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Rev Panam Salud Publica vol.2 n.6 Washington Dec. 1997
The Foundations of Bioethics
H. Tristram Engelhardt. New York: Oxford University Press, Inc., second edition, 1996.
Over a relatively short period of 25 to 30 years, bioethics came to be an academic discipline and the most important of the applied ethics. Engelhardts book, The Foundations of Bioethics, is an im port ant contribution to the literature of this new discipline, as it addresses the basic ethical problems associated with modern medicine in a way that Latin Americans will appreciate. In so doing, Engelhardt approaches ethics from the standpoint of both medical history and a well-developed philosophy of medicine, and he carries out his reflections on bioethics in a hu man istic context. Readers in Latin America and other developing parts of the world may agree with him or strongly disagree, but in the latter case they will need to take their own ethical and philosophical stands in response to this important text.
While traditional medical ethics dates back 2 500 years to the Hippocratics, bioethics emerged and then developed as a separate discipline in the United States during the 1960s. Because of modern Western medicines dependence on laboratory science and advanced technologies, bioethical issues related to research and high technology have emerged wherever this mainstream medicine is practiced. Whether in Europe, Latin America, or Asia, hospitals and doctors are being forced to reform traditional paternalistic practices, which, if continued, would expose vulnerable patients to dangerous exploitation. The change in traditional medical ethics required by modern medicine centers around informed consent.
Bioethics in the United States of America arose in a climate of controversy and disagreement. The new discipline was challenged to find publicly acceptable solutions to complex problems precisely when U.S. culture had lost any semblance of moral homogeneity. If citizens disagree on moral issues, how can complex ethical problems be solved in a publicly defensible way? This question expresses the cultural problem that underlies Engelhardts theories. The ethical dilemmas created by experimentation on patients and by the use of high technology to treat them generated social and ethical questions about what sort of society modern research and medical technologies were creating and how they were affecting the basic meanings of life and death and family. In addition to debate over which medical practices are right or wrong and what constitutes a good society, there was controversy over issues as basic as how to determine right from wrong.
The challenges faced by the new discipline called bioethics were both ethical and epistemological, normative and procedural, moral and philosophical, and all are addressed in Engelhardts book. It is unique among the thousands of books and articles published each year on bioethics in that it provides a solid analysis of the historical and social background of problems, contains a well-developed philosophy of medicine, connects bio ethics with religion, and offers solutions to all the major clinical dilemmas. The book is thorough, profound, and controversial.
Engelhardt is both a physician and a philosopher, and his treatment of medical issues is always accurate and reliable. It is Engelhardts procedural and epistemological beliefs which many Latin Amer ican readers will find challenging. As a philosopher of medicine, he provides a thoroughly thought-out model for understanding what is meant by illness, treatment, and disease. In ethical theory he is a deontologist, for whom individual freedom is the key and central concept. He is also a utilitarian who condones the killing of severely defective infants and profoundly demented adults if suspending the practice of respect will achieve a greater balance of benefits over harms. In addition, he is a social theorist who expounds a social philosophy which underpins the building of peace ful community and is based on respect for the freedom of persons with whom one disagrees. Finally, he is an economic theorist who espouses what Latin Americans will likely judge to be a radical capitalism in which the concepts of ownership and property are applied even to unemancipated children. Engelhardt believes people should be allowed to sell their organs (in the case of a mother, her fetus) for spare parts. Neither leftists nor conservatives in Latin America will be entirely comfortable with his claims.
Besides all of the above, Engelhardt is also a profoundly religious thinker. His background assumption in the second edition of The Foundations of Bioethics is that only fully developed religious traditions provide concrete moral solutions to specific problems. However, he believes these solutions cannot be trans ferred through reasoned discourse or exhortation outside the boundaries of religious communities and therefore cannot be used to make public policy in todays pluralistic society. How, then, can we develop peaceful communities and acceptable public policies about life, death, disease, family, access to care, etc.?
The idea of relying on an updated version of natural law in which reasonable persons from different religious traditions can agree about what practices are most respectful of human life is aggressively rejected by Engelhardt. Reason, he claims, fails to ground accepted community standards, and many contradictory views found in todays societies can be defended rationally. His solution is that societal ethics and public policy must follow from negotiation and be based upon respect for the freedom of all participants.
Of all of Englehardts philosophical convictions, the most pervasive one is libertarianism. He believes that no ethical standard can be defended rationally in a manner that will convince all members of a heterogeneous society. Therefore, rational argument is ineffective for settling moral disputes but is useful for setting up negotiating procedures among es sentially free persons with irreconcilably different views. Thus, rationality contributes to the creation of a peaceful community in which different views of right and wrong are respected. Besides being free and respectful of one another, societys members are obliged to do good (beneficence), but any specific definition of good does not apply beyond the borders of small communities of like-minded individuals. We do good, he argues, to our own; to the rest we owe respect and noninterference.
Whether the libertarian overriding principle of respect for autonomous choice, joined to a negotiation commitment, can really produce the goal of a peaceful society is, in the opinion of this reviewer, doubtful. Free-trade economies are based on the same assumptions, and they produce greater wealth for a minority, greater misery for the majority, and societies that deviate increasingly from the ideal of a peaceful community. Obviously, broad substantive principles, such as justice, fairness, and equality, are also required, along with concrete policies to apply them, like affirmative action and state welfare programs, directed at the most deprived. A peaceful society based only on respect for differences is utopian.
Logical and consistent applications of Engelhardts philosophical beliefs reveal a number of specific bioethical stands which he invariably defends. In defining death he argues for a higher brain function test (neocortical activity) rather than a brain stem standard. On abortion, he defends essentially a morality of maternal consent because fetuses and infants lack complete moral standing as persons, and it is only religious belief that makes abortion immoral. On informed consent, he argues against a reasonable person standard because it would place too heavy a burden on physicians. Regarding ownership, Engelhardt extends the concept to body parts, fetuses, infants, and especially to intellectual products.
Engelhardts bioethics is both similar to and very different from that of defenders of natural law. He argues for what he calls a polytheistic presumption, or the acknowledgment of numerous equally defensible but quite different moral perspectives, as opposed to a monostotic presumption, which accepts as correct just one unique moral view. Engelhardts foundation for a peaceful community requires respect for the many different perspectives which one finds in todays pluralistic society. He not only respects the different perspectives existing in the modern world, but recognizes their claims of truth. Different communities of knowers and evaluators, with different rules for recognizing evidence and reasoning on its basis, are likely to perceive and understand facts and values differently.
And yet Engelhardt claims, in my opinion with some inconsistency, that some ways of reasoning (of which his own rational arguments would be examples) are better and more defensible than others. He believes that reality has rational structures and that sound reasoning can gain access to them. Answers can then be given to moral questions, based on a rational assessment of the realities under consideration, an assumption he shares with natural law thinkers. He also asserts that no rationally supported position on moral right and wrong can ever be final because every rational portrayal of reality in any detail will be conditioned by changing historical and cultural factors.
In the first edition of The Foundations of Bio ethics (1986), Engelhardts discourse about religion and religious perspectives in ethics was consistently negative in tone. Religion was defined by its most obvious and glaring historical failures and judged by its worst acts (the condemnation of Galileo, the Inquisition, forced imposition of beliefs) rather than its best. In the second edition (which was translated into Spanish with the title Los fundamentos de la bioética), Engelhardts attitude toward religion undergoes a profound change. Concrete bioethical problems are presumed to be solved by divine revelation. Engelhardt makes religiously based moral beliefs synonymous with absolute certainty about the most complex and debated questions. For Engelhardt, religiously based moral theory derives from revelation, and a miraculous grace removes all doubt and uncertainty. Religion does for Engelhardt what reason can never accomplish.
Religion in Engelhardts first edition was a mere caricature, but in the second edition it is a source of unalterable moral convictions. However, his religiously based moral stands have a fundamentalist flavor. A scriptural ethics is certainly possible, but mainstream Christian ethicists hold that, with some exceptions (the decalogue) only basic moral attitudes, dispositions, and principles are revealed. They also hold, and I agree, that in order to be believable, religious ethics has to reflect modern biblical scholarship, which is absent in Engelhardt. Only for fundamentalists and sectarians is scripture a grab bag of concrete and unchangeable ethical answers to complex contemporary moral problems.
Is Engelhardts pessimism about the possibility of reaching common ethical understanding or common morality justified? Is his social ethics of libertarianism and individualism the only solution to problems associated with contemporary pluralism? Is nonecumenical ethics of irreconcilably divergent religiously grounded moralities rationally or religiously defensible? Can only persons belonging to the same religious denominations arrive at common ethical beliefs and practices? Or is there something about the human condition, especially when confronting disease and illness, that provides a deep and inexhaustibly rich basis for common morality? Just as children everywhere have the same needs, so do adults who are victims of disease and disability. Sick people have common needs despite their different cultures and patterns of reasoning and despite different ways of coping with such threats.
Cultural differences dont change everything. Even very different religions have much in common, both at the more objective level of ethical first principles and at the more subjective one of ethical attitudes or dispositions. These commonalities, which are reflective of shared human experiences, may not overcome every difference, but they contradict the claim that there are unresolvable disagreements. Unbridgeable polarities contradict the experiential and religious grounds of common ethical standards. Starting with the experience of disease and illness we can, I believe, develop universal ethical solutions to contemporary bioethical problems based on reason: e.g., the already established list of universal standards and policies emanating from international professional associations and international accords. We can, in fact, avoid the ethical pessimism which pervades Engelhardts libertarianism and his nonecumenical solutions for a peaceful community.
Engelhardt is convincing in his description of many aspects of current North American culture. Because the culture of the United States exercises an influence on so many parts of the world, his observations have broad application. He is certainly correct in pointing out that pluralism, whether in the United States or Latin America, creates a dangerous potential for violence. People seek refuge from the danger in smaller communities of like-minded persons who form their own institutions (churches, schools, hospitals). The deeper the faith in the be lief system of ones particular community, the more other beliefs and people are seen as alien and threat ening. Engelhardt perceives the threat and stresses the need to find a way of guaranteeing peace. But more is required to attain social peace than simply letting others be.
Rather than merely the reason-based respect for differences advocated by Engelhardt, common beliefs are required even for heterogeneous societies, as well as frequent contact among persons be longing to communities with different beliefs. From each groups awareness that all the answers are not attainable within any one system comes a search for a broader, deeper, and more adequate truth. Without communication among persons in different communities, pluralism can easily drift into anarchy of ideas and violent conflict. Pluralism requires an agreement about basic values and continued reflection on them. Even ones own religious beliefs have to be examined in light of other belief systems. The principles of truth, justice, freedom, and caring are the foundations of more concrete common moral standards; the immoralities of racism, intolerance, violence, child abuse, drug trade, torture, and enslavement are disvalues which every community and society can agree to reject.
Engelhardts bioethics is strong on analyzing problems and weak on offering hope for possible solutions. The obvious commonalities shared by gravely ill and dying patients which can ground a strong, objective bioethics are ignored. The universally recognized need for diverse religious communities to engage in closer contact and to strive to overcome distorted perceptions of one another is rejected. For Engelhardt, ecumenism has a pejorative connotation, and conversion is the only way to move from one community to another.
We are left with a bioethics of permission and negotiation which is laudable but paper thin. Real people who communicate and negotiate and give permission do so on the basis of the deep moral values which they share. Engelhardts bioethics leaves this deep moral reality unaddressed, when it demands attention and convincing articulation. With out it, we can not even imagine a bioethics capable of setting broad social standards for treating and caring for patients within a just health care delivery system or an international medical community. Who would agree even for a moment on a bioethics in which doctors and patients remain moral strangers and the doctor-patient relationship is deprived of strength and virtue by the granting of permission?
This publication and its translation into Spanish (Los fundamentos de la bioética, Barcelona, Ediciones Paidós Ibérica, S.A., 1995, ISBN 84-493-0031-2) can be obtained directly from the following publishers, respectively: Oxford University Press, Inc., 200 Madison Avenue, New York, New York, USA, and Ediciones Paidós Ibérica, S.A., Mariano Cubí, 92-08021, Barcelona, Spain.
James F. Drane
Department of Philosophy
Edinboro University of Pennsylvania, USA