Value, obligation and the asymmetry question

Is there a prima facie obligation to produce additional individuals whose lives would be worth living? In his paper ‘Is it Good to Make Happy People?’, Stuart Rachels argues not only that there is, but, also, that precisely as much weight should be assigned to the quality of life that would be enjoyed by such potential persons, if they were to be actualized, as to the quality of life enjoyed by actually existing persons. In response, I shall argue, first, that Rachels’ view is exposed to very serious objections, and secondly, that his arguments in support of his position involve a crucial assumption, which cannot be sustained, concerning the relation between, on the one hand, propositions about good-making and bad-making properties, and, on the other, propositions about right-making and wrong-making ones. I shall then argue that there is a very plausible position concerning the conditions under which an action can be morally wrong which entails the following asymmetry: there is a prima facie obligation not to bring into existence individuals whose lives are not worth living, but there is no corresponding obligation to create additional individuals whose lives would be worth living.     

The non-identity problem and genetic harms -- the case of wrongful handicaps

The Human Genome Project will produce information permitting increasing opportunities to prevent genetically transmitted harms, most of which will be compatible with a life worth living, through avoiding conception or terminating a pregnancy. Failure to prevent these harms when it is possible for parents to do so without substantial burdens or costs to themselves or others are what I call "wrongful handicaps". Derek Parfit has developed a systematic difficulty for any such cases being wrongs -- when the harm could be prevented only by preventing the existence of the individual who would have a worthwhile life even with the handicap, then bringing him into existence with the handicap does not make him worse off and so does not wrong him. I argue that a non "person-affecting" principle requiring the avoidance of suffering and limited opportunity correctly accounts for cases of wrongful handicaps without requiring that the individuals with the handicap have been made worse off and therefore wronged. It is an advantage, not a difficulty, of this account that it does not imply that the person with the handicap has been wronged or is a victim with a special moral complaint.     

THE NON-IDENTITY PROBLEM AND GENETIC HARMS – THE CASE OF WRONGFUL HANDICAPS

The Human Genome Project will produce information permitting increasing opportunities to prevent genetically transmitted harms, most of which will be compatible with a life worth living, through avoiding conception or terminating a pregnancy. Failure to prevent these harms when it is possible for parents to do so without substantial burdens or costs to themselves or others are what J call "wrongful handicaps". Derek Parfit has developed a systematic difficulty for any such cases being wrongs — when the harm could be prevented only by preventing the existence of the individual who would have a worthwhile life even with the handicap, then bringing him into existence with the handicap does not make him worse off and so does not wrong him. I argue that a non "person-affecting" principle requiring the avoidance of suffering and limited opportunity correctly accounts for cases of wrongful handicaps without requiring that the individuals with the handicap have been made worse off and therefore wronged. It is an advantage, not a difficulty, of this account that it does not imply that the person with the handicap has been wronged or is a victim with a special moral complaint.     

ON USING PEOPLE MERELY AS A MEANS IN CLINICAL RESEARCH

It is often argued that clinical research should not violate the Kantian principle that people must not be used merely as a means for the purposes of others. At first sight, the practice of clinical research itself, however, seems to violate precisely this principle: clinical research is often beneficial to future people rather than to participants; even if participants benefit, all things considered, they are exposed to discomforts which are absent both in regular care for their diseases and in other areas of daily life. Therefore, in this paper we will consider whether people are used merely as a means by being enrolled in clinical research. On the basis of recent studies of Kantian scholars we will argue that clinical research is compatible with the Kantian principle if the conditions of possible consent and end‐sharing have been met. Participants are not used merely as a means if they have sufficient reasons to consent to being enrolled in clinical research and can share the ends of the researchers who use them. Moreover, we will claim that even if people are used merely as a means by participating in clinical research, it may not always be morally wrong to use them in this way.     

Ectogenesis,abortion and a right to the death of the fetus

Many people believe that the abortion debate will end when at some point in the future it will be possible for fetuses to develop outside the womb. Ectogenesis, as this technology is called, would make possible to reconcile pro‐life and pro‐choice positions. That is because it is commonly believed that there is no right to the death of the fetus if it can be detached alive and gestated in an artificial womb. Recently Eric Mathison and Jeremy Davis defended this position, by arguing against three common arguments for a right to the death of the fetus. I claim that their arguments are mistaken. I argue that there is a right to the death of the fetus because gestating a fetus in an artificial womb when genetic parents refuse it violates their rights not to become a biological parent, their rights to genetic privacy and their property rights. The right to the death of the fetus, however, is not a woman's right but genetic parents’ collective right which only can be used together.     

Conscientious objection in healthcare: How much discretionary space best supports good medicine?

Daniel Sulmasy has recently argued that good medicine depends on physicians having a wide discretionary space in which they can act on their consciences. The only constraints Sulmasy believes we should place on physicians’ discretionary space are those defined by a form of tolerance he derives from Locke, whereby people can publicly act in accordance with their personal religious and moral beliefs as long as their actions are not destructive to society. Sulmasy also claims that those who would reject physicians’ right to conscientious objection eliminate discretionary space, thus undermining good medicine and unnecessarily limiting religious freedom. I argue that, although Sulmasy is correct that some discretionary space is necessary for good medicine, he is wrong in thinking that proscribing conscientious objection entails eliminating discretionary space. I illustrate this using Julian Savulescu and Udo Schuklenk’s system for restricting conscientious objections as a counter‐example. I then argue that a narrow discretionary space constrained by professional ideals will promote good medicine better than Sulmasy’s wider discretionary space constrained by his conception of tolerance. Sulmasy’s version of discretionary space would have us tolerate actions that are at odds with aspects of good medicine, including aspects that Sulmasy himself explicitly values, such as fiduciary duty. Therefore, if we want the degree of religious freedom in the public sphere that Sulmasy favours then we must decide whether it is worth the cost to the healthcare system.     

Spinoza,Styron, and the Ethics of Healing

In this essay I discuss a passage from William Styron’s memoir of his long struggle with chronic severe depression, from the standpoint of a Spinozian understanding of agency and self-worth. In this passage Styron relates how in hearing a piece of music he was abruptly struck by a recollection of “all the joys [his] house had known” and how this brought a realization that it would be wrong for him to kill himself: wrong because it would be an abandonment of those who had shared in those joys and a “desecration” of himself. He tells how this realization led him to admit himself to hospital for treatment and thereby to a slow and difficult recovery. This, I propose, illustrates the Spinozian idea that the value of an individual life is properly understood in terms of that individual’s participation in the actualization of a shared value and that individual agency is empowered by the knowledge of such value.     

Head-counting vs. heart-counting: an examination of the recent case of the conjoined twins from Malta

This paper reexamines the recent case of the conjoined twins from Malta. Survival was said to be possible only through separation, which would actually leave only one twin alive. The parents refused to allow the killing of one to save the other, but the court ruled that this would amount to the neglect of innocent life. The article questions the assumption that the case is indeed a struggle between two people. Further, it questions the assumption that a conjoined twin's natural interest and wish is separation. Historical evidence shows that many conjoined twins do not wish for separation, even when it becomes a question of survival.The article concludes with a critical evaluation of the tendency in contemporary society and particularly in bioethics to regard ethical challenges as rivalry between individuals competing for scarce resources.     

Self‐Euthanasia,the Dutch Experience: In Search for the Meaning of a Good Death or Eu Thanatos

My main purpose in this article is to establish the meaning of a ‘good death’ when death is self‐chosen. I will take as my point of departure the new notion of ‘self‐euthanasia’ and the corresponding practice that has evolved in the Netherlands in recent years. Both physician‐euthanasia and self‐euthanasia refer to an ideal process of a good death, the first being ultimately the physician's responsibility, while the second is definitely the responsibility of the individual choosing to die. However, if we also accept the existence of a fundamental moral difference between ending another person's life and ending your own life, and if we accept this moral difference to be also relevant to the normatively laden good death, then this difference represents a strong reason for preferring self‐euthanasia to physician‐euthanasia.     

‘Accelerated aging’: a primrose path to insight?

Organism envy afflicts most researchers who work on aging in mice; how frustrating it is to see the worm and fly biologists nail down milestone after milestone, citation after citation! Surely genetic trickery can produce mice that age in a comparable jiffy? Alas, our near‐total ignorance of what times the aging process makes it hard to guess what genes to tweak, if indeed aging can be mimicked a presto. Building a case that a given short‐lived mutant ages quickly is a steep and thorny path, requiring more than just plucking a symptom here and there from a list of things that sometimes go wrong in old people or old mice. The hallmark of aging is that a lot goes wrong more or less at the same time, in 2‐year‐old mice, 10‐year‐old dogs and 70‐year‐old people. Finding ways to damage one or two systems in a 6‐week or 6‐month‐old mouse is not too hard to do, but the implications of such studies for improved understanding of aging per se are at best indirect and at worst imaginary and distracting.     

Why Procreative Preferences May be Moral – And Why it May not Matter if They Aren't

There has been much argument over whether procreative selection is obligatory or wrong. Rebecca Bennett has recently challenged the assumption that procreative choices are properly moral choices, arguing that these views express mere preferences. This article challenges Bennett's view on two fronts. First, I argue that the Non‐Identity Problem does not show that there cannot be harmless wrongs – though this would require us to abandon the intuitively attractive ‘person‐affecting principle’, that may be a lesser cost than abandoning some more firmly‐held intuition. But, even if we accept Bennett's claim that these choices are not moral, that does not show them to be mere personal preferences. I argue that there is a class of non‐moral ‘categorical preferences’ that have much the same implications as moral preferences. If a moral preference for able‐bodied children is problematic (as Bennett claims), then so is a non‐moral categorical preference. Thus, showing that these preferences are not moral does not show that they are not problematic, since they may still be categorical.     

Genetic therapy, identity and the person-regarding reasons

It has been argued that there can be no person-regarding reasons for practising genetic therapy, since it affects identity and causes to exist an individual who would not otherwise have existed. And there can be no such reasons for causing somebody to exist because existing cannot be better for an individual than never existing. In the present paper, both of these claims are denied. It is contended, first, that in practically all significant cases genetic therapy will not affect the identity of beings of our kind. This is so irrespective of whether, essentially, we are beings with minds or beings of a certain biological species, the human one. Second, it is contended that, even if genetic therapy were to affect our identity, there could be person-regarding reasons for conducting it, for existence can be better than non-existence for the individual.     

Why does culture increase human adaptability?

It is often argued that culture is adaptive because it allows people to acquire useful information without costly learning. In a recent paper Rogers (1989) analyzed a simple mathematical model that showed that this argument is wrong. Here we show that Rogers' result is robust. As long as the only benefit of social learning is that imitators avoid learning costs, social learning does not increase average fitness. However, we also show that social learning can be adaptive if it makes individual learning more accurate or less costly.     

Reproductive CRISPR does not cure disease

Given recent advancements in CRISPR‐Cas9 powered genetic modification of gametes and embryos, both popular media and scientific articles are hailing CRISPR’s life‐saving, curative potential for people with serious monogenic diseases. But claims that CRISPR modification of gametes or embryos, a form of germline engineering, has therapeutic value are deeply mistaken. This article explains why reproductive uses of CRISPR, and germline engineering more generally, do not treat or save lives that would otherwise have a genetic disease. Reproductive uses of CRISPR create healthy people whose existence is not inevitable in the first place. Creating healthy lives has distinct and lesser moral value from saving or curing lives that would otherwise have genetic disease. The real value in reproductive uses of CRISPR is in helping a very limited population of people have healthy, genetically related children. This diminished value cannot compete with the concerns in opposition to germline engineering, nor is it worth the investment of research money.     

Identity and the ethics of gene therapy

Some conditions detrimental to human well-being, such as sickle-cell anaemia, cystic fibrosis, muscular dystrophy, Lesch-Nyhan disease and various immunodeficiencies, are genetically determined. One potential means of preventing the development of such conditions is the manipulation of genetic material in the conceptus of an organism which would otherwise develop such conditions. Genetic manipulations could take the form either of excising and substituting genetic material, excising but not substituting genetic material, adding but not excising genetic material or reorganizing existing genetic material. To succeed, manipulation would have to change genetic structure so as to change its informational content. It might be thought, however, that all or some such manipulations would involve causing particular individuals to cease to exist and involve bringing into existence new, distinct individuals. Gene therapy could not, therefore, be a procedure which improved the circumstances of the particular individual to whom it is applied. It might be suggested that once the metaphysics of identity and the facts of gene therapy are understood, certain interesting conclusions concerning the ethics of gene therapy emerge. Some such conclusions have been discussed in this journal by Noam J. Zohar and Jeffrey P. Kahn. More, however, needs to be said about them since neither Zohar nor Kahn draws the correct conclusions. While both have pertinent things to say, neither has given a completely clear account of the metaphysics of gene therapy and so neither has completely traced out the implication of the metaphysics for the ethics of gene therapy. This paper attempts to remedy these defects.     

Institutional refusal to offer assisted dying: A response to Shadd and Shadd

Ever since medical assistance in dying (MAID) became legal in Canada in 2016, controversy has enveloped the refusal by many faith‐based institutions to allow this service on their premises. In a recent article in this journal, Philip and Joshua Shadd have proposed ‘changing the conversation’ on this issue, reframing it as an exercise not of conscience but of an institutional right of self‐governance. This reframing, they claim, will serve to show how health‐care institutions may be justified in refusing to provide MAID on moral or religious grounds. I argue that it will not make it easier to justify institutional refusal, and is likely to make it harder.     

THE CLAIM FROM ADOPTION REVISITED

In a recent paper published in this journal, Thomas S. Petersen makes a qualified defense of what he calls ‘the Claim from Adoption’, according to which, ‘instead of expending resources on bringing new children [in developed countries] into the world using reproductive technology and caring for these children, we ought to devote these resources to the adoption and care of existing destitute children’. My purpose in this paper is not to discuss Petersen’s argument in favor of that claim. Rather, I want to show that, even if the Claim from Adoption might be, other things being equal, true, it is not true all things considered. What is, all things considered, true is a much more complex set of statements, including a general prima facie obligation to adopt, as well as an obligation by the state of developed countries to discourage procreation and promote adoption of destitute children.     

Can conscientious objection lead to eugenic practices against LGBT individuals?

In a recent article in this journal, Abram Brummett argues that new and future assisted reproductive technologies will provide challenging ethical questions relating to lesbian, gay, bisexual and transgender (LGBT) persons. Brummett notes that it is likely that some clinicians may wish to conscientiously object to offering assisted reproductive technologies to LGBT couples on moral or religious grounds, and argues that such appeals to conscience should be constrained. We argue that Brummett's case is unsuccessful because he: does not adequately interact with his opponents’ views; equivocates on the meaning of ‘natural’; fails to show that the practice he opposes is eugenic in any non‐trivial sense; and fails to justify and explicate the relevance of the naturalism he proposes. We do not argue that conscience protections should exist for those objecting to providing LGBT people with artificial reproductive technologies, but only show that Brummett's arguments are insufficient to prove that they should not.     

Developing Autonomy and Transitional Paternalism

Adolescents, in many jurisdictions, have the power to consent to life saving treatment but not necessarily the power to refuse it. A recent defence of this asymmetry is Neil Manson's theory of ‘transitional paternalism’. Transitional paternalism holds that such asymmetries are by‐products of sharing normative powers. However, sharing normative powers by itself does not entail an asymmetry because transitional paternalism can be implemented in two ways. Manson defends the asymmetry‐generating version of transitional paternalism in the clinical context, arguing that it maximizes respect for adolescent autonomy. This article offers an alternative argument in favour of the asymmetry‐generating form of transitional paternalism, one that makes appeal to obligations that individuals have to develop self‐governance in others. We should share normative powers asymmetrically in the clinical context for three reasons. First, the asymmetric version of transitional paternalism takes seriously duties to support adolescents’ developing autonomy, alongside other duties that adults have to young people. It does so by enabling young people to be involved in important decisions that they would otherwise be excluded from. This is of value because participation of this sort is central to the cultivation of their self‐governance. Second, only the asymmetric version gives young people a voice in respect of all clinical actions, and only the asymmetric version leaves open the possibility that the coarse lines of legislation might be ‘fine‐tuned’ in individual cases. Third, the asymmetric sharing of normative powers is consistent with the kind of social arrangements that best support autonomy.