Jeffrey Blustein

Choosing for Others as Continuing a Life Story: The Problem of Personal Identity Revisited

hilosophically, the most interesting objection to the reliance on advance directives to guide treatment P decisions for formerly competent patients is the argument from the loss of personal identity. Starting with a psychological continuity theory of personal identity, the argument concludes that the very conditions that bring an advance directive into play may destroy the conditions necessary for personal identity, and so undercut the authority of the directive. In this article, I concede that if the purpose of a theory of personal identity is to provide an answer to the question What is it for a person to persist over time?, then reflection on personal identity poses a potentially serious threat to the moral authority of advance directives. However, as Marya Schechtman observes, questions about how a single person persists through change are not what most of us are interested in when we think about who a person is. Rather, we are interested in what it means to say that a particular set of actions, experiences, and characteristics is that of a given person rather than someone else. The answer I give, following Schechtman, is the “narrative self-constitution view,” and I use this theory in arguing for a novel view of proxy decision making, the “continuer view” This view holds that proxy decision-makers are to act as continuers of the life stories of those who have lost narrative capacity, and it provides a defense of the moral authority of advance directives that is immune to the loss of personal identity objection.

Credentialing Ethics Consultants: An Invitation to Collaboration

The article by Fox et al. (2007) marks an important moment in the history of clinical ethics consultation. It documents what we in the field all know anecdotally: clinical ethics consultation has been expanding exponentially in medical centers nation wide. Whether this development is a benefit to patients and families or adds to the net burdens of their interaction with the healthcare system, depends on several factors: the quality of the ethics consultation service (ECS), the ability of the consultants to incorporate relevant substantive ethical and legal principles into difficult discussions, and the skill of consultants in using a process that shields patients and family members from the juggernaut of medicine and helps them to level the playing field of discussion. If successful, consultants should manage to forge some sort of consensus about previously contested matters, a consensus that facilitates care and that reflects both the wishes of the patient and family and the patient’s best medical interest. Note the following findings from the article about clinical ethics consultation and clinical ethics consultants:

Doing the best for one’s child: satisficing versus optimizing parentalism

The maxim “parents should do what is in the best interests of their child” seems like an unassailable truth, and yet, as I argue here, there are serious problems with it when it is taken seriously. One problem concerns the sort of demands such a principle places on parents; the other concerns its larger social implications when conceived as part of a national policy for the rearing of children. The theory of parenting that creates these problems I call “optimizing parentalism.” To avoid them, I define and defend a new and more morally appealing theory, “satisficing parentalism.”

Setting the agenda for urban bioethics

Urban bioethics has two goals. First, it aims to focus attention on neglected bioethical problems that have particular salience in urban settings. Three problems are highlighted: socioeconomic inequality as a major determinant of health inequality, the foundations of an ethic for public health, and the impact of social context on the therapeutic alliance between patients and physicians. Second, urban bioethics serves as a vehicle for raising deep theoretical and methodological questions about the dominant assumptions and approaches of contemporary bioethics. Demands for cultural sensitivity, so pronounced in the urban context, compel us to reexamine the central commitment in bioethics to personal autonomy. The multiculturalism of urban life also argues for a dialogic approach to bioethical problem solving rather than the monologic approach that characterizes most bioethical thinking. Although my brief for redirecting bioethics will resonate with many critics who do not consider themselves urban bioethicsts, I argue that there are special advantages in using urban bioethics to expose the limitations of contemporary bioethical paradigms.

Reproductive responsibility and long-acting contraceptives.

The right to reproduce is regarded as fundamental in US society. It is however irresponsible for individuals of reproductive age to conceive and bear children for whom they will not be able to meet the child rearing responsibilities. The author notes that the state may try to encourage reproductive responsibility in a number of ways. For example the state can inform men and women about various reproductive risks or provide nondiscriminatory noncoercive incentives to stay in school and delay childbearing. Other measures such as conditioning welfare benefits on the acceptance of a long-term contraceptive however seem to invite coercive and discriminatory treatment of minority group members and the poor and to infringe upon the reproductive freedom of disadvantaged individuals. The notion of reproductive responsibility is of limited usefulness with regard to social policy. The concept of reproductive responsibility can help guide the formulation of public policy to noncoercive ends but must not be called upon to justify coercive state intervention in reproductive behavior to meet even the most narrowly focused objectives.

Philosophical and Ethical Issues in Disability

What is a disability? What sorts of limitations do persons with disabilities or impairments experience? What is there about having a disability or impairment that makes it disadvantageous for the individuals with it? Are persons with severe cognitive impairments capable of making autonomous decisions? What role should disability play in the construction of theories of justice? Is it ever ethical for parents to seek to create a child with an impairment? This anthology addresses these and other questions and is a valuable addition to a growing interdisciplinary literature exploring issues at the intersection of disability studies, philosophy, and bioethics. Most of the authors are well-known from their previous work in the disability field and have already made significant philosophical contributions to it.

Urban bioethics: adapting bioethics to the urban context.

Urban bioethics is an area of inquiry within the discipline of bioethics that focuses on ethical issues, problems, and conflicts relating to medicine, science, health care, and the environment that typically arise in urban settings. Urban bioethics challenges traditional bioethics (1) to examine value concerns in a multicultural context, including issues related to equity and disparity, and public health concerns that may highlight conflict between individual rights and the public good, and (2) to broaden its primary focus on individual self-determination and respect for autonomy to include examination of the interests of family, community, and society. Three features associated with urban life—density, diversity, and disparity—affect the health of urban populations and provide the substrate for identifying ethical concerns and value conflicts and creating interventions to affect population health outcomes. The field of urban bioethics can be helpful in creating ethical foundations and principles for public health practice, developing strategies to respect diversity in health policy in a pluralistic society, and fostering collaborative work among educators, social scientists, and others to eliminate bias among health professionals and health care institutions to enhance patients’ satisfaction with their care and ultimately affect health outcomes. Educational programs at all levels and encompassing all health professions are needed as a first step to address the perplexing and important problem of eliminating health disparities. Urban bioethics is both contributing to the social science literature in this area and helping educators to craft interventions to affect professional attitudes and behaviors.

Conceptions of Genocide and the Ethics of Memorialization

Conceptions of genocide can be broadly divided into individualistic and collectivistic. According to the former, genocide is essentially a crime against (many) individuals; according to the latter, it is a crime against a group, which is not reducible to an aggregate of the individuals who belong to it. This chapter argues for the latter on the grounds that it is necessary to capture the distinctive moral evil of genocide. It also argues for a non-consequentialist way of accounting for the ethical value of memorializing genocide. This is called an expressivist approach and three attitudes that memorials may express are highlighted and explored: respect, self-respect, and fidelity to the dead. Different accounts are then presented to explain how these attitudes can belong not only to individuals but also to groups and how, therefore, an expressivist ethic of remembrance for groups is possible. The chapter concludes with a discussion of the principle of warranted self-testifying, according to which those who suffer harm are in an ethically privileged position to testify to it. This principle is applied to group memorialization of genocidal harm, conceived as a group practice.

Investing in Parenthood

The recent child custody case Weisberger v Weisberger raises a number of ethical issues concerning the rights and responsibilities of parents. Chavie Weisberger, thirty-five, and her husband, both members of an ultraorthodox Hasidic community, appeared before a religious court in 2008 to obtain a divorce. There are two sharply contrasting legal rulings in this case. Setting aside the legally significant fact that Chavie had signed the divorce agreement with the clause requiring her to raise her children Hasidic, which decision is ethically more defensible and why? Were Chavies parental rights violated when the court removed her children from her care? Should her ex-husband have been awarded full custody on the ground that this was in the childrens best interest, and is this the right standard to use in making custody decisions? What parental responsibilities did Chavie and her ex-husband have, and were they satisfactorily discharging them? A theory of the moral foundations of parenthood should provide answers to these questions among others. Joseph Millum, in his excellent new book The Moral Foundations of Parenthood, does this and more. His theory encompasses accounts of the foundation and content of parental rights and responsibilities, the acquisition of parental responsibilities, and the standards governing parental decision-making.

Morality and parenting: An ethical framework for decisions about the treatment of imperiled newborns

This essay is written in the belief that questions relating to the treatment of impaired and imperiled newborns cannot be adequately resolved in the absence of a general moral theory of parent-child relations. The rationale for treatment decisions in these cases should be consistent with principles that ought to govern the normal work of parenting. The first section of this paper briefly examines the social contract theory elaborated by John Rawls in his renowned book A Theory of Justice and extracts from it normative principles that can guide us in our attempt to lay a rational foundation for parenthood. The second section clarifies the implications of a Rawlsian theory for the problem at hand by examining several standards that have been proposed for the treatment of impaired newborns: the strict right-to-life standard, the medical decision standard, and the quality-of-life standard. A Rawlsian standard, by contrast, is autonomy-based. That is, it would have us base our treatment decisions on consideration of the childs capacity for developing critical rationality in making decisions on his or her own. This standard, it is suggested, avoids morally objectionable features of the others.