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The Foundations of Bioethics
By H. Tristram Engelhardt, Jr.
New York, Oxford, 1986. 387 Pp. $27.95.
"The history of bioethics over the last two decades," Tristram Engelhardt writes, "has been the story of the development of a secular ethic." In this provocative and closely-argued volume, he contributes substantially to that history by exploring the nature and limits of any " special secular tradition" in biomedical ethics. Perhaps no contemporary analyst is better prepared for such a task than this physician, philosopher, and historian of medicine.
Engelhardt admits that his original purpose was to ground a secular bioethics by offering a particular understanding of the good life and for securing moral authority for its establishment by general rational arguments. To his "dismay and sorrow," however, such arguments were not available. Thus, what he offers us is acknowledgment of the inevitability of "secular pluralist ethics" in any society, such as ours, which encompasses multiple conceptions of the good and the good that ought to be done. He defines secular bioethics, then, as an attempt to find understandings of health care's meaning, goals, and limitations that can be justified across particular moral traditions, communities, and ideologies. Such understandings will also provide the basis for rational public policy.
Underlying and directing this entire project is Engelhardt's definitional condition that morality involves "a peaceable bond among persons." By this he means that any discernment or resolution of canons of moral probity and authority must avoid recourse to force. In other words, "peaceful negotiation" is the fundamental basis of agreement in resolving moral controversies; therefore, mutual respect for personal self-determination-the negative moral principle of autonomy-is the one absolute, foundational principle binding all moral agents. No person or group has moral authority to force their beliefs or judgments upon other persons without the latter's consent, or unless they have already removed themselves from the peaceable moral community by violating the autonomy of others.
Of course, this notion of autonomy as the fundamental side-constraint in all moral discourse provides only form, and not content, for concrete moral relations. Content is provided by particular conceptions of the
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good and of how human welfare should be furthered. These conceptions Engelhardt treats under his second (and secondary) moral principle: beneficence. While all moral communities-religious, humanistic, medical, among others-invoke specific understandings of beneficence, they are constrained (by the prior principle of autonomy) from forcing those understandings on unconsenting others. So, for instance, a physician has no moral right paternalistically to force the good of medical treatment on an autonomous, unconsenting patient simply because the physician (or any of the rest of us) believes the patient's choice to violate his or her own best interests.
Further, Engelhardt provides careful philosophical analyses of the all-important (for biomedicine) notions of health and person. His analysis of the latter notion is especially challenging, in that he defends a much-debated distinction between humanhood and personhood. Persons are distinguished by their capacity to be "self-conscious, rational, and concerned with worthiness of praise and blame." Thus, fetuses, infants, and profoundly retarded individuals who have never been rational are humans, but not persons "in the strict sense" (even though societies may find it prudent to regard them as at least partial persons "in the social sense"). They are owed our beneficent regard (as are animals), but not the respect due to autonomous persons. This distinction follows, of course, from Engelhardt's definitional condition for morality per se; for if moral community is defined in part by mutual respect for autonomous beliefs and choices, then those incapable of such beliefs and choices cannot be full members of it. Their potential or possible values must be understood in terms of the values they have for other, actual persons. Within this perspective, Engelhardt goes on to develop some predictably controversial implications for abortion policy and for selective treatment of defective newborns and incompetent patients.
Now, this crucial conceptual distinction (human vs. person) suggests an important question raised by the structure of Engelhardt's own argument. He insists that, at the level of personal and social interaction, particular value-beliefs and value-orientations (beneficence-conceptions) cannot override the prior side-constraints of "peaceable moral community" by claiming authority over other, competing beneficence conceptions. But cannot this same sort of limitation be raised to the broader conceptual level of definition? Specifically, why should Engelhardt's definition of the qualities (or values, perhaps) to be attained before a human gains personal moral rights (of non-force) be any more compelling than, say, the contrasting view that humans attain a protectable, invasion-proof moral status at the moment of conception? Both are, in a broad sense, evaluative definitions. The reasoning behind Engelhardt's position is clear enough: his "peaceable moral community" presupposes and requires rational agents with the capacity to make claims of self-determination. Full membership in it is limited, then, to present, rational individuals. But this reasoning merely pushes back to his original definitional stipulation or morality's non-coercive character. Is such a stipulation defensible, given its de facto directive force at the
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broader conceptual level? In short, it may seem to some readers that despite his insistence upon uncoerced autonomy as a basic moral side-constraint, Engelhardt has in fact stacked the deck by definitional fiat in order to preserve and protect the value of self-determination among a certain class of individuals-namely, those who can not only suffer force from others but who can also mount rational claims for their own protection from it.
This possible criticism notwithstanding, Engelhardt's argument is powerful and well-wrought. His writing style is engaging, and his lively Texan-libertarian bent shines through. Moreover, The Foundations of Bioethics is perhaps the most significant defense of a secular pluralist ethics to appear in recent years. It deserves, and will no doubt receive, widespread discussion and debate among philosophers, theologians, physicians, pastors, and all others concerned with conceptual and normative frameworks for addressing moral dilemmas in biomedicine.
JAMES B. TUBBS, JR.
Mercy College
Detroit, Michigan