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Uncertain Bioethics

“Stephen Napier argues with verve and subtlety for a cautious and
restrained approach to acts of killing in bioethics; central to his argu-
ment is the difficulty of being sure that active interventions are per-
missible. This book intriguingly combines insights from a wide variety
of different recent philosophical literatures to offer an important and
interesting contribution to numerous current debates.”
Sophie-Grace Chappell, Professor of
Philosophy at Open University, UK

Bioethics is a field of inquiry and as such is fundamentally an epistemic

discipline. Knowing how we make moral judgments can bring into relief
why certain arguments on various bioethical issues appear plausible to
one side and obviously false to the other. Uncertain Bioethics makes
a significant and distinctive contribution to the bioethics literature by
culling the insights from contemporary moral psychology to highlight
the epistemic pitfalls and distorting influences on our apprehension of
value. Stephen Napier also incorporates research from epistemology
addressing pragmatic encroachment and the significance of peer disa-
greement to justify what he refers to as epistemic diffidence when one
is considering harming or killing human beings. Napier extends these
developments to the traditional bioethical notion of dignity and argues
that beliefs subject to epistemic diffidence should not be acted upon. He
proceeds to apply this framework to traditional and developing issues
in bioethics including abortion, stem cell research, euthanasia, decision-
making for patients in a minimally conscious state, and risky research on
competent human subjects.

Stephen Napier is an associate professor of philosophy at Villanova

University. His previous publications include Virtue Epistemology:
Motivation and Knowledge, and he edited Persons, Moral Worth,
and Embryos. His interests include epistemology, bioethics, and the
metaphysics of persons.
Routledge Annals of Bioethics
Series Editors:
Mark J. Cherry
St. Edward’s University, USA
Ana Smith Iltis
Saint Louis University, USA

11 The Ethics of Gender-Specific Disease

Mary Ann Cutter

12 Death, Posthumous Harm, and Bioethics

James Stacey Taylor

13 Human Dignity in Bioethics From Worldviews to the Public Square

Edited by Stephen Dilley and Nathan J. Palpant

14 Parental Obligations and Bioethics

The Duties of a Creator
Bernard G. Prusak

15 The Bioethics of Pain Management

Beyond Opioids
Daniel S. Goldberg

16 The Ethics of Pregnancy, Abortion, and Childbirth

Exploring Moral Choices in Childbearing
Helen Watt

17 Medical Ethics, Prediction, and Prognosis

Interdisciplinary Perspectives
Edited by Mariacarla Gadebusch Bondio, Francesco Spöring, and
John-Stewart Gordon

18 Care Ethics and Social Structures in Medicine

Ruth E. Groenhout

19 Uncertain Bioethics
Moral Risk and Human Dignity
Stephen Napier
Uncertain Bioethics
Moral Risk and Human Dignity

Stephen Napier
First published 2020
by Routledge
52 Vanderbilt Avenue, New York, NY 10017
and by Routledge
2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
Routledge is an imprint of the Taylor & Francis Group, an informa business
 2020 Taylor & Francis
The right of Stephen Napier to be identified as author of this work has been
asserted by him in accordance with sections 77 and 78 of the Copyright,
Designs and Patents Act 1988.
The Open Access version of this book, available at www.taylorfrancis.
com, has been made available under a Creative Commons Attribution-Non
Commercial-No Derivatives 4.0 license.
Trademark notice: Product or corporate names may be trademarks or
registered trademarks, and are used only for identification and explanation
without intent to infringe.
Library of Congress Cataloging-in-Publication Data
Names: Napier, Stephen E., author.
Title: Uncertain bioethics : human dignity and moral risk / by Stephen Napier.
Description: New York : Taylor & Francis, 2020. | Series: Routledge annals
of bioethics ; 19 | Includes bibliographical references and index.
Identifiers: LCCN 2019012772| ISBN 9780815372981 (hbk : alk. paper) |
ISBN 9781351244510 (ebk)
Subjects: LCSH: Bioethics. | Dignity.
Classification: LCC QH332 .N35 2020 | DDC 174.2—dc23
LC record available at https://lccn.loc.gov/2019012772

ISBN: 978-0-8153-7298-1 (hbk)

ISBN: 978-1-351-24451-0 (ebk)

Typeset in Sabon
by Swales & Willis Ltd, Exeter, Devon, UK
To Katherine,
lux quia lucet
Contents

Acknowledgments x

1 Introduction 1

PART I
Foundational Matters: The Perception of Value,
Persons, and Human Worth 7

2 Moral Inquiry and the Apprehension of Value 9

Motivated Cognition, Attention, and Moral Perception 9
The Problem of Epistemic Circularity 12
“Questioned-Source Contexts” 14
Conclusion 26

3 Epistemic Justification, Peer Disagreement, and Moral Risk 31

The Epistemic Effects of Disagreement:
Dogmatism and Flaccidity 32
Moral Risk, Presumption, and Burden of Proof 43
Conclusion 50

4 Persons and Human Beings 55

Human Beings and Substances 56
When Do You and I Come into Existence? 63
Persons are not Human Beings 65
Critique of the Functional Brain View 70

5 Human Dignity 83
Two Tasks and a Note on Method 85
Dignity: Three Aspects 86
viii Contents
Discharging Misunderstandings 94
Alternatives: Interests and Autonomy 100
Conclusion: The Ecumenical Nature of Dignity 103

PART II
Dignity at the Beginning and End of Life 107

6 Abortion 109
What is the Act of Abortion? 109
The Moral Analysis 112
The Argument from Epistemic Diffidence 121
Conclusion 131

7 Human Embryonic Destructive Stem Cell Research 135

The Twinning Argument 137
The Totipotency Argument 141
Rescue Cases 144
Natural Loss Arguments 149
The Argument from Epistemic Diffidence 151

8 Euthanasia 159
Definitions and Clarifications 160
What Can Be Presumed 164
The Arguments 166
Appraisal of the Arguments 173
Conclusion 181

PART III
Balancing Dignity and Autonomy 187

9 Decision-Making for Patients with Suppressed

Consciousness 189
The Minimally Conscious State 190
Undercutting the Argument from Advance Directives 192
Objections 201
Epistemic Diffidence and the Argument for
Not Removing PEG Feeding 204
Conclusion 206
 Contents ix
10 Decision-Making for Patients with Apparent Competency 209
The Basing Condition 211
Competency Assessments 214
The Argument for Stricter Conditions 215
Clarifications and Application to Cases 218
Conclusion 221

11 Risky Research on Competent Adults: Justice

and Autonomy 225
Children Actually Enjoy Greater Protection 227
Children Should Not Enjoy Greater Protection:
Direct Benefit and Theodicy 229
Objections 231
Conclusion 243

12 Conclusion 246

Bibliography 248
Index 271
Acknowledgments

The following individuals contributed to the present project in various

ways. David Benrimoh, Joe Butera, John Carvalho, Dan Cheely, Rev.
Alfred Cioffi, Michael Degnan, Mark Doorley, Jason Eberl, Karl Hahn,
Stephen Heaney, Rev. James McCartney, Matthew O’Brien, David
Prentice, Benjamin Richards, Mike Rota, John Travaline, Helen Watt,
Peter Wicks, and Brett Wilmot commented on some of the material pre-
sent here. Edmund Howe and Matthew Braddock wrote separate essays
in reply to some of the material herein (Howe’s is published). Sarah-
Vaughan Brakman and Peter Koch formed a writing group that involved
sharing comments on our respective work. This proved immensely help-
ful. David Hershenov reviewed, in exquisite detail, two penultimate
chapters. I sent him 8,000+ word count documents, and received 5,000+
ones in return. I have no excuse for any errors except that philosophy is
difficult. I’d like to thank two anonymous reviewers and the editors at
Routledge, namely, Mark Cherry, Andrew Weckenmann, Allie Simmons,
and freelance editor Judith Harvey for their very helpful guidance and
feedback on this project.
In writing this book I have made use of previously published material.
Chapter 3 includes some material from my article, “The Justification of
Killing and Psychological Accounts of the Person,” American Catholic
Philosophical Quarterly 89(4) (2015): 651–680. Chapter 6 includes par-
agraphs from “Vulnerable Embryos: A Critical Analysis of Twinning,
Rescue, and Natural-Loss Arguments,” American Catholic Philosophical
Quarterly 84(4) (2010): 783–812. Chapter 8 includes paragraphs
from “Perception of Value and the Minimally Conscious State,” HEC
Forum 27(3) (2015): 265–286; and “The Minimally Conscious State,
the Disability Bias and the Moral Authority of Advance Directives,”
International Journal of Law and Psychiatry (2018), doi: 10.1016/j.
ijlp.2018.03.001. Chapter 9 derives mostly from “When Should We
Not Respect a Patient’s Wish?” Journal of Clinical Ethics 25(3) (2014):
196–206. And Chapter 10 derives mostly from “Challenging Research
on Human Subjects: Justice and Uncompensated Harms,” Theoretical
Medicine and Bioethics 34(1) (2013): 29–51. I wish to thank the editors
 Acknowledgments xi
and the anonymous reviewers of these journals for their significant contri-
butions to my thinking. Finally, I wish to thank the Office of the Provost
at Villanova University for funding the Veritas Award which helped me
write significant portions of the manuscript.
1 Introduction

An informative introduction should frame the content that follows

such that the reader is better able to understand the author’s intent and
fundamental concerns. It should suggest how the work may be looked
along as well as looked at. The change in preposition is important. This
book should be understood as an essay on what the intellectual virtues
of humility and justice look like in discrete areas of bioethical inquiry.
Looking at it, one will find arguments for and against various claims.
Looking along it, one should glean why one should take a more epistemi-
cally humble stance when arguing for permissible killing or harming. By
looking along this essay, one catches a glimpse of how one should weigh
the evidence and measure one’s credulity on certain bioethical positions.
For any inquiry, there is the object of inquiry, and the inquirer; both
receive attention in this book.
Bioethics is a field of inquiry and as such is fundamentally an epis-
temic discipline. It aims to know what the right/wrong action or policy is.
The locus of attention for this project is on the epistemic significance of
various developments in moral psychology and contemporary epistemol-
ogy applied to bioethical inquiry. Specifically, this book aims to answer
the following question: under what conditions is an agent S justified in
believing that P [an act of killing a human being] is permissible when S
is the agent of that action? Or more simply, under what conditions is an
agent justified in believing a proposition ‘it is permissible to kill x’ when
one is acting on that belief?
The idea of moral risk referenced in my title can be understood in rela-
tion to our typical way of using risk in healthcare delivery. Typically, risk
is understood as roughly parasitic on cause–effect relations as when we
say, “there is a risk of nausea and vomiting if you take this drug.” Here,
risk is understood as a probability that a disvaluable state of affairs might
occur. The notion of moral risk with which I am concerned pertains rather
to the very judgment of disvalue (or value). Moral risk is a function of act-
ing on what might very well be an erroneous moral judgment. Hence, the
first step in this project is to articulate how our moral judgments might err.
Knowing how we make moral judgments can bring into relief why
certain arguments on various bioethical issues appear plausible to one
2 Introduction
side and obviously false to the other. This is the first feature of my project
that aims to make a significant contribution: namely, to cull the insights
from contemporary moral psychology to highlight the epistemic pitfalls
and distorting influences on our apprehension of value.
A second contribution of my project is to collate the lessons learned
from the epistemological literature addressing moral risk (cf. Fantl &
McGrath, 2009), the nature of presumptions in argument (Freeman,
2005), and the epistemic significance of peer disagreement (Christensen,
2011; Elga, 2007) to justify what I refer to as epistemic diffidence on
numerous bioethical issues. The notion of moral risk and the signifi-
cance of peer disagreement are simple to understand and that they exert
epistemic effects is clear in many cases (consider the stronger standard
of evidence for criminal cases versus civil cases). The difficult project is
explaining why risk and disagreement exert epistemic effects at all.
The first two contributions together justify epistemic diffidence when
one is considering harming or killing human beings. The cost of being
wrong that ‘killing a human being is permissible’ is high; it is subject to
peer disagreement, and it is doubtful that, given the evidence from the
cognitive sciences, we should be so trustful of our moral intuitions (or
the post-hoc reasoning justifying those intuitions (Haidt, 2001)). Beliefs
subject to epistemic diffidence should not be acted upon.
The argument I wish to defend in this book may be understood in
outline as follows:

1 The belief B that ‘x is permissible,’ where x is an act of intentional

killing or harming of a human being, is subject to epistemic diffidence.
(Hereafter, ‘x’ is a variable only for the issues I discuss in this work.)
A belief B is subject to epistemic diffidence if and only if:1
i B suffers from an undercutting defeater or is unstable (both
notions explained below),
ii The justification for B does not offset the cost of being wrong,
and
iii The justification for B does not discharge the effects of peer disa-
greement.2
2 If B is subject to epistemic diffidence, it would be impermissible to act
on that belief.
3 Therefore, it is impermissible to act on ‘x is permissible’ where x
includes the specific actions that I address in this book.

A few points are worth noting about this argument. First, the belief B is
restricted to those acts of intentional killing or harming that I address in
this book. I remain neutral as to whether this argument is sound for any
case of intentional killing or harming either of a human being, or non-
human animal. Second, the dialectical work of the chapters is to justify
that the epistemic standards or degree of justification needed to permit
 Introduction 3
acting on the belief that ‘x is permissible’ are not met. Third, the dialectical
work of this book is not to argue that all things considered the beliefs
that ‘x is permissible’ are false. My argument requires a lower horizon
of acceptability while also arguing that one should be epistemically diffi-
dent towards acting on such beliefs. This is probably the most distinctive
aspect of my project. Lowering the dialectical horizon is not done best by
defending one’s favored theory, and then applying it to specific cases. The
horizon is lowered partly by focusing on how we form our theoretical
commitments in the first place. Fourth, the notion of epistemic diffidence
is, in this work, an epistemological notion. The moral implications of
it are made explicit in premise 2. As such, Chapters 2 and 3 (summa-
rized below) aim to justify premise 2. The remainder of the chapters aim
to justify premise 1, substituting in for ‘x’ each issue – whether it is
abortion, euthanasia, etc.
The project aims to frame both traditional and novel bioethical
problems in light of the epistemological lessons I highlight. In doing so,
I argue that a dialectical shift occurs to the advantage of those who take
a prohibitive stance on the issues discussed.
Chapter 2 aims to answer the question, “How do we typically think on
moral issues?” The chapter explicates what is called Moral Foundations
Theory (Graham et al., 2013), which includes four theses: nativism, cul-
tural influences, intuitionism, and pluralism. There are two pericopes of
the theory I wish to highlight in this chapter. The first is that intuitions
come first, and moral reasoning comes second. The second aspect of the
theory that I draw attention to is the explanation for why we have the
intuitions we do. On this point Graham et al. (2013) highlight the impor-
tance of cultural influences and more subjective motivational influences
(Kunda, 1990).
Knowing that our intuitions are subject to such influences may under-
cut our confidence in them. An undercutting defeater is a reason for
thinking that things might not be as they appear (Pollock & Cruz, 1999).
I see widgets on an assembly line that look red. The foreman informs me
that they look red because they are illuminated by red incandescent bulbs
such that they look red whether or not they really are. What the foreman
tells me is an undercutting defeater to my belief that the widgets are red.
That something looks red is still a reason for thinking that it is red, but
an undercutting defeater renders that appearance inert to justify believ-
ing that x is red. Discovering how we morally think and process moral
information functions in a similar way. Whether or not an action really is
permissible, my moral intuitions might apprehend it as permissible any-
way given certain facts about how we think morally. The non-alethic
influences on our moral perception function like the red incandescent
light bulbs; they give me reason for thinking that the moral world might
not be as it appears to be.
Another conclusion that follows from Chapter 2 is slightly weaker but
still sufficient for my purposes. One could say that upon taking seriously
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