Griffin Trotter

Bioethics and Deliberative Democracy: Five Warnings from Hobbes

Thomas Hobbes is one of the most ardent and thoroughgoing opponents of participatory democracy among Western political philosophers. Though Hobbess alternative to participatory democracy-assent by subjects to rule by an absolute sovereign-no longer constitutes a viable political alternative for Westerners, his critique of participatory democracy is a potentially valuable source of insight about its liabilities. This essay elaborates five theses from Hobbes that stand as cogent warnings to those who embrace participatory democracy, especially those (such as most bioethicists) advocating for deliberative democracy based on a rational consensus model. In light of these warnings, the author suggests an alternative, modus vivendi approach to deliberative democracy that would radically alter the current practice of bioethics.

Bioethics and healthcare reform: a Whig response to weak consensus.

Contemporary bioethics begins with the perception that medical values are a matter of public, rather than merely professional, interest. Such was the message of delegates in Helsinki and of the New Jersey court that decided for Quinlan. It is a theme that lurks within almost every major bioethical treatise since the first edition of Principles of Bioethics . This perception also undergirds the increasingly popular suggestion that moral authority in the patient-physician relationship resides neither in the medical profession, nor in the singular will of the patient, but in moral communities that link both parties with higher social orders.

Preferred allocation for registered organ donors

A shortage of transplantable organs in the United States can be traced to low rates of donation. Incentives for organ donation might partially remedy these organ shortfalls. Although incentives countervail the dominant philanthropy model, this model is neither well supported by ethical argument nor strictly applied. Preferred allocation, consisting in the practice of awarding extra priority points to previously registered organ donors who need transplants, is attractive in that it offers a potentially effective incentive while deviating less radically from entrenched practices than financial incentives. It is supported by the public and conforms to intuitions about justice and reciprocity. Moreover, it highlights moral features of the transplant community as a particular moral community within the greater medical community.

The UNESCO Declaration on Bioethics and Human Rights: A Canon for the Ages?

The UNESCO Universal Declaration on Bioethics and Human Rights of 2005 purports to articulate universal norms for bioethics. However, this document has met with mixed reviews. Some deny that the elaboration of universal bioethics norms is needed; some deny that UNESCO has the expertise or authority to articulate such norms; some regard the content of the UNESCO document as too vague or general to be useful; and some regard the document as a cog in the effort of like-minded cosmopolitans to codify their particular moral intuitions in international law. This issue examines the potential merits and pitfalls of the Universal Declaration on Bioethics and Human Rights.

Moral Consensus in Bioethics: Illusive or Just Elusive?

This issue of CQ was conceived in Salt Lake City, at the third annual meeting of the American Society of Bioethics and Humanities (ASBH). There, Presidentelect Laurie Zoloth delivered a stirring address, emphasizing the role of bioethics in responding to social deprivations and suggesting that ASBH “take a stand” on important issues where members share consensus. Not all the stirrings were pleasant. Debate erupted about the propriety of consensus statements, especially regarding possible deleterious effects on academic discourse, misappropriation of dues, and the proliferation of quasi-political factions. The roots of this controversy extend deeply into the collective psyche of contemporary bioethics. Perhaps the most conspicuous theme of twentieth-century intellectual history was the observation that moral values are historically and culturally contingent, and hence irremediably plural. Moral pathologists classified this insight as the Enlightenment’s fatal malignancy, yet it blossomed into a decorous postmodern tradition. Its legacy is a paradox that will be facing us for many years. Moral pluralism, initially viewed as a value-neutral, unintended byproduct of contingency, has transmogrified into ethics’ guiding value —the new telos for nonteleological society. Bereft of other options, many bioethicists now cite pluralism as the name of the good. On this pretext, we busy ourselves spinning off a plurality of freestanding, incompatible, and sometimes mutually intolerant pluralisms.1 This paradox is exacerbated by the persistence of nonpostmodern moral traditions that do not recognize the intrinsic goodness of pluralism. More distressingly, there is no guarantee that if left largely to their own resources (as presumably they would be in broader pluralistic settings) these wayward traditions will ever come around. The problem, then, is that moral pluralism, as a candidate for a universal moral standard, seems to be self-defeating. It can be achieved only by suppressing alternative moral visions. Where, then, will we find enough moral common ground to facilitate social progress? Into this breach the discipline of bioethics has leapt with a vengeance. Two basic responses, each reflecting a sort of transvaluation of pluralism along with other dominant Western values, seem to have emerged. Each response has several variations, and many are present in the current issue. On one hand, we have thinkers who interpret pluralism through the lens of equality. Here the ideal is to maximize life opportunities for all people and to create a secure environment in which individuals and communities can pursue cooperative ideals harmoniously and safely. This version posits a consensus-oriented meth-

The Moral Basis for Healthcare Reform in the United States

In speculating on the motives for government, English philosopher Thomas Hobbes identified the pervasive role of fear and the danger of violent death, holding famously that where no government prevails to secure physical safety and property, there can also be no enduring knowledge, art, or civilization—leaving human lives “solitary, poore [sic], nasty, brutish and short.”

Genesis of a Totalizing Ideology: Bioethics’ Inner Hippie

The 1960s was a formative period for contemporary bioethics. Many of today’s most established and influential bioethicists matured academically during this time, developing patterns of thought that persist in their contemporary work. This essay examines the manner in which values that attained prominence during the 1960s countercultural movement have manifested in dogmas, inadequacies and contradictions that plague contemporary bioethics. It suggests that bioethics’ project of establishing an authoritative moral consensus and enforcing it politically is to some extent grounded in 1960s values, and is untenable as a comprehensive vision for many of the same reasons that predecessor movements in the 1960s also proved untenable.

The Illusion of Legitimacy: Two Assumptions that Corrupt Health Policy Deliberation

Public deliberation about health policy in the United States often hinges on two untenable basic assumptions about political legitimacy. The first assumption, common in public debate throughout the United States, is that federal oversight of health care is justified under a federal compact binding all citizens. This assumption is false because the federal compact precludes such oversight. Indeed, the ascendancy of national government (and demise of federalism) over the past 70 years was engineered through the subversion of the federal compact, creating an expansive legitimation gap. The second assumption--that political legitimacy can be established through appeals to expert consensus about fundamental conceptions of justice or human rights--is prevalent among bioethicists. I argue that this assumption is illicit because it hinges on a weak, rationalistic form of majoritarian democracy that conflates public acquiescence with public approval. If the public mission of academic bioethics involves protecting the integrity of public deliberation, then these two basic assumptions should be challenged.

Abortion, Secular Dogma, and the Sacrament of Sex: Another Failed Attempt to Impose Moral Idiosyncrasies Through the Ruse of Argument

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Autonomy as self-sovereignty.

The concept of autonomy as self-sovereignty is developed in this essay through an examination of the thought of American transcendentalist philosophers Emerson and Thoreau. It is conceived as the quality of living in accordance with one’s inner nature or genius. This conception is grounded in a transcendentalist moral anthropology that values independence, self-reliance, spirituality, and the capacity to find beauty in the world. Though still exerting considerable popular and academic influence, both the concept of autonomy as self-sovereignty and the underlying anthropology diverge in important ways from counterparts that are prominent in contemporary bioethics. Autonomy as self-sovereignty calls into question the manifold ways that patients (and citizens) are brought to heel by institutional (and political) values they do not themselves affirm. It also emphasizes the inevitable deep plurality of moral visions of health and appropriate healthcare, rejecting tendencies (strong in mainstream bioethics) to regard “health” as a univocal concept or healthcare as a basic need, to attempt to conform “reasonable” clinical decision-making to a single model, and to appoint government as a guarantor of access to healthcare or a regulator of healthcare standards. Autonomy as self-sovereignty, like its competitors, can justify itself only in question-begging terms. Still, bioethics might do well to recognize it within the mix of moral visions.