- Email: [email protected]
Locating core values in bioethics
+Model JEMEP-116; No. of Pages 3
ARTICLE IN PRESS
Ethics, Medicine and Public Health (2016) xxx, xxx—xxx
Available online at
ScienceDirect www.sciencedirect.com
DOSSIER ‘‘CORE VALUES IN BIOETHICS’’ /Editorial
Locating core values in bioethics Situer les valeurs fondamentales en matière de bioéthique
Bioethics is still in its relative infancy as a multidisciplinary pursuit. At various stages in its development, theorists have entertained the notion that a set of core values lies at the foundation of the multifaceted inquiries that have become a part of its effort in the applied clinical field, empirical research, and undertakings with respect to a prioritization of its underlying principles. Professor Gerald Young of York University in Canada has offered an innovative and ambitious dimension to any undertaking aimed at isolating core values in bioethics. Unconvinced that there is a universal set of values, his departure point chooses to ground our thinking in principles connected to consensus values to be determined by individual professional groups. It is anticipated that fundamental values will recur, but what is important to him is the completeness of the terms of reference that are applicable to real work done in bioethics, where standards of conduct are put to the test. Therefore, he adds new referentials to ones normally found in established biomedical groups. Gerald Young explores ethics that functions as a system, and ethics as it relates to science, law, assessment procedures, validation, and verification. Because of his psychological orientation, Professor Young presents a model of maturation in ethical thought, which he sees as a necessary ingredient to an understanding of how ethical thought is credible vis-à-vis the tasks that are laid before professionals in their decision-making. This is an unusual component of the discourse in bioethics but, he would argue, essential to putting bioethics into practice in the construction of rules and codes and in confronting dilemmas. He believes that his model is applicable both to individual and institutional situations. As bioethical problems occur from the period of studentship through the gamut of clinical responsibilities and obligations affecting researchers, his model is presented as a potential for guiding decision-making throughout one’s professional life cycle. Professor Temkin, a highly reputed philosopher who has written extensively on the theory of equality, observes that there is a tension that is sustained between theory and practice in the sense that once governing principles have been deconstructed, it is oftentimes puzzling how connections can be made between the insights arrived at and applications to specific cases, both in the areas of actual medical practice and research. Rather, it increases the confusion that arises when the misleading simplicity of certain concepts is exposed but the complexity of the issues remains, asking for further research, either through deeper philosophical understanding or through determining how applications might or might not lead to resolution. Larry Temkin delves into the nuances of economy and efficiency pertaining to health and concentrates on the ingredients of disability adjusted life years (DALYs) and quality adjusted life years (QALYs). In the second part of his essay, he investigates the concept of
http://dx.doi.org/10.1016/j.jemep.2016.03.004 2352-5525/© 2016 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Weisstub DN. Locating core values in bioethics. Ethics, Medicine and Public Health (2016), http://dx.doi.org/10.1016/j.jemep.2016.03.004
+Model JEMEP-116; No. of Pages 3
ARTICLE IN PRESS
2
Dossier ‘‘Core Values in Bioethics’’
equity and unpacks the significance of egalitarian and prioritarian concerns as they impact on our treatment of health policy. It is an assumption of his essay that the medical field has evolved its reach to the point that a host of normative questions have arisen as part of the enterprise of medicine in action at various levels of profession and government. One of the compelling aspects of Temkin’s article is his approach to the subject in the context of differentiating ‘life stages’ in order to illuminate how we can best understand its fair and just application. This has serious implications for government planners. Anton van Niekerk has researched extensively in the area of research ethics in developing countries. In his essay ‘‘NonRacism as a Core Value in Bioethics’’, he boldly enters the question of how research, that has as a component of its project differentiation based on race, can be justified in view of the aspirational values of an enlightened bioethics. Indeed, the lessons from what has occurred in the past with regard to fascist or colonial regimes researching ‘inferior subjects’, even to the point of completely dehumanizing them, have given rise to questions about whether the results of such research could ever be used, even if the findings do have some scientific merit. The examples to which Anton van Niekerk refers are legendary. The crux of his argument is that a distinction can be meaningfully made between ‘racism’ and ‘racialism’. The former is premised on denigration, whereas the latter is motivated to investigate how groups can benefit from research containing a racial or ethnic component. Having said that, there is the gnawing question of the extent to which, in nefarious regimes, such information could still be used disadvantageously and revert to the exploitation of designated groups within health systems. Anton van Niekerk embraces the idea that there has to be a weighing of the benefits to a group accrued from diagnosis and research against the potential social costs, for example, of relating race or ethnicity to genetics. Jennifer Radden, on the subject of mental health and bioethics, contends that the autonomy-based contractualist model of bioethics needs to be superimposed by a more communitarian public health approach. Her submission is that the bioethics literature has been overwhelmed by an individualistic concentration which has failed to recognize the extent to which any proper understanding of utilitarianism or an alternative deontological set of assumptions can only be fully achieved when we begin to participate in a process of how concentrating on all members of society produces advantages not only for the collectivity but for the individual who becomes less stigmatized and whose illness can be appreciated as the product of economic and environmental conditioning. In her article, she demonstrates that experiments and research, for example in Australia, have already delivered positive results. The subject of depression is the concentration point of her article, but other instances of health planning could equally have been utilized. There are certain illnesses which have captured a major piece of the available resources for health prevention, diagnosis, and treatment. The mental health sphere does not dominate but, certainly, indicates a route that should be increasingly attended to in order for medicine to achieve its stated values. Addressing the use of epidemiology and appreciation of the multi-dimensional nature of
health determinants is the proposed direction for bioethics, according to Professor Radden. She asserts that the independent variable of the ‘individual’ posited by classic liberalism is not only idealized, but undesirable. Despite this, she concludes that there are inherent risks in trumping a collectivist vision of bioethics over an autonomy/rights ethical system. Finally, it is her perspective that it is worth the risk that in our commitment to our public vision, we remain vigilant in the areas where the protection of individual rights has to be attended to. Natural law theory is a perennial theme within the history of legal philosophy in Western jurisprudence. The center point of its prominence lies undoubtedly in the Thomistic tradition, which has been sustained throughout the millennia. Although centered in legal philosophy primarily within the Catholic schools of theology and law, its influence has been strongly felt in liberal ecumenical works as well as in associated Judeo-Christian thinking. Its detractors have associated natural law theory with the presentation of absolutes, core values that accommodate to no mitigating factors; however, its more refined versions contradict such a picture of rigidity and place natural law within practical constitutional frameworks where reasonable exceptions are justifiable. Natural law has been espoused in various guises and, apart from ‘Thomism’, versions of it have appeared, informed by the enlightenment and humanistic philosophies as well as located in forms of evolution or biological theories. The mainstay, however, that interconnects all versions of natural law theory is the commitment to a higher realm of values around which a subset of values can be subsumed. This does not necessarily imply a prima facie metaphysical construction from which these values can be deduced. Lloyd Steffen, who has authored works on natural law theory, elucidates that natural law ethics is the most significant reference point for identifying core values in bioethics. He turns to a ‘just war’ as a reasoned platform from which to deal with our commitment to saving a human life, grounded in exceptional conditions. It is Professor Steffen’s viewpoint that there needs to be an appeal to reason based upon a carefully guided set of fundamental principles about the value of human life. There are situations, he asserts, where defending life at all costs, namely, a combination of economy, common sense, sensitivity, and respect for human dignity, become morally futile. There will inevitably be controversial issues about how such positions by natural law theorists differ from pragmatism or constitutional democratic liberalist concepts which are non-metaphysical and do not include revelatory documents. Such debates have been part and parcel of the history of natural law theory. But, true to form, Lloyd Steffen joins a longstanding history of serious claims about how we ground core values relating to life and its protection in medical ethics. His vision is one about the nature of the ‘good life’ applied to each and every member of humankind. It is an appeal to aspire to and to agree upon universal human values to act as a primary directive for outcomes in ‘hard cases’ in medical ethics. The gift of natural law theory, according to Professor Steffen, is that it can function as an overriding blanket, taking into account consequentialist arguments and deontologically stated absolutes, while being governed by neither but available for an open dialogue to look for exceptions against an ever-present background of the highest-level principles to
Please cite this article in press as: Weisstub DN. Locating core values in bioethics. Ethics, Medicine and Public Health (2016), http://dx.doi.org/10.1016/j.jemep.2016.03.004
+Model JEMEP-116; No. of Pages 3
ARTICLE IN PRESS
Dossier ‘‘Core Values in Bioethics’’ which humanity must subscribe. Above all, his treatment of natural law is an invitation to an exchange among seemingly opposed philosophical positions which, through natural law theory, can incorporate the most ethically justifiable conclusions for both social and individual goods. Jacob Dahl Rendtorff provides us with the connection between core values and the advancement of bioethics in its relationship to European biolaw. He explains that this is an interactive process where the connectors are being transformed and modified through the instruments of the courts, the parliamentary powers of legislation, and the executive branches of government. He lays out a map of what constitutes the foundational principles of the bioethics part of the interactive model, naming four: autonomy, dignity, integrity, and vulnerability. Once these cornerstones are explained, it is important to acknowledge the symbolic function of how these values play out within a democratic system of law. How principles function in relation to rules and the ethics of judicial activism as it relates to legislative responsibility is a strongly felt debate among legal theorists and social philosophers. As he rightly points out, there is a strong difference expressed between Ronald Dworkin and Jürgen Habermas. Ronald Dworkin, in his vociferous publications, has demonstrated how principles are wedded to the American Constitution. He has explicated how these principles have a weight that is the spirit behind innumerable progressive interpretations by the American courts, which can be rationalized as the overarching penumbra for how rules are to be applied, the latter being, in their raw form, a mechanistic function. In contrast, Habermas has the notion that it is the legislative arm that should properly inform us of how controversial medical issues must be resolved. This should reflect the will of the people as opposed to deferring to judicial activism. This culturally significant issue is especially
3 sensitive in Europe, given its diversity and varied historical antecedents. This area in legal philosophy is a fascinating inquiry and one that deserves special attention within the European community. It is also a timely debate given the current disputes about the role and function of the US Supreme Court in matters of bioethics that will be presented to it in the upcoming years. As Rendtorff sees it, bioethics must provide the terms of reference for the legislature, and biolaw is the concretization of its rules and norms found in the decision-making outcomes of judge-made law. Professor Rendtorff expresses this process as demonstrating a ‘reflexive law’ with ‘biolaw’ as the mediating force between and among religious, cultural, and philosophical inputs. There is no doubt that modern technology will transform our perceptions of the human body. It is the hope and aim, as Rendtorff conceives it, that European law will not lose sight of its foundational values in reacting to the challenges that will be placed before it.
Disclosure of interest The author declares that he has no competing interest. Titulaire de la Chaire de psychiatrie légale et d’éthique biomédicale Philippe-Pinel, Honorary Life President of the International Academy of Law and Mental Health (IALMH) D.N. Weisstub (JD, LLD) Faculté de médecine, université de Montréal, International Academy of Law and Mental Health, C.P. 6128, Succ. Centre-Ville, Quebec H3C3J7, Canada E-mail address: [email protected]
Please cite this article in press as: Weisstub DN. Locating core values in bioethics. Ethics, Medicine and Public Health (2016), http://dx.doi.org/10.1016/j.jemep.2016.03.004
ARTICLE IN PRESS
Ethics, Medicine and Public Health (2016) xxx, xxx—xxx
Available online at
ScienceDirect www.sciencedirect.com
DOSSIER ‘‘CORE VALUES IN BIOETHICS’’ /Editorial
Locating core values in bioethics Situer les valeurs fondamentales en matière de bioéthique
Bioethics is still in its relative infancy as a multidisciplinary pursuit. At various stages in its development, theorists have entertained the notion that a set of core values lies at the foundation of the multifaceted inquiries that have become a part of its effort in the applied clinical field, empirical research, and undertakings with respect to a prioritization of its underlying principles. Professor Gerald Young of York University in Canada has offered an innovative and ambitious dimension to any undertaking aimed at isolating core values in bioethics. Unconvinced that there is a universal set of values, his departure point chooses to ground our thinking in principles connected to consensus values to be determined by individual professional groups. It is anticipated that fundamental values will recur, but what is important to him is the completeness of the terms of reference that are applicable to real work done in bioethics, where standards of conduct are put to the test. Therefore, he adds new referentials to ones normally found in established biomedical groups. Gerald Young explores ethics that functions as a system, and ethics as it relates to science, law, assessment procedures, validation, and verification. Because of his psychological orientation, Professor Young presents a model of maturation in ethical thought, which he sees as a necessary ingredient to an understanding of how ethical thought is credible vis-à-vis the tasks that are laid before professionals in their decision-making. This is an unusual component of the discourse in bioethics but, he would argue, essential to putting bioethics into practice in the construction of rules and codes and in confronting dilemmas. He believes that his model is applicable both to individual and institutional situations. As bioethical problems occur from the period of studentship through the gamut of clinical responsibilities and obligations affecting researchers, his model is presented as a potential for guiding decision-making throughout one’s professional life cycle. Professor Temkin, a highly reputed philosopher who has written extensively on the theory of equality, observes that there is a tension that is sustained between theory and practice in the sense that once governing principles have been deconstructed, it is oftentimes puzzling how connections can be made between the insights arrived at and applications to specific cases, both in the areas of actual medical practice and research. Rather, it increases the confusion that arises when the misleading simplicity of certain concepts is exposed but the complexity of the issues remains, asking for further research, either through deeper philosophical understanding or through determining how applications might or might not lead to resolution. Larry Temkin delves into the nuances of economy and efficiency pertaining to health and concentrates on the ingredients of disability adjusted life years (DALYs) and quality adjusted life years (QALYs). In the second part of his essay, he investigates the concept of
http://dx.doi.org/10.1016/j.jemep.2016.03.004 2352-5525/© 2016 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Weisstub DN. Locating core values in bioethics. Ethics, Medicine and Public Health (2016), http://dx.doi.org/10.1016/j.jemep.2016.03.004
+Model JEMEP-116; No. of Pages 3
ARTICLE IN PRESS
2
Dossier ‘‘Core Values in Bioethics’’
equity and unpacks the significance of egalitarian and prioritarian concerns as they impact on our treatment of health policy. It is an assumption of his essay that the medical field has evolved its reach to the point that a host of normative questions have arisen as part of the enterprise of medicine in action at various levels of profession and government. One of the compelling aspects of Temkin’s article is his approach to the subject in the context of differentiating ‘life stages’ in order to illuminate how we can best understand its fair and just application. This has serious implications for government planners. Anton van Niekerk has researched extensively in the area of research ethics in developing countries. In his essay ‘‘NonRacism as a Core Value in Bioethics’’, he boldly enters the question of how research, that has as a component of its project differentiation based on race, can be justified in view of the aspirational values of an enlightened bioethics. Indeed, the lessons from what has occurred in the past with regard to fascist or colonial regimes researching ‘inferior subjects’, even to the point of completely dehumanizing them, have given rise to questions about whether the results of such research could ever be used, even if the findings do have some scientific merit. The examples to which Anton van Niekerk refers are legendary. The crux of his argument is that a distinction can be meaningfully made between ‘racism’ and ‘racialism’. The former is premised on denigration, whereas the latter is motivated to investigate how groups can benefit from research containing a racial or ethnic component. Having said that, there is the gnawing question of the extent to which, in nefarious regimes, such information could still be used disadvantageously and revert to the exploitation of designated groups within health systems. Anton van Niekerk embraces the idea that there has to be a weighing of the benefits to a group accrued from diagnosis and research against the potential social costs, for example, of relating race or ethnicity to genetics. Jennifer Radden, on the subject of mental health and bioethics, contends that the autonomy-based contractualist model of bioethics needs to be superimposed by a more communitarian public health approach. Her submission is that the bioethics literature has been overwhelmed by an individualistic concentration which has failed to recognize the extent to which any proper understanding of utilitarianism or an alternative deontological set of assumptions can only be fully achieved when we begin to participate in a process of how concentrating on all members of society produces advantages not only for the collectivity but for the individual who becomes less stigmatized and whose illness can be appreciated as the product of economic and environmental conditioning. In her article, she demonstrates that experiments and research, for example in Australia, have already delivered positive results. The subject of depression is the concentration point of her article, but other instances of health planning could equally have been utilized. There are certain illnesses which have captured a major piece of the available resources for health prevention, diagnosis, and treatment. The mental health sphere does not dominate but, certainly, indicates a route that should be increasingly attended to in order for medicine to achieve its stated values. Addressing the use of epidemiology and appreciation of the multi-dimensional nature of
health determinants is the proposed direction for bioethics, according to Professor Radden. She asserts that the independent variable of the ‘individual’ posited by classic liberalism is not only idealized, but undesirable. Despite this, she concludes that there are inherent risks in trumping a collectivist vision of bioethics over an autonomy/rights ethical system. Finally, it is her perspective that it is worth the risk that in our commitment to our public vision, we remain vigilant in the areas where the protection of individual rights has to be attended to. Natural law theory is a perennial theme within the history of legal philosophy in Western jurisprudence. The center point of its prominence lies undoubtedly in the Thomistic tradition, which has been sustained throughout the millennia. Although centered in legal philosophy primarily within the Catholic schools of theology and law, its influence has been strongly felt in liberal ecumenical works as well as in associated Judeo-Christian thinking. Its detractors have associated natural law theory with the presentation of absolutes, core values that accommodate to no mitigating factors; however, its more refined versions contradict such a picture of rigidity and place natural law within practical constitutional frameworks where reasonable exceptions are justifiable. Natural law has been espoused in various guises and, apart from ‘Thomism’, versions of it have appeared, informed by the enlightenment and humanistic philosophies as well as located in forms of evolution or biological theories. The mainstay, however, that interconnects all versions of natural law theory is the commitment to a higher realm of values around which a subset of values can be subsumed. This does not necessarily imply a prima facie metaphysical construction from which these values can be deduced. Lloyd Steffen, who has authored works on natural law theory, elucidates that natural law ethics is the most significant reference point for identifying core values in bioethics. He turns to a ‘just war’ as a reasoned platform from which to deal with our commitment to saving a human life, grounded in exceptional conditions. It is Professor Steffen’s viewpoint that there needs to be an appeal to reason based upon a carefully guided set of fundamental principles about the value of human life. There are situations, he asserts, where defending life at all costs, namely, a combination of economy, common sense, sensitivity, and respect for human dignity, become morally futile. There will inevitably be controversial issues about how such positions by natural law theorists differ from pragmatism or constitutional democratic liberalist concepts which are non-metaphysical and do not include revelatory documents. Such debates have been part and parcel of the history of natural law theory. But, true to form, Lloyd Steffen joins a longstanding history of serious claims about how we ground core values relating to life and its protection in medical ethics. His vision is one about the nature of the ‘good life’ applied to each and every member of humankind. It is an appeal to aspire to and to agree upon universal human values to act as a primary directive for outcomes in ‘hard cases’ in medical ethics. The gift of natural law theory, according to Professor Steffen, is that it can function as an overriding blanket, taking into account consequentialist arguments and deontologically stated absolutes, while being governed by neither but available for an open dialogue to look for exceptions against an ever-present background of the highest-level principles to
Please cite this article in press as: Weisstub DN. Locating core values in bioethics. Ethics, Medicine and Public Health (2016), http://dx.doi.org/10.1016/j.jemep.2016.03.004
+Model JEMEP-116; No. of Pages 3
ARTICLE IN PRESS
Dossier ‘‘Core Values in Bioethics’’ which humanity must subscribe. Above all, his treatment of natural law is an invitation to an exchange among seemingly opposed philosophical positions which, through natural law theory, can incorporate the most ethically justifiable conclusions for both social and individual goods. Jacob Dahl Rendtorff provides us with the connection between core values and the advancement of bioethics in its relationship to European biolaw. He explains that this is an interactive process where the connectors are being transformed and modified through the instruments of the courts, the parliamentary powers of legislation, and the executive branches of government. He lays out a map of what constitutes the foundational principles of the bioethics part of the interactive model, naming four: autonomy, dignity, integrity, and vulnerability. Once these cornerstones are explained, it is important to acknowledge the symbolic function of how these values play out within a democratic system of law. How principles function in relation to rules and the ethics of judicial activism as it relates to legislative responsibility is a strongly felt debate among legal theorists and social philosophers. As he rightly points out, there is a strong difference expressed between Ronald Dworkin and Jürgen Habermas. Ronald Dworkin, in his vociferous publications, has demonstrated how principles are wedded to the American Constitution. He has explicated how these principles have a weight that is the spirit behind innumerable progressive interpretations by the American courts, which can be rationalized as the overarching penumbra for how rules are to be applied, the latter being, in their raw form, a mechanistic function. In contrast, Habermas has the notion that it is the legislative arm that should properly inform us of how controversial medical issues must be resolved. This should reflect the will of the people as opposed to deferring to judicial activism. This culturally significant issue is especially
3 sensitive in Europe, given its diversity and varied historical antecedents. This area in legal philosophy is a fascinating inquiry and one that deserves special attention within the European community. It is also a timely debate given the current disputes about the role and function of the US Supreme Court in matters of bioethics that will be presented to it in the upcoming years. As Rendtorff sees it, bioethics must provide the terms of reference for the legislature, and biolaw is the concretization of its rules and norms found in the decision-making outcomes of judge-made law. Professor Rendtorff expresses this process as demonstrating a ‘reflexive law’ with ‘biolaw’ as the mediating force between and among religious, cultural, and philosophical inputs. There is no doubt that modern technology will transform our perceptions of the human body. It is the hope and aim, as Rendtorff conceives it, that European law will not lose sight of its foundational values in reacting to the challenges that will be placed before it.
Disclosure of interest The author declares that he has no competing interest. Titulaire de la Chaire de psychiatrie légale et d’éthique biomédicale Philippe-Pinel, Honorary Life President of the International Academy of Law and Mental Health (IALMH) D.N. Weisstub (JD, LLD) Faculté de médecine, université de Montréal, International Academy of Law and Mental Health, C.P. 6128, Succ. Centre-Ville, Quebec H3C3J7, Canada E-mail address: [email protected]
Please cite this article in press as: Weisstub DN. Locating core values in bioethics. Ethics, Medicine and Public Health (2016), http://dx.doi.org/10.1016/j.jemep.2016.03.004