John D. Arras

The fragile web of responsibility: AIDS and the duty to treat.

Do physicians by virtue of their role as health care professionals have a duty to care for HIV infected patient? Must they subject themselves to the very small but nevertheless terrifying risk of becoming infected themselves in order to live up to the ethical demands for their calling? For most physicians toiling in the front lines against AIDS this is a new and totally unanticipated moral question that has yet receive a clear and satisfying answer. Perhaps the most important feature of AIDS for bioethics is that it forces the recognition that society and its physicians have a decidedly fractured understanding of their proper role and duties in the face of risk. The AIDS crisis has in fact awakened medicine from its 30-year slumber during the pax antibiotica. In doing so it has confronted our society with a decision of great magnitude concerning medicines own ends good and role. On 1 side of the debate are those who would have the professional reaffirm its traditional ideal of self-sacrifice for the benefit of patients; on the other are those who would advocate a more self-centered role for physicians a role perhaps more in keeping with the recent drift of the profession away from ideals of service and towards more entrepreneurial scientific or bureaucratic models of practice. Some physicians may seek radically to alter medicines self-conception to abandon its traditional conception of the good and attendant virtues in favor of some other norm. Physicians as a professional group may well attempt to follow this path for the remainder of the AIDS epidemic. If they do however it should be painfully obvious both to them and to the rest of society that they will have thereby abandoned a noble calling.

Bioethics & Human Rights: Access to Health-Related Goods

There are many good reasons for a merger between bioethics and human rights. First, though, significant philosophical groundwork must be done to clarify what a human right to health would be and—if we accept that it exists—exactly how it might influence the practical decisions we face about who gets what in very different contexts.

The Severely Demented, Minimally Functional Patient: An Ethical Analysis

rs. Smith, an 85-year-old resident of a nursing home, was transferred to the hospital for treatment of pneumonia. AlM though she has responded well to antibiotic therapy, her overall condition and prognosis remain grim. For the past 3 years her mental state has been steadily deteriorating due to a series of strokes which have finally rendered her severely demented. She is now nonambulatory, incapable of sitting up in bed, and uncommunicative most of the time. When she does talk, her speech is completely incoherent and repetitive. Mrs. Smith shows no signs of recognizing or remembering her family and primary caregivers. The nurses in charge of her care assert that she appears to experience pleasure only when her hair is combed or her back rubbed. During her recovery from the pneumonia, Mrs. Smith began to have problems with swallowing food. Following a preciptous decline in her caloric intake, her son and daughter (the only involved family members) consented to the placement of a nasogastric tube. Mrs. Smith continually pulled out the tube, however, and continues to resist efforts to reinsert it. The health care team faces difficult choices regarding Mrs. Smith’s care. Foremost among them is whether her physicians should surgically insert a gastrostomy tube in spite of her aversive behavior. Mrs. Smith has neither left behind a living will nor has she indicated to family or friends at the nursing home what her preferences would be regarding Iife-sustaining care in this sort of circumstance. Both her son and daughter have stated that she would nevertheless not have wanted a gastrostomy tube inserted and would, if she could presently decide, prefer an earlier death to being sustained indefi-

The hedgehog and the Borg: Common morality in bioethics

In this commentary, I critically discuss the respective views of Gert and Beauchamp–Childress on the nature of so-called common morality and its promise for enriching ethical reflection within the field of bioethics. Although I endorse Beauchamp and Childress’ shift from an emphasis on ethical theory as the source of moral norms to an emphasis on common morality, I question whether rouging up common morality to make it look like some sort of ultimate and universal foundation for morality, untouched by the dialectics of time and reflective equilibrium, was an equally good move. As for Gert’s magisterial conception of common morality, I conclude that certain elements of his system are controversial at best and woefully inadequate at worst. He has a tendency to find in common morality what he himself put there, and his highly restricted conception of duties of assistance strikes this reader as ad hoc, inadequately defended, and unworthy of a project whose goal is to lessen the amount of misery in the world.

Must We Be Courageous

Courage is indispensable. Telling caregivers they must be courageous in difficult circumstances is sometimes a back-handed endorsement of oppression, however.

Pragmatism in bioethics: been there, done that.

It has often been remarked that bioethics is a quintessentially American phenomenon. Broadly speaking, bioethics as a field has tended to enshrine the value of autonomy, it places individual rights above communal well-being, and it has adopted a largely permissive and optimistic view of emerging biotechnologies. In contrast to much European thinking at the intersection of ethics and medicine, American-style bioethics has been resolutely middlebrow, eschewing grand philosophical schemes in favor of pragmatic policy-making and democratic consensus. It was, then, perhaps only a matter of time before various theorists began proposing a marriage between bioethics and pragmatism, which is the homegrown American philosophy. The rise of a distinctly pragmatic strain of bioethical thinking promises to add a new dimension to the methodological ferment that has energized this field during the past ten years. Since the beginning of the contemporary bioethics movement in the 1970s, the field’s lingua franca and dominant methodological orientation has been the “principlism” of philosopher Tom Beauchamp and religious ethicist James Childress.1 Instead of grounding moral inquiry in either philosophical theory or the particulars of concrete situations, principlism has sought to locate the crux of moral reasoning in the identification, interpretation, and balancing of “middle-level” moral principles, such as those bearing on individual autonomy, beneficence, and justice. So dominant has been principlism’s reign within the field of bioethics that commentators routinely refer to Beauchamp and Childress’s articulation of these principles as the “Georgetown mantra.” 2

Bioethics and Human Rights: Curb Your Enthusiasm

as they put it, Annas simply ‘‘hasmisunderstood andmisrepresented our positions on several key points.’’ Speaking as editors, such provocative phrases from both sides make for ‘‘Great Debate’’ fodder, indeed. We can only hope that, as readers, you concur. This introduction does little to explain the arguments produced herein, and, undoubtedly, the end of this debate has not settled the problems addressed. We hope that in reading the full text of the exchanges, what is provided is useful insight and needed stimulation for future arguments concerning the relationship between bioethical issues and human rights concerns. Aswasnotedwith the inaugural ‘‘GreatDebate,’’ thisCQ department is dedicated to bringing ‘‘noted bioethicists [together in order to] debate . . . some of the most perplexing contemporary bioethics issues.’’ In that light, we hope you find the following a fruitful debate between respected colleagues who wish, like all of us, to reach better conceptual clarity for the sake of our moral attitudes and behaviors. We (the editors) apologize for and it should be noted that in their Rejoinder to Annas, Fenton & Arras refer to material that was in the galley proofs of Annas’s debate paper. In proofing, Annas chose to change some of his material, which directly impacted the Rejoinder. Unfortunately, those changes came too late for Fenton & Arras to make substantive changes. The impacted quotations are noted in Fenton & Arras’s text.

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.

Taking Duties Seriously? The Decline of Duties in a Rights Culture

The notion of moral duty has fallen on hard times. Once regarded by the Ancients and many Moderns as the fundamental moral category, as the bedrock even of moral and political rights, the concept of duty languishes in our culture as an object of neglect and suspicion. For us, duties tend to exist either as the pale correlates of rights or as the fiercely contested dictates of an oppressive state or overbearing moralists.

Utility, Natural Rights, and the Right to Health Care

Although our society spends ten percent of its gross national product on health care, the benefits of this prodigious outpouring are distributed rather unevenly. Although the majority of people are insured, at least to some extent, against both catastrophic illness and some of the costs of garden-variety medical care, roughly ten percent of our population has no health insurance at all.1 A patchwork of charitable and government-sponsored programs provide care to many indigent citizens, yet a significant number of the poor, the unemployed, and the uninsured fall through the ever-widening gaps in the so-called “safety net.” In the event of serious disease or disability, these people cannot pay, and many of them fail to obtain the health care that they need.