technology 206 Surrogacy 207 Ethical Debates 207 Rights 208 Procreative Liberty 208 Life 208 Respect for Human Life 210 Unity of Marriage, Sex, and Reproduction Religious Views 211 211 BIOETHICS ACROSS CULTURES Sunni and Shi’ a Views of Reproductive Technology Secular Views 214 Gender Liberation and Self-Determination BIOETHICS ACROSS CULTURES ARTs and Women in India 216 CASES AND CONTROVERSIES Dahl v. Angle: Who Owns Frozen Embryos? What to Do with Frozen Embryos? Love, Sex, and Marriage References 215 217 217 218 219 12 The Assisted Reproduction Debate II: Empirical Considerations 221 The Commerce of Reproduction Questions of Lineage 222 BIOETHICS ACROSS CULTURES Wombs for Rent in India 223 221 212 CONTENTS Religious Considerations 224 Legal Considerations 225 The Meaning of Family and The Well-Being of Offspring 225 BIOETHICS ACROSS CULTURES Dead Men To Father Children in Israel and England Conclusions 227 228 CASES AND CONTROVERSIES In re Baby M: First Surrogacy Case 229 Jacob v. Shultz-Jacob: Three Adults with Parental Rights Wanted: A Few Good Sperm for Choice Mothers References 232 13 The Prenatal Testing Debate I: Embryo Screening The Boy in the Plastic Bubble 235 Medical Uses of Pre-Implantation Genetic Diagnosis 236 Having Healthy Children 237 Creating Compatible Donors 237 Generating Embryonic Stem Cells 238 The Ethical Debate 238 Embryo Creation and Destruction 238 Trait Selection 239 BIOETHICS ACROSS CULTURES Eugenics Around the World 240 BIOETHICS ACROSS CULTURES Biotechnology in China 241 CASES AND CONTROVERSIES The Genetic Information Nondiscrimination Act The Genetic Matchmaker 242 243 Growing a Baby with a Disorder References 231 231 244 245 14 The Prenatal Testing Debate II: Sex Selection Proper use of Technology 248 Pre- vs. Postconception Technology Sexism 249 248 Sex Ratios in Local Populations 250 Commodification of Reproduction 251 247 235 xiii xiv CONTENTS BIOETHICS ACROSS CULTURES Chinese Bias for Baby Boys 251 BIOETHICS ACROSS CULTURES Clinics’ Pitch to Indian Émigrés Consumer Eugenics Conclusions 252 253 255 CASES AND CONTROVERSIES Genetic Risks: To Disclose or Not To Disclose? Made-to-Order Babies 257 Slouching Toward Gattaca? The Creation of “Synthia” References 256 258 259 259 15 The Stem Cell Debate I: Background and Terminology 262 Loosening the Stem Cell Binds 263 Embryonic and Non-Embryonic Stem Cells Differentiation Lines 265 264 265 Obtaining Stem Cells 266 Pre-Implantation or Spare Embryos Created Embryos 266 266 BIOETHICS ACROSS CULTURES Japanese Create Fatherless Mouse with Three Mothers Reprogrammed Stem Cells 267 267 BIOETHICS ACROSS CULTURES ESC Research in Iran 268 Cloning 268 CASES AND CONTROVERSIES The Pernkopf Anatomy Irreconcilable Differences The Missyplicity Project References 269 270 271 272 16 The Stem Cell Debate II: The Ethics of the Science Personal Ethics 274 Research Ethics 275 Destruction of the Early Embryo 275 274 CONTENTS BIOETHICS ACROSS CULTURES Embryonic Stem Cell Research Worldwide 278 Spare versus Created Embryos 278 Alternatives to Embryo Destruction 280 Social Ethics 282 Disruption of Traditional Understanding 283 BIOETHICS ACROSS CULTURES Human-Animal Hybrid in Britain Threats to Social Justice Conclusions 284 285 286 CASES AND CONTROVERSIES Cloning and Cultural Conflict NIH ESC Guidelines 286 287 Frozen Embryos: The Personal Decision Behind the Public Controversy References PART IV 288 289 Issues at the End of Life Introduction: Jack’s Back References 291 291 292 17 Definition and Criteria of Death 293 DCD and The Death of Ruben Navarro Traditional Heart-Lung Definition 295 Whole-Brain Death Definition 293 296 Challenges to the Whole-Brain Formulation 297 Return to the Heart-Lung Formulation 297 Adopt a Higher-Brain Formulation 297 Adopt a Brainstem Formulation 298 The Biological vs. Psychosocial Debate: Organisms vs. Persons 298 Death of the Organism: A Biological Perspective 299 BIOETHICS ACROSS CULTURES Japan’s Organ Transplantation Law 300 Death of the Person: A Psychosocial Perspective BIOETHICS ACROSS CULTURES A Cross-Cultural Perspective on Brain Death Lingering Questions about Brain Death Definition or Permission? 305 305 301 304 xv xvi CONTENTS Help or Harm? 306 Event or Process? Conclusions 307 306 CASES AND CONTROVERSIES Terry Wallis: The Man Who Woke Up After Nineteen Years 308 Baby Theresa 309 In the Conservatorship of Wendland References 310 311 18 Conceptual Issues in Suicide and Euthanasia The Assisted Death of Piergiorgio Welby 313 Suicide: The Problem of Definition 314 Self-Sacrificial Deaths Coerced Deaths Euthanasia 316 314 315 Definition: Narrow and Broad Interpretations Killing vs. Allowing to Die 317 316 BIOETHICS ACROSS CULTURES Suicide Tourists 318 A Distinction with or without a Difference? Voluntary and Nonvoluntary Decisions Voluntary Decisions 323 321 323 BIOETHICS ACROSS CULTURES “Compassionate Murder” in Canada Nonvoluntary Decisions Conclusions 324 324 325 CASES AND CONTROVERSIES Pope John Paul II: Life-Sustaining Treatments and Vegetative State 326 The Boston Declaration on Assisted Dying Barney Clark’s Key References 327 328 328 19 Suicide in the West: A Brief History The Suicide of Isadore Millstone 330 330 BIOETHICS ACROSS CULTURES Al-Qaida and Suicide Terrorism 332 Suicide as an Offense to God, Neighbor, Self: Plato and Aristotle 332 313 CONTENTS Suicide as a Rational Act: The Stoics 333 Suicide as Sinful: Augustine and Aquinas 334 Suicide as Beneficial to Self and Others: Hume On Suicide 334 335 Suicide as Violating Moral Responsibility: Kant The Argument from Free Will 336 336 The Argument from Human Nature 336 The Argument from Autonomy 337 The Argument from Divine Will 338 Suicide as a Social Utility: Bentham and Mill 338 BIOETHICS ACROSS CULTURES Field of Tears in South Korea Conclusions 339 340 CASES AND CONTROVERSIES The “Rational” Suicide of Carolyn Heilbrun Final Exit Network 341 The Suicide of Garrett Hardin References 340 342 343 20 The Assisted Death Debate I: Individual Morality 345 The Assisted Death of Velma Howard Principles 346 Utility/Happiness 345 346 Respect for Persons 349 Divine Command 351 BIOETHICS ACROSS CULTURES Englaro Case Tears Italy Apart Virtue 354 355 Roles and Professions 357 BIOETHICS ACROSS CULTURES The Groningen Protocol 358 CASES AND CONTROVERSIES The Coup de Grace 360 Hurricane Katrina: Mercy Killing When Disaster Strikes 361 Does Responsible Care Include Assisted Dying? References 363 362 xvii xviii CONTENTS 21 The Assisted Death Debate II: Social Policy and Law 366 The Final Campaign of Booth Gardner 366 Individual Rights 368 Human or Moral Rights Welfare Rights 371 368 BIOETHICS ACROSS CULTURES YouTube Plea from Australia Equality 372 373 Disparate Impact 373 The General Welfare 375 State Paternalism 376 BIOETHICS ACROSS CULTURES World Legal Opinion on Assisted Death Conclusions 378 380 CASES AND CONTROVERSIES Oregon’s Death with Dignity Act Dying and the War on Drugs Baxter v. Montana 382 383 The “Euthanasia Underground” References 381 384 385 22 Rationing Health Care at the End of Life The Death of Barbara Wagner 388 389 Health Care Rationing 390 Arguments for Age-Based Rationing 391 The Fair Innings Argument 392 The Prudential Lifespan Account 392 Arguments Against Age-Based Rationing The High Cost of End-of-Life Care Rationing by Medical Futility 394 393 394 Physician Beneficence vs. Patient Autonomy Arguments for a Judgment of Futility 396 Professionalism 396 Responsible Stewardship 397 Arguments Against a Judgment of Futility BIOETHICS ACROSS CULTURES QALY in the UK 398 395 397 CONTENTS No Consensus about the Definition of Futility Uncertain Prognoses/Mistaken Diagnoses Social Contract 400 Conclusions 400 401 CASES AND CONTROVERSIES The Case of Helga Wanglie 401 Gilgunn-Massachusetts General Hospital The Death of Toddler Emilio Gonzales References 398 402 403 404 Conclusion: Bioethics, Religion, and Liberal Democracy Religious vs. Secular Bioethics Liberal Democacy 410 408 Rethinking the “Jeffersonian Compromise” Unprovable First Principles of All Worldviews Double Standard 412 No Common Ground for Dialogue 413 Toward an Overlapping Consensus 413 BIOETHICS ACROSS CULTURES Cross-Cultural International Bioethics Religion in Public Bioethics 415 CASES AND CONTROVERSIES The Battle Over Bioethics 417 References INDEX 421 419 414 411 411 408 xix Preface T he seeds of this book were sown in the spring of 2005 when Congress intervened in the matter of Terri Schiavo, a patient described by physicians as “vegetative.” The widely publicized case pitted the wishes of Terri’s husband, Michael, who wanted his wife’s feeding tube removed, against the objections of her birth family, the Schindlers. The courts and prominent bioethicists framed the conflict as a dispute over what Terri wanted and who should say. Mainstream media used it to show how politicized bioethics had become. Largely left unexamined, it seemed to me, were deeper, philosophical questions stoking the controversy. Schiavo passed but not its hold on me. The more I thought about it, the more the case struck me as paradigmatic for what frequently happens whenever we go beyond the procedural aspects of bioethical decision making and think deeply about the decisions themselves. We come to realize that controversial ethical issues often are not about ethics at all but about other more philosophical concerns, such as our understanding of human nature and destiny, truth and authority, meaning and value, or the proper relationship between individual and society. Indeed, many of the controversial moral problems of today’s biological science and medicine are like this. It is not so much that they invite opposed moral viewpoints but that they evoke irreconcilable answers to profound, underlying questions: What is a human being or a person? When does human life begin and death come? How do medicine and the broader culture situate death in human life? Are illness, pain, suffering, and death evils to be defeated, or can they have transcendent value? What kind of universe do we occupy—one with meaning and purpose or a universe utterly indifferent to human affairs, including our pain and suffering? What is the ideal society? What practices does it allow and prohibit? xx PREFACE How are we to know all these things—on whose authority? Must we, in the end, rely totally on ourselves or is there some higher knowledge? Such questions suggest that much of the controversy in bioethics is traceable to perennial philosophical debates. Is there any value in placing today’s bioethical dilemmas in their ancient philosophical context? I think there is. It can depoliticize them and put them at a more human level. We see that these dilemmas play out in bioethics but they are not limited to this and addressing them in bioethics requires addressing them elsewhere as well. Reflections such as these inspired Bioethics in a Cultural Context—Philosophy, Religion, History, Politics. BCC offers a fresh approach to introductory bioethics by examining the subject through a wider lens than the customary issue analysis. Yes, the text covers all of today’s hot-button bioethical controversies related to life’s beginning and end. But rather than merely scanning views with their supporting argumentation, the text places the issues in cultural and historical context and delves into the philosophical and religious subsoil that makes them so divisive and, daresay, so interesting. BCC, in brief, endeavors to enrich the material that is generally considered in introductory bioethics by going beyond today’s most polarizing bioethical controversies to show how they have arisen and why the answers are important. STRUCTURE BCC is divided into four parts, with introduction and conclusion. The introduction sets the theme, provides a road map for the book as a whole, and helps students make sense of moral conflict. PART I SACRED AND SECULAR FOUNDATIONS provides a survey of the major historical influences on Western bioethics and its practice. PART II ORIGINS AND CONTEXT OF BIOETHICS surveys the figures, thought, and events that contributed to the founding of modern bioethics; it also discusses the field’s basic principles, the contemporary critique of them, and several alternative perspectives. PART III ISSUES AT THE BEGINNING OF LIFE extends understanding of the foundations, origins, and context of bioethics to notable issues in reproductive medicine. PART IV ISSUES AT THE END OF LIFE joins the main controversies that surround personal decisions and public policy at life’s end. The conclusion gives unity to the text as a whole by reviewing its key concepts and controlling idea in the context of the divide between secular and religious perspectives in modern bioethics. xxi xxii PREFACE ORGANIZATION The central notion around which BCC is organized is that controversial bioethical issues and cases raise ultimately persistent questions whose origins are not really unique to bioethics and whose answers have implications ranging far beyond. A lively introductory chapter sets this theme by using Schiavo as a focal point for showing that, while many biomedical issues are new, the fundamental differences they raise between ways of knowing and understanding are as old as Western civilization itself. Given its historical sensibilities, the text turns immediately in Chapter 1 to the West’s two major traditions of knowing and understanding: medieval religion and Enlightenment science. Chapter 2 shows how these different ways of perceiving the world led to different and enduring ways of doing ethics, with particular regard to divine command theory, religious and secular natural law, Kant’s ethics, and utilitarianism. Taken together, Chapters 1 and 2 provide rarely given but valuable background for understanding the historical tensions between the religious/theological and the secular/philosophical that came to shape the conception of bioethics and were ultimately resolved in favor of secularism, only to reassert themselves in the bioethical and political controversies that today surround issues of birth and death. Discussion of the philosophical and religious roots of bioethics sets up in Chapters 3 through 7 a presentation of the field’s origins and context. Chapter 3 shows how Enlightenment-bred values and ideals of secular modernity characterized the intellectual milieu that formed after World War II and peaked at the dawn of modern bioethics. It surveys the social climate, medical advances, and court rulings that contributed to the urgency for bioethics in the late 1960s and early1970s; it also profiles many of the philosophers and theologians who pioneered the field. Given that the groundwork of these trailblazers ultimately took the form of the so-called Belmont principles of 1979, Chapters 4 and 5 take a close examination of these comprehensive standards of bioethics and their applications. Although these foundational principles remain influential, Chapter 6 shows why a perceived overweening attachment to one of them, individual autonomy, has invited assorted criticism. Chapter 7 considers alternative perspectives, including feminist ethics of care and narrative ethics. Having traced the development of bioethics from its origins to current state, the book then turns to the two predominant kinds of bioethical issues that tax us today. Chapters 8–16 cover the major controversies at the beginning of life— abortion, embryo screening, surrogate mothering, commercial egg donation, genetic testing, prenatal sex selection, and stem cell research. Chapters 17–22 take up the major controversies that surround the end of life, as they pertain to the definition and criteria of death, suicide, assisted suicide, euthanasia, and judgments of medical futility as a means of rationing health care. The coverage reprises the book’s linchpin idea by showing how these issues owe their inherent controversy to fundamentally different ways of knowing and understanding, specifically to opposed views about the definition of human life and personhood, PREFACE the purpose for existence, the reach of personal liberty, and the nature of the ideal society. The text’s concluding chapter invites further discourse by discussing the concept of individual autonomy and rights in the liberal democracy. It addresses the challenge to bioethics posed by trying to balance, on one hand, Western concepts of rights with, on the other, religious concepts of divine sovereignty or commitment to religious principles that may conflict with individual autonomy. FEATURES I wrote BCC mindful of a general audience unfamiliar with bioethics as a subject and activity. The text had to be accessible and substantive, with a good range of topics and issues that were contextualized, clearly explained, and sparked with copious examples and real-life cases. Here are some of the text’s features that aim to give students with varying learning styles and experiences opportunities to understand the moral implications of the dramatic changes occurring today in American health care. 1. Introductions to Parts Helping give the work a sense of unity and coherence, each part has its own introduction that ties the forthcoming material thematically to the book as a whole. 2. Conversation Starters Chapters begin with an event, a situation, a case, or an illustration that draws attention to the chapter’s main point of interest. 3. Conclusions Chapters close with some judgments and opinions suggested by their contents. 4. Examples and Illustrations Liberal use of popular and public materials are designed to make the content clear and the narrative compelling. 5. Bioethics Across Cultures Scattered throughout the text, these fifty-four inserts are intended to impart cross-cultural awareness and appreciation of how different religions and cultures work to resolve complex issues in bioethics. Some of these global excursions feature individuals who, though perhaps obscure in the United States, have headlined bioethical imbroglios abroad—Eluana Englaro in Italy, Angelique Flowers in Australia, and Richard Latimer in Canada, for instance. Following all of the cross-cultural presentations are questions as diverse as “What’s the morality of drugs not being available in the country where the drug trials are taking place?” “Is the value of a person’s life in an impoverished developing nation the same as the value of an affluent Westerner’s life?” “Is Major League Baseball morally justified in conducting genetic testing on promising young Latin American players?” “Does feminist bioethics offer a unique perspective on global violence against women?” xxiii xxiv PREFACE “Is it right for the United States to withhold aid from foreign reproductive care agencies that discuss or offer abortion services?” “What moral issues are involved in outsourcing surrogacy?” “What are the principal differences between Buddhist understanding of illness and suffering and that of Judaism, Christianity, and Islam?” 6. Cases and Controversies Several real-life cases and controversies with questions for analysis appear at the end of every chapter, seventy-four in all. Well-toned and neutrally presented, this mix of classic and contemporary material, of suitable length for classroom use, provides an opportunity to extend the ideas and principles laid out in the chapters, while encouraging self-examination and critical analysis. Sometimes showcased are famous events or court decisions, such as the Sherri Finkbine thalidomide tragedy, the Baby M surrogate motherhood ruling, and the Griswold v. Connecticut birth control decision. Just as often, however, it’s a fresh case or controversy, including: medical workers’ involvement in C.I.A. interrogations; the Steve Jobs liver transplant; conscientious objection to selling the morning-after contraceptive pill; the 2009 Benitez decision involving denial of artificial insemination based on marital status; selling blood across the U.S.-Mexico border; mandated vaccination with Gardasil; the first gene therapy death; mercy deaths during Hurricane Katrina; and the creation of “synthetic life.” 7. Multidisciplinary Coverage Besides the philosophical and religious, this text strives to include diverse clinical, academic, historical, legal, and scientific perspectives. This accounts for the uncommon treatment of some familiar material and the inclusion of unique topics. For example, as a prelude to issues at the beginning of life, Chapter 8 treats conceptual issues in reproductive technology, including scientific views about when life begins and whether they’re compatible with traditional religious teaching. In Chapters 9 and 10, the usual arguments for and against abortion are interwoven with a narrative about the philosophical/religious thought, medical advances, social/political activism, and legal landmarks in reproductive rights that led up to and have followed Roe. Chapter 19 overviews the intellectual history surrounding suicide in the West and shows how this mix of religious and secular opinion, modified by cultural conditions and demands, has come to shape contemporary law, morality, and feeling about physician-assisted death. Chapter 22 places medical judgments of futility in the economic context of health care prioritization. And the aforementioned conclusion takes up the challenge of navigating the chasm between secular and religious PREFACE bioethics in the liberal democracy. Typically ignored or downplayed in bioethics texts, these disciplines help illuminate today’s bioethical debates, placing what may be unfamiliar content into more familiar contexts. 8. Extensive Documentation Numerous online resources provide opportunities for convenient reference and research. WAYS OF USING THE TEXT Recognizing the wide range of ways for teaching bioethics, I’ve tried to make BCC easy to customize without losing its individual voice. The book’s tidy organization, myriad topics, and numerous cases should give instructors great flexibility in how they use the text and structure their courses. BCC can be broken into parts for abbreviated courses and for additions or omissions. Easily digestible sections allow a similar adaptability within chapters. As the chapters themselves are relatively self-contained, they generally can be assigned in any order without loss of coherence. Common sense exceptions would be the introduction and conclusion and chapters dealing with conceptual matters (e.g., Chapters 8, 17, and probably 15). Because many instructors prefer to dwell only on some parts of a lengthy book and assign others for outside reading, it’s important that the text be clear and accessible to a wide variety of readers. This is especially true with controversial content of a philosophical and religious nature. I’ve tried to address this challenge by presenting the material in a frank and respectful tone, and in a style plain enough to serve both those who need background and those ready to engage the serious biomedical issues facing society. The brevity of each section and, I trust, the fair and balanced explanations should appeal to a wide breadth of readers. Like many texts, this one can be taught cover to cover. Where time constraints or other factors prevent this, the text as a whole can be conveniently tailored to meet individual preferences. Instructors eager to get to the issues, for example, can skip immediately from the introduction to Parts III and IV, perhaps assigning select chapters from the earlier parts for outside reading. Alternatively, those wanting to introduce basic bioethical principles before proceeding to the issues could move immediately to Chapters 4, 5, 6, and 7, after the introduction. It’s also possible to focus exclusively on the cases and, perhaps, cross-cultural inserts, with the text assigned as background. Ideally, most of the chapters are crafted such that a lecturer or seminar leader would have little additional work to do in preparation to teach the material. Chapter 1 warrants a special word because it offers something singular for a bioethics text: a concise history of Christian religion and the intersection of secularism. How one uses this chapter, if at all, largely depends on how much attention one wishes to pay to the intellectual history of Western civilization from the rise of Christianity to the Enlightenment, with specific regard to such crucial matters as our views of human nature and personhood; our understanding of illness, suffering, and death; and our conception of science and medicine and xxv xxvi PREFACE their relationship to religion. In general, those inclined to make the inclusion of theology and cross-cultural religious perspectives more explicit in their teaching of bioethics probably would assign all of Chapter 1, whereas those disinclined would pick and choose or even skip it entirely, again without loss of textual coherence. My personal feeling is that it’s very difficult, if even possible, to engage bioethics in the United States today without seriously acknowledging the formidable influence of religion on social policy and clinical practice. It’s a sure bet that many students who read this book, not to mention the instructors who teach from it, hold sincere, religiously inspired moral opinions on such matters as abortion, preconception sex selection, stem cell research, suicide, or assisted death. And those who don’t are no less affected by the highly influential religious voices and opinions of those occupying seats of institutional or political power. Add to this (1) the contribution of religious thinkers some forty-odd years ago to the nascent field of applied medical ethics, and (2) the current tensions between religious and moral interests in the making of national science policy, as doctors and patients must weigh the issues and the options. It seems to me, then, that the inclusion of the sacred alongside the secular in treating bioethics in the context of culture is not only felicitous today but also imperative. At the very least, it can show students how they’ve come by their beliefs and that religious approaches to difficult, ethical questions are not purely monolithic but are themselves diverse and even at odds with one another. It can also inform them of the historical relationship between religion and philosophy, and how religious ideas can influence ideas we later come to define as philosophical ones, nowhere more so than in bioethics. Finally, it can take students to the next level: a critical examination of the role of religious belief in shaping bioethical policy and practice. These observations notwithstanding, I realize that some instructors will more lament than welcome the inclusion of religious perspectives in a bioethics text. Again, they can freely adapt BCC to their tastes without sacrificing coherence. ACKNOWLEDGMENTS The abundant end-of-chapter citations suggest the profound debt I owe to the great many scholars and writers whose thought and work helped shape this book. For the humbling opportunity to tap into their knowledge and wisdom, my sincere thanks to sponsoring editor Joann Kozyrev. For her scrupulous attention to the details of production, my gratitude extends to Sushila Rajagopal. And for their generous commentary and encouragement, I gratefully acknowledge the following reviewers: Joseph Aieta III, Lasell College Kem Barfield, Three Rivers Community College Barbara Bellar, DePaul University Nancy Billias, Saint Joseph College PREFACE David Boersema, Pacific University Paul Boling, Bryan College Kae Chatman, Arkansas State University, Beebe Mary Giegengack-Jureller, Le Moyne College Brian Glenney, Gordon College Paul Haught, Christian Brothers University Mitra Huber, The College of St. Elizabeth Phil Jenkins, Marywood University Jeffery Johnson, Eastern Oregon University Joel Martinez, Lewis & Clark College Michael McKeon, St. Gregory’s University Mark McLeod-Harrison, George Fox University Rolland Pack, Freed-Hardeman University Hannah Love, Pacific Lutheran University Roger Russell, University of St. Francis J. Aaron Simmons, Hendrix College Les Stanwood, Skagit Valley College Cindy Wesley, Lambuth University xxvii This page intentionally left blank Introduction Bioethics, Schiavo, and Cultural Politics O n the evening of March 19, 2005, the US Congress did something it had never done before. With time running out on how much longer she could remain alive, Congressional leaders announced that they would allow the parents of a 41-year-old Florida woman to petition the federal courts to have a feeding tube replaced for their brain-damaged daughter. The next day President Bush flew back to Washington from his Texas ranch to sign the emergency legislation. Two days earlier the president had told the nation: The case of Terri Schiavo raises complex issues. Those who live at the mercy of others deserve our special care and concern. It should be our goal as a nation to build a culture of life, where all Americans are valued, welcomed, and protected—and that culture of life must extend to individuals with disabilities.1 It was in 1990 when Terri Schiavo (1963–2005) incurred severe neurological damage when a chemical imbalance stopped her heart, cutting the oxygen supply to her brain. The then 26-year-old was left in what physicians term persistent vegetative state (PVS), capable of breathing on her own but unable to eat or speak. No fewer than seven board-certified neurologists said her condition was permanent and irreversible, though not terminal. With proper care Terri could live many years, a fate her husband and legal guardian didn’t think she would want. So Michael Schiavo requested that doctors stop the artificial feeding. When his wife’s Catholic parents objected, the stage was set for a lengthy legal battle that culminated in a court order to remove Schiavo’s feeding tube. Once the feeding tube was removed, evangelical Christian conservatives, who had helped reelect President Bush in 2004 and swell Republican majorities in Congress, requested and obtained the unprecedented emergency legislation allowing the Schindlers to petition federal courts to resume tube feeding. But 1 2 INTRODUCTION their legal tactic failed, and Terri Schiavo died on March 31, nearly two weeks after the removal of her life-sustaining feeding tube. In a message to supporters and media shortly after her death, Terri Schiavo’s brother said, “Throughout this ordeal we are reminded of the words of Jesus’ message on the cross: ‘Forgive them for they know not what they do.’”2 Bobby Schindler’s biblical allusion was to the bitter feud between the Schindlers and Michael Schiavo. But his words were suggestive of something larger, for Schiavo wasn’t only about a divided family. It was also about a divided country. As widely depicted, Schiavo was a dramatic battle in the struggle to define America known popularly as the “culture war.” Over the past two decades, the term culture war (or culture wars) has become a catchphrase for a variety of polarizing political and social issues: teen pregnancy, sex education, pornography, drugs, gun control, same-sex marriage, funding for the arts and public broadcasting, feminism, immigration, multiculturalism, environmentalism, judicial nominations, religion in public life. Although the issues touch almost every aspect of social life, in no field are they more numerous or contentious than in medicine and health care. It is there that matters at life’s beginning and end invite especially passionate debate and irreconcilable positions. In the case of Terri Schiavo, public opinion was divided, albeit not evenly, on the question of proper treatment for PVS patients. Advances in medical science and technology have contributed to like disagreement in other areas: abortion, infertility treatment, prenatal testing, preconception sex selection, organ transplantation, and stem cell research, to name a few. All have forced upon us difficult choices in our personal and professional lives, as well as in public policy. This book deals with these matters and the spirited social debates they have triggered. It’s about bioethics in the context of culture, including philosophy, religion, history, and politics. BIOETHICS Etymologically, bioethics consists of two Greek words: bios for “life” and ethos for “character or custom.” From ethos comes “ethics,” which suggests the view of bioethics as an application of ethics to the life sciences, especially medicine and health care. For this reason bioethics is sometimes called biomedical ethics. So conceived, bioethics derives its content largely from biology and medicine and its theory and guiding principles from the larger field of ethics. ETHICS Ethics may be defined, broadly, as the general term for the philosophical study of morality or, simply, moral philosophy. This label says something important about what ethics does and how it does it: It studies morality philosophically. To say that ethics studies morality means that it is concerned with an individual’s or culture’s standards of character and conduct. Consider that in growing up we absorb from our families and societies all sorts of notions about good and bad, right and wrong, rights and responsibilities. Later we may think philosophically about what we’ve inherited: We may critically examine and test our acquired moral values and standards by closely inspecting the reasons for and against them. When we undertake this close inspection of our inherited moral customs, we’re doing ethics, specifically normative ethics. Normative Ethics Normative ethics is the area of ethics or moral philosophy concerned with judgments and theories about obligation and value, good character, well-being, and right action. It is basically interested in answering two “ought questions.” One is a question of conduct: “What ought I do?” The other is a question of character: “What ought I BIOETHICS, SCHIAVO, AND CULTURAL POLITICS be?” In both instances, normative ethics seeks prescriptions, that is, authoritative rules or directions, for right action and good character. Its prescriptive interest distinguishes normative ethics from fields with merely a descriptive or scientific interest in ethics, such as cultural anthropology or sociology. Cultural anthropologists sometimes give accounts of permissible cultural practices that our society finds objectionable, including polygamy, arranged marriages, suicide as requirement of widowhood, killing for honor, severe punishments for blasphemy or adultery, and female circumcision, or genital mutilation. The anthropologist generally is interested in reporting and culturally explaining these practices, not judging them. As a scientist she’s simply saying what is, rather than what ought to be, the case. The normativist, on the other hand, wants to know whether such practices are preferable, whether they are ever moral, and on what grounds. The anthropologist’s interest in morality, then, concerns how things are, whereas the ethicist’s interest concerns how things should or ought to be. The sociologist, to take another example, is more interested in how people assign credit and blame than when it’s right to do so. In describing, the anthropologist and sociologist engage in descriptive or nonnormative ethics. In prescribing, the ethicist (or moralist) does prescriptive or normative ethics. Frequently today prescriptive, or normative, ethics extends to specialized areas such as the environment; or to professions such as business, government, law, or medicine. What is thought of value and obligation, in general, is applied to specific areas, practices, or activities. Bioethics is like this. It often analyzes what moral standards and judgments ought to drive health care matters. Thus: What ought we do in a case like Schiavo? What rules, guidelines, or principles are we to follow? What should we most honor in deciding—the patient’s biological existence? The quality of her life? Her wishes? If she hasn’t left “clear and convincing” evidence of what she would want, how are we to proceed? Other circumstances elicit similarly normative questions. What principles, standards, or norms are we to use in matters involving human cloning, stem cell research, or genetic screening, as examples? 3 Trying to answer questions like these gives bioethics its normative edge. But Schiavo wasn’t only about what Terri wanted and who was to say, and neither is bioethics. Schiavo was also about something that often happens whenever we go beyond procedural aspects of bioethical decision making and think deeply about the decisions themselves. It is then that we confront some of the most basic questions we can formulate about ourselves and our destiny. What is a human being? What is a person? What is the meaning of life and suffering? What is death and when does it come? What do we owe those who, though not dead nor dying, are profoundly disabled and dependent? And perhaps the most important question of all: How are we to answer these questions? What guidelines do we follow? Inquiries such as these bear directly on judgments of value and obligation, and they indicate another area of ethics relevant to bioethics. It’s termed metaethics. Metaethics Of importance to many modern theorists, metaethics is the branch of ethics that goes beyond the interests of normative ethics into the origins of ethical concepts. For example, whereas normative ethics is interested in knowing what things are morally good and bad, metaethics ponders the meaning of moral goodness. Trying to understand the nature of ethical properties and evaluations requires an exacting study of the meanings of moral terms like good and bad, the sentences in which they appear, and the methods of reasoning involved in making moral evaluations. Additionally, metaethics often is drawn into the orbit of highly speculative questions. For instance, whereas normative ethics asks what is right and wrong, metaethical theory seeks to determine whether we live in the kind of universe where there is anything that is right or wrong apart from what any of us thinks, feels, or believes. In other words, metaethics, in part, seeks an answer to the question: Is there or is there not anything objectively right or wrong independent of human opinion? A related metaethical question involves whether some things are always moral or always immoral. Are there discoverable absolute standards for determining right and wrong? Or do right and 4 INTRODUCTION BIOETHICS ACROSS CULTURES Canada’s Terri Schiavo In October 2007, Grace Hospital in Winnipeg, Canada, admitted 84-year-old Samuel Golubchuk with multiple organ failure. Earlier, in 2003, Golubchuk had part of his brain removed after a fall. His condition deteriorated rapidly while in the hospital, and Grace doctors told the family they wanted to take him off life support. The family balked, citing their Orthodox Jewish faith. To do so, they said, would be contrary to their father’s wishes and his religious beliefs as an Orthodox Jew who held life to be sacred. “Doctors don’t know everything,” Golubchuk’s son told Canadian Television News, “God is the major doctor.” The family went to court and obtained an injunction forbidding the hospital and doctors “from removing the plaintiff … from life support care, ventilation, tube feeding, and medication”—an order that if violated could lead to fines or imprisonment. Rather than obey the court order, Dr. Anand Kumar, a critical care specialist, resigned, as did two other Grace physicians. In explaining his decision, Dr. Kumar said: “If we honestly attempt to follow the court mandate to focus on keeping Mr. Golubchuk from his natural death, we will likely have to continue to surgically hack away at his infected flesh at the bedside in order to keep the infection at bay.” Calling further treatment “tantamount to torture,” Dr. Kumar protested: “This is grotesque. To inflict this kind of assault on him without a reasonable hope of benefit is an abomination. I can’t do it.” Golubchuk, the man whom conservative groups in the United States took to calling “Canada’s Terri Schiavo,” died of “natural causes” at Grace Hospital on June 24, 2008. Question Do you think Dr. Kumar did the right thing in resigning, or should he have followed the court order? In the wrong depend on context or consequence? These questions are of theoretical interest. But more than that, they suggest why cases such as Schiavo, and bioethics, itself, can be so controversial. Consider, for example, that many people today believe that some things are always right or wrong, regardless of their context; others believe that right and wrong always depend on cultural or individual midst of the Golubchuk affair, an article appeared in the Canadian Medical Association Journal, co-authored by its editor-in-chief, responding to the charge that physicians were trying to “murder” Golubchuk. It stated in part: If this is murder, many of Canada’s doctors belong in jail. Legally, doctors are practitioners of a duty of care. An obligation to provide extraordinary care to dying patients, including patients who are minimally responsive, forces one to breach the everyday duty of care, which is to provide the best balance between probable harms and foreseeable benefits. That is why an approach that excludes the option to withhold or withdraw life-sustaining care is unworkable. Do you agree that in cases like these physicians should have the authority to make medical decisions to withhold or withdraw life-sustaining treatment from a patient without the consent of the patient or the patient’s family? Or do you agree with the Golubchuks, that competent religious authority should be permitted to make crucial decisions in the event of incapacitation? (SOURCES: Amir Attaran et al, “Ending Life with Grace and Agreement,” CMAJ, April 22, 2008, pp. 1115–1116. Retrieved March 15, 2009, from http://www.pubmedcentral.nih.gov/articlerender.fcgi? artid=2292789); Sam Solomon, “End-Of-Life War Outlives Golubchuk,” National Review of Medicine, July 2008. Retrieved March 20, 2009, from www.nationalreviewofmedicine.com/issue/2008/07/5_patients_ practice_07.html; The College of Physicians and Surgeons of Manitoba, “Statement Withholding and Withdrawing Life-Sustaining Treatment.” Retrieved March 17, 2000, from www.cpsm.mb.ca/cgi-bin/ perlfect/search/search.pl?q=withholding; Hillary White, “Samuel Golubchuk Dies Naturally,” LifeSite News, June 25, 2008. Retrieved March 20, 2009, from http://www.lifesitenews.com/ldn/2008/jun/ 08062504.html.) preference. Obviously, these basic beliefs clash; they can’t both be true. They represent radically different ways of making sense of life. An action that is acceptable according to one belief may not be acceptable according to the other. Individuals or groups holding these opposed beliefs are said to be in moral conflict. Moral conflicts occur when disputants are acting within different beliefs about how the world BIOETHICS, SCHIAVO, AND CULTURAL POLITICS operates. Schiavo was an example of a moral conflict. But Schiavo was hardly unique. Indeed, no field today is driven more by moral conflicts than biomedicine. MAKING SENSE OF MORAL CONFLICT Many scholars have attempted to make sense of the moral and cultural conflicts that continue to confront us. One of the more careful overviews comes from James Davison Hunter, a professor of sociology and religious studies at the University of Virginia. Writing in the 1990s, Hunter suggested that the United States was locked in a competition to define social reality that involved a unique realignment in American politics based upon conflicting beliefs about what we are as human beings and who we are as a nation. Unlike past cultural clashes, typically fought along class, religious, or political party lines, the contemporary one, according to Hunter, was being waged along unfamiliar lines defined by conceptions of reality and transcendent values. He described it as a struggle to define America, or more precisely: a struggle to define what and who we are. Although Hunter was not talking about bioethics specifically, his conception of the cultural struggle’s issues and adversaries is worth sketching because it provides a window into the nature of the moral conflicts that often make bioethics so divisive today. Issues Briefly, Hunter frames the competition to define what we are as a struggle to define such fundamental matters as human nature and destiny, good and evil, truth and authority, meaning and value. Despite their complexity, we might initially express the clashing cultural views about these subjects simply as oppositions. For example: On one hand, the belief that we are here on earth for a reason and with some ultimate destination such as heaven; on the other, the belief that we live in an indifferent universe, that life has no more or less defined meaning than what each of us makes of it 5 On one hand, the belief in the sanctity of life, that every human life is inherently valuable regardless of its state or circumstance; on the other, the belief in the quality of life, that life has value so long as it is meaningful and enjoyed On one hand, the belief that we are persons from when we are unborn to when we die; on the other, the belief that only after birth do we become persons, which we may cease to be before death For Hunter, opposed perspectives such as these speak to the struggle to define social reality. Given the bulk of its content—ultimate reality, human nature and destiny, the meaning of life, the ultimate sources of knowledge—the question of what we are is largely speculative. Hunter’s next question—the who we are question—is, by contrast, more practical. It has political overtones, because it’s about social relationships involving power, authority, and social policies. It also has moral and religious import, because it’s about the standards that will guide those relationships and policies. The who we are question is about how we as Americans will order our lives and govern ourselves. It’s about the limits of public and collective life, about what we will permit and prohibit. Who we are, in a word, is about something that has vexed human beings through all of recorded history: the notion of the ideal society. What is the ideal society? Is it the one that permits, limits, or prohibits: gay marriage and adoption; “obscene art”; prayer, sex education, and the teaching of intelligent design in public schools? In the realm of bioethics: Is the ideal society the one that does or does not permit access to “morning after” birth control pills, mandatory vaccinations, medical marijuana, stem cell research, experimentation on early stage embryos, preconception trait selection, noncoital reproduction, assisted death, compensation for human tissue donation, and research cloning? Does the ideal society largely permit freedom of research and individual action in these biomedical areas, or does it restrict and even deny such freedom at home and actively discourage it abroad? Does the ideal society mandate health care services to everyone or doesn’t it? 6 INTRODUCTION BIOETHICS ACROSS CULTURES Religion and HIV/AIDS in Africa In January 2006, Ambassador Randall Tobias, who served as President George W. Bush’s global AIDS czar, issued written guidelines that spelled out the Bush administration’s conservative religious approach to preventing HIV/AIDS in Africa. Groups that received US funding, Tobias warned, should not target youth with messages that presented abstinence and condoms as “equally viable, alternative choices …” in their sex education programs. Meanwhile, groups that supported the president’s conservative religious agenda started to receive money that traditionally went to more experienced organizations. One such group, the Children’s AIDS Fund, received roughly $10 million to promote abstinence-only programs overseas. FreshMinistries, a Florida organization with little experience in tackling AIDS, also received $10 million. A Bush administration directive further said that two-thirds of global AIDS-prevention money was to go to promoting abstinence and fidelity, and before overseas groups could receive US funding they were take a “loyalty oath” to condemn prostitution. Supporters of the program said it was working, and two months before leaving office President Bush was recognized for his international efforts in the fight against the spread of AIDS. In presenting him with the International Medal of PEACE, California megachurch Adversaries Hunter gives substantial coverage to the sides locked in cultural and moral conflict. He defines them in terms of where they stand on the issue of what and who we are. Today approximately 15 to 20 percent of the nation considers itself profoundly religious and staunchly conservative; another 15 to 20 percent considers itself profoundly secular and staunchly liberal.3 These groups fall within the cultural adversaries that Hunter terms orthodox and progressivists. The labels don’t matter, but what they signify does, for it throws light on some of the most influential voices in today’s public debates about bioethical issues. According to Hunter, orthodoxy is committed to a view of reality that is “independent of, prior to, pastor Rick Warren said, “No world leader has done more for world health than President George Bush…. Literally millions of lives have been saved in the last five years.” But AIDS experts told a different story. They claimed that the preoccupation with abstinence was handicapping the fight against the deadly virus. Health workers saw the influence of America’s Christian Right in the chastity message and believed the Bush administration was using its financial might to pressure them into accepting evangelical ideology at the expense of public health. They encouraged the new Obama administration to rethink Bush’s policy. Meanwhile, Pope Benedict XVI came in for criticism when, during a March 2009 trip to Africa, he reaffirmed his predecessors’ long-standing opposition to condoms. “You can’t resolve [the spread of AIDS] with the distribution of condoms,” the pontiff told reporters. “On the contrary, it increases the problem.” Health workers battling the epidemic on the front lines reacted much as they did to the president’s program. They said the Pope valued religious dogma above the lives of African people. The British medical journal Lancet (3/28/2009) weighed in, calling on the Pope to retract is statements: When any influential person, be it a religious or political leader, makes a false scientific statement that could be devastating to the health of millions of people, they should and more powerful than human experience.”4 It is inclined to believe in “an external, definable, and transcendent authority” from which we come to know what is true and good, how to live, why we are here, and where we are going. For the orthodox, this objective, higher authority defines, at least in the abstract, “a consistent, unchangeable measure of value, purpose, goodness, and identity, both personal and collective.”5 Orthodoxy, in short, deals with the issue aspect of cultural conflict by telling us once and for all what and who we are. Not for all but for the great many orthodox, the superior authority is the God of the Bible. These religious orthodox believe in a higher knowledge that comes from faith, revelation, Scripture, or religious BIOETHICS, SCHIAVO, AND CULTURAL POLITICS retract or correct the public record. Anything less from Pope Benedict would be an immense disservice to the public and health advocates, including many thousands of Catholics, who work tirelessly to try and prevent the spread of HIV/AIDS worldwide. The Catholic Church teaches that fidelity within marriage and abstinence are the best ways to stop AIDS. On the other hand, The New York Times’ Nicholas D. Kristof has written of “many Catholic nuns and priests heroically caring for AIDS patients— even quietly handing out condoms.” Indeed, a growing number of conservative Christians have expressed concerns about evangelicals so preoccupied with sexual morality that they seem to forget or ignore the poor, needy, and ill. Richard Stearns, head of World Vision in the United States, a Christian organization with evangelical roots, asks, “Where were the followers of Jesus Christ in the midst of perhaps the greatest humanitarian crisis of our time?,” the AIDS crisis in Uganda, which records the highest proportion of AIDS orphans in the world, many of whom head families or are parts of communities without any adult supervision. “Surely,” writes Stearns, “the Church should have been caring for these ‘orphans and widows in their distress.’ (James 1:27).” tradition. (In far fewer numbers are secular, or nonreligious, orthodox, who find transcendent authority and objective values and truth in something other than God and the consolation of revealed truth, perhaps in nature, the social order, or human evolutionary development.) Hunter counts among the predominant religious orthodox: evangelical Protestants, orthodox and neo-conservative Jews, and conservative Roman Catholics. Also included would be social conservatives, a political label for those who generally believe that government has a role in enforcing traditional values, such as the importance of the biological family and respect for human life from conception to natural death.6 Social conservatives are overwhelmingly Christian. 7 Question “The evangelicals are absolutely right: abstinence is the best way of preventing the spread of HIV/AIDS.” So says Sigurd Illing, who specializes in providing diplomatic advice for disadvantaged and marginalized African nations such as Somaliland. “But,” the Bavarian diplomat is quick to add, “some people aren’t receptive. We need an end to this bedevilling of condoms by people who take a high moralistic stance and don’t care about the impact that this has on reality.” Do you agree with Illing? Or do you think that sexual-based morality has a place in the formation of public health policy? Discuss the controversy in the context of moral and cultural conflict. (SOURCES: Geraldin Sealey, “Epidemic Failure,” Rolling Stone, June 2, 2005. Retrieved March 10, 2009, from http://www.rollingstone.com/politics/story/7371950/an_epidemic_failure/; NA, “Public Health and Religion: AIDS, America, Abstinence,” The Independent, June 1, 2006. Retrieved March 15, 2009, from www.independent.co.uk/news/world/africa/publichealth-and-religion-aids-america-abstinence-480593.html/; Brittney Bain, “President Bush Awarded For Fight Against AIDS,” December 1, 2008, The PEW Forum on Religion & Public Life. Retrieved March 16, 2009, from http://pewforum.org/news/display.php?NewsID=17044/; NA, “Vatican Defends Pope Condoms Stand,” Reuters, March 18, 2009. Retrieved March 18, 2009, from http://www.reuters.com/article/worldNews/ idUSLI43220920090318; Carol Hilton, “Lancet Calls for Pope’s Repentance on HIV Comments,” March 30, 2009. Retrieved March 30, 2009, from http://www.medicalpost.com/news/article.jsp?content=20090224_171348_2428/; Nicholas D. Kristof, “Learning From the Sin of Sodom,” The New York Times, February 28, 2010, p. 11; Richard Stearns, The Hole in Our Gospel: What Does God Expect of Us?, Nashvile: Thomas Nelson, 2009.) It wasn’t surprising to find many of the orthodox—evangelical Christians, traditional Jews and Catholics, social conservatives—bitterly outspoken in their condemnation of withholding artificial nutrition from Terri Schiavo. Members of these groups variously likened the withholding of food and water to letting a helpless infant starve to death or to “cruel and unusual punishment.”7 The Vatican, through its newspaper L’Osservatore Romano, even compared Schiavo’s situation to that of an innocent person sentenced to capital punishment, a view largely shared by US bishops and Muslim authorities. For these religious and social conservatives, Terri Schiavo’s life plainly had value regardless of her condition, because they believe that life’s 8 INTRODUCTION worth doesn’t depend on “what a person can do, experience or achieve,” to quote The New York Times politically conservative columnist David Brooks. Rather, Brooks explained at the time, they believe that “[t] he life of a vegetative person or a fetus has the same dignity and worth as the life of a fully functioning adult.”8 This makes life’s value absolute. Life is a sacred or divine gift that the ideal society recognizes by treating Terri Schiavo’s life as worthwhile as her husband’s, yours, or mine. The ideal society protects the unconditional value of life by prohibiting deathhastening policies and decisions at the end of life as well as at life’s beginning. Such a view inspires prohibitions on what otherwise would be freedom of action or self-determination, whether of individual or scientist.9 In opposition to cultural orthodoxy, Hunter sets cultural progressivism, which does not tell us once and for all who we are but subscribes to a reality, truth, and authority that are ever unfolding. For cultural progressivists, there is no higher or transcendent authority of good and bad, right and wrong. Such matters are for us humans to determine. So is defining ultimate truth. This doesn’t mean that the progressivists lack or are indifferent to standards of conduct. But unlike most of the orthodox, who overwhelmingly source notions of goodness and badness to divine higher authority, the progressivists mainly attribute them to human beings. They believe that people set the ground rules of conduct, personal and social. This makes those guidelines and directives debatable, flexible, and changeable. For the progressivists, the view that lives such as Terri Schiavo’s must be preserved at all costs is wildly unrealistic, even cruel, given the advanced state of medical technology today, which can blur the distinction between living and merely existing. It isn’t life that counts, the progressivists tend to say, it’s life’s dignity or quality. Like Terri Schiavo’s, life can pass into mere existence, and it’s up to the individual and family to say when that happens. For many progressivists, therefore, the ideal society recognizes the conditional value of life and honors it, perhaps by permitting death-hastening policies and decisions at the end of life. It also allows the individual and scientist a large measure of freedom of action, or self-determination, at the beginning of life. Predictably within the progressivist camp Hunter numbers various secularists, or those without religious beliefs. But, significantly, he also includes reform Jews and liberal Catholics and Protestants. Thus, some religious progressivists described the withdrawal of Schiavo’s artificial feeding as appropriate. A prominent rabbi, for example, said that artificial nutrition was not food but medical treatment; and, therefore, he said it could be withdrawn, given the medical hopelessness of Schiavo’s condition. He also urged people to accept their mortality, as he said the Bible makes clear. Even some evangelicals agreed, saying that feeding tubes are like breathing machines, which would make removing them no more starvation than removing ventilation is suffocation. A professor of Christian ethics at an evangelical university thought that withdrawing the feeding tube would be appropriate if that was what Schiavo wanted. And, taking aim at the Vatican and US bishops, a professor at a leading Catholic university, Daniel C. Maguire of Marquette, said that both were out of step with “mainstream Catholic theology against extraordinary measures to sustain life.” Maguire called Schiavo a “15-year atrocity” that represented a tendency to idealize physical life and forget the natural process of death.10 For his part, Catholic theologian and priest Richard McBrien of Notre Dame attacked the Vatican’s capital punishment analogy as “theologically erroneous—and irresponsibly so, given the highly public nature of this controversy.”11 Cultural historians can judge the merits of Hunter’s culture war concept. For us it serves as an appropriate entrée to our study, because it brings out the philosophical differences and disputants that largely drive today’s spirited cultural discourse in bioethics. This book takes the position that contemporary bioethics is less about specific issues and more about their subterranean moral conflicts. Certainly, Schiavo was controversial. But the view here is that, ultimately, Schiavo owed its controversy, as does bioethics itself, 9 BIOETHICS, SCHIAVO, AND CULTURAL POLITICS not to procedural matters but to fundamental disagreements about which of opposed conceptions of reality, truth, and goodness will mainly shape society. ABOUT THIS BOOK Over 2,000 years ago, in his dialogue Euthyphro, Plato (427–348 BCE) posed the question: Is it the case that something is good because God approves it, or is it the case that God approves what is good? If the former, then ethics is properly understood as an aspect of religion and theology. If the latter is the case— that God approves what is good—then ethics is properly understood as moral philosophy, or a rational study of moral values and rules independent of religion and theology. Plato’s question cannot be settled to everyone’s satisfaction. This partly explains the irresolvable moral tensions and conflicts in a culture such as ours, that inherits both moral traditions, the sacred and the secular. These fundamentally different ways of doing ethics especially show up in bioethics, which engages content of the highest religious interest and value, such as what makes a human being, when life begins and ends, and how properly to determine human sexuality and make a baby. To tap the ancestral lines of these interlacing perspectives, as we do in Part I, Sacred and Secular Foundations, is to begin to understand the historical influences that still resonate in today’s moral conflicts and debates in bioethics. Also to be discovered in the past, and the more recent, are the signal political events, scientific advances, and social developments, along with the religious, political, and philosophical thought that profoundly shaped the founding of modern bioethics in the 1960s and early 1970s. These we’ll sketch in Part II, Origins and Context of Bioethics. Parts III and IV will extend our understanding of the foundations, origins, and context of bioethics to Issues at the Beginning of Life and Issues at the End of Life, respectively. The often-wrenching personal decisions at life’s beginning and end, together with their related divisive social policies, are made today in a medical, social, and political environment that’s quite different from the early days of modern bioethics. Of special note is the biblically inspired bioethical vision of the religious conservatives that currently is challenging the field’s dominant secular construction. A prominent US religious figure has even suggested that civil law should support a “Christian bioethical vision.”12 Should it? Does religion have a role in public bioethics? Do arguments based on religious principles have a place in society’s debates about bioethical policy? Such questions, which speak to the relationship of religion, medical science, and public policy are an increasingly important part of the cultural discourse in bioethics. The book’s Conclusion, Bioethics, Religion, and Liberal Democracy, addresses these matters. CASES AND CONTROVERSIES Reproductive Flashpoints The new reproductive technologies that allow people to begin life outside the womb or prevent it—or end it—the “morning after” have produced intense bioethical debates. Here is a handful of culturally divisive issues that we’ll examine in detail elsewhere in this text. Many people are concerned that we are acting as if it is a right to have children. Religious people generally say that children are a gift from God, a privilege, not something that is ours by right. Is infertility a medical problem to be overcome, or are children a gift we can’t demand? In order to maximize the chances of a successful pregnancy, many ova are collected and many spare embryos are made. But what to do with the spares? They can be thrown away, frozen for future attempts, used for medical research, or even put up for “adoption.” Religious and social conservatives are especially unhappy with the (Continued ) 10 INTRODUCTION CASES AND CONTROVERSIES (CONTINUED) destruction of embryos, as they believe that life begins at conception and to experiment on or destroy life is morally wrong. What do you think is the best use of the estimated 400,000 frozen embryos stored in the United States? octuplets after taking fertility drugs. What does your faith tradition say about the Suleman case? Is it an example of science being properly used in the cause of new life, as desired by a woman who sees bringing new children into the world as her highest good? Many religions teach that sex has a dual purpose— to unite the couple and to procreate. Some of them, such as Roman Catholicism, are concerned that treatments for infertility separate the two purposes, and they would say that infertility treatments are therefore wrong. Many Christians, however, including Catholics and Protestant and Anglican denominations, as well as Jews and Muslims, say that as long as infertility treatment isn’t used to replace sex within marriage it’s permissible. What do you think the purpose of sex is? Do infertility treatments interfere with its purpose? The pregnancy rate among 15- to 19-year-olds increased 3 percent between 2005 and 2006—the first jump since 1990–before dropping 2 percent between 2007 and 2008. Abortion also inched up for the first time in a decade, according to 2006 data. Teen pregnancy and abortion have long been among the most pressing social issues and have triggered intense political debate over sex education. According to a landmark study reported in 2010, sex education classes that focus on encouraging children to remain abstinent can convince a significant proportion to delay sexual activity.13 Should the federal government fund programs that encourage abstinence until marriage or focus on birth control? In January 2009 Nadya Suleman, an unmarried mother on public assistance with six children, was dubbed “Octomom” when she gave birth to CASES AND CONTROVERSIES Refusal Legislation “Right of Conscience” bills, also known as health care refusal measures, were introduced in several states’ legislatures in 2008. In a later chapter we’ll take a closer look at such legislation. Suffice it here to point out that these measures generally immunize facilities and providers from any form of liability for choosing not to inform, refer, or provide health care services of which the provider or facility has a religious, moral, or ethical objection. The measures are promoted by the “Medical Right,” a term coined to show the connection of religiously influenced medical organization to the “Religious Right,” a political force primarily comprising fundamentalists in the Protestant and Roman Catholic traditions. The Christian Medical and Dental Society, the Catholic Medical Association, Americans United for Life, and Pharmacists for Life International are among the organizations active in advocating for health care refusal clauses. About half of the proposals would shield pharmacists who refuse to fill prescriptions for birth control and morning-after contraceptive pills because they believe the drugs cause abortions. Many of the proposals are far broader measures that would shelter a doctor, nurse, aide, technician, or other employee who objects to any therapy. Included might be in vitro fertilization, physician-assisted suicide, embryonic stem cells, and possibly even providing treatment to gays and lesbians. Questions for Analysis 1. To their critics, refusal measures represent the triumph of religious ideology over the full range of legal medical services. Do you agree? 2. Julian Savulescu, former editor of the prestigious Journal of Medical Ethics, says that conscience has little place in the delivery of modern medical care. If individuals are not prepared to offer legally permitted, efficient, and beneficial care to a patient because it conflicts with their values, the Oxford University professor says they shouldn’t be doctors. “Doctors should not offer partial medical services or partially discharge their obligations to care for their patients.” Is Savulescu correct?14 ,15 BIOETHICS, SCHIAVO, AND CULTURAL POLITICS 11 CASES AND CONTROVERSIES Religion and Termial Care For many patients and their physicians, avoiding the pain and suffering of a terminal disease is top priority. This is not necessarily the case, however, with very religious patients. One study that followed 345 cancer patients to their deaths found that patients who wanted aggressive care and received it had lower ratings of physical distress.16,17 According to Betty Ferguson, a registered nurse who studies end-of-life issues, “We’ve had patients who said, ‘Well, God suffered. Jesus suffered. So if I suffer, it’s going to make me more like God.’” Ferguson’s Orthodox Jewish patients often express the belief that life is worth living no matter how debilitated they are.18 What does your faith tradition teach about the meaning and purpose of suffering, pain, and death? What in your view is a “good death”? Do you think doctors should talk to their patients about their patients’ religious views to determine what is motivating their preferences for aggressive care? REFERENCES 1. President’s Statement on Terri Schiavo, March 17, 2005. Retrieved July 23, 2008, from http://www. whitehouse.gov/news/releases/2005/03/200503177.html. 2. “‘May God give grace to our family,’” CNN.com, April 1, 2005. Retrieved July 23, 2008 from http:// www.cnn.com/2005/US/03/31/schiavo/. 3. E. J. Dionne, Jr., “Why the Culture War Is the Wrong War,” The Atlantic Monthly, January/February 2006. Retrieved August 4, 2008, from http:// www.theatlantic.com/doc/200601/culture-war. 4. James Davison Hunter, Culture Wars: The Struggle To Define America, New York: Basic Books, 1991, p. 120. 5. Ibid., p. 44. 6. Tim Rutten, “War, After the Smoke Clears,” Los Angeles Times, January 17, 2007, p. E8. 7. Teresa Watanabe and Larry B. Stammer, “Diverse Faiths Find No Easy Answers,” Los Angeles Times, March 24, 2005, p. A21. 8. David Brooks, “Arguments of Morality and Reality,” The New York Times, March 29, 2005, p. A1. 9. Mark Mellman, “Another Country,” The New York Times, September 17, 2008, p. A27. 10. Tim Rutten, “Schiavo Case Bares Political Sea Change,” Los Angeles Times, March 26, 2005, p. E18. 11. See note 7 above. 12. Francis Cardinal George, “The Need for Bioethical Vision,” in Cutting-Edge Bioethics: A Christian Exploration of Technologies and Trends, John F. Kilner, C. Christopher Hook & Diann B. Uustal, eds., Grand Rapids, MI: William B. Eerdmans Publishing. 2002, p. 97. 13. John B. Jemmott III, Loretta Jemmott, and Geoffrey T. Fong, “Efficacy of a Theory-Based AbstinenceOnly Intervention Over 24 Months: A Randomized Controlled Trial With Young Adults,” Annals of Pediatric and Adolescent Medicine, February 2010, pp. 152–159. 14. Rob Stein, “Health Workers’ Choice Debated,” Washington Post, January 30, 2006, p. A1. 15. Julian Savulescu, “Conscientious Objection in Medicine,” BMJ, February 4, 2006, pp.2294–2297. 16. Andrea C. Phelps et al. “Religious Coping and Use of Intensive Life-Prolonging Care Near Death in Patients With Advanced Cancer,” JAMA, March 19, 2009, pp. 1140–1147. 17. Roni Caryn Rabin, “Study Links Religion and Terminal Care,” The New York Times, March 18, 2009, p. A18. 18. Karen Kaplan, “For Many, Faith Leads to Aggressive Treatments,” Los Angeles Times, March 18, 2009. Retrieved March 24, 2009, from www.spokesman. com/stories/2009/mar/18/for-many-faith-leads-toaggressive-treatments. This page intentionally left blank P A R T I Two Enduring Traditions INTRODUCTION: SACRED AND SECULAR FOUNDATIONS For centuries thoughtful people have pondered and disagreed on basic questions about human nature and destiny, suffering and death, truth and meaning, and right and wrong. Placed in an historical context, then, the deep cultural divisions evident in a case like Schiavo are not new. Rather, they can be viewed as part of an ongoing dialogue—sometimes civil and muted, sometimes uncivil and strident— that extends back into the distant past. Many of the issues, of course, are fresh, certainly those in biomedicine. But the fundamental differences between ways of knowing and understanding are as old as Western civilization itself. This part of the book surveys the West’s two great traditions of knowing and understanding. Chapter 1 deals with the legacies of medieval religion and Enlightenment science, while Chapter 2 examines their enduring moral and political endowments. The theme of Part I is that these two distinct and venerable ways of knowing and understanding—one sacred, the other secular—are active philosophies helping to shape today’s bioethical controversies. This page intentionally left blank Chapter 1 Medieval Religion and Enlightenment Science T he Institute on Biotechnology & the Human Future in Chicago offers assessments of the scientific benefits and risks of new developments in biotechnology, while at the same time analyzing their cultural and ethical significance.1 One of the Institute’s fellows is C. Ben Mitchell, an associate professor of Bioethics and Contemporary Culture at Trinity International University in Deerfield, Illinois, just north of Chicago. Mitchell is also a consultant with the Center of Bioethics and Human Dignity at Johns Hopkins University and editor of Ethics & Medicine: An International Journal of Bioethics. The widely published Mitchell, who holds a doctorate in philosophy with a concentration in medical ethics, has a name for the present age. He calls it “Technopian” for its daunting list of technologies that worry as much as thrill him. WELCOME TO TECHNOPIA In the brave new world of “Technopia” Mitchell forecasts, we can expect to enjoy: the ability to clone humans and predetermine the sex of children and their genetic makeup; drugs tailor-made to the genetic makeup of individual patients; genetically derived therapies for the prevention and cure of most cancers, heart disease, AIDS, and other diseases, including new strains of vaccineresistant ones such as malaria; the ability to “program” out of human genes the propensities to contract various diseases and illnesses; repair of damaged brain cells, spinal cord, and other diseased or damaged human tissues; animals that grow replacement organs for the 50 percent of humans who currently die before getting a transplant organ from a human donor; and 15 16 CHAPTER 1 a “smart mouse” that points the way to eliminating aging in humans. “Clearly,” Mitchell admits, “the future may reap great benefits from biotechnologies such as genetic engineering, cloning, cybernetics, nanotechnology, and a litany of other neologisms yet to be invented.” But Mitchell, a Christian bioethicist who consults on matters of public policy, is quick to add: “The future may also portend tragedy, a loss of human dignity, and a world which is increasingly hostile to concerns which transcend the world of contemporary scientific research.” For Mitchell and many others,2 one of those concerns is “to re-establish what, exactly, it means to be human.” After all, as he explains, “[I]f being human is all about the brain, then supercomputers might be able to contain all the information in the brain and then be designated as ‘human’.” That possibility especially horrifies religious and social conservatives. They say that the Bible establishes profoundly different criteria for humanhood and offers a moral vision that, strictly speaking, does not include many of the wonders of modern biotechnology. (Biotechnology refers to the application of biological research techniques to the development of products and processes to improve human health.) This scriptural outlook, which is associated with but not limited to religious fundamentalism and social conservatism, provides millions of Americans with a religious framework for understanding human nature, knowing human destiny, interpreting misfortune, finding meaning, relating to others, and evaluating government. It also helps shape their opinions about social policy, particularly in bioethics. The roots of this highly influential scriptural view trace back to Christian-dominated Europe in the millennium between approximately 500 and 1500 CE, known as the Middle Ages. THE MEDIEVAL CHURCH Established as the state religion in 391 CE, the Roman Catholic Church became the most powerful organization of the time following the collapse of the Western Roman Empire in the fourth and fifth centuries. Embracing most Western Europeans, the Church offered to the spiritual lives of people what the feudal and manorial system offered to their political and economic lives: unity, solidarity, and security.3 In a time of tumult and uncertainty, the medieval Church gave assurance and hope of a better life to come. Its theological orientation, summarized as follows, left no doubt as to the meaning of life and death [T]he stretch on earth is only a short interlude, a temporary incarceration of the soul in the prison of the body, a brief trial and test, fated to end in death, the release from pain and suffering. What really matters is the life after the death of the body. One’s existence acquires meaning not by gaining what this life can offer but by saving one’s immortal soul from death and eternal torture, by gaining eternal life and everlasting bliss.4 Surrounding this view was a constellation of biblical stories considered to have profound explanatory or symbolic significance. Descriptively, these scriptural narratives and their interpretations accounted for human origin, nature, and destiny, as well as for the presence of evil in the world, including illness, suffering, and death. They helped people understand what and who they were, where they were going, and why they faced so much adversity along the way. Prescriptively, they told people how they should live, including how to structure such social institutions as marriage, family, and government. Crucial to the development and expression of this biblical perspective were the views of the Church’s most brilliant and influential of writers and thinkers, Saint Augustine (354–430) and Saint Thomas Aquinas (1225–1274). Although separated by 800 years, and despite many sharp differences between them, Augustine and Aquinas both treated the Bible as the ultimate source of knowledge about humankind’s origin, nature, destiny, and relationship with God. Millions of people still do. MEDIEVAL RELIGION AND ENLIGHTENMENT SCIENCE THE AUTHORITY OF THE BIBLE The Bible, which contains the sacred writings of all Christian religions, includes the Hebrew Scriptures, termed Old Testament (written between 1400 and 400 BCE), and Christian Scriptures, or New Testament, (completed and preserved between 50 and 100–150 CE). Significantly, the word testament comes from the Greek diatheke meaning “covenant.” For believers, the Bible remains a sacred covenant, or agreement, between God and his people, in which God reveals himself, makes certain promises, and requires certain behavior in return. For both Augustine and Aquinas, as well as for people generally during the Middle Ages, the Bible was the chief, if not exclusive, source of knowledge and understanding about themselves, their world, and the fate of both. But early Christians also recognized that the Scriptures could be obscure and difficult. The imperfect, fallible human mind could misunderstand and be led astray by them. To correct for this possibility, according to its founders, God established the Church as his representative on earth. As the Bible’s infallible interpreter, the Church existed to make revelation rational. It also functioned to spread biblical truth, which included suppressing heresy, or opinions at variance with official teaching. In this way, the early Church strove to avoid confusion and safeguard the sum of truths revealed in the Scriptures. THE BIBLICAL ACCOUNT OF CREATION “In the beginning God created the heavens and the earth” (Gen. 1:1). With these primordial words, the first book of the Bible asserts the existence of a single, unchanging, divine sovereign who created the universe. This monotheistic belief is regarded as Judaism’s unique contribution to the ancient religions of the Mediterranean, all of which—Egyptian, Babylonian, Assyrian, Greek—subscribed to polytheism, the belief in many gods, often quarrelsome and typically 17 indifferent to the world and its inhabitants. The God of Genesis, by contrast, is one and personal, righteous, and loving. By expressing himself in creation, this biblical God gives to the world unity and meaning, and to its inhabitants intrinsic value and significance. Human Nature Of the human aspect of creation, Genesis records that the first human, Adam, was made a “living being” or psycho-physical self by the “breath” or spirit of God: “The Lord god formed man of dust from the ground, and breathed into his nostrils the breath of life; and man became a living being” (Gen. 2.7; cf. Ps. 104. 29–30; Job 34.14–15). The first human, then, was both corporeal and spiritual; a unity of a material body and a spiritual, animating soul. Being imago Dei, made in the image of God, he shared something of the divine intellect and will. Through the intellect he could know that a single God exists, and through the will he could choose and act to love God. This uniquely human capacity to choose and act was fundamental to the covenant between God and Adam. The Relationship and the Covenant According to Genesis 3:2–3, God commanded Adam: “You may freely eat of every tree of the garden, but of the tree of knowledge of good and evil you shall not eat, for in the day that you eat of it you shall die.” Clearly, then, the first human is depicted as naturally free to obey or disobey, to do good or evil, to choose life or death. Thus is established the relationship of God’s lordship and the human’s subservience. The essence of this covenant or contract was that Adam would use his God-given faculties properly. In the classical Greek construction, proper use of uniquely human faculties basically meant rational development. Through reason, the Greek philosophers taught, one was to control destructive impulses, discover moral law in the universe, and find meaning in life. In the biblical view, by contrast, the unique human faculties of intellect and will characterized the first human as a beloved and compliant 18 CHAPTER 1 child of God. According to the biblical covenant, Adam could expect from a righteous God love, mercy, and justice; God, in turn, could expect of him fidelity and obeisance. Man, in brief, must act responsibly, that is, to choose to do right, not as he saw it, but as God willed it. In this way, order and harmony were established in the divine-human relationship and in creation, generally. Signifying the station of this completely good creature, the Creator then crowns the first human with “glory and honor” (Ps. 8.5) by giving him “dominion over all the earth and everything in it” (Gen 1.26). God then completes man’s happiness by placing him in a divine garden, Eden, and creating Eve to be Adam’s wife. (Gen 2:21–22) Given this idyllic account of creation, the earliest theologians, and later ones, faced what is called “the problem of the existence of evil.” why is there evil; and if God is all powerful, why does he permit it? Must it be concluded that God is not all good or not all powerful? An attempt to answer this question is sometimes called a theodicy (from the Greek theo meaning “god” dike meaning “justice or order”). Theodicy is the traditional theological term for a reasoned attempt to vindicate God’s goodness and power in the face of evil. Theologically, a theodicy tries to establish the compatibility of evil and divine justice so that the existence of evil cannot shatter our trust in the world, forcing us, unaided, to make sense of the seemingly senseless. Although Augustine didn’t invent the term—the German philosopher Gottfried Leibniz (1646-1716) did in his book Theodicy (1710)—Augustine did attempt to reconcile the existence of evil with the existence of an omniscient, omnipotent God. His explanation is an important aspect of the medieval religious view that still has wide appeal, especially in many people’s feelings and attitudes toward illness, suffering, and death. THE PROBLEM OF EVIL The Augustinian Theodicy We generally think of evil as being either “natural” or “moral.” Natural evil refers to an apparent malfunctioning of the physical world, whereas moral evil is human made. Natural evil includes not only so-called disastrous acts of nature such as storms and earthquakes, but also illness, disease, pain, suffering, and ultimately death. Moral evil includes destructive behavior by humans toward others, such as lying, cheating, and killing. While perceptions of evil may vary, evil always threatens our ability to act in the world and to understand it. Church historian Walter Sundberg puts it this way: Evil “raises the fundamental human question of intelligibility. If we cannot order evil, then both practical and theoretical reason are threatened.”5 In her book on the subject, philosopher Susan Neiman even goes so far as to call this fundamental question of intelligibility raised by evil the guiding force of modern thought.6 In any event, for theologians the “intelligibility” that the presence of evil threatens is the belief in an allgood, all-powerful God. Expressed as a question, then, the problem of evil is this: If God is all good, Consistent with the Bible, Augustine’s theodicy involved man’s fall from grace, or state of divine influence and sanctification. The biblical basis of the fall is two passages from Genesis. The first—“God saw all that he had made and saw that it was very good” (Gen. 1:31)—establishes a divine creation free of evil. The second describes the human’s first recorded act, an act of free choice proposed by the serpent, who, addressing Eve, contradicts God’s admonition to man: “You shall not die. For God knows that when you eat of it your eyes will be opened and you will be like God, knowing good and evil” (Gen. 3.4–5). Succumbing to pride, Adam is persuaded by Eve to betray his creaturely position and, figuratively, make of himself God, thereby breaking the sacred relationship and covenant. Because of this misu...
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The study I chose to talk about is the Tuskegee study. I chose the study because it really stuck
out with me about the injustice towards African American people and those with syphilis. The
government gave them free meals and free medical exams, but that does not balance out the
pain and the unethical treatment of the people. The people in the study were missed lead and
they did not know what they were getting themselves into and us could not give consent. I
think that this is wrong because anyone who chooses to participate in an experiment should be
given king sensual papers and know what they’re getting themselves into. They were not
allowed to get medical treatment for their syphilis which I also think is wrong and that it could
put their lives in extreme danger because this disease was deadly. I think that this study shows
that injustice against African Americans were present and are still present in today’s society.
Overall, I think that the study was very unethical and included home for treatment and should
have never been done in the first place. I think there are more ethical ways to go about this and
they chose not to because of racism.

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1. The Tuskegee study really stuck out with me with the injustice towards...


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