Equal Access to Health Care and Food Justice/Food Deserts
Medical ethics is based on a set of moral values and principles adopted by doctors, nurses, and others involved in the medical profession. This set of values can conflict with the personal values of the health care provider, making the ethical conundrum that much greater.
5.1 The Issue: Mercy Killing
Mercy killing, also known as euthanasia, is the act of allowing a person to die painlessly by withholding medical intervention. This is a hotly debated topic among the medical community and ethicists alike.
One of the most famous legal controversies in recent years was the case of Terri Schiavo. Ms. Schiavo's case was both heart wrenching and controversial, and the passions became so inflamed on both sides of the debate that it is, in fact, difficult for one side to regard the other side as presenting the facts in the case fairly and in a way that is not biased.
In February 1990, Terri Schiavo suffered cardiac arrest and collapsed in her home in Florida, leading to an extended time in which her brain was deprived of oxygen. She was taken to the hospital and intubated and ventilated, but was in a coma. After being in a coma and diagnosed as in a "vegetative state," two physicians changed her status to "Persistent Vegetative State" (PVS). Various therapeutic techniques were attempted with no success. In 1998, having been appointed her legal guardian, Ms. Schiavo's husband, Michael, petitioned that her feeding tube be removed. Ms. Schiavo's parents (Robert and Mary Schindler) objected to this on the basis of her Roman Catholic beliefs. In 2000, on the basis of testimony indicating what Ms. Schiavo's wishes would have been in such a situation, the court granted Mr. Schiavo's petition, and the Schindlers appealed. After a series of verdicts, at various levels in the Florida judicial system, Ms. Schiavo's feeding tube was removed. The Florida legislature then enacted what became known as "Terri's Law," giving Florida Governor Jeb Bush the authority to have the tube reinserted, which he did. The Florida Sixth Circuit of Appeals then heard Michael Schiavo's appeal, and found Terri's Law unconstitutional, a ruling that was confirmed by the Florida Supreme Court. The U.S. Supreme Court refused to hear the case and, in 2005, after a great deal of legal wrangling on both sides, and enormous political controversy and media coverage, Ms. Schiavo's feeding tube was removed, and she died on March 31, 2005. The autopsy, carried out by Chief Medical Examiner Jon Thogmartin, revealed that Ms. Schiavo's condition was, in Thogmartin's words, "irreversible, and no amount of therapy or treatment would have regenerated the massive loss of neurons" (Phillips, 2005).
This case brought a great deal of attention to a variety of issues, including the relationship between the individual and the state, a state's right to intervene, end-of-life issues, and euthanasia. In this chapter, we will try to shed some light on these and related topics, and see how ethics can help clarify these problems and help us understand possible solutions to them.
The Physician's Dilemma and the Hippocratic Oath
Hippocrates of Cos is well known for his famous "Oath," which most American physicians take upon graduating from medical school. Perhaps the best-known statement in that Oath is "Do no harm." While the Oath has been adjusted and changed over the centuries, this basic precept is commonly regarded as a fundamental obligation of a physician. More specifically, the Oath also states that the physician "will not give a lethal drug to anyone if I am asked, nor will I advise such a plan" (National Library of Medicine, 2002, para. 4).
This, of course, puts physicians in a bind, or, to use the more technical term, a dilemma. An ethical dilemma is a situation in which a person has to make a moral choice, and whatever choice that person makes, the result is undesirable. Moral or ethical dilemmas are familiar to most of us: For instance, should a mother steal food to feed her starving children? She must decide between stealing and not stealing; if she does steal, she risks being arrested (and possibly losing her children); if she does not steal, she puts her children in peril (and possibly, again, risks losing her children). Many such dilemmas arise in the application of ethical theory to the challenges we confront; the physician faces a specific one, due to the demands of the Hippocratic Oath.
Straight to the Source
The Oath of Hippocrates
Here is one translation (by Francis Adams) of the famous Oath attributed to Hippocrates (ca. 400 bce):
The famous oath taken by most American physicians is attributed to Hippocrates of Cos.
I SWEAR by Apollo the physician, and Aesculapius, and Health, and All-heal, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation—to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion. With purity and with holiness I will pass my life and practice my Art. I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work. Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further from the seduction of females or males, of freemen and slaves. Whatever, in connection with my professional practice or not, in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret. While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times! But should I trespass and violate this Oath, may the reverse be my lot!
Assume a physician has a patient who is terminally ill. The physician either must treat the patient or not treat the patient; treating the patient may prolong his or her life, but also his or her suffering (thus doing harm); but if the physician does not treat the patient, the patient will die (again, doing harm). Regardless of what the physician does, the patient is harmed; how can a physician attempt to resolve this dilemma? More specific still, if a physician provides a patient with the means to terminate his or her life, doesn't this explicitly violate the Oath? We will look at various solutions in what follows, including palliative care and hospice, and euthanasia, as well as what might be considered a more traditional approach—keeping a patient alive as long as possible. As a dilemma, no solution is ideal; but a good bit of thought has gone into what the best available solution is.
Assisted Suicide
In the last few decades, more and more countries have examined, and in some cases adopted, laws that allow the terminally ill to end their lives under medical supervision. The general term for this procedure is physician-assisted suicide (PAS), and it has raised substantial concerns from those who believe this conflicts with religious views and minimizes the value of life, as well as for other reasons. Before considering some of the ethical issues involved, it will be useful to examine what PAS looks like, in the terms in which it has been discussed in the United States.
As the name indicates, in PAS, a physician assists with a patient's decision to end his or her life. The physician can provide counseling (including offering alternatives), as well as any other information the patient needs or requires. But, distinct from euthanasia (which we will look at below), the physician does not carry out the procedure that ends the patient's life; rather, the patient does this.
State and Country Laws Regarding Physician-Assisted Suicide
At the end of 2012, three states had made physician-assisted suicide (PAS) legal: Oregon passed its law in 1994, Washington in 2008, and Vermont in 2013. Montana approved PAS in 2009 (the law is currently under judicial review). Meanwhile, 39 states have laws prohibiting PAS.
Three states (Alabama, Massachusetts, and West Virginia) and the District of Columbia prohibit assisted suicide by common law. Four other states (Nevada, North Carolina, Utah, and Wyoming) either have no specific laws, have common law that is ambiguous, or otherwise do not explicitly address PAS.
In the following countries, PAS is legal, but except for Switzerland, all prohibit foreigners from traveling to their country for the purpose of obtaining assisted suicide. Dates indicating the legalization of assisted suicide are given in parentheses:
Switzerland (1940)
Colombia (1997)
Albania (1999)
The Netherlands (2002)
Belgium (2003)
Luxembourg (2008).
In the United States, Oregon's Death With Dignity act has been particularly influential (and controversial). The state of Oregon's Public Health site (http://public.health.oregon.gov) offers extensive information on the legislation.
In 1997, in two cases (Vacco v. Quill and Gregoire v. Glucksberg), the Supreme Court ruled there was no constitutional right to PAS, noting specifically the potential for the abuse of such laws as was seen in the case of Nazi Germany, when many with physical and mental challenges were murdered. At the same time, the Court did not say that states could not proceed to explore legislative means to legalize PAS. In Oregon, in 1997, the legislation approved specific methods that physicians could use to assist with a patient's desire to terminate his or her life. As noted above, this policy that legalized PAS in Oregon explicitly stated that the physician could not carry out the procedure, but rather was allowed to provide to the patient those drugs that, taken in the prescribed amount (namely, an overdose), would lead to the patient's death. But the patient would be responsible for administering the drugs. The Supreme Court upheld the constitutionality of Oregon's PAS law in 2006.
This raises a number of ethical questions, of course. Some insist, simply, that suicide is wrong. Thus, any doctor who even assists in such a procedure is doing something fundamentally immoral. As we have also seen, PAS can be argued to violate the Hippocratic Oath, both in the general sense of harming the patient, but in the more specific sense of providing drugs that will harm the patient. Finally, and as the Supreme Court noted in 1997, there is a potential that legalizing PAS tends to cheapen life in general, potentially leading to a slippery slope in which more and more people, whether due to illness or disability, are likely to choose PAS, and even have the procedure recommended to them. For those who object to PAS, one or more of these reasons is compelling to reject its legalization.
In contrast, those who advocate the legalization of PAS point to various factors, such as that those who are suffering excruciating chronic pain, with no hope of its cessation, are simply being kept alive to suffer. Furthermore, adults are autonomous human beings, and the state has no right to interfere with the choice an adult makes, even if that choice is to terminate one's own life. Finally, those whose backgrounds do not include religious proscriptions against PAS are being forced to conform to religious and ethical standards that are not their own.
Patient Autonomy
There is an assumption here that, as mentioned above, adults are autonomous human beings. In other words, they are free to choose what they do—where they live, who they interact with, what they do for a living—as long as their choices do not interfere with others' choices. For instance, I can choose to eat pizza every morning for breakfast; no one has the right to tell me otherwise. However, I cannot go sit in my neighbor's front yard every morning to eat my breakfast, without that neighbor's permission. This is because my (odd) desire to eat my breakfast in her front yard potentially interferes with whatever she would like to do with that yard—including keeping me out of it. In this case, my autonomy would conflict with hers, and given various other assumptions about rights and property, her right prevails over my desire.
As we will see again later, however, there are some questions about autonomy that seem to raise challenges to some people's sense of freedom. I may believe I have a right to drink and drive, but doing so unfairly puts others at risk; thus society, through legislation, can prevent me from drinking and driving, or punish me for doing so. A somewhat trickier question arises with some safety issues: Do I have the right to ride my motorcycle without a helmet? If I am willing to risk injury or death by doing so, is that my right? But what if I am badly injured and have no insurance; society almost certainly will send an ambulance to pick me up, take me to the hospital where I am treated, and the bill will be absorbed not by me, but by the taxpayers. Society thus has to determine whether it would prefer to leave injured uninsured motorcyclists on the side of the road, or to pay for their health care. Perhaps you can see how these kinds of tensions occur with some frequency; for instance, does society have a right to tell me where I can smoke? Could society even prevent me from smoking? Where does the individual's rights end, and society's begin?
With PAS, the question is controversial. Does society have a right to prevent people who wish to kill themselves from doing so? Many religions and cultures have a traditional prohibition against suicide, but one might argue, in contrast, that many other traditional views—about women, ethnic minorities, and homosexuals—can be seen as objectionable, so just because a view is traditional does not make it correct. Some have argued that PAS fails to respect the dignity of human life; for instance, if humans are creations of God, to reject life is to reject God's most precious gift. Others have argued, in contrast, that denying a person the right to PAS is to deny him or her the autonomy that is essential to human beings. We will continue to encounter this kind of tension that arises from different conceptions of the human being; PAS is one issue that brings this tension into particularly sharp focus.
Advances in Medicine
Life expectancy for an American (of both sexes and all races) in 1950 was 68.2 years; in 2010, it was 78.7 years. (For comparison's sake, in 1930 it was 59.7 years) (infoplease, 2011). Just from these figures, it is clear that we are living longer and longer lives; in part due to better understanding of nutrition and lifestyle and in part due to safer jobs, but another important component comes from advances in medicine. A person in 1950 who had a heart attack may well have died; in 2010, not only might that person not die, but regular check-ups may prevent it from even occurring.
Advanced medical care can prolong life, but what are the costs and benefits of doing so?
Many of these advances have taken place in the care of the elderly; heart disease, cancer, multi-organ failure, and chronic diseases no longer generally indicate an immediate death sentence; many such patients are kept alive now when in the past they could not be. For those who choose this path, it is no doubt important and worth the expense, but it is expensive; for instance, according to Penelope Wang of CNN Money, "One out of every four Medicare dollars, more than $125 billion, is spent on services for the 5% of beneficiaries in their last year of life" (Wang, 2012, para. 4). Furthermore, some might argue that there is a difference between living and living well; if one is on a respirator, for instance, for a year, that would be living, but probably not living well.
The ability of medicine to prolong life has led to greater life expectancies, as we have seen. But it also raises the question of an economic tradeoff: Should these amounts of money be spent to maintain a person, regardless of the condition of that person? What are the benefits to someone who lives an extra year but with limited or no mobility, and possibly in frequent or even constant pain? Physicians cannot, by themselves, answer this question; rather this is a question that all, as members of society, must ask. We must, in turn, ask who makes the decision; is it the individual, the individual in consultation with his or her family and/or physician? Does society have the right to say that since medicine can keep people alive—regardless of their condition—it must do so? Again, we see the tension between some views of human dignity and others' views of autonomy.
The Most Difficult Issue of All?
It is hard to imagine a more difficult challenge to confront than that of a parent with a child who is suffering from a terminal illness or disease. No responsible parent wishes to see a child suffer, or be in pain; at the same time, the decision to do something about it presents an excruciating situation.
Very rarely is PAS suggested in this context, particularly for younger children; as pointed out by the Patients' Rights Council, "[O]pponents of assisted suicide are affronted by any suggestion that it would be available to young people" (Marker, 2013, para. 3).
Those who work in this area offer these thoughts:
It seems unimaginable that children can be diagnosed with incurable diseases that will lead to their untimely death, but the world is not a fair place. . . . Almost all children need to be told honestly and accurately about their illness, treatment, and prognosis. Children are amazingly perceptive and will pick up on the fact that things are not okay, that they are not going to be okay. (Band Back Together, n.d., para. 3–5)
The standard option available in this heartbreaking situation seems to be hospice and/or palliative care (care designed to reduce pain and suffering). Hospice care can also involve these aspects of dealing with such a tragedy:
emotional support
nursing services
nutritional counseling
respite care (temporary relief from the intense strain of hospice care to parents who are caring for children at home)
art, music, and play therapy
activities for siblings
spiritual care (helping explore the meaning of death and helping with religious ceremonies or rituals)
practical assistance with everyday tasks
grief counseling and support (for parents, family members, and close friends).
As we have seen, a number of ethical dilemmas, often generating significant tension between questions of freedom and questions of dignity, arise specifically within medicine. To be sure, even the descriptions of the positions involved can be contentious; after all, does one wish to be described as denying human dignity, or limiting human freedom? These debates become still more complex, and their resolution more difficult, when one begins to factor in cost, the extraordinary advances in medicine, and the insistence on the part of some that the state has no right to prevent a human being from doing what he or she wishes if it does not prevent others from doing what they wish to do. As we will see in the next section, these do not exhaust the ethical problems that can arise in clinical medicine.
Euthanasia
Richard's wife of 40 years, Elizabeth, has been diagnosed with pancreatic cancer. Elizabeth, who is in her 70s, has been told by several different physicians that the disease is unquestionably terminal, that she should expect to live, at the most, 18 months, and that she will experience increasing levels of pain. There are drugs that can minimize the pain, but they are sometimes ineffective at fully relieving it. As the weeks go by, Elizabeth experiences pain that continues to grow more and more severe, and is frequently in agony; her doctor has given her the strongest drugs available, and in massive doses, but they seem not to work. Increasingly, Richard has to sit there, helplessly, watching his wife suffer almost unendurable pain.
This is the kind of case that some ethicists have argued should support euthanasia (from the Greek for "good death"), or the right to die. The argument is straightforward: A person is 99% certain to die within a certain time, but before that death naturally occurs, the patient is kept alive only to suffer. Doesn't it make more sense to allow that person to avoid that suffering, and to voluntarily choose a somewhat earlier but painless death? What purpose is served, in other words, by keeping a person alive only to experience constant, agonizing pain? As noted above, euthanasia is distinct from PAS; in the case of euthanasia, the doctor actually assists in, or carries out, the procedure that terminates a patient's life. It is worth asking whether euthanasia and PAS bring distinct moral considerations to bear, specifically for the physician: In other words, could a physician be justified in helping a patient commit suicide (PAS) and be unjustified in carrying out a procedure that would similarly lead to that patient's death (euthanasia)? Many, of course, think both are unjustified, and see no moral distinction between the two. Thus, many of the questions raised below can be asked about euthanasia, PAS, or both.
End-of-Life Costs
One of the economic factors that has received much more attention lately is the fact that a disproportionate amount of health care spending comes in the last year of one's life. As The Wall Street Journal observed, "In 2009, the top 10% of Medicare beneficiaries who received hospital care accounted for 64% of the program's hospital spending, the Journal's analysis found" (Adamy & McGinty, 2012, para. 6).
A large, aging population will test the financial resources of individuals and societies alike.
Obviously enough, those in the last years of their lives are often the most ill, and often require the most expensive treatments. The question, given rising health care costs, is whether society should consider (or not) the costs of such expensive treatments, relative to the benefits they provide. On the one hand, few of us can put a price on a year of someone's life, regardless of that person's age. On the other hand, as CBS reported,
By law, Medicare cannot reject any treatment based upon cost. It will pay $55,000 for patients with advanced breast cancer to receive the chemotherapy drug Avastin, even though it extends life only an average of a month and a half; it will pay $40,000 for a 93-year-old man with terminal cancer to get a surgically implanted defibrillator if he happens to have heart problems too. (CBSNews, 2010, para. 20)
The funds for treatment are not, of course, infinite; this would seem to require some very difficult choices to be made. Others, however, suggest that this is rationing of health care, and requires someone, or some agency—whether it be a physician, an insurance company, or the government—to decide who lives another year, and who doesn't. As David Walker, former head of the Government Accountability Office put the point, "Individuals and employers ought to be able to spend as much money as they want to have things done. But when you're talking about taxpayer resources, there's a limit as to how much resources we have" (CBSNews, 2010, para. 27).
Ethical Viewpoints
As mentioned above, much of the opposition to both euthanasia and PAS comes from a religious orientation. On this view, life is a gift from God and is precious. To end it prematurely is to reject that gift. Only God should determine when a life should end; as St. Thomas Aquinas put it, "[W]hoever takes his own life sins against God." Suicide also, according to some religious traditions, indicates a lack of trust in God and a rejection of God's plan for that person. Other objections to euthanasia are similar to the objections we saw against PAS: Not explicitly based on religion, these criticisms point to the consequences that might follow from its legalization—that there will be an increase in such suicides and a corresponding loss of respect for life, and that patients may feel pressure—subtle or not so subtle—from family members or physicians to terminate their lives prematurely. Still others are concerned that a person may choose euthanasia on the basis of inadequate reasons, such as a long period of depression or as a reaction to a specific tragic event.
Assuming Elizabeth has euthanasia available to her as an option, she and her husband still confront an extremely difficult decision, and one that has to be made under the most challenging circumstances. We also see that, unfortunately, even though ethics may help make clear what is involved in making this decision, it ultimately may not be able to provide a solution that is completely satisfactory to everyone. Indeed, regardless of the view one adopts—utilitarianism, deontology, virtue ethics, or even one of the more contemporary alternatives to these—the debate will continue. One deontologist might well suggest that it is always wrong to end one's life willingly, whereas another may insist that respect for human life demands that a human life continued only to endure suffering, should be terminated. A virtue ethicist may, on the one hand, argue that immoderate measures taken to prolong suffering violates the appropriate level of moderation demanded by the Golden Mean, whereas another might argue that the preciousness of human life requires that life not be terminated, and that here, moderation itself is inappropriate. A utilitarian might argue that the greatest good for the greatest number is the result when needless pain is minimized; on the other hand, a different approach to utilitarianism might insist that the greatest good for the greatest number is only guaranteed if all members of a society reject euthanasia in order to make clear the ultimate value of the lives of all members of society.
As a debate between two utilitarians—one arguing for and one arguing against euthanasia—makes clear, we can begin to see more clearly that individual ethical decisions may not always simply be individual decisions. If Elizabeth chooses euthanasia and terminates her life, then that decision affects many others in society, and is, of course, representative of one view within her larger society. Others may condemn her decision on the basis of their own ethical or religious views, but do they have the right to insist that those views be the basis for laws that are enforced for everyone, including those who reject their ethical and religious values? We probably don't think kosher laws—such as the prohibition against eating pork—should be imposed on those who don't accept kosher dietary laws. But should, for instance, a Roman Catholic believe that her view on euthanasia or PAS be imposed on someone who doesn't share her beliefs, or even actively rejects them, as might an agnostic or an atheist?
As is often the case when ethical dilemmas are dealt with in terms of public policy and legislation, certain compromises are sought. Many argue that one solution is to continue to find drugs and other forms of palliative care that provide effective responses to the anguish a person such as Elizabeth has to deal with. The hospice movement, which treats terminal patients with dignity, emphasizes the reduction of suffering during the end of life, and promotes death with dignity, has become an increasingly attractive option for those who resist endorsing euthanasia, PAS, or both.
5.2 The Issue: Medical Research
Medical research is one of the fastest growing fields in the world; the race to find the cure for cancer, Alzheimer's, Parkinson's, and many other diseases occupies scientists around the globe. But with each new advance in medicine, another ethical dilemma is faced. However, this is not new; ethical debates over medical research have gone on for centuries.
The Nuremberg Code
After the horrors of World War II and the atrocities carried out by the Nazis were fully revealed, it was discovered that, among other things, Nazi doctors had carried out various kinds of medical experiments on human beings. In the "Doctor's Trial" of 1947, the judge rejected the Nazi doctors' claim that their research was fundamentally no different than what they had carried out before the war. The judge's ruling served as the impetus to the development of principles for what constitutes legitimate research and illegitimate research. These continue to serve as guidelines—referred to as the Nuremburg Code—for how medical research is to be done in a morally justifiable way, as well as indicating what must not be done by those doing this kind of research; similar guidelines have been developed by both the federal government and individual state governments.
Straight to the Source
Principles of the Nuremburg Code
The voluntary consent of the human subject is absolutely essential.
The experiment should be such as to yield fruitful results for the good of society.
The experiment should be so designed and based on the results of animal experimentation and a knowledge of the natural history of the disease.
The experiment should be so conducted as to avoid all unnecessary physical and mental suffering and injury.
No experiment should be conducted where there is an a priori reason to believe that death or disabling injury will occur.
The degree of risk to be taken should never exceed that determined by the humanitarian importance of the problem to be solved by the experiment.
Proper preparations should be made and adequate facilities provided to protect the experimental subject against even remote possibilities of injury, disability, or death.
The experiment should be conducted only by scientifically qualified persons.
During the course of the experiment the human subject should be at liberty to bring the experiment to an end.
During the course of the experiment the scientist in charge must be prepared to terminate the experiment at any stage, if he has probable cause to believe, in the exercise of the good faith, superior skill and careful judgment required of him that a continuation of the experiment is likely to result in injury, disability, or death to the experimental subject.
Source: http://ori.dhhs.gov/education/products/RCRintro/c03/b1c3.html
Mental Health Research and Treatment
A particularly sensitive and controversial area of research that raises its own set of ethical challenges is research in areas of mental health, including those who have been diagnosed with a mental illness. The controversies here begin with the very language used; some researchers and activists object to the very term "mental illness," and suggest alternative terminology, such as "psychiatric survivor" or "one diagnosed with a mental disorder." The United States National Institute of Mental Health and the American Psychiatric Association utilize the term "mental illness," and that language will be followed here, but it is important to know that there is a continuing debate over this and other related vocabulary, and the language also continues to change and evolve.
Various groups—including the National Institute of Mental Health, the American Psychiatric Association, the American Psychological Association, and the National Association of Social Workers, among others—have developed codes of ethics for how patients in clinical settings, as well as in more general research, must be treated. Many of these are quite detailed and specific (the American Psychiatric Association's "The Principles of Medical Ethics, With Annotations Especially Applicable to Psychiatry" is 35 pages) and follow the developments that have taken place in the mental health field. Such statements as the World Medical Association's Declaration of Helsinki (1964) and the Belmont Report (1979) have continued to make more specific what moral and ethical principles must be employed in doing any kind of clinical medicine and medical research. Naturally, research into mental illness requires still more specific stipulations, principles, and guidelines. What kinds of ethical issues can arise in the context of doing research on mental health issues?
Perhaps the most important issue in this setting is patient confidentiality. Particularly in an area that has been the source of social stigmas for so long—consider all the words English has to indicate someone is potentially dealing with a mental illness—it is crucial that a patient can expect his or her information to remain confidential. As Russ Newman, the American Psychological Association's executive director of APA's Practice Directorate stated,
[M]ental health is unique in that successful treatment depends on both the existence of privacy and the expectation of privacy. There is no other health field in which the mere threat of loss of privacy can interfere with the success of treatment. (APA, 2005, para. 5)
But it is pretty easy to see why difficult issues can arise here. Perhaps a therapist is seeing a patient with a sexually transmitted disease. The patient has numerous partners—and potential partners—to whom the patient refuses to reveal the existence of this disease. Does the therapist have an obligation to inform the appropriate authorities? At what point does confidentiality end due to threats to public safety? (The legal profession, of course, faces similar issues with confidentiality; what if a client informs his lawyer that he has planted some bombs in various parks around town; does the attorney have an obligation to inform the police of this?)
Psychiatrists, psychologists, counselors, and others have long recognized the tension that exists between the need to protect patient confidentiality and the public's right to be protected. Thus, most professional organizations make explicit exceptions when the public risk is significant, as indicated in this statement by the American Medical Association in its statement of patient confidentiality:
If there is a reasonable probability that a patient will inflict serious bodily harm on another person, for example, the physician should take precautions to protect the intended victim and notify law enforcement authorities . . . the physician's duty of confidentiality at times must give way to a stronger countervailing societal interest. (AMA, n.d. para. 14)
Ordinarily, then, research and treatment of mental illness follows the general guidelines of any research that involves, or can directly affect, human beings, with the additional provision emphasizing confidentiality and those aspects of mental health that are specific to such research and treatment.
Experimenting With Disadvantaged Populations
Earlier we mentioned autonomy, the assumed independence generally granted to adults to do as they please, provided that the choices do not infringe upon the rights of others. This is emphasized by the very first principle articulated in the Nuremberg Code, that the "voluntary consent of the human subject is absolutely essential." No one should be coerced, or otherwise forced, to be a subject of medical research; to do so is to ignore the innate dignity human beings possess. Any such involuntary, forced experimentation, as done by the Nazis, strips human beings of that dignity and treats them less human beings and more as lab rats. Hence, autonomy is crucial here; participation in such research is only legitimate if it is voluntary.
This may make intuitive sense, but there are those who are not necessarily fully autonomous in our society. For instance, those who have been incarcerated are clearly not fully autonomous; they obviously cannot do as they please. If they lack this kind of autonomy, do researchers have the right to use them in their research? Here again, the language is important, and the way the question itself is posed can indicate one's perspective on how to answer it. Compare the following two statements:
Prisoners have violated certain laws and thus indicated their lack of willingness to live in civilized society to one degree or another. We should give them the opportunity to give back to that society, and make amends, by helping the cause of advancing medical research from which all of us can, potentially, benefit.
Prisoners do not give up their humanity by being prisoners; they are already incarcerated, and a majority of their freedoms have been taken away. That is how our justice system works, but to further demean them by treating them as "human guinea pigs" is morally wrong, particularly when it is relatively easy to coerce them, directly or indirectly, into participating in such research.
The idea here is the same, of course: Using prisoners for medical research. But as you can see, how the situation is described tells us a great deal about how one regards this issue. As the second comment above notes, prisoners are particularly vulnerable: Participating in such research may bring with it rewards, whether certain privileges within the facility, increased access to or cheaper commodities (drinks, candy, snacks, cigarettes), or even some small cash payments. In a prison, of course, these incentives may be considerably more significant than they would be outside a prison; after all, many of us would decline being experimented upon in return for inexpensive sodas. As we have discussed for some time now, however, this can lead to a situation in which prisoners may be taken advantage of; indeed, some prisoners have been reported to be subject to medical experimentation without their knowledge. The question then becomes this: Does the first principle of the Nuremberg Code—"voluntary consent of the human subject is absolutely essential"—apply to prisoners? Do they forfeit that protection by being convicted of a crime and incarcerated?
As T. Howard Stone has observed in his introduction to "Prisoners as Human Subjects,"
Clinical research involving prisoners as human subjects may be an important undertaking. Prison populations are characterized by many problems involving the human condition, including poor health status, with the prevalence of many of these problems significantly higher among prisoners than among non-prisoners. Some of these problems are thought to be associated with criminal behavior. . . . However, history has demonstrated that research involving prisoners implicates some of the most troubling ethical issues of our time. (2004, p. 6)
In general, researchers must be aware, when considering whether or not a person is a suitable subject for medical research, of what sense of freedom is really involved, and whether this person is being coerced (or even being used as a research subject without his or her knowledge). While prisoners are a specific and clear example of those who are obviously not fully autonomous, what about someone who is poor? If a clinical trial offers $500 to take a regime of experimental drugs, a wealthy person might not think it worth the risk; after all, the reason the drug is being tested, is at least in part, to determine both its effectiveness and its safety. But someone who desperately needs $500 might well think it worth the risk. Imagine someone who may need that $500 to pay his rent; without it, he may become homeless. Would we regard such a person as generally acting autonomously, and giving his genuine voluntary consent?
This issue began to receive considerable scrutiny in the press in the 1990s, when Eli Lilly was discovered to have been recruiting the homeless and the indigent for drug testing. As Laurie Cohen wrote in The Wall Street Journal, Lilly's action was based on economic reasons, as voluntary drug testing is an expensive proposition, costing companies anywhere from $125 to $250 a day to promote studies and compensate participants (1997).
Many other pharmaceutical companies were criticized for what was perceived as taking advantage of, or exploiting, the poor and disadvantaged in the United States to run drug tests. Often, they chose to do such testing outside of the United States; as Donald Bartless and James Steele documented at length, these companies increasingly turned to other countries, often with relatively high poverty rates, to test their products: "[T]housands are taking place in countries with large concentrations of poor, often illiterate people, who in some cases sign consent forms with a thumbprint, or scratch an ‘X' (2011, para. 5).
5.3 The Issue: Abortion
Few issues in the United States have generated the kind of controversy that abortion has—a controversy that continues to rage. It is also unlikely that the debates over abortion will subside any time soon, although some have suggested that such developments in medical technology, such as Plan B or "the morning-after" pill, may eventually cause it to do so. Fundamentally, a pregnancy occurs when a fertilized egg is implanted in a woman's womb; an abortion is the termination of that pregnancy. The basic issues in the debate are well known, and probably do not need much rehearsal; it is the interpretation of those basic issues, how they are described, and what the implications of that interpretation are, that generate controversy. Here we will look, briefly, at the best-known positions on this topic, before introducing some of the details that receive a bit less attention, but which also raise important moral and ethical questions.
Language and Abortion
In the United States, the standard terminology used to describe the basic positions in the abortion debate are "pro-life" and "pro-choice." Those who are pro-life oppose abortion, in some or all cases, and those who are pro-choice favor the woman's right to choose an abortion, in some or all cases.
The language here is important, of course, and it is worth considering its implications.
Are those who claim to be pro-choice willing to be characterized as "anti-life"?
Are those who claim to be pro-life willing to be characterized as "anti-choice"?
What other implications of this language emerge when we look at it more carefully?
What is the difference between describing a person as in favor of abortion rights and in favor of abortion?
Another controversy over abortion reflects a similar issue with language: pro-life supporters describe a specific procedure as a "partial-term" abortion; pro-choice advocates refer to this as "late-term" abortion. The depth of this controversy is indicated by the fact that there is a disagreement regarding when a pregnancy is late in its term; some identify this as the 16th week of gestation, some the 20th week of gestation, others as the 27th week (third trimester) of gestation.
The Pro-Choice Perspective
On one side of the debate is the question of who makes the final decision about whether a woman should have an abortion. Here, as we have seen in other moral questions, the language itself will indicate people's perspective on how they might answer the question. If a woman desires an abortion, we might ask: Who makes this decision? Is the decision solely that of the woman herself, or the woman in consultation with her physician or others (such as a religious advisor or family members)? Or should the woman not be allowed to make this decision and instead be required to carry the pregnancy to term, as dictated by government policy?
Those who favor abortion rights argue that this is an extremely personal decision, and that decision must be left to the person who understands it best: the woman herself. To take this decision out of her hands is to lessen her fundamental right to autonomy, which in most other cases is presumed to be a basic right that cannot be abridged. Those drafting policy are, of course, not familiar with her circumstances, nor do they consider her thinking and reasoning when making this decision. To tell a woman that if she becomes pregnant she has no right to determine the outcome of her pregnancy, regardless of her physical or mental health, economic circumstances, or cause of the pregnancy fails to treat her as an autonomous human being. If that autonomy is as important in other legal and ethical issues as it is generally presumed to be, then this constitutes a fundamental violation of her rights. Florynce Kennedy, a lawyer and activist, commented on this idea in a statement widely attributed to her, "If men could get pregnant, abortion would be a sacrament." In Kennedy's view, the restrictions against abortion are the result of a long history of denying women rights (such as the right to vote, own property, and obtain credit), and thus a willingness to restrict women's autonomy, a restriction that relatively few men have experienced and even fewer men, today, would tolerate. The basic result of this perspective is, then, that if there is a decision to be made about an abortion, it should be made by the person most knowledgeable about the situation, and most affected by it: namely, the woman. To allow others to make this decision is a denial of her fundamental rights to her own life and how that life is lived.
The Pro-Life Perspective
In contrast to the "pro-choice" position are the various perspectives that are grouped together as "pro-life." The basic assumption that drives this position—and thus its opposition to abortions being generally legal and available—is that the embryo is a human being and has rights that cannot be denied. While different people and groups disagree about when life begins, all of them agree that, at some point, the fetus must be regarded as a human being, with its own rights, which it is immoral to deny. Often emphasized is the fact that the fetus is extraordinarily vulnerable, and thus the state has a compelling interest to step in and prevent the termination of its life (and, consequently, the denial of all its rights). In this way, then, the state has a compelling interest to prevent a woman from having an abortion and can impose various legislative restrictions to abortion and various penalties for those who seek to circumvent those restrictions.
Often those who oppose abortion support their position by appealing to religious doctrine. The Roman Catholic Church, for one, has been at the forefront of the movement to restrict or ban abortion, referring to Christian doctrine and its interpretation to conclude that abortion is a violation of that doctrine. John Paul II, in his 1995 Encyclical Evangelium Vitae (The Gospel of Life) wrote of "the sacred value of human life from its very beginning" (para. 5). Different Protestant denominations, while often rejecting abortion in most or all cases, may disagree about specific circumstances, such as if an pregnancy threatens the life of the mother. Thus, some Protestants argue that no abortions should ever be allowed, while others adopt the position that there can be compelling reasons to allow it. There are debates in Islam, as there are within many religious traditions, about when it is impermissible to terminate a pregnancy; the general view seems to be that no abortions are permissible after the fourth month of the pregnancy. Judaism, again, has distinct interpretations within it, and different traditions within Judaism—Orthodox, Conservative, Reform—adopt different positions on abortion, although generally Judaism recognizes that protecting the life and well-being of the mother can justify an abortion.
A Pharmaceutical Compromise?
Though not abortifacients, emergency contraception pills such as Plan B are still controversial.
As noted above, some developments in medicine have made it more likely that at least some of this controversy may subside. The development in France of RU-486 (Mifepristone) in the late 1980s serves as one example; this pill functioned as an abortifacient (inducing abortion) and thus could be taken to terminate a pregnancy, specifically in the first trimester. Plan B, also known as the "morning-after" pill, is not an abortifacient. It is taken by a woman after having unprotected sex, and it prevents or delays ovulation, or prevents or otherwise interferes with the fertilization of an egg. Because it is not an abortifacient, it does not cause a miscarriage or abortion, and thus it is not effective if one is already pregnant.
Because Plan B does not terminate a pregnancy—there is no fertilized egg or implantation of it—the objections to this form of birth control have tended to focus on what it implies about culture. The spokesperson for the United States Conference of Catholic Bishops' Secretariat of Pro-Life Activities, Deirdre McQuade, issued this statement:
Many studies have shown that wider access to so-called ‘emergency contraception' reduces neither pregnancy nor abortion rates, but can contribute to higher rates of sexually transmitted disease, especially among young people. . . . No public health consideration justifies the unsupervised sale of such drugs to young teens. (CatholicCulture.org, 2013, para. 4)
In contrast, Cecile Richards, president of the Planned Parenthood Federation of America argues for the safety and effectiveness of emergency contraception, insisting that teens as well as adults are capable of using it correctly (Brusk & Carter, 2013).
Two things should be noted about this dispute. First, the debate no longer seems to be about abortion per se; even if life begins at conception, Plan B does not affect this. Hence, the debate here seems to move away from questions of biology and conception to a debate about society and its values. We might well ask what the basis is of the objection to Plan B that does not hold for the sale and distribution of condoms. Meg Waite Clayton has, in fact, argued that this reflects society's double standard in how males and females are treated:
The only reasonable objection to making Plan B available over-the-counter to anyone of any age is that, as parents, we want to know if our children are sexually active. But then why aren't we questioning the easy ability to buy 100 condoms for less than the cost of movie tickets for a boy and his date? (2013, para. 5)
The objection to the morning after pill, then, must be based on something other than an objection to abortion.
Second, this may be a good indication of how medicine can change the debate, and it is safe to assume that various other developments in medicine will lead to other ways of preventing or terminating pregnancies in the privacy of one's home. Here again, however, we see political and social issues arise: If a pill is developed that prevents pregnancy that is not an abortifacient, should it be covered by health care plans? Should insurance plans—including Medicaid—be required to cover it? Should pharmacists who object to it—for, perhaps, religious or ethical reasons, not as an abortifacient—be required to stock and sell this pill? As you can see, the debates will continue, although the terms of the debate may change.
Post-Birth Abortion: Slippery Slope or Not?
As chapter 3 discussed, a "slippery slope" is a traditional fallacy that, more or less, argues on the basis of "if you give a person an inch, he will take a mile." For example, if a police officer doesn't stop me for speeding one mile an hour over the speed limit, or two miles, or three miles, can this be continued in that way? Does that mean I won't be stopped for speeding for driving four, five, 10, 15, 20, 30, 50 miles an hour over the limit? It is a mistake to argue that since I won't be stopped for driving 36 miles an hour, I won't be stopped for driving 85 miles an hour on the same road. The line has to be drawn somewhere.
In fact, some have argued for what is called "after-birth" abortion, a procedure that leads to the death of the child after it has been delivered. According to their argument, if one accepts the legitimacy of abortion at 20 weeks, or 30 weeks, or 36 weeks (as advocated by those who think late-term abortions should be legal), then the reasons that support that conclusion also support an even later-term "abortion." In other words, being outside the womb is as arbitrary a "cut-off" point as is any other time before it, whether it be "quickening" (the fetus moving on its own); viability (the fetus being able to survive outside the womb); or the distinction among the first, second and third trimesters. Perhaps the slippery-slope point is clearest when considering a baby that survives a late-term abortion procedure; at this point of this "slope," would anyone not regard something done to terminate that baby's life to be some sort of homicide? One may be tempted to see this as an "academic" argument, put forth to examine the logic of abortion, rather than a genuine defense of what would, traditionally, be regarded as infanticide. We suggest, then, that any specific criterion invoked to prevent or allow abortion involves a "slippery slope." Because a slippery slope is a fallacy, or bad argument, we may be more interested in exploring the logic of the abortion debate.
A potential slippery slope fallacy may also go in the other direction: If the fetus is a human being at 36 weeks, then presumably it is at 30 weeks, 20 weeks, 10 weeks, etc. Indeed, some have used this to argue that the fetus is a human being at conception. But could this be regarded as arbitrary as well? Do sperm or eggs have potentiality sufficient to deserve some kind of protection? Why or why not? And, as we will see in the next section, fertilized eggs in fertility clinics present their own set of problems, given that they seem, on some views at any rate, to be persons. Thus, the question arises of what should be done with those fertilized eggs that are not implanted and brought to term.
Abortion and Ethics
As noted, the issue of abortion continues to be extremely controversial, invoking strong passions on all sides. Since Roe v. Wade was decided in 1973, some forms of abortion have been legal in the United States. Also, since that landmark case, various specific changes have been made in terms of parental consent, waiting periods, and degree of government involvement. As Roe itself established, as the pregnancy continues, the compelling interest of the government in the fetus and the outcome of the pregnancy increases. Particularly at the state level, a number of restrictions have been introduced, and as of 2013, four states (North Dakota, South Dakota, Arkansas, and Mississippi) have only one abortion clinic. For those who advocate the right to an abortion, these changes often affect poor women, who may not be able to afford the time necessary to drive across a state and wait 24 or 72 hours for the procedure; the ethical question then becomes whether such women really have such a "right" if they are prevented, for financial reasons, to avail themselves of it.
As also noted, the debate will continue, although, as we also saw, some developments in medicine may make some of the debates obsolete, or require the arguments involved to shift their focus from medical issues to cultural issues. Issues fundamental to the abortion debate continue, for the present, to focus on these basic questions:
When does life begin?
Is the fetus a human being at conception, at quickening, at viability, at delivery, or after delivery?
Can it be determined, in a nonarbitrary way, when life begins?
Who makes the final choice about whether to have an abortion?
Does the government have the right to tell a woman what she can and cannot do, particularly about such a personal issue?
Are there exceptional situations—rape, health of the mother, incest—that may justify an abortion that would otherwise not be justified?
Why, for instance, would a fetus conceived through rape and/or incest have a different status than a fetus not conceived through rape and/or incest?
None of these questions have easy answers. But close attention to the language used, consideration of the arguments on the various sides that have been proposed, and listening to those views that conflict with one's own view are all things that the study of philosophy—specifically, ethics—enthusiastically promotes. Philosophy may not solve these debates, of course, but it can certainly help clarify the issues and promote a more productive engagement between the various interested parties involved in that debate.
5.4 The Issue: Stem Cell Research
Earlier we saw that developments in medicine can change the terms of some ethical debates. We have seen that being able to keep people alive longer can raise difficult questions about the end of life, just as Plan B or morning-after contraception can alter the traditional debate over abortion. One other such development is worth looking at, if only briefly: the development of stem cell therapy, as well as some of the related questions about in-vitro fertilization and what are, and are not, appropriate subjects for research.
The topic of stem cells, stem cell therapy, and stem cell research is a complex one, and can quickly lead to technical discussions of pluripotency versus multipotency, blastocysts, and other specifics better treated in biology, genetics, and biochemistry. For our purposes, we can regard stem cells as those biological cells that can self-generate, and be used, theoretically, for a variety of purposes, specifically replacing damaged tissue. Generally, stem cells that one encounters in popular discussions are either embryonic stem cells or adult stem cells; cord blood stem cells, taken from the umbilical cord, or cells from amniotic fluid are also sometimes discussed. While oversimplifying, adult stem cells are generally not what is called "pluripotential": That is, they cannot grow into various different kinds of cells, while embryonic stem cells are pluripotential. (Cord blood cells show promise of being pluripotential, but this is still a subject of some debate.) This makes embryonic stem cells much more useful in therapeutic applications, for one can design such cells for treating designated areas, whether corneal cells (as in proposed stem cell therapy glaucoma) or neural cells (as in proposed stem cell therapy for muscular dystrophy or spinal cord injuries).
This kind of therapy holds great promise, although currently mostly potential promise, for the treatment and even cure of an enormous number of diseases. In addition to those mentioned, stem cell therapy research is currently being done on the following diseases and conditions, among others: heart disease, ALS (Lou Gehrig's Disease), cancer, deafness, and baldness. There are also many uses in veterinary medicine being explored, and the research itself is an international effort, with particularly robust efforts being found in the People's Republic of China and South Korea, as well as Mexico and, of course, the United States.
The research is proceeding very rapidly, and just as those promises held out by stem cells generate important ethical issues with which society must struggle, this also makes it difficult to know what the current state of research and development will be in 5 or 10 years. That is, we may be able to imagine neither these developments, nor the problems those developments may produce. So we can focus on one specific controversy that has already received a fair amount of attention—the use of embryonic stem cells.
Research involving embryonic stem cells may promise medical advances but also raises a number of ethical questions.
Using Embryos for Research
The issue over using embryonic stem cells is relatively straightforward. On the one hand, as we have seen, pluripotent, embryonic stem cells offer researchers a vast opportunity to develop new therapies that have otherwise resisted treatment, and, at least potentially, may create possibilities in medicine hitherto unimagined. On the other hand, embryonic stem cells are derived, as the name indicates, from embryos. If life begins at conception, then the embryo, even at the earliest stages of development, is regarded as a human being. Using its cells is to treat it as an object to be "harvested," failing to treat it with the dignity required of human life and, ultimately, if and when the embryo is destroyed, some regard this as murder.
Economists might regard this as a classic tradeoff, in which something is gained (advances in medicine, which may be substantial) and something is lost (the embryo). Of course, if one does not regard an early stage embryo—a blastocyst—as a human being but at best a potential human being, one may well react differently than one who regards life to begin at the stage of the blastocyst (or conception). As we will see below, this raises a very interesting question for ethical theory; we may think that utilitarians would adopt one view, while other theorists would oppose that utilitarian view. As is often the case in ethical theory, the results are not as simple as we might initially suppose. One way of beginning to consider these difficult questions is to look at the question of in vitro fertilization, relative to the specific problem of embryos that are not, ultimately, implanted.
When Does Life Begin?
Questions in ethics often end up raising questions that are investigated by other branches of philosophy. For instance, many ethical questions may depend on what we know; if we are to determine, for instance, what the greatest good is for the greatest number of people, then we need to be able to determine whether we know what the relevant good is, and we need to see if we are able to establish that we know which people will be affected by a given decision. These are questions of ethics, but they also raise questions in the theory of knowledge, or epistemology. Similarly, questions about abortion, stem cell research, and end-of-life crises can rest on determining a very difficult set of questions, specifically, "When does life begin?" and "When does life end?" These questions are obviously of significance in attempting to resolve them in ethics, but they also seem to be questions that lead to metaphysics. Determining when life begins and ends also requires us to ask, "What is life?" and that question seems fundamentally metaphysical.
Our answer to this metaphysical question, however, may often simply be determined by our approach to it. If we appeal to certain naturalistic methods, such as biology as it is generally practiced in the United States, we might regard any of these as suitable answers:
Life beings at conception, when the sperm and egg are united in fertilization;
Life beings at gastrulation, when the fertilized egg can no longer divide (approximately 14 days);
Life beings when distinct brainwave activity begins; or
Life begins at birth.
Still other criteria have been offered, in terms of when fetal life begins, such as "quickening" or the spontaneous movement of the fetus, or viability, when the fetus is sufficiently developed to survive outside the womb. As most biologists are quick to point out, however, there may be an ambiguous use of the word "life" here; we might well distinguish between the idea of biological life and a human life. And many would say that this just moves the question from "When does life begin?" to "Is there a distinction to be drawn between ‘life' and ‘human life'?
Obviously, those who oppose some of these ideas are likely to state that life begins with the fertilized egg, that there is no difference between "life" and "human life," and, consequently, all human life begins at conception and the life involved has dignity and deserves protection, just as does any other human life. This is the view of the Roman Catholic Church and many other Christian denominations; some have raised the issue, of course, of whether this position has been consistently carried out, or if more attention is paid to protecting innocent life, or human life, in the womb than outside of it.
5.5 Applying the Theories
We began with the tragic and explosive case of Terri Schiavo, a controversy that raised, once again, the difficult questions about what life is, and when a human life ends. As we have also seen, similar difficult questions arise in the context of what we conclude about when life begins. How we answer these questions—indeed, how we state these questions—can say a great deal about our ethical intuitions, as well as which ethical theory we find most productive in helping us clarify moral problems and helping us attempt to resolve them. It should be sufficiently clear by now that no answers will satisfy everyone, particularly in these contexts. But it is to our advantage to make clearer what the issues are, minimize or eliminate irrelevant aspects of the issues, and try to justify, to the best of our ability, our own responses to these issues. Ethical theory can often be of great assistance in accomplishing all of these goals. But rather than trying to indicate what various ethical theories would say about each and every one of the many topics we have discussed, we will focus on the specific question of whether embryonic stem cells can be used for research: In short, is it morally justifiable to use embryonic stem cells to develop new techniques and therapies in medicine? As we go through these ethical responses, however, it is important to see that the specific arguments here about stem cells have a much broader application to a wide range of ethical challenges and dilemmas.
Utilitarian
The utilitarian adopts, as a basic—if oversimplified—principle the idea that a decision is best if that decision leads to the most favorable outcome for the greatest number of people affected by that decision. More traditionally stated, the utilitarian seeks the greatest good for the greatest number. How might this principle be applied to the question of embryonic stem cells? Is it obvious that all utilitarians will agree on the result?
A potential response may be that stem cell therapy offers enormous potential to medicine, and if just some of those results are achieved, the benefits are almost incalculable. Those who, in the past, died very young may well live long, fulfilling lives, and help others live similarly fulfilling lives. Those in pain may not suffer but live without that pain; those who could not walk may walk, those who could not see may see. The benefits from these results are almost impossible to imagine; what amount of money would someone pay to get his or her sight back? In contrast, to get to these results, or even to try, requires destroying a relatively small, finite number of embryos in their early development. Many such embryos already die from natural causes, by miscarriage and other spontaneous abortions; the standard rate cited is about 15–20% of pregnancies end in this fashion. Perhaps in an ideal world, all fertilized eggs would be brought to term, and there would be no such natural loss of embryos. But we do not live in such a world; otherwise, we would not have, among other things, the crippling diseases that we are trying to prevent and defeat. Thus, the utilitarian has to weigh the results for humanity of the potential benefits of such stem cell therapy against the potential benefits of those embryos—many of which will never result in human beings—that are brought to term. Whether one wishes to do this qualitatively, by comparing the general results of one decision over another, or quantitatively, by trying to systematically measure the benefits of one decision over the other, the result seems obvious and compelling. There is no possible interpretation whereby the benefits of some embryos being "saved" outweigh the benefits to the people of the Earth, and to future generations, of stem cells developed through the sacrifice of these embryos. Continuing with embryonic stem cell research is the obvious choice to make, and is wholly justifiable from a moral standpoint.
Still, it is important to note that few ethical theories can be treated as some sort of recipe (or algorithm), where one applies a view to a particular question and expects a specific result, agreeable to all who endorse that theory. Consequently, just because two people both find utilitarianism an attractive ethical theory, they may not agree on how it should be applied in specific cases, nor on what the results of that application will be. There are complications, as well, in applying utilitarianism in general.
One difficulty, of course, is trying to weigh the benefits involved. How might we compare the benefits of 10 people regaining their sight against one person regaining the ability to walk? Are such calculations even possible? In addition, the time frame one uses can make a great deal of difference in evaluating benefits. Is a significant benefit that lasts just a few years comparable to a smaller benefit that lasts much longer? Again, can one compare, for instance, getting back 50% of one's hearing for 10 years with getting back 25% of one's hearing for 20 years?
Deontological
Kant, the best-known and most influential deontologist, used three different ways to express what he called the "categorical imperative," a rule that imposes its moral demands, necessarily, on all rational agents. While there is considerable controversy as to whether Kant's three formulations are, as he claims, equivalent, we can focus on what is perhaps the best-known of the three: "Act in such a way that you treat humanity, whether in your own person or in the person of any other, never merely as a means to an end, but always at the same time as an end" (Kant, 2008, p. 34).In other words, all human beings deserve dignity and respect (unless, by their actions, they forfeit this respect), and to treat a human being solely as a means to an end—to treat a human being instrumentally—is to violate the categorical imperative and, thus, to act in a fundamentally immoral way.
Here we shall assume that at some early stage of development the embryo possesses the status of a human being. Of course, a great deal in this debate turns upon this assumption: whether it is a good assumption to make and, if it is, at what stage one can identify a fetus as a human being. Only when one attributes personhood to the fetus do many of these considerations come into play, which is undoubtedly why this is the focus of so much controversy. In any case, as a human being, it must be treated as an end in itself; it cannot be treated solely as a means to someone else's goal, no matter how noble that goal is. For instance, if I thought I could make it rain in the Sahara desert, and was confident that sacrificing one person as part of the rain-making ritual, that would still be wrong; my goal may be completely noble (bringing water to the desert and improving thousands of lives), but it would be wrong to do so because it would treat the sacrificial victim solely as a means to that end. Thus, even if we recognize the goals of stem cell research as valuable and potentially beneficial to all humanity, we cannot treat human life—including embryonic life—as mere means in order to achieve those goals. Furthermore, most of the benefits of stem cell research are, at this point, potential; even if we concede how rich that potential is, it has not been determined that these therapies will, in fact, be successful. It is immoral to sacrifice some number of human lives on the basis of a promise of potential, regardless of what that potential may be.
Consequently, because treating human embryos as mere means to an end, and treating human beings solely as means to an end, violates the categorical imperative, it is clearly immoral to carry out embryonic stem cell research. It is a fundamental violation of the respect and dignity owed to all human life.
Relativist
Different cultures have different attitudes toward life, as well as when life begins and ends. My culture may regard the fertilized egg as fully human and believe that all human beings are owed respect; in this culture, stem cell therapy would be immoral and illegal. But another culture may regard the fertilized egg as, at best, a potential human being; this culture may view life as beginning at birth. If a child is born with some kind of condition that will prevent the child from living a full life, or the fetus is discovered to have various significant health problems while still in the womb, there is no problem in this culture if that life is terminated. The first culture may regard the second culture's perspective as wholly immoral; but the second culture may, in the same way, regard the first culture's as immoral, by forcing a woman to give birth to a child who will suffer for a few years and then die a painful death, all of which has to be witnessed by that woman.
Who is to say which culture has it right? And there are, of course, many other perspectives to be found in cultures around the world. Is anyone in a position to identify what the correct perspective is? If so, what is our obligation if another culture is seen to have an immoral approach? If a country killed 8.5 million of its own citizens a year, that would be regarded as genocide; if it did it for 40 years, resulting in 336 million deaths, it would be regarded as one of the greatest crimes in human history. Yet would anyone advocate going to war with the People's Republic of China over the number of reported abortions carried out since 1971 (Rabinovitch, 2013)? Why not?
If a culture wishes to pursue stem cell research, then, no other culture has the right to object, let alone to force its own moral views on that culture. By the same token, if a culture wishes to prevent stem cell research, no other culture has the right to object. Each culture determines its own values, and there is no "correct" moral response here: Rather, there are only those responses that fit a given culture, or a correct relative to that culture.
As we've discussed previously, people often find relativism attractive; it seems to be easily applied, avoids arguments, and allows everyone to think and believe as he or she wishes.
There are a couple of problems, however, that may make the actual application of relativism a bit more difficult.
One problem is, after a little reflection, fairly obvious: Few if any cultures hold all the same values. How do we draft laws and policies in a culture, or a community, in accordance with the relativistic idea that there are no particular "right" answers? If the majority adopts a particular moral view that oppresses a minority in that culture, is there any way to object to that oppression in a coherent way that could have any force?
The other problem is a bit more conceptual and relates to what we have seen as the "paradox of tolerance." What if one culture insists that its beliefs are correct for that culture, and one of its beliefs is that those cultures who disagree with those beliefs should be invaded, and forced to accept the first culture's beliefs or be killed? Is there a way that one can object to that from the perspective of relativism?
