(Textbook is attached)C. In chapter eleven, Veatch describes virtue ethics. Use FIVE of the following concepts from biomedical virtue
ethics to reach an ethical conclusion about the case of Dr. Cline: (i) virtues, (ii) character, (iii) benevolence, (iv)
virtue lists, (v) professional virtues, (vi) care.”Dr. Cline, the Fertility Doctor (from Mihir Zaveri, The New York Times, Aug. 30, 2018)
To couples at the end of their ropes who wanted children but could not conceive them for medical reasons, Dr. Donald
Cline was a savior of sorts, offering to match the women with sperm from anonymous men resembling their partners.
Many couples sought Dr. Cline out at his Indianapolis-area fertility clinic during the 1970s and ’80s. They had
children, who grew up and had children of their own.
What the couples did not know was that on an untold number of occasions, Dr. Cline was not using the sperm of
anonymous donors. He was using his own.
Now, Dr. Cline’s former patients and their children are asking enormously consequential questions: How many
women did he deceive? How many children did he father? Most perplexingly, why did he do it?
The authorities who are investigating Dr. Cline have confirmed through DNA testing that two women were
biological children of his. Through 23andMe and other similar genetic testing websites, three dozen half siblings of those
women have been found, said Jacoba Ballard, 38, one of the biological daughters. She expects the number to grow.
In some instances, state prosecutors said, Dr. Cline even told women that he was using their husbands’ sperm but
provided his own.”
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2
Third Edition
3
THE BASICS OF BIOETHICS
Robert M. Veatch
Kennedy Institute of Ethics
Georgetown University
4
First published 2012, 2003, 2000 by Pearson Education, Inc.
Published 2016 by Routledge
2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
711 Third Avenue, New York, NY, 10017, USA Routledge is an imprint of the
Taylor & Francis Group, an informa business
Copyright © 2012, 2003, 2000 Taylor & Francis. All rights reserved.
All rights reserved. No part of this book may be reprinted or reproduced or utilised
in any form or by any electronic, mechanical, or other means, now known or
hereafter invented, including photocopying and recording, or in any information
storage or retrieval system, without permission in writing from the publishers.
Notice:
Product or corporate names may be trademarks or registered trademarks, and are
used only for identification and explanation without intent to infringe.
ISBN-13: 978-0-205-76562-1 (pbk)
Cover Designer: Bruce Kenselaar Library of Congress Cataloging-inPublication Data Veatch, Robert M.
The basics of bioethics / Robert M.Veatch. – 3rd ed.
p. cm.
Includes bibliographical references.
ISBN-13: 978-0-205-76562-1 (alk. paper) 1. Medical ethics. 2. Bioethics. I.
Title.
5
R724.V39 2012
174.2–dc23
2011030636
6
BRIEF CONTENTS
Contents
List of Figures
List of Cases
Preface
Chapter 1
A Map of the Terrain of Ethics
Chapter 2
The Hippocratic Oath and Its Challengers: A Brief
History
Chapter 3
Defining Death, Abortion, Stem Cells, and Animal
Welfare: The Basis of Moral Standing
Chapter 4
Problems in Benefiting and Avoiding Harm to the
Patient
Chapter 5
The Ethics of Respect for Persons: Lying, Cheating,
and Breaking Promises and Why Physicians Have
Considered Them Ethical
Chapter 6
The Principle of Avoiding Killing
Chapter 7
Death and Dying: The Incompetent Patient
Chapter 8
Social Ethics of Medicine: Allocating Resources,
Health Insurance, Transplantation, and Human
Subjects Research
Chapter 9
Human Control of Life: Genetics, Birth Technologies
and Modifying Human Nature
Chapter 10
Resolving Conflicts Among Principles
Chapter 11
The Virtues in Bioethics
Appendix
Index
7
8
CONTENTS
List of Figures
List of Cases
Preface
Chapter 1
A MAP OF THE TERRAIN OF ETHICS
The Levels of Moral Discourse
The Level of the Case
Rules and Rights (Codes of Ethics)
Normative Ethics
Metaethics
A Full Theory of Bioethics
Key Concepts
Bibliography
Works on Basic Ethics
Works on Biomedical Ethics
Chapter 2
THE HIPPOCRATIC OATH AND ITS CHALLENGERS:
A BRIEF HISTORY
The Hippocratic Tradition
The Hippocratic Oath
Modern Codes in the Hippocratic Tradition
The Collapse of the Hippocratic Tradition
Codes and Oaths Breaking with the Hippocratic Tradition
Sources from Outside Professional Medicine
Key Concepts
Bibliography
Notes
Chapter 3
DEFINING DEATH, ABORTION, STEM CELLS, AND
ANIMAL WELFARE: THE BASIS OF MORAL
9
STANDING
Persons, Humans, and Individuals: The Language of Moral
Standing
The Concept of Moral Standing
Moral and Descriptive Uses of the Term Person
Moral and Nonmoral Uses of the Word Human
Defining Death
A Somatic Definition of Death
A Whole-Brain-Oriented Definition of Death
The Higher-Brain Definition of Death
Definitions and Moral Standing
Abortion
Symmetry between Definition of Death and Abortion
Possible Basis for a Breakdown in the Symmetry
Human Stem Cells
Stem Cells and Moral Standing
Stem Cells and Cooperation with Evil
The Moral Status of Non-Human Animals
Key Concepts
Bibliography
The Definition of Death
Abortion
Stem Cells
Moral Standing of Non-human Animals
Notes
Chapter 4
PROBLEMS IN BENEFITING AND AVOIDING HARM
TO THE PATIENT
Complications in Determining What Benefits Patients
Subjective Versus Objective Estimates of Benefit and Harm
Medical Versus Other Personal Benefits
Conflicting Goals Within the Medical Sphere
10
Ways to Balance Benefits and Harms
The Problem of Medical Paternalism
Key Concepts
Bibliography
Notes
Chapter 5
THE ETHICS OF RESPECT FOR PERSONS: LYING,
CHEATING, AND BREAKING PROMISES AND WHY
PHYSICIANS HAVE CONSIDERED THEM ETHICAL
The Principle of Fidelity
Fidelity and the Notion of Loyalty
The Ethics of Confidentiality
The Principle of Autonomy and the Doctrine of Informed
Consent
The Concept of Autonomy
Positive and Negative Rights
Informed Consent, Autonomy, and Therapeutic Privilege
Standards of Disclosure for Consent to Be Adequately
Informed
The Principle of Veracity: Lying and the Duty to Tell the
Truth
The Change in Physician Attitudes
Accounting for the Change in Attitudes
The UNESCO Universal Declaration on Bioethics and
Human Rights
Key Concepts
Bibliography
Notes
Chapter 6
THE PRINCIPLE OF AVOIDING KILLING
Active Killing Versus Allowing to Die
Distinguishing Active Killing from Allowing to Die
New Legal Initiatives for Physician-Assisted Suicide
Stopping Versus Not Starting
The Distinction Between Direct and Indirect Killing
11
The Distinction Between Ordinary and Extraordinary
Means
The Meaning of the Terms
The Criteria for Classifying Treatments Morally Expendable
The Subjectivity of All Benefit and Harm Assessments
Withholding Food, Fluids, CPR, and Medications
Key Concepts
Bibliography
Notes
Chapter 7
DEATH AND DYING: THE INCOMPETENT PATIENT
Formerly Competent Patients
The Principle of Autonomy Extended
Substituted Judgment
Going Beyond Advance Directives
Mechanisms for Expressing Wishes
Issues to Be Addressed in an Advance Directive
Never-Competent Patients Without Family or Other PreExisting Surrogates
The Principles
The Legal Standard
Who Should Be the Surrogate?
Never-Competent Patients with Family Surrogates
What Is the Standard Underlying This Family Discretion?
Key Concepts
Bibliography
Notes
Chapter 8
SOCIAL ETHICS OF MEDICINE: ALLOCATING
RESOURCES,
HEALTH
INSURANCE,
TRANSPLANTATION,
AND
HUMAN
SUBJECTS
RESEARCH
The Need for a Social Ethic for Medicine
The Limits of the Ethics of Individual Relations
12
The Social Ethical Principles for Medical Ethics
Allocation of Health Care Resources
The Demand for Health Care Services
The Inevitability of Rationing
Ethical Responses to the Pressures for Cost Containment
The Role of the Clinician in Allocation Decisions
Health Insurance
The Affordable Care Act of 2010
Ethical Issues
Organ Transplantation
Is Performing Transplants “Playing God”?
Procurement of Organs
Organ Allocation
Research Involving Human Subjects
Distinguishing Research and Innovative Therapy
Social Ethics for Research Involving Human Subjects
Key Concepts
Bibliography
Social Ethical Theory
Allocation of Scarce Medical Resources
Health Insurance
Organ Transplantation
Research Involving Human Subjects
Notes
Chapter 9
HUMAN CONTROL OF LIFE: GENETICS, BIRTH
TECHNOLOGIES, AND MODIFYING HUMAN NATURE
The Human as Created and as Creator
Medical Manipulation as Playing God
Having Dominion over the Earth
Genetics and the Control of Human Reproduction
Genetics
13
New Reproductive Technologies
Key Concepts
Bibliography
Notes
Chapter 10
RESOLVING CONFLICTS AMONG PRINCIPLES
Different Concepts of Duty
Absolute, Exceptionless Duties
Prima Facie Duties
Duty Proper
Theories of Conflict Resolution
Single-Principle Theories
Ranking (Lexically Ordering) Principles
Balancing
Combining Ranking and Balancing
Ways of Reconciling Social Utility and Justice
Translating Principles to Rules
Conclusion
Key Concepts
Bibliography
Notes
Chapter 11
THE VIRTUES IN BIOETHICS
Virtue Lists
Problems with the Virtues
The Wrong Virtue Problem
The Naked Virtue Problem
Conclusion
Key Concepts
Bibliography
Appendix
Hippocratic Oath
Principles of Medical Ethics (2001) of the American Medical Association
14
Universal Declaration on Bioethics and Human Rights (2005)
Index
15
LIST OF FIGURES
FIGURE 1
The Four Levels of Moral Discourse
FIGURE 2
Rules and Rights
FIGURE 3
Three Questions of Normative Ethics
FIGURE 4
Metaethics: The Meaning and Justification of Ethical Judgments
FIGURE 5
Types of Codifications of Medical Ethics
FIGURE 6
Two Definitions of Person
FIGURE 7
Three Definitions of Death
FIGURE 8
Where Hippocratic Utility Fits in a Grid of Types of Ethical
Principles
FIGURE 9
Spheres of Well-being
FIGURE 10
Elements of Medical Well-being
FIGURE 11
High-Risk/High-Gain vs. Low-Risk/Low-Gain Therapy Choices
FIGURE 12
Types of Ethical Principles
FIGURE 13
Four Basic Distinctions in Death and Dying
FIGURE 14
FIGURE 15
FIGURE 16
Active Killing Versus Forgoing Life Support (Actions vs.
Omissions)
Invalid Arguments for the Omission/Commission Distinction
Types of Incompetent Patients and the Standards Used in
Surrogate Decisions
FIGURE 17
Ethical Principles—Final Form Including Social Principles
FIGURE 18
Schematic Representation of Aggregate Benefit Per Day of Stay
in the Hospital
FIGURE 19
Lists of Virtues
16
LIST OF CASES
CASE 1
The Boy Who Ate the Pickle
CASE 2
Physician Assistance in a Merciful Homicide
CASE 3
The Man Living Without a Heart
CASE 4
Infant Heart Transplant
CASE 5
The Physician Who Favors Hysterectomies
CASE 6
Risks and Benefits in a Randomized Clinical Trial
CASE 7
Is Birth Control Bad for One’s Health?
CASE 8
The Promised Internship
CASE 9
The Case of the Homosexual Husband
CASE 10
Natanson v. Kline: When May Information Be Withheld?
CASE 11
Canterbury v. Spence
CASE 12
Limits on the Physician’s Duty to Promote Health
CASE 13
Terri Schiavo: The Role of Relatives in Refusing a Feeding Tube
CASE 14
Chad Green: The Case of Limited Familial Discretion about
Chemotherapy
CASE 15
DRG Limits and Myocardial Infarction 120
CASE 16
Allocating Livers: Local vs. Regional Priority
CASE 17
Justice in Design of Research
CASE 18
Using Stem Cells to Re-Grow Spinal Cord Nerve Cells
CASE 19
Experimenting with Gene Therapy: The Case of Jesse Gelsinger
CASE 20
The Mary Beth Whitehead Case
CASE 21
Conflicting Promises: A Physician in a Bind
17
PREFACE
A great deal has happened in the fast-moving world of bioethics since the previous
edition of this book appeared in 2003. The U.S. government has passed a health
care bill designed to provide basic health insurance to many more Americans. Stem
cell research has progressed to the point that the first experiments using stem cells
in humans have been launched renewing the moral controversy over procurement
of these cells from human embryos. Human hearts have been procured and
transplanted from critically ill newborns who were allowed to die by their parents
and physicians stimulating major controversy over whether the infants were
actually dead when their hearts were removed. The tragic case of a permanently
unconscious woman named Terri Schiavo created a public furor when state and
federal politicians intervened to attempt to stop the removal of her feeding tube.
UNESCO has adopted the Universal Declaration on Bioethics and Human Rights,
the first global code of ethics adopted not by a professional physician organization
but by a public international agency representing virtually all the citizens of the
world. It is becoming increasingly commonplace for kidneys obtained from living
donors to be exchanged among pairs and even large groups of recipients creating
new possibilities for safer and more efficient transplant, but leaving certain needy
people essentially at the end of the line for organs.
At the same time, the world of the academic and professional study of
bioethics has become increasingly complex and sophisticated. New general
theories of the ethics of health care have emerged; new scholarship makes clearer
the disputes that lead to major options for public policy and clinical decisions. New
bold claims have been made about a “common morality” that can be the source of
national and international ethical stances in bioethics.
All of these developments are addressed in the third edition of The Basics
of Bioethics. This volume had its origins in the courses I have taught over the
years, first at Columbia University’s College of Physicians and Surgeons, Vassar
College, and Brown University, but for the past decades at Georgetown University
as well as regular visiting professorships at the St. George’s University School of
Medicine in Grenada and Union University in New York. These chapters started
out as the lectures I have given to upwards of 12,000 medical school and
philosophy students throughout my career. The analysis and the cases have been
tried on countless students and colleagues for whom I am forever grateful.
When the first edition of The Basics of Bioethics appeared in the final
18
weeks of the twentieth century, no current, brief survey existed that was a suitable
introduction to the field. Textbooks, anthologies, casebooks, and single-authored
perspectives were available to provide perspective on the issues of bioethics, but
no introduction to the field of bioethics under several hundred pages in length. The
first edition served that purpose. It was intended for health professionals and lay
people who wanted an introduction to the issues in a relatively small edition
suitable for use in short courses in schools of medicine, nursing, and the other
health professions; continuing professional education; undergraduate courses in
philosophy, religion, and the social sciences; and in adult education.
This new edition continues to be committed to that purpose. It provides a
relatively brief introduction to bioethics intended for those who are not specialists
in the field. My goal is to present an understandable, fair, and balanced survey of
the major issues embedded in a systematic framework based on the ethical
principles and other theoretical tools increasingly available to bioethics.
Major changes in Basics of Bioethics, third edition:

In Chapter 2, a discussion of the moral status of embryonic stem cells
and a new case study of infant heart transplant and whether an infant
whose heart survives transplant can be considered dead by cardiac
criteria are added.

Chapter 5 now includes a discussion of the new UNESCO Universal
Declaration of Bioethics and Human Rights.

Coverage of the case of withdrawing nutrition from Terri Schiavo is
added to Chapter 7.

Chapter 8 is updated with a discussion of Obama’s “Affordable Health
Care Plan” as well as a discussion of living donor organ procurement. A
discussion of the new liver transplant policy and the controversy over
whether livers should be allocated locally or over a broader area is also
included.

A new case of the first attempt in humans to use stem cells to regenerate
spinal cord nerve cells to try to treat a paralyzed spinal cord injury
patient can be found in Chapter 9.

Updated references and examples appear throughout the entire third
edition.
This edition retains the chapter structure of the second edition including
new chapters added at that time. It adds to each chapter new material on
developments since the appearance of the second edition. The approach is
systematic. Rather than discussing issue by issue every topic in the current
bioethics literature, we begin with an introduction to ethical theory and a brief
history of biomedical ethics. The first chapter is designed for the reader who has
not been exposed to formal ethical theory. It provides a “map” of the ethical
19
terrain, a schema outlining four levels of moral discourse or ethical analysis. This
scheme is summarized in the diagram that appears at the front and back of this
volume. On this diagram virtually every dispute in bioethics can be mapped.
Some disagreements exist at one of the levels. For example, much of
bioethics in the late decades of the twentieth century involved controversies over
which ethical principles prevailed. This can be seen in the central shaded boxes at
the level of “Normative Ethics” in the figure. Other disputes involve questions of
whether to resolve moral controversies by working at this normative level or at
some other level (by applying a code of ethics or by focusing on an individual case,
for instance). Portions of this central diagram of the “Four Levels of Moral
Discourse” are reproduced in various chapters when the ethical controversies of
bioethics are presented in greater detail. I hope this diagram will make more clear,
especially to the reader not trained in ethical analysis, exactly what the basis is for
moral disagreements in the field of biomedical ethics.
Law has in a sense taken over the practice of medicine. In a way that is too
bad. Law is obviously important, but it’s not all there is to medicine. Medicine is a
profession, and, traditionally, one of the chief characteristics of a profession is that
it has its own ethic. At least until recently selfregulation was the definitive sign that
medicine was a profession; it didn’t engender much controversy. In this volume,
we look at the controversies over selfregulation in medicine and some of the
ethical problems that emerge. This edition is able to incorporate a major
development in this movement to a more public bioethics—the adopting by
UNESCO of its Universal Declaration on Bioethics and Human Rights which
places bioethics norms for the first time in the hands of the global public—patients
and the public as well as health professionals.
We ask in the first two chapters why the old Hippocratic Oath is in trouble,
and what the alternatives are. In Chapter 3 we discuss what may first seem like a
disparate collection of topics: abortion, stem cells, the definition of death, and the
welfare of non-human animals. We shall see that they all raise the question of who
has moral standing and why. Next, in Chapter 4, we discuss the ethics of benefiting
patients. That may sound like a platitude. It seems like it is obvious that the health
professional’s goal must be to benefit his or her patient. However, we shall see that
benefiting patients is increasingly controversial morally. There are in fact many
situations in which physicians decide not to provide benefit, at least if they follow
more contemporary ethical thinking, rather than the traditional Hippocratic Oath.
Next, in Chapter 5, we deal with the major challenge to the Hippocratic
perspective, what is often referred to as the ethics of respect for persons or the
ethics of liberal political philosophy. This includes an alternative set of ethical
principles that is now being used in place of the Hippocratic Oath. We will be
talking about rights of patients and rights of physicians, particularly in terms of
fidelity, autonomy, and veracity, and why these principles are causing big
problems for health professionals.
20
Chapters 6 and 7 deal with one of the hottest issues in medical ethics, the
care of the terminally ill. Traditional medical ethics of the past hundred years was
committed to preserving life, sometimes preserving it at all costs. Life, at least
human life, was deemed sacred or ultimately valuable. We shall see that this notion
is enormously complex. Euthanasia has variously been taken as referring to active
killing for mercy, the forgoing of medical treatment even though the result is likely
to be death, and sometimes simply any good death. In Chapter 6 we will begin to
examine these issues by dealing with competent patients. Then in Chapter 7 we
will grapple with what the real complications are today—dealing with incompetent
patients who are terminally ill and consider if these patients would be better off if
they were not treated so aggressively. It is here that this edition incorporates the
now-infamous case of Terri Schiavo.
We then turn, in Chapter 8, to the issue of medical ethics for the twentyfirst century, the social ethics of health care including the morality of allocating
scarce medical resources as well as other conflicts such as medical research pitting
the individual against the interests of society. In this edition we include a
discussion of the major ethical issues raised by the Affordable Health C …
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