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A Philosophical Disease: Bioethics, Culture and Identity

BMJ 2000; 320 doi: (Published 10 June 2000) Cite this as: BMJ 2000;320:1611
  1. John Harris, Sir David Alliance professor of bioethics
  1. University of Manchester

    Carl Elliott

    Routledge, £12.99, pp 256

    ISBN 0 415 91940 1

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    Bioethics needs philosophers with medical experience, and even more it needs philosophers who can write well and interestingly about bioethics without oversimplifying the issues. Elliott scores on both counts: he deploys considerable philosophical erudition and an ability to combine literary and philosophical sources to help us understand the dilemmas of modern medicine. In doing so, he certainly celebrates complexity. He fails, however, to be persuasive on either of his other main theses—that we have much to learn from Wittgenstein about bioethics and that general suspicion of theoretical approaches to bioethics is warranted.

    In a fascinating chapter entitled “What's wrong with living heart transplantation?” Elliott tries to solve the riddle of how it is possible generally to admire those who are willing to lay down their lives for others but to deny them this admiration and the right to earn it when they require medical assistance. His unpacking of the dilemma and its complexities is admirable, though I found his style and methodology indistinguishable from those that he implicitly and explicitly criticises. He notes that a “doctor is supposed to value the interests of his patients equally … By performing the transplant, he is endorsing the donor's sacrifice, and thereby valuing the interests of the recipient more than those of the donor.” Elliott appeals to the theory of equality but misunderstands its demands. He fails to notice that if the doctor refuses to carry out the transplant he will be valuing the interests of the donor more than those of the recipient. Since, by hypothesis, both donor and recipient can't live, equality understood as “equal valuation of interests” cannot help with this dilemma—either way one person's crucial interests are sacrificed. However, giving weight to the autonomy dimension of the requirements of equality might indicate a resolution, since one course of action equally respects the autonomous decisions of both parties.

    While developing his “General Antitheory of Bioethics,” Elliott criticises those philosophers who deploy theories of personhood but misses his target. He thinks that the structure of arguments from personhood is: “X is a person; therefore killing X is wrong.” He ridicules such arguments by suggesting that “trying to define what a person is in order to get moral guidance about the acceptability of ending a being's life is like a man trying to define what ‘sister’ is in order to get moral guidance about whether it would be morally acceptable to have sexual relations with her.” But the structure of arguments from personhood is quite different. Theorists who give personhood a prominent place try to identify the various features of an individual that make that individual morally important in particular ways, including ways that make its life morally valuable. Thus, it is not because an individual is a person that its life is morally valuable, rather it is because it has those features that make life morally valuable that it is a person. In theories of personhood, the fact that an individual is a person is the conclusion of a moral argument, not, as Elliott suggests, one of its premises.

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