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Current Controversies in BioethicsReview - Current Controversies in Bioethics
by S. Matthew Liao and Colin O'Neil (editors)
Routledge, 2017
Review by Kostas Koukouzelis
Feb 20th 2018 (Volume 22, Issue 8)

Following progress in bioethics the volume at hand presents five currently important, albeit controversial topics in five areas of the ongoing bioethical discussion. The topics which also organize the layout of the book deal with research ethics, clinical ethics, reproductive ethics, neuroethics and public health ethics. The editors have very helpfully organized the material by including a pair of original essays for each topic by leading philosophers on the field in order to help readers enrich their approach with new perspectives, arguments and counter-arguments.

The first topic, i.e., that of research ethics, addresses the following question: how should we satisfy ancillary-care duties? The two chapters develop based on a fundamental agreement. Researchers have duties to provide ancillary care that research participants need even when this is not already morally required to conduct the study safely and soundly. This agreement aside, the justifications they provide differ substantially. Henry S. Richardson argues that researchers have special obligations – what he calls the 'partial entrustment' model. For Richardson these special obligations (a) are an instance of a general moral phenomenon he calls 'moral entanglement', whereby we acquire special obligations to look after needs that surface when we have accepted a privacy waiver from someone, (b) pop up in order to close gaps in the overall system of beneficence. S. Matthew Liao and Colin O' Neil justify researchers' responsibilities based on a human rights approach. According to this approach, everyone has a right to the fundamental conditions for pursuing a good life qua human being, and when researchers encounter needs that jeopardize these conditions they have responsibility to meet them.

The second topic deals with an interesting comparison. Whereas psychopaths and those with autism spectrum disorder (ASD) share a deficit in empathy, there is some evidence that the former lack moral understanding when the latter possess it. This observation, if true, would undermine moral accountability for psychopaths, if they cannot act on moral reasons. But what about ASD subjects, who, on a certain view, suffer from the same deficit (lack of empathy)? Accordingly, Dana Nelkin and Agnieszka Jaworska develop opposing accounts of moral accountability in order to explain what happens with the aforementioned difference. Nelkin locates the difference in the general inability on behalf of psychopaths to take up a normative perspective. This inability stems not from a lack of empathy but from impairment in stimulus-reinforcement association found especially in psychopaths. Jaworska locates the difference in that psychopaths cannot act on reasons in a rich sense, that is, on reasons that involve evaluation, and not just on considerations which simply favor some action over another.       

The third topic of the book deals with the by now notoriously challenging 'non-identity' problem that Derek Parfit masterfully described in his 1984 book Reasons and Persons. Although the literature on the subject is enormous and still growing, the dialogue in the book under review is worth following. The 'non-identity' problem is especially relevant in reproductive ethics or ethics of creation, albeit equally involves environmental ethics and sustainability. The thrust of the 'non-identity' problem is that we do not harm future persons if our activity now has caused their coming into existence with their particular (numerical) identities, whereas, otherwise they would not exist as the individuals they are. For example, in a case involving selection of embryos by a couple obtained through IVF, half of them have an abnormality connected to Down syndrome. Instead of choosing screening of the embryos against Down syndrome the couple asks the doctor to randomly select an embryo for implantation, which finally leads to the coming into existence of a child with that disorder. Have they harmed (by making her worse off) and therefore wronged that particular child? Contributions to the topic differ in the answers they provide. Contrary to philosophers who think the child is wronged although not made worse off, Melinda Roberts and David Wasserman argue that this view is mistaken. The child born with the Down syndrome owes her existence to her parents' choice not to screen, and, as long as the latter do their best to show respect for their child they do not wrong her. On the other hand, Saul Smilansky argues for the opposite view. The child born with Down syndrome is not made worse off, but is nevertheless wronged. He supports his view with an interesting variation of arguments.  

The next two chapters in the book deal with a specific problem in the new subfield of bioethics, which is neuroscience and its formidable recent developments. The challenge is currently posed by the development and use of novel drugs that in addition to treating neurological and psychological problems have an effect on behavior by enhancing cognitive capacities or memory. Are such developments also harmful for people, both users and others? How do they influence belief formation and decision making and ultimately how do they change our conception or ascription of moral responsibility? The authors here deal with the phenomenon of addiction which is important when bioethics examines the connection between such a phenomenon and moral responsibility. Timothy Schroeder and Nomy Arpaly on the one side and Neil Levy on the other are in agreement that addiction is stemming from a malfunctioning of dopamine system, but disagree, first, on how significant that is, and, second, on the degree to which addiction mitigates blame and why this is so. I will not even try to briefly present the thrust of their arguments here as they are complex and need much space, yet remain important as they highlight differing perspectives on the theory of moral responsibility.

The last topic of the book is about an extremely important debate that comes from political philosophy in the field of the so called public health: egalitarianism. This is a field in bioethics that shifts interest from individuals (patients, physicians) to populations in relation to policy making. The question is how different policy choices affect the distribution of health and health care? The two chapters now engage with the virtues and criticisms against the most prominent theory of egalitarianism, that is, luck egalitarianism championed by philosophers like Ronald Dworkin and G.A. Cohen (but arguably not Rawls). Luck egalitarianism requires that disadvantages stemming from brute bad luck should be compensated as they are not deserved. In public health dilemmas luck egalitarianism requires compensation for disabilities and diseases the individual suffers through no fault of her own. But what about health problems stemming from imprudent choices, such as lack of exercise or smoking that can cause heart attacks or cancer? Luck egalitarianism applies the principle of individual responsibility and blocks the provision of public-funded health treatment. This particular view has sparked a fierce criticism from many people lately (Elisabeth Anderson is the most prominent), that accuse luck egalitarianism for being excessively harsh.

Both chapters here make an effort to rescue this version of egalitarianism from such a criticism, albeit based on different argumentation. Zofia Stemplowska relaxes luck egalitarianism's scope of responsibility by saying that responsibility should be assigned only when it is relatively easy for the individual to avoid a health problem. However, if I may say, this criterion of 'easiness' is too controversial. Nil Eyal defends luck egalitarianism's basic thesis by arguing that we should also find a test for personal responsibility regarding health choices. Such a test will show, according to him, that when we reflect on cases that involve victims facing grave health risks the relevant consideration is not exclusively a 'rule of rescue' mentality, but other equally important factors. Such factors include, for example, whether the resources available in a public health system could be used to save more people.

The collection of essays in the volume under review is thought-provoking and engages with recent developments. The collection is also very usefully supplied by suggested further readings at the end of each different section and by study questions. This is something that makes the book also a good reading for both experts and students, albeit of a more advanced level. Finally, towards the end, there is a supplemental guide to further controversies in bioethics accompanied with recently published literature. This is an interesting and provocative selection of essays in bioethics, indeed, a pleasure to read.     

 

© 2018 Kostas Koukouzelis

 

Kostas Koukouzelis, Philosophy and Social Studies Department, University of Crete


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