Introduction

Abstract

In the first article of this issue of The Journal of Medicine and Philosophy, Jonathan Hughes continues an important debate surrounding the precautionary principle, responding to John Harris and S⊘ren Holm's, “Extending Human Lifespan and the Precautionary Paradox,” which appeared in an earlier volume of this journal (2002). Hughes develops a cogent and persuasive critique of Harris and Holm's argument that the precautionary principle is incoherent and is not a valid principle for rational choice or moral decision making. In order for their argument to have any force, Hughes argues, it must be based upon an interpretation of the precautionary principle that is actually used by advocates of that principle and, if the argument is intended to draw the more general conclusion that no form of the precautionary principle should be used, that the range of reasonable interpretations of the principle must be considered.

Hughes claims that Harris and Holm fail to meet these criteria because they combine the strongest or most conservative elements of existing formulations of the precautionary principle in constructing the principle they use in their analysis. As a result, the thresholds for the seriousness of the consequences and the amount of evidence required to engage the precautionary principle are both very low, meaning that, on Harris and Holm's account, the principle will be called on in a wider variety of situations than it would be on a weaker account. In addition, Hughes argues, their version of the principle is further strengthened by the response they interpret the principle as requiring — that the technology raising these concerns be prohibited — as opposed to requiring that risk-management or other less drastic measures be implemented. The arguments put forward by Harris and Holm are, therefore, only effective against the most conservative versions of the principle, and are not informative about the possible validity of its weaker interpretations. Hughes states that Harris and Holm's arguments do show that very strong forms of the precautionary principle should be rejected, but suggests that weaker versions of the principle could be valuable to ethical analysis. Hughes could have advanced the discussion of this issue even further had he proposed a more plausible version of the principle.

For additional perspectives on the precautionary principle, readers are referred to the 2004 special issue of the Journal of Medicine and Philosophy (Volume 29, Issue 3) on this topic.

In her thought-provoking article, Pepe Lee Chang takes on the common intuition that pharmaceutical companies have a special obligation to provide life-saving drugs to impoverished people in third world countries. Chang cites several authors (Resnik, 2001; Daniels, 2001; Brock, 2001) who support this view, arguing from several different angles that because pharmaceutical companies have the ability to save the lives of many people with minimal effort, they have a moral obligation to do so. In particular, because these companies are related to health care and profit from “health-related activities,” this is a special obligation of pharmaceutical companies (De George, 2005). It is on this claim that Chang focuses her objections.

Chang argues that none of the existing theories of corporate obligation support a special obligation for pharmaceutical companies to save lives. Stockholder and Stakeholder theories of corporate obligation do not create such duties for companies because impoverished people in third world countries are (generally) neither stockholders nor stakeholders in those companies. Social Responsibility theories of corporate obligation may provide a foundation for the existence of an obligation for companies to save lives. (Chang generalizes that they do, but this may depend upon the version of the social responsibility theory used.) Chang argues that social responsibility theories, like other moral theories, have a “symmetry property,” that is, their obligations must be obligations of all kinds of companies equally. She claims that, “The symmetry property is necessary for a coherent moral theory,” (p. 471) and that this property means that any obligation to save the lives of people in the third world would be similar for all kinds of companies. This is a foundational premise of Chang's argument, and one worthy of consideration.

If the symmetry property is, indeed, true, the original intuition that pharmaceutical companies have some special obligation would only be defensible if some morally relevant difference could be found between pharmaceutical companies and other types of companies. Chang identifies several candidate differences and convincingly argues that they do not provide grounds for the differentiation of pharmaceutical companies. One possible candidate not considered is that, in many cases, it is only that specific company (because of intellectual property restrictions) that can save lives of people with a particular condition at such limited cost, unlike most of the other types of companies identified (i.e. companies that could save lives by donating money or even food, water, or shelter).

Finding no morally relevant difference between pharmaceutical companies and other types of companies, Chang concludes that we must therefore, extend the obligation to save lives to other types of companies, recast this special obligation as a non-moral duty that might not be subject to the symmetry property, or find a new theory of corporate moral obligation that can account for the intuition that pharmaceutical companies have a special obligation to save lives.

In their article, Joseph DeMarco and Paul Ford compare three methods of managing competing moral norms in pluralistic moral theories: specification, casuistry, and balancing. The paper provides a nice overview of these three approaches and offers an analysis of which of these approaches is most appropriate for resolving difficult cases and for teaching in bioethics. Specification is rejected by the authors as an adequate approach to managing competing moral claims. The process of specifying moral claims, it is argued, relies upon other methods of moral reasoning that are not transparent in the final specified moral claims. As a result, DeMarco and Ford accurately observe, this approach obscures the true substance of moral deliberation. The authors suggest that it is, in fact, balancing that underlies the development of specificatory premises. (While this could be the case, there are other possible methods for this specificatory process. For one example, see Alan Donagan, The Theory of Morality, who suggests specifying principles through “unformalized analytical reasoning in which some concept either in the fundamental principle or in a derived precept is applied to some new species of case” [1977, p. 72]). Two other well-known objections to specification are also noted: the idea that it would be burdensome and perhaps impossible to develop a complete set of specified moral claims and that, if such a project could be completed, it would be too unwieldy to use.

The authors are also critical of casuistry as an approach to decision-making in hard cases and as a method of teaching bioethics. This method, they argue, has problems similar to those that plague specification — namely, the difficulty involved with assembling a set of relevant cases for use in casuistic analysis and the logistical challenges of using such a set of cases. In addition, DeMarco and Ford claim that it is not actually the similarity of a particular case to paradigmatic cases that is doing the moral work in casuistry, but rather the comparison of the cases' morally relevant features by balancing. (Again, balancing may not be the only possible method of comparing paradigmatic cases. See Baruch Brody, Life and Death Decision Making, in which he argues that the process used, “rather than being a weighing process, is a process of judgment” [1988, p. 77]). Like specification, then, casuistry is harmful for moral thinking because it covers up the true moral work that underlies a moral decision.

Balancing is identified as the preferred approach to moral deliberation because it requires the explicit comparison of ethical considerations, resulting in a more transparent approach to moral reasoning. Readers are invited to consider if this is equally important in the context of decision making about hard cases and the context of teaching bioethics. DeMarco and Ford further conclude that balancing is the most appropriate method with which to teach bioethics because it is straightforward to teach, develops good moral reasoning habits, helps students to identify all of the morally relevant factors, and requires acknowledgement of the values that are overridden by any particular choice. This is a persuasive argument that has important implications for pedagogy in bioethics.

Andrew Ward's article makes a valuable contribution to the underdeveloped inquiry into the ethical issues surrounding the underinsured. He seeks to better understand what it is to be underinsured by identifying the criteria that characterize aspects of “inadequate” insurance coverage. Central to the article is a critique of an existing typology of underinsurance developed by Bashshur, Smith, and Stiles (1993). Ward concurs with Bashshur, Smith, and Stiles' conclusion that “adequate” insurance coverage is not synonymous with full insurance coverage and that some cost sharing may be required by an adequate health insurance plan. He disagrees, however, with these authors' account of how the conditions defining underinsurance are to be understood. Essentially, rather than the three-dimensional account proposed by Bashshur, Smith, and Stiles, which includes Structural, Experiential, and Perceptual dimensions, Ward argues for a two-dimensional schema including a Benefits dimension and an Economic dimension. In defending his proposal, Ward claims that some of the considerations that Bashshur, Smith, and Stiles categorize as Experiential are no different from the considerations in the Structural dimension, so that these two sets of considerations should be combined into the Benefits dimension. The remaining considerations in the Experiential dimension could then be better described as Economic. Finally, Ward argues persuasively that the subjective assessment of the insurance coverage should not constitute a separate dimension of insurance evaluation (Perceptual), but should instead be viewed as aspects of the other two dimensions.

A question that naturally follows this analysis is whether these two dimensions could be further reduced to a single Economic dimension, as the Benefits dimension could simply be redefined as a measurement of co-insurance (with the insured paying 100% co-insurance for those items that are not covered by the insurance plan). Ward, however, resists this conclusion.

One particularly noteworthy general conclusion within Ward's detailed analysis is the necessity of defining a benchmark insurance plan that partially or totally specifies what constitutes adequate insurance coverage. Several possible descriptions of such a benchmark plan based upon the revised typology are offered. The reader is invited to consider whether or not such a benchmark insurance plan would be the same in all contexts or whether it would be relative to the community or nation for which it is developed.

In his contribution, Norman K. Swazo takes on the difficult and timely issue of whether or not philosophical analysis can be useful in ethical decision making in real-world situations. To this end, he analyzes the discussions and policy recommendations of discussions held in three meetings of the Biological Response Modifiers Advisory Committee (BRMAC) of the Food and Drug Administration (FDA) and one discussion held by the DNA Advisory Committee of the National Institutes of Health (NIH). These meetings were organized in response to adverse events reported in X-SCID clinical trials in France. Swazo reviewed the transcripts from these meetings, looking for evidence of appeals to ethical principles and for use of an ethical framework in the dialogue.

In all four meetings, the committee members' comments focused primarily on the evaluation and management of the risks and benefits of the experimental therapy to trial participants. Some limited discussion of informed consent also took place. Overall, however, Swazo noted “no evidence” that the committee's work was informed by an ethical framework. In addition, the role of bioethicists in these discussions was very limited.

Using three different formal arguments, Swazo illustrates how philosophical analysis could have been helpful in these meetings. He claims that any of these three arguments would have provided a reasoned resolution to the ethical questions facing the committees. Swazo uses his arguments as evidence that philosophical analysis could have improved the quality of the recommendations reached. This claim strongly supports one of the purported purposes of the field of bioethics and so is one that many bioethicists would like to embrace. At the same time, however, it raises a number of related controversial questions: Who counts as a bioethicist? How are acceptable ethical frameworks differentiated from unacceptable ones? How should a resolution be reached when philosophical analyses conflict?