Bioethics Principles, Issues,

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Bioethics
Principles, Issues, and Cases
Fourth Edition

Lewis Vaughn

New York Oxford

O X F OR D U N I V E R S I  Y P R E S S

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Library of Congress Cataloging-in-Publication Data

Names: Vaughn, Lewis, author.
itle: Bioethics: principles, issues, and cases / Lewis Vaughn.
Description: Fourth edition. | New York: Oxford University Press, [2020] |
Includes bibliographical references and index.
Identifiers: LCCN 2019017497 (print) | LCCN 2019015775 (ebook) |
ISBN 9780190903268 (paperback: alk. paper) | ISBN 9780190903282 (epub)
Subjects: LCSH: Medical eth ics. | Bioethics.
Classification: LCC R724 .V38 2020 (ebook) | LCC R724 (print) |
DDC 174.2—dc23
LC record available at https://lccn.loc.gov/2019017497

9 8 7 6 5 4 3 2 1

Printed by LSC Communications, United States of America

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xii Preface

 Leslie P. Francis, University of Utah

Te Oxford University Press Ancillary Resource Center Devin Frank, University of Missouri–Columbia
(ARC) at www.oup-arc.com/vaughn-bioethics-e Kathryn M. Ganske, Shenandoah University
houses an Instructor’s Manual with est Bank and Martin Gunderson, Macalester College
PowerPoint Lecture Outlines for instructor use. Stu- Helen Habermann, University of Arizona
dent resources are available on the companion website Stephen Hanson, University of Louisville
at www.oup.com/us/vaughn and include self-quizzes, Karey Harwood, North Carolina State
flashcards, and helpful web links. University
Sheila R. Hollander, University of Memphis
Scott James, University of North Carolina,

Wilmington
Tis edition of the text is measurably better than
James Joiner, Northern Arizona University
the first thanks to the good people at Oxford Uni-
William P. Kabasenche, Washington State
versit y Press—e specially my editor Robert Mi ller
University
and assistant editor Alyssa Palazzo—and many
Susan Levin, Smith College
reviewers:
Margaret Levvis, Central Connecticut State
Keith Abney, Polytechnic State University University
at San Luis Obispo Burden S. Lundgren, Old Dominion University
Kim Amer, DePaul University Joan McGregor, Arizona State University
Jami L. Anderson, University of Michigan ristram McPherson, Virginia ech
Carol Isaacson Barash, Boston University Jonathan K. Miles, Bowling Green State
Deb Bennett-Woods, Regis University University
Don Berkich, exas A&M University James Lindemann Nelson, Michigan State
Stephan Blatti, University of Memphis University
William Bondeson, University of Missouri, Tomas Nenon, University of Memphis
Columbia Laura Newhart, Eastern Kentucky University
Lori Brown, Eastern Michigan University Steve Odmark, Century College
David W. Concepción, Ball State University Assya Pascalev, Howard University
Catherine Coverston, Brigham Young Viorel Pâslaru, University of Dayton
University David J. Paul, Western Michigan University
Russell DiSilvestro, Assistant Professor, Anthony Preus, Binghamton University
California State University, Sacramento Susan M. Purviance, University of oledo
John Doris, Washington University in St. Louis Sara Schuman, Washtenaw Community College
Denise Dudzinski, University of Washington David Schwan, Bowling Green State University
School of Medicine Anita Silvers, San Francisco State University
Craig Duncan, Ithaca College M. Josephine Snider, University of Florida
Anne Edwards, Austin Peay State University Joseph Wellbank, Northeastern University
John Elia, University of Georgia Gladys B. White, Georgetown University
Christy Flanagan-Feddon, Regis University David Yount, Mesa Community College
Jacqueline Fox, University of South Carolina
School of Law

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Principles and Teories

1

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CHAPTER 1

Moral Reasoning in Bioethics

Any serious and rewarding exploration o bio- Second, it would be difficult to imagine moral
ethics is bound to be a challenging journey. issues more important—more closely gathered
What makes the trip worthwhile? As you might around the line between lie and death, health
expect, this entire text is a long answer to that and illness, pain and relie, hope and despair—
question. You thereore may not ully appreciate than those addressed by bioethics. Whatever
the trek until you have already hiked ar along our view o these questions, there is little doubt
the trail. Te short answer comes in three parts. that they matter immensely. Whatever answers
First, bioethics—like ethics, its parent disci- we give will surely have weight, however they all.
pline—is about morality, and morality is about Tird, as a systematic study o such ques-
lie. Morality is part o the unavoidable, bitter- tions, bioethics holds out the possibility o an-
sweet drama o being persons who think and eel swers. Te answers may or may not be to our
and choose. Morality concerns belies regarding liking; they may confirm or conute our precon-
morally right and wrong actions and morally ceived notions; they may take us ar or not ar
good and bad persons or character. Whether we enough. But, as the ollowing pages will show,
like it or not, we seem conronted continually the trail has more light than shadow—and
with the necessity to deliberate about right and thinking critically and careully about the prob-
wrong, to judge someone morally good or bad, lems can help us see our way orward.
to agree or disagree with the moral pronounce-
ments o others, to accept or reject the moral
  
outlook o our culture or community, and
even to doubt or affirm the existence or nature Morality is about people’s moral judgments,
o moral concepts themselves. Moral issues are principles, rules, standards, and theories—all o
thus inescapable—including (or especially) those which help direct conduct, mark out moral prac-
that are the ocus o bioethics. In the twenty-first tices, and provide the yardsticks or measuring
century, ew can remain entirely untouched by moral worth. We use morality to reer gener-
the pressing moral questions o air distribution ally to these aspects o our lives (as in “Morality
o health care resources, abortion and inanti- is essential”) or more specifically to the belies
cide, euthanasia and assisted suicide, exploitative or practices o particular groups or persons (as
research on children and populations in devel- in “American morality” or “Kant’s morality”).
oping countries, human cloning and genetic en- Moral, o course, pertains to morality as just
gineering, assisted reproduction and surrogate defined, though it is also sometimes employed
parenting, prevention and treatment o HIV/ as a synonym or right or good, just as immoral
AIDS, the confidentiality and consent o patients, is ofen meant to be equivalent to wrong or bad.
the reusal o medical treatment on religious Ethics, as used in this text, is not synonymous with
grounds, experimentation on human embryos morality. Ethics is the study o morality using the
and etuses, and the just allocation o scarce lie- tools and methods o philosophy. Philosophy is
saving organs. a discipline that systematically examines lie’s

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4 PART 1: PRINCIPLE S AND THEORIE S

big questions through critical reasoning, logical some or all o these as proper guides or our ac-
argument, and careul reflection. Tus ethics— tions and judgments. In normative ethics, we
also known as moral philosophy—is a reasoned ask questions like these: What moral principles,
way o delving into the meaning and import o i any, should inorm our moral judgments?
moral concepts and issues and o evaluating the What role should virtues play in our lives? Is the
merits o moral judgments and standards. (As principle o autonomy justified? Are there any
with morality and moral , we may use ethics to exceptions to the moral principle o “do not
say such things as “Kant’s ethics” or may use kill”? How should we resolve conflicts between
ethical or unethical to mean right or wrong, moral norms? Is contractarianism a good moral
good or bad.) Ethics seeks to know whether an theory? Is utilitarianism a better theory?
action is right or wrong, what moral standards A branch that deals with much deeper ethical
should guide our conduct, whether moral prin- issues is metaethics. Metaethics is the study o
ciples can be justified, what moral virtues are the meaning and justification o basic moral be-
worth cultivating and why, what ultimate ends lies. In normative ethics we might ask whether
people should pursue in lie, whether there are an action is right or whether a person is good,
good reasons or accepting a particular moral but in metaethics we would more likely ask what
theory, and what the meaning is o such notions it means or an action to be right or or a person
as right, wrong, good, and bad. Whenever we try to be good. For example, does right mean has the
to reason careully about such things, we enter best consequences, or produces the most happi-
the realm o ethics: We do ethics. ness, or commanded by God ? It is the business o
Science offers another way to study morality, metaethics to explore these and other equally
and we must careully distinguish this approach undamental questions: What, i anything, is
rom that o moral philosophy. Descriptive the difference between moral and nonmoral be-
ethics is the study o morality using the meth- lies? Are there such things as moral acts? I so,
odology o science. Its purpose is to investigate what sort o things are they, and how can they
the empirical acts o morality—the actual be- be known? Can moral statements be true or
lies, behaviors, and practices that constitute alse—or are they just expressions o emotions
people’s moral experience. Tose who carry out or attitudes without any truth value? Can moral
these inquiries (usually anthropologists, sociol- norms be justified or proven?
ogists, historians, and psychologists) want to Te third main branch is applied ethics, the
know, among other things, what moral belies a use o moral norms and concepts to resolve
person or group has, what caused the subjects to practical moral issues. Here, the usual challenge
have them, and how the belies influence behav- is to employ moral principles, theories, argu-
ior or social interaction. Very generally, the di- ments, or analyses to try to answer moral ques-
erence between ethics and descriptive ethics is tions that conront people every day. Many such
this: In ethics we ask, as Socrates did, How ought questions relate to a particular proessional field
we to live? In descriptive ethics we ask, How do such as law, business, or journalism, so we have
we in fact live? specialized subfields o applied ethics like legal
Ethics is a big subject, so we should not be ethics, business ethics, and journalistic ethics.
surprised that it has three main branches, each Probably the largest and most energetic subfield
dealing with more or less separate but related is bioethics.
sets o ethical questions. Normative ethics is the Bioethics is applied ethics ocused on health
search or, and justification o, moral standards, care, medical science, and medical technology.
or norms. Most ofen the standards are moral (Biomedical ethics is ofen used as a synonym,
principles, rules, virtues, and theories, and the and medical ethics is a related but narrower term
lofy aim o this branch is to establish rationally used most ofen to reer to ethical problems in

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Chapter 1: Moral Reasoning in Bioethics 5

medical practice.) Ranging ar and wide, bio- about art; norms o etiquette about polite social
ethics seeks answers to a vast array o tough behavior; grammatical norms about correct use
ethical questions: Is abortion ever morally per- o language; prudential norms about what is in
missible? Is a woman justified in having an abor- one’s interests; and legal norms about lawul and
tion i prenatal genetic testing reveals that her unlawul acts. But moral norms differ rom these
etus has a developmental deect? Should people nonmoral kinds. Some o the eatures they are
be allowed to select embryos by the embryos’ sex thought to possess include the ollowing.
or other genetic characteristics? Should human
embryos be used in medical research? Should Normative Dominance. In our moral practice,
human cloning be prohibited? Should physicians, moral norms are presumed to dominate other
nurses, physicians’ assistants, and other health kinds o norms, to take precedence over them.
care proessionals always be truthul with patients Philosophers call this characteristic o moral
whatever the consequences? Should severely im- norms overridingness because moral consider-
paired newborns be given lie-prolonging treat- ations so ofen seem to override other actors.
ment or be allowed to die? Should people in A maxim o prudence, or example, may suggest
persistent vegetative states be removed rom lie that you should steal i you can avoid getting
support? Should physicians help terminally ill caught, but a moral prohibition against stealing
patients commit suicide? Is it morally right to con- would overrule such a principle. An aesthetic (or
duct medical research on patients without their pragmatic) norm implying that homeless people
consent i the research would save lives? Should should be thrown in jail or blocking the view o
human stem-cell research be banned? How a beautiul public mural would have to yield to
should we decide who gets lie-saving organ trans- moral principles demanding more humane treat-
plants when usable organs are scarce and many ment o the homeless. A law mandating brutal
patients who do not get transplants will die? actions against a minority group would conflict
Should animals be used in biomedical research? with moral principles o justice and would there-
Te ethical and technical scope o bioethics is ore be deemed illegitimate. We usually think
wide. Bioethical questions and deliberations that immoral laws are deective, that they need to
now all to nonexpert and expert alike—to pa- be changed, or that, in rare cases, they should be
tients, amilies, and others as well as to philoso- defied through acts o civil disobedience.
phers, health care proessionals, lawyers, judges,
scientists, clergy, and public policy specialists. Universality. Moral norms (but not exclusively
Tough the heart o bioethics is moral philoso- moral norms) have universality: Moral princi-
phy, ully inormed bioethics cannot be done ples or judgments apply in all relevantly similar
without a good understanding o the relevant situations. I it is wrong or you to tell a lie in
nonmoral acts and issues, especially the medi- a particular circumstance, then it is wrong or
cal, scientific, technological, and legal ones. everyone in relevantly similar circumstances to
tell a lie. Logic demands this sort o consistency.
It makes no sense to say that Maria’s doing
    
action A in circumstances C is morally wrong,
Morality then is a normative, or evaluative, enter- but John’s doing A in circumstances relevantly
prise. It concerns moral norms or standards that similar to C is morally right. Universality, how-
help us decide the rightness o actions, judge the ever, is not unique to moral norms; it’s a charac-
goodness o persons or character, and prescribe the teristic o all normative spheres.
orm o moral conduct. Tere are, o course, other
sorts o norms we apply in lie—nonmoral norms. Impartiality. Implicit in moral norms is the
Aesthetic norms help us make value judgments notion o impartiality—the idea that everyone

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6 PART 1: PRINCIPLE S AND THEORIE S

should be considered equal, that everyone’s inter- the moral lie—is to do moral reasoning. I our
ests should count the same. From the perspective moral judgments are to have any weight at all, i
o morality, no person is any better than any they are to be anything more than mere per-
other. Everyone should be treated the same unless sonal taste or knee-jerk emotional response,
there is a morally relevant difference between they must be backed by the best o reasons. Tey
persons. We probably would be completely ba- must be the result o careul reflection in which
fled i someone seriously said something like we arrive at good reasons or accepting them,
“murder is wrong . . . except when committed by reasons that could be acknowledged as such by
mysel,” when there was no morally relevant di- any other reasoning persons.
erence between that person and the rest o the Both logic and our commonsense moral ex-
world. I we took such a statement seriously at all, perience demand that the thorough sifing o
we would likely not only reject it but also would reasons constitutes the main work o our moral
not even consider it a bona fide moral statement. deliberations—regardless o our particular moral
Te requirement o moral impartiality pro- outlook or theory. We would think it odd, per-
hibits discrimination against people merely be- haps even perverse, i someone asserted that
cause they are different—different in ways that physician-assisted suicide is always morally
are not morally relevant. wo people can be di- wrong—and then said she has no reasons at all or
erent in many ways: skin color, weight, gender, believing such a judgment but just does. What-
income, age, occupation, and so orth. But these ever our views on physician-assisted suicide, we
are not differences relevant to the way they would be justified in ignoring her judgment, or
should be treated as persons. On the other hand, we would have no way to distinguish it rom
i there are morally relevant differences between personal whim or wishul thinking. Likewise she
people, then we may have good reasons to treat hersel (i she genuinely had no good reasons or
them differently, and this treatment would not her assertion) would be in the same boat, adrif
be a violation o impartiality. Tis is how phi- with a firm opinion moored to nothing solid.
losopher James Rachels explains the point: Our eelings, o course, are also part o our
moral experience. When we ponder a moral
Te requirement o impartiality, then, is at issue we care about (abortion, or example), we
bottom nothing more than a proscription against may eel anger, sadness, disgust, ear, irritation,
arbitrariness in dealing with people. It is a rule or sympathy. Such strong emotions are normal
that orbids us rom treating one person differ- and ofen useul, helping us empathize with
ently rom another when there is no good reason others, deepening our understanding o human
to do so. But i this explains what is wrong with suffering, and sharpening our insight into the
racism, it also explains why, in some special consequences o our moral decisions. But our
kinds o cases, it is not racist to treat people di- eelings can mislead us by reflecting not moral
erently. Suppose a film director was making a truth but our own psychological needs, our own
movie about the lie o Martin Luther King, Jr. personal or cultural biases, or our concern or
He would have a perectly good reason or ruling personal advantage. Troughout history, some
out om Cruise or the starring role. Obviously, people’s eelings led them to conclude that
such casting would make no sense. Because there women should be burned or witchcraf, that
would be a good reason or it, the director’s “dis- whole races should be exterminated, that black
crimination” would not be arbitrary and so men should be lynched, and that adherents o a
would not be open to criticism.1 different religion were evil. Critical reasoning
can help restrain such terrible impulses. It can
Reasonableness. o participate in morality—to help us put our eelings in proper perspective
engage in the essential, unavoidable practices o and achieve a measure o impartiality. Most o

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Chapter 1: Moral Reasoning in Bioethics 7

or economic. Thus murder and embezzlement are

IN DEPTH both immoral and illegal, backed by social disapproval
and severe sanctions imposed by law. Controversy
MORALITY AND THE LAW
often arises when an action is not obviously or seri-
ously harmful but is considered immoral by some who
want the practice prohibited by law. The conten-
Some people confuse morality with the law, or iden-
tious notion at work is that something may be made
tify the one with t he other, but the two are distinct
illegal solely on the grounds that it is immoral, re-
though they may often coincide. Laws are norms
gardless of any physical or economic harm involved.
enacted or enforced by the state to protect or pro-
This view of the law is known as legal moralism, and
mote the public good. They specify which actions
it sometimes underlies debates about the legalization
are legally right or wrong. But these same actions
of abortion, euthanasia, reproductive technology,
can also be judged morally right or wrong, and these
contraception, and other practices.
two kinds of judgments will not necessarily agree.
Many issues in bioethics have both a moral and
Lying to a friend about a personal matter, deliberately
legal dimension, and it is important not to confuse
trying to destroy yourself through reckless living, or
the two. Sometimes the question at hand is a moral
failing to save a drowning child (when you easily
one (whether, for example, euthanasia is ever morally
could have) may be immoral —but not illegal. Racial
bias, discrimination based on gender or sexual orien-
tation, slavery, spousal rape, and unequal treatment
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permissible); whether a practice should be legal or
illegal then is beside the point. Sometimes the ques-
tion is about legality. And sometimes t he discussion
of minority groups are immoral—but, depending on
concerns both. A person may consider physician-
the society, they may not be illegal.
assisted suicide morally acceptable but argue that it
Much of the time, however, morality and the law
should nevertheless be illegal because allowing the
overlap. Often what is immoral also turns out to be
practice to become widespread would harm both
Adillegal. This is usually the case when immoral actions
cause substantial harm to others, whether physical
patients and the medical profession.

all, it can guide us to moral judgments that are purports to explain right actions, or make judg-
trustworthy because they are supported by the ments about right or wrong actions.
best o reasons. Moral values, on the other hand, generally
Te moral lie, then, is about grappling with a concern those things that we judge to be morally
distinctive class o norms marked by normative good, bad, praiseworthy, or blameworthy. Nor-
dominance, universality, impartiality, and rea- mally we use such words to describe persons (as
sonableness. As we saw earlier, these norms can in “He is a good person” or “She is to blame or
include moral principles, rules, theories, and hurting them”), their character (“He is virtu-