REVIEWED BY WILLIAM J. BUCKLEY, PhD
Life Choices: A Hastings Center Introduction to Bioethics
Edited by Joseph H. Howell and William F. Sale
Georgetown University Press, Washington, DC
1995, 560 pp., $28.95
This aptly titled anthology is a superb collection of 39 solid essays on a range of important bioethical issues by 36 prominent figures. Each of the succinct and readable essays appeared in various volumes of the Hastings Center Report (except for two essays from 1979 and 1980, most are from the late 1980s and early 1990s).
Grouped into seven categories, these essays provide a wealth of insights and documentation about a wide range of topics. The collection succeeds as a whole because of the high quality of its sectional introductions, case studies, and follow-up questions (for each article), all of which prevent historically located claims from appearing as disjointed artifacts of past arguments. A map is not a territory, and no review can capture the delicate intricacies of all the rich arguments in this book. Nonetheless, what follows will survey some of the main topics and contributions.
In part I, "Can Ethics Provide Answers?", James Rachels responds to the challenges of cultural relativism (moral values determined by custom) and emotivism (moral values based on expressions of strong feelings) by arguing for the value (and limits) of rational methods in moral inquiry. Sidney Callahan surveys "The Role of Emotion in Ethical Decisionmaking." As the editors make plain, each subsequent part focuses on challenges to both our reasoning and our caring.
"Biomedicine, Rights, and Responsibilities" (part II) examines patient autonomy in contrast to the interests of family members, healthcare providers, and society as a whole. Its three essays explore responsibility in decision making (who should make decisions rather than how). Alexander Morgan Capron warns against shifting the burden of medical decision making from physicians and patients to the courts. John Hardwig argues for the primacy of family interests in contrast to those of patient autonomy and public policy, whereas Jeffrey Blustein defends patient autonomy against family interests and other communitarian (social) visions of interests.
Although all predate the 1992 Planned Parenthood v. Casey abortion ruling, the four essays in "Reproductive Freedom and Responsibility" (part III) are still relevant to the current abortion debate. For example, Gilbert Meilaender examines the "personhood argument"--that only rational, conscious beings are human persons--and the "bodily support argument"--that a woman ought to have complete choice over what happens within her body; and Mary B. Mahowald tries to sort out the complexities in abortion decisions to arrive at possible areas of agreement. Recent news stories may revive interest in Lisa Sowle Cahill's 1987 essay on RU-486, which weighs the merits of early termination of pregnancy against moral problems consequent to privatizing abortion.
"Termination of Treatment" (part IV) analyzes the effects of biomedical technologies on distribution, limits, and termination of healthcare. Although all of its essays predate two federal circuit court cases and the U.S. Supreme Court decision of June 26, 1997, the articles remain very informative. Essays by noted authors explore many issues, including aggressive medical practices; age as a criterion for withholding treatment; triaging ICU patients with poor prognoses; consent; emotional and symbolic meanings for those involved in providing and withholding resuscitation; circumstances in which nutrition might be withheld; organ harvesting from anencephalic infants; and arguments for and against assisted suicide and euthanasia.
"Family, Parenthood, and New Reproductive Technologies" (part V) explores the moral conflicts that arise from new reproductive technologies. Ruth Macklin discusses how artificial means of reproduction affect our understanding of family, Janice G. Raymond addresses "altruistic" rather than commercial surrogacy, and Paul Lauritzen contrasts four feminist objections to new reproductive technologies with his own experiences. In a final subsection, "The Care and Handling of Human Embryos," four essays examine the benefits of embryo (versus prenatal) screening and the need for clinical policies and embryo therapy; the costs of embryo diagnosis; and the freezing of embryos.
In part VI, seven essays investigate issues surrounding the removal of human organs and tissue, including property rights, the role of consent, and the use of fetal tissue for transplantation. Traditional notions of "gifts" and "voluntary consent" are being challenged by the commercial possibilities of biotechnological research. Lori B. Andrews proposes guidelines for transplantation designed to protect donors and recipients. Other essayists recommend changes in the current system of voluntary organ donation; clarify the complex legal and ethical issues of organ procurement; and sort out the contending interests and obligations in fetal tissue transplants.
Because of the potential benefits and risks posed by the Human Genome Project, part VII focuses on the use of genetic information and the application of gene therapy, including problems that new diagnostic tests will bring to normal prenatal care and possible discrimination in the workplace. C. Keith Boone acknowledges the new moral challenges of genetic engineering but objects to reductionistic claims, termed "bad axioms" ("Playing God," "Interfering with Nature," etc.). W. French Anderson examines the potential for human genetic engineering and differentiates between somatic cell gene therapy for serious diseases and enhancement genetic engineering.
The merit of selecting articles from such a well-respected journal as the Hastings Center Report is the high quality of lively discussions about important topics. Indeed, some authors challenge the claims made by authors in other articles. Of course, republishing previously written essays involves liabilities: Subsequent events and some conversations have moved onward (e.g., more recent judicial decisions about abortion, euthanasia, and assisted suicide). Lest anyone naively assume that inclusion in the anthology indicates unqualified endorsement of positions argued, the editors' penetrating questions that conclude each essay sometimes challenge the assertions of an author.
A recurring communitarian motif among many authors is to "deprivatize" bioethical decisions about a range of topics (from abortion to organ transplantation and assisted suicide) in a political culture that exalts individual rights. With few exceptions, most essays appeal to canons of key texts, laws, and medical and ethical journals in the Anglo-American world; this is hardly surprising given the pioneering role that organizations like the Hastings Center have had in shaping what has come to be known as "bioethics." With one exception (Lisa Sowle Cahill, p. 132), rare appeals to distinctively religious sources are simple citations. Surprisingly, neither authors nor editors are explicit about how some essays might have originated from or contributed to specific debates (e.g., Capron's 1987 piece and AMA reports and opinions about anencephalic infants as organ donors in December 1988, March 1992, and June 1994). Because the arrangement and sequence of articles seem to be topical rather than chronological, some essays that were published earlier appear later in this text.
Aside from these limitations, and numerous typographical errors, this text is substantively invaluable, with clearly written, carefully edited, and well-chosen essays that are interesting because they examine controversial topics in a reader-friendly way. This book is an excellent resource for personal reading, professional teaching, and adult education in healthcare and educational settings.
William J. Buckley, PhD
Mount Saint Mary's College
Emmitsburg, MD