Religion, Morality, and Public Policy

This chapter explores how religious convictions have functioned in the debate about whether human reproductive cloning should be banned, regulated, or permitted—a debate that erupted in 1997 following the belated announcement of “Dolly’s” birth. This historical case study examines and assesses the arguments that arose at the time, particularly in the context of the National Bioethics Advisory Commission (NBAC) report Cloning Human Beings. The NBAC hearings included testimony on religious views on human reproductive cloning, and its report examined and assessed those views. The chapter also considers NBAC’s deliberations about federal funding of human embryonic stem cell research that further illuminates the place of religious convictions in public bioethics. It concludes that in public bioethics the process of reaching a decision—or, in NBAC’s case, a recommendation—should attend to the widest possible range of positions and rationales, but that the outcome in substance and in public justification needs to involve, as Robert Audi argues, a sufficient or adequate secular reason.

Triage in a Public Health Crisis

This chapter examines triage in a public health crisis resulting from a bioterrorist attack. Systems of triage, whether informal or formal, generally have an implicit or explicit utilitarian rationale—they are usually designed to produce the greatest good for the greatest number under conditions of scarcity. It is important to distinguish medical utility from social utility and, within the latter, between broad and narrow social utilitarian judgments. Judgments of broad social utility recognize the differential social value of people’s lives, whereas judgments of narrow social utility recognize the differential value of specific social functions and roles and assign priority to the individuals discharging certain functions and performing certain roles. Judgments of broad social utility infringe the egalitarian principle of equal regard in a way that judgments of medical utility do not. It is not justifiable to use broad social utility as a basis for rationing in general or in an emergency, but it is possible to justify triage based on medical utility and also on narrow social utility. Public trust will be essential in any public health crisis—hence, the public needs to have confidence that the procedures and standards of triage are fair and are fairly implemented.

The Failure to Give

After considering the huge and persistent gap between the supply of deceased donor organs for transplantation and the number of patients on the waiting list for a transplant, this chapter considers different ethical frameworks for evaluating first-person failures to donate organs after death and then assesses selected public policies designed to overcome these failures. Policies to facilitate first-person deceased organ donation often seek to alter the individual’s risk/cost-benefit calculations in deciding whether to register as a donor (for instance, by providing financial incentives); financial incentives can be ethically justifiable under some circumstances if they encourage and facilitate donation but do not implicate the sale of organs. Other proposed policies seek to nudge the individual’s declaration of organ donation through mandated choice or required response or through opt-out policies, often called “presumed consent,” under which not opting out counts as a donative decision. Available evidence suggests that mandated choice, required response, and presumed consent would probably be ineffective and perhaps even counterproductive in the United States at this time, but that some carefully designed combination could possibly be both ethically acceptable and effective.

Conscientious Refusals in Healthcare

This chapter focuses not on the ethics of individual conscientious refusals but rather on ethically justified responses of institutions, organizations, and governments to such refusals. It asks under what conditions, if any, the state, society, institutions, and professions should exempt conscientiously objecting healthcare professionals from performing procedures or providing services or products that they find objectionable but that are legal and patient-sought. Using several cases and drawing several distinctions (e.g., religious and/or moral objections, and universal and selective objections), this chapter employs the metaphor of constrained balancing to develop a framework for accommodating many conscientious refusals, as distinguished from conscientious obstructions. At a minimum, this balance requires disclosure of information about options in all cases and referral/transfer of patients in certain cases. This chapter also identifies ways to resolve ongoing debates about expansive claims of complicity or unacceptable participation in wrongdoing sometimes invoked by conscientious objectors.

Public Health Ethics

This chapter, which grew out of a Greenwall Foundation–funded working group of a dozen or so ethicists, lawyers, and public health practitioners, provides a rough conceptual map of the terrain of public health ethics. It examines the nature of public health and public health interventions, and it identifies a number of general moral considerations (principles) relevant to public health policy and practice and often, especially as articulated in basic human rights, promotive of public health. Because these moral considerations are general and broad, they require specification and weighting. In cases of conflict, five “justificatory conditions” need to be met: effectiveness, proportionality, necessity, least infringement, and public justification. These conditions help to determine whether protecting or promoting public health warrants overriding individual liberty in particular situations.

Public Health and Civil Liberties

This chapter focuses on public health ethics in a particular context—a liberal, pluralistic, democratic society that embodies explicit commitments to several basic civil liberties: bodily integrity, privacy, freedom of movement, freedom of association, and freedom of religion and conscience. When civil liberties set limits on public health interventions, a presumptivist framework is more defensible and helpful than either an absolutist or a contextualist one for determining appropriate interventions. This framework recognizes several conditions for rebutting the presumption, in certain circumstances, against interventions that infringe civil liberties. Through an exploration of the metaphor of the Intervention Ladder, proposed by the Nuffield Council on Bioethics, this chapter examines several possible ways to secure individuals’ cooperation with public health measures, such as vaccinations, directly observed therapy, and quarantine, without infringing their civil liberties. It is often possible to achieve compliance through expressing rather than imposing community.

Putting Patients First in Organ Allocation

This chapter originated in the author’s testimony before a congressional hearing on organ allocation policy. The ethical issues it addresses remain in play, as evidenced in the 2018–2019 debates about liver allocation policy. This chapter defends the fundamental conviction of the report of the Task Force on Organ Transplantation: Donated organs should be viewed as scarce public resources to be used for the welfare of the community. Organ procurement and transplant teams receive donated organs as “trustees” and “stewards” on behalf of the whole community, that is, the national community (with qualifications). Donated organs should be allocated to patients anywhere in the country according to ethically acceptable standards and logistical constraints, thus reducing the relevance of “accidents of geography” except where these are clearly important for transplantation outcomes. In short, patients, not transplant programs, should be put first. In accord with principles of justice and fairness, it is important to specify and balance, through a public process with public input, several criteria in policies of organ allocation: patient need and probability of successful outcome, along with time on the waiting list. Unless the criteria for patient selection are fair and are perceived to be fair, public distrust may hamper organ donation and perpetuate the scarcity of organs for transplantation.

Paternalism in Healthcare and Health Policy

This chapter provides conceptual clarity about paternalism along with a framework for ethically assessing paternalistic actions in both clinical practice and health policy. Not only does paternalism remain common and formidable in both contexts but also it has gained new momentum over the last two decades, for instance, as “neopaternalists” have offered arguments for governmental policies that, at a minimum, seek to protect or benefit individuals through shaping or steering their choices without actually limiting or coercing those choices. This chapter examines the nature of paternalism, particularly by probing its moral foundations and limits and drawing several distinctions that bear on its justification (weak and strong, pure and mixed, hard and soft). It also considers circumstances in which different types of paternalistic interventions may be justified, and, finally, assesses the “new paternalism,” based on behavioral economics and psychology, that now figures in many proposals for health-related public policies.

Introduction

The introduction characterizes “doing public bioethics” as analyzing and assessing actual and proposed public policies regarding biomedicine, healthcare, and public health. It may include attention to public discourse and public culture, and to professional discourse and practice, as ways to influence public policy or as an end in and of itself. “Public bioethics” also refers to commissions, councils, task forces, and the like, that are governmentally established, sponsored, or funded for the purpose of deliberating collectively about bioethical issues, again with a primary goal of recommending public policies. In addition to examining different types of public bioethics bodies, the introduction provides an overview of the volume and its chapters along with an indication of their context and origins, including the author’s experiences on public bioethics bodies.

John Stuart Mill’s Legacy for Public Health Ethics

This chapter shows that the legacy of John Stuart Mill’s ethical framework for public health is far more complex and interesting than his On Liberty suggests, even when that classic work is properly understood. A largely neglected resource in Mill’s thought for public health is the ethical framework he actually used, in public testimony and correspondence, to address a heated controversy about the British government’s efforts in the Contagious Diseases Acts to reduce the transmission of sexually transmitted diseases. This displays his fuller range of ethical principles for public health, the way he resolved conflicts among those principles, and his somewhat surprising reluctance to endorse what we now call “harm-reduction measures,” which utilitarians, though not Mill, generally find justifiable in public health policy and practice.