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Is There an Ethicist in the House?Review - Is There an Ethicist in the House?
On the Cutting Edge of Bioethics
by Jonathan D. Moreno
Indiana University Press, 2005
Review by Lawrence D. Hultgren, Ph.D.
Dec 12th 2006 (Volume 10, Issue 50)

Is There An Ethicist in the House? is a collection of fifteen articles and essays representative of Jonathan Moreno's writings from 1988 - 2003 on clinical ethics in general and the role of the hospital philosopher in particular. Currently professor of biomedical ethics and director of the Center for Biomedical Ethics at the University of Virginia Health System, Moreno has logged over twenty-five years as a teacher, researcher, and practicing professional in the field. However, he gently warns us at the outset that his book is not an introduction to the field of bioethics but rather a reframing of the subject from the perspective of a philosophical naturalist. To the more academic reader, this confession confirms the author's "struggle with the limitation of particularity in a way that never hampered the great universal metaphysicians, at least in their treatises (32)." However, to the general reader, Moreno emerges as a contemporary "public philosopher" in the Deweyan tradition, and his book reveals "that bioethics is a personal subject in a way that other professional ethics fields are not" (3).

Part One, "A Hospital Philosopher," is a somewhat autobiographical account of the author's transformation from a classroom humanities professor to a clinical bioethicist, the "ethicist in the house or a 'hospital philosopher'." Part Two, "Naturalizing Bioethics in Theory and Practice," is more philosophical as Moreno reflects on the emerging tasks of the clinical bioethicist. Here he proffers the intriguing conclusion that "bioethics has an undeniably American flavor and that bioethics is mainly an American field in it origins" (51). Unable to find the field's roots in either the analytic or Continental philosophical traditions, Moreno turns to the tradition of American philosophic naturalism. Here he discovers a parallel between the key bioethical themes of moral autonomy and pluralism and ideas in ethical naturalism. To show that bioethics is American as well in its style, he concludes this section with an essay on "Ethics by Committee" which critically discusses the adoption of the consensus model by most hospital ethics committees.

In Part Three, "Human Use," Moreno turns to the ethics of clinical trials, a field that currently bears his own distinctive mark. His over-arching objective is to discuss the difficulty in crafting a just public policy for the use of human subjects in research. In the first essay chosen for this section, Moreno offers a brief but dense history of the use of human subjects in research and the resultant dilemma between the individual interests of the research subject ("individual good") and scientific progress ("public good"). While the historical argument weighs heavily against the investigator's discretion ("weak protectionism"), Moreno cogently raises a moral red flag against an emotionally opposing response of "strong paternalism." Such a regulatory move, he argues, could result in the investigator's taking what Josiah Royce has referred to as a "moral holiday." Splitting the extremes, Moreno's solution is a "moderate protectionism [which] accepts the importance of personal virtue but does not find it sufficient" (126).

In the next essay, Moreno narrows his focus to the historical and practical issues that accompany the use in medical research of so-called "convenient and captive populations" such as prisoners, institutionalized children and adults, military personnel, and students and staff. Although a general "protectionist" attitude has emerged regarding the participation of such vulnerable subjects, Moreno argues that a more refined concept of justice needs to be developed "[b]ecause these groups are not convenient or captive - or even vulnerable - in the same ways" (130).

The concluding piece in this section examines the neglected topic of biomedical and behavioral research involving subjects with "decisional impairment that is chronic rather than acute, and pathological rather than associated with 'normal' youth or aging" (153). Blending personal experiences with regulatory history, Moreno again finds himself in a Spock-like dilemma between "the good of the one" and "the good of the many." Facing such diverse requirements of ethical research, Moreno reiterates the need for "an exquisitely delicate balance" (172).

The nineteenth century religious philosopher Soren Kierkegaard once remarked that "we live forwards but understand backwards." In the fourth section of his book, "The Meanings of Nuremberg," Moreno, always the philosophical naturalist, places such proposed wisdom within an historical context and offers an alternative. At least with respect to the history and ethics of biomedical and behavioral research, he argues, we may have lived forwards, but we have misunderstood backwards! Drawing upon his unique experiences with the President's Advisory Committee on Human Radiation Experiments in 1994-95, his "dream job for an archives groupie," he argues against the received understanding that the revelations of Nazi medical crimes and the Nuremberg Code "had a tremendous influence on American medicine and our experimental practices" (176). In the papers collected for this section of the book. Moreno offers an intriguing and important corrective to the traditional scholarship on the history and ethics of human research.

The concluding section, Part Five: "New Directions," highlights the challenges faced by contemporary bioethicists and is well worth the read. It opens with the author sharing an engaging "forty-ish twinge." In the opening article, Moreno's fortieth birthday spurs a personal reflection on his own genetic status as well as on new developments regarding "cancer, truth, and genetics."

He then examines "Neuroethics: An Agenda for Neuroscience and Society." In this specially commissioned 2003 article, he asks whether traditional philosophy of mind or "'folk psychology,' the commonsense means at our disposal to explain behavior with reference to beliefs, desires, expectations, goals, and so on," (223) may be reduced to neuronal states or replaced by discussions about "the extrastriate visual cortices in the fusiform and superior temporal gyri" (220)? Rather than answering this and other related questions directly, Moreno demonstrates instead that such questions are not all that different from more traditional and familiar bioethical issues. Once again he draws historic analogies to show "that neroethics is in some ways old wine in a new bottle" (232).

"Bioethics after the Terror" is a rather poignant confirmation that the field of bioethics is a set of social practices as well as a body of moral theory. Written just two weeks after the attacks on the World Trade Center, Moreno proffers that the resultant "sense of group vulnerability and patriotic unity" may lead to a "sentiment of social solidarity" 238). And he muses that such a sentiment might eventually mature into a "principle of community" that could even ascend to the pantheon of bioethical principles.

In a concluding and tantalizing chapter written for this book, Moreno begins by drawing a parallel between psychoanalysis as "the impossible profession" and his work as a bioethicist. However, he is more sanguine about his profession, and he sketches a 'mission possible' for bioethicists. For example, in response to those who condemn bioethicists for their work as so-called "ethicists-for-hire" with industry, Moreno argues that bioethicists are professionals, too. Therefore, their expertise should be fee-for-service to the institution that hires them as with any other professional.

Drawing upon his own experiences on governmental advisory committees, Moreno distinguishes politics, "not a bad thing at all," from politicization, "the distortion of those normal and useful functions by allowing particular ideologies to run away with the process" (247). However, rather than retreating to the familiar bashing of the politicization of bioethics, Moreno wants to enter the fray. He challenges bioethicists "to locate themselves ideologically" and not be averse to "c]hoosing up sides between conservative and liberal on at least some issues" [250]. However, he does not tell us which issues he has in mind.

In this timely collection of writings, Jonathan Moreno demonstrates the maturity of the field of bioethics, "well into its fourth decade as a self-conscious area of study (at least in the United States)" (212). Indeed, it has been twenty years since bioethics "saved the life of ethics," as Stephen Toulmin once concluded. However, if "bioethics itself has become part of the establishment, as have those who profess it " (234), as Jonathan Moreno concludes, one must wonder why the title calls for an "ethicist" rather than a "bioethicist"?

 

2006  Larry D. Hultgren

Larry Hultgren describes himself as follows:

A.B. Grinnell College majoring in Philosophy and Religion; Ph.D. Vanderbilt University in Philosophy. Currently Professor of Philosophy at Virginia Wesleyan College, Norfolk, VA. Since I am at a liberal arts college, my teaching runs the gamut of philosophy offerings. I am especially interested in interdisciplinary pursuits, and I direct the college's Social Ecology Program and our innovative PORTfolio Project, which attempts to bring the liberal arts to life for our students by connecting the classroom with real world experiences. I also serve on the Bioethics Committee of the Children's Hospital of the King's Daughters in Norfolk, VA, and serve on the Board of Directors of the Bioethics Network of Southeast Virginia.


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