MASSIMO REICHLIN
OBSERVATIONS ON THE EPISTEMOLOGICAL
STATUS OF BIOETHICS
Key Words: applied ethics, bioethics, medical ethics, interdisciplinarity
The words denoting the most important realities and events of our
lives are almost exclusively abstract terms, which badly fit the
complexity of what they single out. The particular interest we
have in those realities causes us to use them a lot, despite the lack
of general criteria for usage: as a consequence, most of these
words become extremely vague and poly-semantic, so that it is
not always clear what it is that we are talking about. It is no
surprise that the same also happened to the term 'bioethics'. In
this paper we will try to pick out the most important tendencies
with reference to the problem of the epistemological status of
bioethics, limiting the analysis to the American and Italian
situations. We will take as a starting-point the analysis of the
definitions of bioethics that have recently been given, in the belief
that they synthetically and inchoatively convey an author's
general approach to bioethical issues.
Massimo Reichlin, Ph.D., Department of Medical Humanities, Scientific Institute H San
Raffaele, Via Olgettina, 60 - 20132 Milan, Italy.
The Journal of Medicine and Philosophy 19: 79-102,1994.
© 1994 Kluwer Academic Publishers. Printed in the Netherlands.
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ABSTRACT. Different definitions of bioethics in American and Italian literature
are reported. It is argued that they refer to three different conceptions of the
epistemological status of bioethics: the first conceives of it as an application of
moral principles to biomedical problems, the second as a methodology for the
working out of clinical judgement, the third as a broader and interdisciplinary
public inquiry. It is suggested that each approach grasps a part of the truth, for
each singles out one level of the bioethical work. Bioethics is in fact a complex,
three-level form of knowledge. The misunderstanding of this complexity has led
to some confusion and to conflicts of attribution among those who are concerned
with it.
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1. THE APPLIED ETHICS PATTERN
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The particular circumstances of the creation of the neologism
/
bioethics/ have not contributed to clearness in the subject we are
going to survey. When Van Rensselaer Potter introduced this
term, meaning a "cybernetic approach to the search for wisdom"
(Potter, 1971), he certainly had in mind something deeply different from what we ordinarily mean by 'bioethics'.1 In short,
Potter claimed the necessity of a new scientific ethic, one arising
from the biological sciences themselves. This naturalistic perspective seemed to imply that the empirical sciences are in themselves
a source of values for men.
Few people today share this opinion (Chiarelli, 1984; Prodi,
1987). Most people tend to conceive of bioethics as ethics applied to
a particular field of inquiry. Nevertheless, the actual nature of this
application often remains unexplained, together with the
specificity of this field of inquiry and its differences from medical
ethics, medical deontology as expressed in professional codes and
forensic medicine. As a consequece, it is seldom clear whether
bioethics can correctly be regarded as a discipline or we had better
think of it as an interdisciplinary domain.
The tendency to speak of bioethics as applied ethics mainly
arose from the definition given by The Encyclopedia of Bioethics,
which became an essential reference mark. In this work, W.T.
Reich defined bioethics as "the systematical study of human
conduct in the area of the life sciences and health care, insofar as
this conduct is examined in the light of moral values and principles" (Reich, 1978, Vol. 1, p. XIX). In a sense, this definition
seemed to imply that introducing the word 'bioethics' and editing
an encyclopedia of this 'discipline' did not mean starting an
altogether new enterprise, but rather, renewing an old effort to
significantly correlate human action in a particular field of life
with some criteria of valuation which are generally and usually
valid for every kind of human action. What is expressed in this
definition, after all, is that ethics is already 'at the disposal' of
some area of human endeavour; it is a patrimony of truths having
their own validity. The matter of applying them to a specific field
of human action has become particularly problematic because of
the new enormous possibilities of action that have developed.
Thus, bioethics can be conceived of as a "systematical" inquiry,
because it is the application of a preceeding knowledge and not a
Epistemological Status ofBioethics
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framework to be built up ex novo. The novelty of bioethics thus
seems to be limited to a certain widening of horizons due to
scientific and technological development. Unlike medical ethics confined within the limits of the physician-patient relationship bioethics embraces in Reich's opinion all health professions. It
includes, for example, psychology and psychiatry, extends to
therapeutic and non-therapeutic biomedical and behavioral
research, includes a broad range of social issues connected to the
biomedical field and extends to the issues involving animal and
plant life, such as laboratory experimentation and the protection
of the environment.
This position is clearly restated by K.D. Clouser in the article
'Bioethics' of the same work. In direct contrast to those who think
of bioethics as a really new discipline, quite heterogenous from
philosophical ethics and traditional medical ethics, Clouser
maintains that '"medical ethics' is basically just ordinary ethics
applied to the realm of medicine. [...] Bioethics is just ordinary
ethics applied to the bio-realm" (Clouser, 1978, p. 120). In this
perspective there are no new values peculiar to the biomedical
field, nor do the specific conditions in which biomedicine acts
constitute a reason for creating a new discipline to deal with these
problems with peculiar style and methodology. There is no need
for, say, building a new style of ethical reflection as a consequence
of the irreducible plurality of moral beliefs and of the failure of all
normative ethical systems; neither is interdisciplinarity mentioned
as a main feature of this rational enterprise.
This strictly philosophical definition of bioethics is also to be
found in many Italian authors. In Italy the influence exerted by
this American definition of bioethics is complemented by the
ascendancy of the teaching of the Catholic Church. Especially
during the last century, Catholic theologians have often dealt with
problems related to what they called 'medical morality' which are
today usually ascribed to bioethics. As a general pattern, the
Catholic tradition of moral thinking tends to assess bioethical
questions by relating them to basic principles of Christian
anthropology, that is to the so-called 'metaphysics of the person',
or 'personalism' (McCormick, 1984; Shelp, 1985a).
Such a formulation is clearly expressed in the works of E.
Sgreccia, one of the most outstanding Catholic moral theologians
concerned with bioethics. In his main work Sgreccia defines
bioethics as "that part of moral philosophy that assesses the
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1.1 Some distinctions in the applied ethics pattern
Many authors within the applied ethics pattern have suggested
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ethical validity of the interventions on man's life, and particularly
of those interventions connected with the practice and development of medical and biological sciences'' (Sgreccia, 1988, p. 49). A
perfect continuity, therefore, is assumed between general
philosophical inquiry into human action and bioethics as an
inquiry in a specific area of that action. This inquiry employs the
so-called 'triangular method'. At the first vertex lies the description of the problem at issue in scientifically accurate terms; the top
of the triangle is constituted by the philosophical and
anthropological analysis of the question, and the third vertex
represents the proper application in the fields of medical ethics,
medical deontology, jurisprudence and forensic medicine. This
procedure, according to Sgreccia, "is the best method for personalistic ethics, in which at the top of the triangle is the fullness
of value, the human person" (Sgreccia-Di Pietro, 1987-88, p. 226).
In Italy many people with very different ideological commitments agree with this interpretation of the epistemological status
of bioethics. Of course, Catholic scholars accept almost unanimously this interpretation (Leone, 1987; Viafora, 1988; Tettamanzi, 1990), but also secular philosophers of great prestige
agree in characterizing bioethics as a form of applied ethics. For
example, U. Scarpelli maintains that bioethics is simply "ethics as
far as it is particularly concerned with the phenomena of organic
life, of the body, of generation, development, maturity and old
age, of wealth, illness and death" (Scarpelli, 1987, p. 7). The
acceptance of a common epistemological pattern obviously does
not prevent conclusions from being very different. Starting from
this conception of bioethics, Scarpelli concludes by affirming the
principle of tolerance as the only possible foundation of bioethics,
in accordance with his general theory of strict ethical non-cognitivism. Our analysis, however, is not concerned with the assessment of the various normative and metaethical theories, but aims
at the description and assessment of the different positions at the
epistemological level; in other words, we deal with the
interpretation of the different ways in which the discipline
'bioethics' has been conceived of, and respectively of what the
genuine bioethical work should be like.
Epistemological Status ofBioethics
83
Beauchamp and Childress' Principles of Biomedical Ethics. This
book constitutes one of the most explicit and articulated expositions of a 'theory of principles' (or 'principlism'). According to
this theory, which dominated American bioethics in the last
decade, the basic method in bioethics is to show how rules of
behaviour can be drawn in the analysis of particular cases, justifying them by their subsumption under a basic principle. This
theory, therefore, concentrates its attention on principles at the
theoretical level and conceives the method of bioethics at the
practical level as an application of such principles to specific
clinical cases. In view of this method of application, Beauchamp
and Childress suggest that introducing the word 'bioethics' could
be unhelpful and even misleading.
"Biomedicine" is a short-hand expression for science, medicine and health care.
Biomedical ethics is thus comparable to political ethics and business ethics. The
term 'bioethics', which is sometimes used to describe our area of interest, can be
misleading. It suggests that we are dealing with an independent field, rather
than with the application of general moral principle to an area of human activity.
This usage may obscure the applicability of the action-guides to different
activities such as politics and business as well as science, medicine and health
care (Beauchamp-Childress, 1983, p. 9).
Thus there is no need of anything new; general ethical principles
of autonomy, beneficence and justice enable one to settle particular ethical questions without losing sight either of the strictly
philosophical character of the discipline, or of the actual complexity of the problems.
Many authors, at least implicitly, share this idea of a rejection of
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qualifications. Some are worried about distinguishing bioethics
from traditional medical ethics and believe they can justify the
introduction of a new word by pointing to new problems and
technologies (Viafora, 1989). Others add that this widening of the
field also involves the broadening of the disciplinary approaches
to such problems (Cattorini, 1990). Introducing interdisciplinarity
as a main character of bioethical work often seems to doubt the
strictly philosophical approach that is distinctive of the applied
ethics pattern.
Other ethicists maintain a strong thesis of continuity between
general ethics, medical ethics and bioethics and even doubt the
appropriateness of the neologism. A particularly significant
expression of this dissent is to be found in the introduction to
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1.2 Bioethics in the opinion of the autonomy theorists
Contractarians and libertarians tend to mark a sharp break with
the tradition of medical ethics. This 'school' underlines deep
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the word 'bioethics'. Especially in the United States it is common
to speak of 'medical ethics' or 'biomedical ethics' rather than of
Inoethics'. This rejection often carries criticism of what many
intend by 'bioethics'. In Pellegrino and Thomasma's works, the
use of the expression 'medical ethics' indicates that the remarkable revival of studies in this field should not mean the denial of
traditional medical ethics, grounded in the Hyppocratic spirit.
This revival, rather, should consist in a reappraisal of that spirit,
shaped by beneficence towards the patient but limited in its
paternalism (Pellegrino-Thomasma, 1988). This position is
grounded on a strong philosophical account of the therapeutic
relationship and explicitly objects to the conception of bioethics as
the protection of the patients' rights - a conception that stresses
the physician's duties rather than his virtues. Pellegrino and
Thomasma's work aims to insert the valuation of the patient's
autonomy in the wake of traditional Hyppocratic medical ethics.
In Italy, the specifically philosophical nature of bioethics,
against any interpretation of it in the terms of professional codes
of behaviour, forensic medicine, or even jurisprudence, is strongly
claimed by S. Spinsanti, who is inclined to use the expression 'biomedical ethics'. Spinsanti pays particular attention to the distinction between the specifically ethical field and the medico-deontological one. Professional codes of medical deontology have a
quite utilitarian nature: their rules are but a sort of self-regulation
by the members of a professional association and aim to the
advantage of the profession as a whole. Such rules do not express
the properly moral nature of an action, but are satisfied with its
correctness. In fact, they are not deduced from a system of clear
and rationally defensible ethical propositions, but merely reflect
the general spirit that inspires the profession, a spirit exposed to
remarkable historical changes. In this strictly philosophical view,
Spinsanti believes that 'bio-medical ethics' is a better expression
than 'bioethics', because it better arranges the whole spectrum of
the traditional ethical problems, relating them to the altogether
new questions, such as the responsibility towards the environment and the future generations (Spinsanti, 1987).
Epistemological Status ofBioethics
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differences between the moral tradition deriving from Hyppocrates and today's bioethical reflections. The former was
confined to the physician-patient relationship and, as a consequence of its stress on the principle of beneficence, resulted in
paternalistic outcomes. The good of the patient was completely
subordinated to the physician's perception and decision, and the
therapeutic relationship took on the characteristic of domination.
The many abuses of this relationship, especially in the field of
experimentation on human subjects (Reich, 1990), resulted in a
movement for the protection of the patients' rights, in analogy
with the movement for civil rights and feminism. Bioethics is
therefore considerably based on those social and political thrusts
which animated American life in the sixties. In this context,
particularly influenced by the secular tradition of liberal political
philosophy, the items on the agenda of bioethics include much
more than the physician-patient relationship and range over the
broader social and political implications regarding distributive
justice and the allocation of resources. Robert Veatch underlines
the role undertaken by laypersons in the working-out of medical
decisions: the patient-physician relationship has become a contractual one and in this context "the principle of autonomy as well as
justice has emerged full-blown as a new foundation for medical
ethics" (Veatch, 1987, p. IX; see also Veatch, 1981). In such a
formulation, bioethics retains the characters of a philosophical
enterprise, but it is clearly cast as a kind of public and social
ethics, in the wake of the revival of political philosophy and the
theory of justice.
This position is best characterized by H.T. Engelhardt Jr., the
author of The Foundations of Bioethics. Engelhardt wishes to keep
bioethics in the domain of philosophy, nevertheless, he characterizes bioethics as completely heterogenous in its foundation as
compared to the foundations of all previous moral systems.
Unlike these, bioethics starts from the presupposition of the
impossibility of the foundation of a rational ethic from some
privileged point of view. "The history of bioethics over the last
two decades has been the history of the development of a secular
ethic" (Engelhardt, 1986, p. 5), that is, of an ethic that has
definitely given up the 'monotheistic presumption'. This means
that it has given up the possibility of a 'divine' point of view
which should disclose the rational coherence of facts and values
and rather maintains an irreducible plurality of moral perspec-
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2. BIOETHICS AS AN INTERDISCIPLINARY DOMAIN
Although the applied ethics pattern, tied to a strictly philosophical
conception of bioethics, seems predominant, other trends in
contemporary reflection lay much more emphasis on the novelty
of its epistemological status. In Italy, for instance, M. Mori wishes
to broaden the disciplinary domain of bioethics, particularly
underlining its normative implications in the domain of law. In
direct controversy with Clouserrs position - and therefore with
the applied ethics pattern - Mori denies that the task of bioethics
should be that of assessing the "new problems" brought on by the
technological progress with the means supplied by the traditional
deontological and utilitarian theories. Actually, the technological
progress as such has not brought on problems unknown before;
rather, it has favoured "the achievement of a new culture and,
together with this, causes the diffusion in the society of the
request for the utilization of the new capacities of intervention
according to the moral principles typical of the new culture'"
(Mori, 1990, p. 193). In brief, according to Mori this cultural
process consists in the substitution of a quality-of-life ethic (QLE)
for the traditional sanctity-of-life ethic (SLE), that was grounded
on the metaphysical thesis of finalism, from which it derived an
absolute duty towards the respect of human life (Mori 1989). This
shift in the general framework explains why in bioethics the old
problems of medical ethics and sexual morality are still discussed:
in fact, these problems are now set out in very different terms. The
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rives, all equally defensible. The claim of this 'polytheistic
presumption" implies the acknowledgement of the intrinsic
narrowness of 'secular reasoning": bioethics, as a consequence,
functions "as the logic of a pluralism, as the means for the peaceable negotiations of moral intuitions" (Engelhardt, 1986, p. 11).
Bioethics, then, is philosophical reflection, yet it is conditioned
from the start by the irreducible pluralism of moral intuitions. The
acknowledgement of such a pluralism as a constitutive principle
commits bioethics to the role of contracting for the peaceable
solution of moral controversies. The philosophical and normative
nature of rationality gives way to a strictly formal and merely
procedural conception; the protection of the rights of autonomy
defines the role of bioethics as the application of a formal principle
of tolerance to the political management of biomedical problems.
Epistemological Status of Bioethics
87
typical interdisciplinarity of today's bioethical debate finds an
explanation in the following passage:
The attention paid to the so-called common sense morality and,
even more, the role given to the empirical sciences in the workingout of ethical judgements seem to imply the abandonment of the
strictly philosophical characterization of bioethics asserted by the
upholders of the applied ethics pattern. Mori defines bioethics as
"a rational and systematic reflection on the various moral, legal
and social problems brought on by the extraordinary development of medicine and of the other sciences of life" (Mori, 1988, pp.
7-8). The epistemological status is altered; bioethics here is not
simply a part of moral philosophy, because the philosopher is
concerned with matters of principle, matters relating to being and
truth, while the legal and social problems are empirical matters.
Consequently, Mori also uses some vague expressions when he
refers to bioethics as the "whole of the reflections in some way
relevant to the various moral and normative problems brought on
by the human intervention in medical and biological world"
(Mori, 1988, p. 38).
Another Italian philosopher, E. Agazzi, explicitly assumes the
interdisciplinarity of bioethics as a matter of fact and turns to the
question whether it is possible to assign a specific role to ethics
within this interdisciplinary domain. This position, therefore, is in
direct contrast with that of the applied ethics pattern. For one
thing, Agazzi believes that the interdisciplinarity of bioethics
implies that ethics should be limited to the analysis and the
assessment of the plurality of values at stake. It should aim to "the
building of an authentic ethos, resulting from a thought-out
collective agreement on a constellation of values seriously and
responsibly assumed" (Agazzi, 1990, p. 21). Morality includes a
plurality of values, the consistency of which cannot be presup-
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when (in past years) the debate was shaped by SLE, the 'empirical'
(psychological, sociological, etc.) data on human behaviour that were object of
the various social sciences were useful in order to favour an easier adjustment of
conduct to the absolute norm, so that the various 'empirical' disciplines were
dependent on normative ethics and the interdisciplinarity did not assume the
central role it now has. Instead, when QLE begins to prevail, the various
disciplines are given a quite new importance for they become necessary in order
to single out the suitable norms to assure a high standard of 'quality of life' and
to ascertain if it has been achieved (Mori, 1990, p. 198).
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Massimo Reichlin
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posed and this pluralistic context prevents bioethics from being
normative in a strong sense and only allows a weaker sort of
negotiation.
There often seems to be some oscillation, a sort of reluctance to
let bioethics fall within a well-known and strictly defined epistemological field. Many authors show a certain ambiguity when
giving their opinion on this matter, and generic formulations are
sometimes put forward in order to account for the complexity
with which bioethics is confronted. Possibly this is a reflection of
the general attitude of distrust of the contemporary world with
regard to philosophy and its ability to solve its age-old controversies. Some authors - maybe unconsciously - seem to acknowledge the insufficiency of philosophy faced with problems of
such great importance.
A similar tendency can also be noted in some passages by
David Roy. According to Roy, "bioethics seeks to show in a
systematic way - and thus through the way of interdisciplinarity the whole of the conditions that must be taken into account if we
wish to exercise our responsibility to protect life and human life in
a universe ever more characterized by the accelerated and complex development of biomedical sciences'" (Roy, 1987, p. 309). In
this definition the ambiguity about the character of interdisciplinarity clearly emerges. There is almost a contradiction between the claim to a systematic nature and that to interdisciplinarity. If a branch of knowledge seeks to be systematic, it
must be a means of unification of some multiplicity, it must have a
core of epistemological unity; in other words, a knowledge cannot
be systematic if it is not also specific. Now, what in this perspective is the specificity of bioethics? If one were faithful to interdisciplinarity, then bioethics would not have a specific epistemological ratio but rather, would be a sort of dialogue among different
disciplines, with the same object seen from various points of view.
In this case it seems that one should give up the systematic nature
of bioethics. Bioethics could just give provisional answers, or even
only empirical indications on some particular issues, giving up the
attempt for a deeper and broader view on the whole field, a
comprehensive and foundational point of view.
This modest and not strictly philosophical side of bioethics is
clearly at work in Daniel Callahan's approach. He characterizes
bioethics as a discipline entrusted with the working-out of a
methodology to help the physicians in making 'good decisions'
r
Epistemological Status ofBioethics
2.1 The rejection of the systematic approach and the new casuistry
The most extreme view among those who oppose the applied
ethics pattern is perhaps maintained by M. Cuyas, a Spanish
theologian who also works in Italy and who is particularly concerned with bioethical issues. He believes that the complexity and
the importance of the items that are today on the bioethical
agenda are such as to justify the introduction of a new term in
order to denote something new. According to Cuyas, bioethics is a
really new and different enterprise, "characterized by interconfessional and interdisciplinary dialogue and by the attention paid to
the consequences of a certain course of action from an
international point of view" (Cuyas, 1987, p. 43). The novelty,
once again, seems a matter of methodology: it is a new style of
"ethical reflection" on problems not altogether new (at least not
all of them). Therefore - and this is the most radical consequence bioethics cannot be characterized as a real 'discipline', as a set of
truths to be applied to a particular field of human life.
It is rather a new style of moral reflection, a new method of research, a method of
approaching old or new biomedical problems, characterized by dialogue and
even more by a strong effort to understand others' point of view, assuming in the
meantime the different approaches relating to each competence. Such an inquiry
must be placed in the vast horizon of the consequences for humanity implied by
such decisions, for the present and for the future. It is therefore a task forever in
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from a sociological, psychological and historical point of view
(Callahan, 1973). Far away from the applied ethics pattern, Callahan seems to mean that this discipline is not a field of
knowledge in some way defined, with a certain set of propositions
rationally justified but is rather a methodology, a style of reflection to be adopted with regard to certain problems. Callahan
underlines the 'advisory' role of bioethics (and also of ethicists)
with respect to the professionals of the life sciences. There is an
important 'formative' dimension, a task of stimulating the moral
conscience in order to work out ethical judgements which
nevertheless remain in the last resort situational, pertaining to a
single conscience, although informed. In the end, the validity of
these moral judgements is not related to the domain of truth,
typical of the philosophical and rational inquiry, but rather to the
sociological, psychological and historical sciences, that is, to
extremely situational points of view.
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Massimo Reichlin
the making, devoted to singling out the problems and to examining them closely,
tending to their long-term solution and taking into account consequences as
carefully as possible. Therefore, I believe bioethics is much more a process of
inquiry and service than a set of formulations and achieved goals (Cuyas, 1987,
p. 44).
j
1
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This kind of approach seems to be the most radical, in that it
draws some conclusions to which Roy and Callahan seemed
unwilling to subscribe: if interdisciplinarity and dialogue are
stressed, it is impossible to qualify bioethics as a discipline, as a
specific form of knowledge. It more correctly becomes a way of
talking, a new style of moral research. As a consequence, nobody
can claim a specific competence in this domain. The paradigmatic
expression of the working-out of this 'knowledge' then becomes
an Ethics Committee, in which experts from different fields place
their specific competences at the service of common decisionmaking. This deliberation actually has a sort of political nature, in
that it is mainly concerned with the political and social consequences of actions in the short or long range, rather than with
their proper moral quality.
It was just the experience of Ethics Committees that inspired a
trend that explicitly contradicts the applied ethics pattern and
aims to overcome its abstraction and uselessness in the specific
valuation of single cases.2 This recent trend in American thought
has been given the name of 'new casuistry' for it explicitly refers
to the style of argumentation fully elaborated by the Jesuit moral
theologians and confessors in the 16th and 17th centuries. According to the interpretation of the original sense of the casuistic
method given by A. Jonsen and S. Toulmin, this pattern of moral
reasoning is not a form of deductivism, that is, a mere application
of general principles to particular cases; casuistry, rattier, gives
priority to the valuation of the single case with regard to the
working-out of the moral rule. In this sense, the new casuistry
constitutes an overthrow of the deductivism characteristic of the
applied ethics pattern. The applied ethics method, and
particularly the so-called 'principlism' that has been its most
coherent expression over the last twenty years, is charged with
abstractedness and intellectualism in that it claims to first pick out
the principles to be applied to the single cases; but, as J.D. Moreno
notes, "moral philosophy cannot in itself provide 'the answers' or
at least not in the genuinely hard cases [...] The reason is that the
Epistemological Status ofBioethics
91
The locus of certitude in the commissioners' discussions did not lie in an agreed
set of intrinsically convincing general rules or principles, as they shared no
commitment to any such body of agreed principles. Rather, it lay in a shared
perception of what was specifically at stake in particular kinds of human situations. Their practical certitude about specific types of cases lent to the Commission's collective recommendations a kind of conviction that could never have
been derived from the supposed theoretical certainty of the principles to which
individual commissioners appealed in their personal accounts. In theory their
particular concrete moral judgments should have been strengthened by being
Validly deduced' from universal abstract ethical principles. In practice, the
general truth and relevance of those universal principles turned out to be less
certain than the soundness of the particular judgments for which they supposedly provided a 'deductive foundation' (Jonsen-Toulmin, 1988, pp. 18-19).
Actually, this procedure seems characteristic of those institutional
bodies of ethical reflection that, owing to their very nature, avoid
a strictly philosophical examination and are rather concerned with
a normative formulation that can be a source of inspiration for the
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hard cases are such precisely because they reveal the points at
which systems of moral beliefs rub up against each other"
(Moreno, 1991, p. 54). The casuistic approach, instead, brackets the
'matters of principle', giving up the search for an agreement at the
level of the ethical theories. It is rather concerned with the step-bystep analysis of specific cases, aiming to single out the moral
values at stake and to give specific answers: principles are then
abstracted from the answers given to single cases. This
interpretation of moral reasoning is clearly antitheoretical, for it
presupposes the impossibility of articulating the moral principles
at the theoretical level. Principles are picked out within the
particular factual contexts as a reflection on the meaning of the
judgements we concretely work out in single cases. This priority
of the practical side is such that principles function as 'summaries'
of the meanings embedded in the actual practices (Toulmin, 1981):
"Rather than serving as a justification for certain practices, principles within the new casuistry often merely seem to report in
summary fashion what we have already decided" (Arras, 1991, p.
34).
As Jonsen and Toulmin explicitly maintain, this was the method
of the National Commission for the Protection of Human Subjects
of Biomedical and Behavioral Research, in which they both
participated:
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Epistemological Status of Bioethics
93
3.1 The foundational side, or applied ethics
The first side of bioethics to be mentioned is surely the strictly
philosophical and foundational one. If it is true that the
application to a specific field and the abandonment of metaethical
issues in favour of the normative ones is the only alternative to the
futility of the philosophical reflection upon morality (Toulmin,
1982), it is as much true that no normative proposal can resist
critics if it is not founded on rationally defensible arguments and
if it does not reflect a more general ethical theory - a theory which
elaborates a precise conception of the human good and provides
the means for the discernment between what constitutes its
fulfilment and what should be regarded as its perversion and
denial.
From this point of view it is of the greatest importance for
bioethics to keep a close contact with general ethics and to be an
application of general moral principles to a specific field. Even at a
theoretical level, however, bioethics cannot be conceived of as a
mere application of abstract principles, even less than other fields
in applied ethics can: here the existential components of the
situation deeply affect moral arguments, for bioethics is directly
confronted with matters of life and death and can never entirely
objectify its field of inquiry.
Besides, for what concerns the specific field of biomedical
ethics, this ethical reflection has its proper role within the particular ambit of the therapeutical relationship, that is deeply
affected by the values that are embedded in it and constitute its
peculiar ethos. One of the main sources of bioethical dilemmas is
actually this unbalanced relationship between one who has a
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Our attempt starts from the trivial recognition that actually we
'do different things7 when we 'do bioethics': nevertheless, it is
difficult to deny that the word 'bioethics' correctly applies to each
of these 'things'. Our proposal is, then, that we should distinguish
three levels within bioethics, each of them claiming a relative
autonomy and a methodological and epistemological specificity.
These levels are moreover related to one another, in a hierarchical
scheme which, however, does not imply a relation of causation or
of logical entailment, but rather a sort of influence exerted by the
superior level over the interpretative and deliberative process of
the inferior level.
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Massimo Reichlin
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scientific and technological power and one who is generally the
beneficiary, and sometimes the object or even the victim of this
power: this is the horizon against which both the therapeutical
and the experimental praxis take place. As a consequence, it is
possible that some principles should be given a particular weight
in the biomedical field - a weight they may not have in some
other field: it is just the peculiar nature of the therapeutic relationship that suggests the stressing of some aspects rather than others.
For instance, the principle of beneficence can be given a quite
distinctive significance in the medical context, for medicine can be
seen as an activity peculiarly grounded on a commitment to
proximity and care towards the suffering: while an attitude to
caring for others is probably a general feature of moral human
conduct, doubtless it is the basic value that gives sense to the
medical profession itself. When this particular feature of the
medical profession is correctly understood as the main source of
values and conflicts in bioethics, it becomes clear that the foundational moment cannot put aside an accurate phenomenology of
the therapeutic relationship: applying ethics will thus be a sort of
dialectical interplay between theoretically singled out principles
and the hermeneutics of the values embedded in the medical
practice.
This does not mean that bioethics can be entirely reduced to the
limits of medical ethics. For one thing, bioethics is a common need
for every person concerned with the future of our species and of
the environment, while 'medical ethics' is more correctly intended
to mean 'ethics of the physician'. Actually, bioethical issues also
concern the patient, in that it is a matter of determining the sense
and value, with regard to the fulfilment of the good for man, of
scientific knowledge and technological possibilities that deeply
affect some of the most important and intimate ambits of human
life. It makes no sense to say, for example, that the moral assessment of the techniques of artificial reproduction should be the task
of the physician: on the contrary, laypersons have a great role in a
jointly liable management of such enormous technological possibilities.
Besides, some issues peculiar to bioethics clearly lie outside the
domain of medical ethics, and are rather the appropriate subject of
a strictly philosophical reflection. The most outstanding of these is
surely the status of the human embryo, an issue that traces back to
the remote controversy on 'animation' and still takes a decisive
Epistemological Status ofBioethics
95
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place in the debates on abortion, prenatal diagnosis and in vitro
fertilization: this issue is evidently connected with the more
general debate on what it is to be a human person, as is also the
case with the opposite question concerning the end of human life.
The issue of the definition of death is in fact another relevant
example of a genuine philosophical problem to be ascribed to the
domain of bioethics. Moreover, there are questions related to the
philosophy of medicine that can be referred to as a necessary
introduction to the veritable ethical issues: prominent among
these are the concepts of health and disease and the debate on
whether the goal of medicine should be limited to therapeutics or
rather extended to the search for an improvement of man's
potentialities and performances.
Lastly, the valuation of the consequences that both clinical and,
especially, experimental practices may have on the environment is
also to be included within the realm of bioethics. This involves the
working out of an ethic of biological research, particularly
devoted to a careful interpretation of man's relationship and
responsibilities towards nature and the whole system of life.
These issues clearly lie outside medical ethics: relevant categories
of moral discernment in these matters are not those connected
with beneficence in the therapeutic relationship but rather with
responsibility towards the species and the future generations.
It seems correct to exclude reference to an interdisciplinary style
from the characterization of this level of analysis. Actually, here
there is no real interdisciplinarity; rather, a knowledge of the field
to which the ethical reflection is applied must be presupposed, so
that the judgement may be informed. This, however, is not dissimilar to - even if probably more complex than - other fields in
applied ethics. The interdisciplinary aspect here amounts to the
impossibility of working out a theoretical foundation in bioethics
without being acquainted with the scientific and technical terms
of the problems connected to the praxis of the biomedical sciences,
just as it is impossible to develop a business ethics without a
certain knowledge of the world of business.
With regard to this first level, we must agree with the position
of the upholders of the 'applied ethics pattern', although this is
not equivalent to agreeing with the stereotypes arisen from this
pattern, both in the United States and in Italy: bioethics is a field
of applied ethics and, even though the issues at stake concern
everyone, a peculiar competence seems properly acknowledged to
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Massimo Reichlin
those who specifically and professionally deal with moral
philosophy.
3.2 The clinical side
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A great part of contemporary moral philosophy, especially
English-speaking, has conceived moral problems as theoretical
ones, concerning the moral assessment of decisions taken by ideal
agents. Most philosophers, however, have acknowledged in the
last years that genuine moral problems are practical problems of
moral decision making and therefore, from a philosophical point
of view, involve the analysis of the procedures of decision
making. If ethics is conceived of as a matter of practical reason,
that is, as the problem of what is the best course of action in a
specific situation, one cannot avoid stressing with Aristotle the
determining role of habituations, the habitus to good deliberation
supported by the ethical virtues. Therefore, an ethical theory
grounded on rationally founded principles must always be
supported by an ethics concerned with the education of a responsible ethos, an ability of perception and discernment of moral
values. Assuming that the ethical reflection does nothing but
setting the best conditions for a correct exercise of freedom, one
will be led to recognize that a moral obligation has its proper
place only in the heart of conscience: the actual and cogent
working-out of moral rules takes place in the ethical situation, that
is, in the clinical praxis. Bioethics has therefore this second basic
character, of being irreducibly clinical (Wear, 1991).
It appears, then, that physicians can boast a certain peculiar
competence on this side. This clinical dimension should be integrated with the foundational aspects and should aim at the
concrete verification of the conditions of applicability of general
principles and norms. However, this second moment has an
unavoidable specificity in that it is up to the physician's (and the
patient's) conscience to determine what application of a general
rule will constitute the 'right solution' in a particular case
(Richardson, 1990). In Roy's words, we could say that clinical
ethics is not applied philosophy or theology. "Clinical ethics is an
original activity, distinct from others [...] Clinical ethics needs the
contribution of philosophical reflection to control and critically
examine the practical judgements it gives. However, it is not a
philosophical nor a theological enterprise" (Roy, 1990, p. 107).
I
Epistemological Status ofBioethics
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3.3 The paralegal side, or Ethics Committees
In contemporary bioethics it is probably the unusually popular
interest in these moral issues that contributes to their complexities
and divisiveness. To face this situation ethics committees have
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The philosopher can help in this field to the extent that he can
draw attention to the theoretical principles and contribute to the
close analysis of the case at issue, showing the philosophical
consequences of the different practical choices: however, a specific
competence in this area cannot but be left to the physician and to
his conscience.3 An expert in professional codes may also offer a
useful advise at this level; nevertheless, this is properly the field of
medical ethics, in the strict sense of "ethics of the physician'. In
this context Agazzi's and Callahan's4 remarks have a particular
relevance that bioethics should be the building of an authentic
ethos and the working-out of a methodology suitable to suggest
consistent answers and decisions to the health professionals. It is
by overemphasizing this aspect, to the detriment of the foundational level, that a contraposition has been set up in the last years
between the so-called 'bioethics of principles' and a new 'bioethics
of virtues' (Shelp, 1985b; Drane, 1989).
It would not be appropriate to assign the character of epistemological interdisciplinarity to this properly clinical level. This
category is not properly relevant with relation to the actual
process of decision making, but rather to that of medical education. It is entirely appropriate to develop forms of teaching meant
to give the health professionals a perception of the ethical and
anthropological dimensions connected with their technical actions. With regard to this goal, there is a vast spectrum of
knowledge that constitute a background from which a virtuous
habitus may arise. In bioethical education, there are many subjects
that contribute to the shaping of conscience or to an anthropological perception, including medical epistemology, philosophy of
medicine, psychology, forensic medicine, history of medicine,
moral theology, and within certain limits even literature or arts
(Hunter, 1991; Downie, 1991). It is clear, however, that the specific
ratio that is effective also at this level is that of moral decision
making. The interdisciplinarity is relevant only from an educational point of view and does not affect the specific moral situation.
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Massimo Reichlin
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been born as an institutional place of representation for the
various parties and the different interests and values to be
safeguarded. These new institutions have had the necessity to
provide themselves with methods of inquiry fit for their task.
Ethics committees have thus created a peculiar style of ethical
reflection, one quite different from the more theoretical and
abstract reasoning of moral philosophers. Urged to elaborate
guidelines for legislation and even, in the case of local committees,
to deliberate about single authorizations and prohibitions, ethics
committees have necessarily adopted a casuistical style, deeply
concerned with the time, ways and circumstances of its normative
interventions.
In this unusual context of normative reflection interdisciplinarity gains particular relevance. This owes much to the fact
that ethics committees are not primarily concerned with the
foundational aspects or the theoretical assessment of concrete
cases; rather, their focus is mainly on the strictly practical aspects,
that is, the deliberation about the concrete realization or the
refusal of certain scientific and technological practices. This
involves more than the proper moral quality of actions. It includes
a broader range of problems, from the possible social impacts of
the decisions undertaken to the problems of consistency with the
legal and institutional systems of the different countries, from the
issues relating to a sound and balanced management of economic
resources to the protection of the dignity and the prestige of a
particular profession.
This realm of 'political' considerations encompasses much more
than the simple account of the individual's moral point of view
and extends far beyond the narrow limits of the physician-patient
relationship. Particularly in governmental or other institutional
committees, what is often focussed in the discussion is the general
role to be ascribed to health care as an institution among others in
our contemporary societies: the aim of the debate is thus to frame
the system of health care into a consistent public ethics, outlined
on the grounds of a general theory of justice and society.
Sociologists, jurists, experts in forensic medicine and deontology,
politicians and statesmen have a role in this debate. Philosophers
are entitled to participate in this discussion just as much as the
others, for this is the proper locus of interdisciplinarity. When
referring to this level of inquiry we can also say that bioethics is
not a true discipline, but rather, a way of talking and, within
Epistemological Status ofBioethics
99
4. CONCLUSIONS
The descriptive analysis of some different approaches to bioethics
that can be reported in recent literature has led us to identify three
levels of the work in bioethical reflection. The first level is concerned with a deep theoretical analysis of human action in the
field of biomedical sciences, in the light of a general ethical theory:
this will include a general theory of human action and an account
of what can be regarded as the 'good for man' and of what constitutes a 'good life'. The second level is mainly concerned with
the development and education of a responsible ethos in health
professionals, including an ability of perception of the moral
values already imbedded in the actual practices: the aim of this
work is to ensure the translation of abstract philosophical principles into the habitus to good deliberation and to the concrete
exercise of the ethical virtues. Lastly, a third level is that of a
'political', sociological and legal assessment of the problems at
stake, in order to elaborate guidelines and give recommendations
for legislation: at this level a sense of interdisciplinarity and a
pluralistic and tolerant approach to the discussion is needed.
Our claim is that the suggested scheme may be of help in order
to avoid conflicts of attribution among those working in the three
different areas: particularly, the qualification of bioethics as a
complex, three-level inquiry may prevent the tendency to regard
one's own field as the only decisive point of view in assessing
problems in biomedical ethics. On the contrary, we wish to
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certain limits, a logic of pluralism. Here we can consent to many
of the points put forward by Roy, Cuyas, and the new casuists.
The role of ethicists in the theoretical analysis and in the institutional process of decision-making about specific cases is doubtless
quite different. "As the ethicist becomes more directly engaged in
this process he or she assumes a role in the 'political' processes
that are an essential part of the management of rivalries among
communal values'' (Moreno, 1991, p. 54). This kind of normative
process, which is elaborated in terms of public ethics, requires a
spirit of tolerance and flexibility and a certain disposition to
compromise, and may imply the acceptance of a minimal ethic as
a common basis for public regulations. Maybe - as Jacques Testart
noted some time ago - the name 'bio-politics' would better define
the width of interests and values that are at stake at this level.
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Massimo Reichlin
NOTES
1
The term 'bioethics' was first mentioned in Potter's article "Bioethics, the
Science of Survival", published in Perspectives in Biology and Medicine 3,1970: this
article is actually the first chapter of the book cited. See Chiarelli and Gadler,
1989.
2
There is also, however, a trend of protest against the applied ethics pattern and particularly against the theory of principles - from a foundational,
philosophical point of view. See the second issue in 1990 of The Journal of
Medicine and Philosophy, devoted to the "Philosophical Critique of Bioethics", and
particularly Clouser and Gert, 1990, and Green, 1990.
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underline that the three levels are strongly and inherently interrelated with one another. However, the different tasks they involve
should be accomplished by different persons with different
expertise: jurists should not claim competence at the first level,
while philosophers should not substitute for physicians in the
assessment of concrete cases.5 Our scheme does retain the primacy
of the theoretical inquiry, which should be seen as the top of a
hierarchical relation among the three levels. However, we would
like to stress: first, that bioethical work is not over when all the
theoretical problems are settled (if ever possible); and, second,
that the questions arising at the two other levels cannot be settled
by simply deducing consequences from a theoretical understanding of the matter.
We believe that the distinctiveness of bioethical reflection is to
be found just in this plurality of levels of moral reflection that
should not be over-simplified. Some might deplore the exiguity of
such a result, claiming that it leaves us with great difficulties to
solve. In particular, the weight of the hierarchical relation among
the levels should be more closely defined: consequently, it might
be pointed out that propositions and normative suggestions
should be given a different weight at the different levels, for
particular solutions of cases at the clinical level could hardly claim
a quasi-universal value as a philosophical principle. In recognizing that such questions do deserve further reflection, we claim
however the relevance of marking these distinctions and assessing
the plurality of approaches in contemporary bioethics: while the
three levels are not likely to grant absolute complementarity, the
avoidance of conflicts of attribution among those concerned is
likely to bring some clarity in this complex field of inquiry, letting
everybody say just what he is entitled to say.
r
Epistemological Status ofBioethics
101
3
REFERENCES
Agazzi, E.: 1990, 'Introduzione. II luogo dell'etica nella bioetica', in E. Agazzi
(ed.), Quale etica per la bioetica?, Angeli, Milano.
Arras, J.D.: 1991, 'Getting Down to Cases. The Revival of Casuistry in Bioethics',
The Journal of Medicine and Philosophy 16,29-51.
Beauchamp, T. and Childress, J.: 1983, Principles of Biomedical Ethics, Oxford
University Press, New York.
Callahan, D.: 1973, 'Bioethics as a Discipline', Hastings Center Report 1, 66-73.
Cattorini, P.: 1990, 'I principi dell'etica biomedica e le teorie etiche', in E. Agazzi
(ed.), Quale etica per la bioetica?, Angeli, Milano, pp. 67-83.
Chiarelli, B. and Gadler, E.: 1989, 'Nota storica. Van Rensselaer e la nascita della
bioetica', Problemi di bioetica 5,61-63.
Chiarelli, B.: 1984, 'Storia naturale del concetto di etica e sue implicazioni per gli
equilibri naturali attuali', Federazione Medica 37, 542-546.
Clouser, K.D.: 1978, 'Bioethics' in W.T. Reich (ed.), Encyclopaedia ofBioethics, vol.
I, The Free Press, New York, pp. 115-127.
Clouser, K.D. and Gert B.: 1990, 'A Critique of Principlism'. Journal of Medicine
and Philosophy 16,216-236.
Cuyas, M.: 1987, 'Caratteristiche e tendenze della bioetica', Sanare Infirmos 5,
39^5.
Downie, R.S.: 1991, 'Literature and Medicine', Journal of Medical Ethics 17, 93-96,
98.
Drane, J.F.: 1988, Becoming a Good Doctor. The Place of Virtue and Character in
Medical Ethics, Sheed and Ward, Kansas City.
Engelhardt, Jr. H.T.: 1986, The Foundations of Bioethics, Oxford University Press,
New York.
Green, R.M.: 1990, 'Methods in Bioethics. A Troubled Assessment', Journal of
Medicine and Philosophy 16,179-197.
Hunter, K.M.: 1991, 'How to Be a Doctor. The Place of Poetry in Medical
Education', Second Opinion 16,64-78.
Jonsen, A. and Toulmin S.: 1988, The Abuse of Casuistry. A History of Moral
Reasoning, University of California Press, Berkeley.
Leone, S.: 1990, Lineamenti di Bioetica, 2nd ed., Medical Books, Palermo.
McCormick, R.: 1984, Health and Medicine in the Catholic Tradition, The Crossroad
Downloaded from http://jmp.oxfordjournals.org/ at Fondazione Centro S. Raffaele del Monte Tabor on June 27, 2012
J.D. Moreno also notes that clinical ethics is something deeply different from
moral philosophy or a simple application of it: "applied moral philosophy is not
simply moral philosophy applied. Clinical ethics is like a river with many
tributaries, and moral philosophy is only one, though major, tributary" (Moreno,
1991, p. 54).
4
See above, pp. 87-89.
5
This obviously casts some doubt on the role of 'philosophers in residence'. This
is however too great a question to be assessed in this paper.
102
Massimo Reichlin
Downloaded from http://jmp.oxfordjournals.org/ at Fondazione Centro S. Raffaele del Monte Tabor on June 27, 2012
Publishing Company, New York.
Moreno, J.D.: 1991, 'Ethics Consultation as a Moral Engagement', Bioethics 5,
44-56.
Mori, M. (ed.): 1988, Questioni di bioetica, Editori Riuniti, Roma.
Mori, M.: 1989, 'Bioetica. Concetto, teorie, problemi', Notizie di Politeia 16,29-38.
Mori, M.: 1990, 'La bioetica: la risposta della cultura contemporanea alle questioni morali relative alia vita', in C.A. Viano (ed.), Teorie etiche contemporanee,
Bollati Boringhieri, Torino, pp. 186-224.
Pellegrino, E.D. and Thomasma D.C.: 1988, For the Patient's Good. The Restoration
of Beneficence in Health Care, Oxford University Press, New York.
Potter, V.R.: 1971, Bioethics. Bridge to the future, Prentice Halls, Englewood Cliffs.
Prodi, G.: 1987, Alia radice del comportamento morale, Marietti, Genova.
Reich, W.T. (ed.): 1978, Encyclopedia of Bioethics, The Free Press, New York.
Reich, W.T.: 1990, 'La bioetica negli Stati Uniti', in C. Viafora, Vent'anni di bioetica,
Fondazione Lanza Gregoriana Libreria Editrice, Padova, pp. 141-175.
Richardson, H.S.: 1990, 'Specifying Norms as a Way to Resolve Concrete Ethical
Problems', Philosophy and Public Affairs 19,277-310.
Roy, D.: 1987, 'La Bioetique. Une responsabilite nouvelle pour le control d'un
nouveau pouvoir', Relations 36,308-312.
Roy, D.: 1990, 'Orientamenti e tenderize della bioetica nel ventennio 1970-1990',
in C. Viafora (ed.), Vent'anni di bioetica, Fondazione Lanza Gregoriana Libreria
Editrice, Padova, pp. 93-122.
Scarpelli, U.: 1987, 'La bioetica. Alia ricerca dei principi', Biblioteca della liberta 22,
7-32.
Sgreccia, E.: 1988, Manuale di Bioetica, Vita e Pensiero, Milano.
Sgreccia, E and Di Pietro M.L.: 1987-88, 'Che cos'e la bioetica', in Enciclopedia
della scienza e della tecnica EST, Mondadori, Milano, pp. 223-226.
Shelp, E.E. (ed.): 1985a, Theology and Bioethics, Kluwer Academic Publishers,
Dordrecht, Holland.
Shelp, E.E. (ed.): 1985b, Virtue and Medicine, Reidel, Boston.
Spinsanti, S.: 1987, Etica bio-medica, Paoline, Cinisello Balsamo.
Tettamanzi, D.: 1990, Bioetica. Nuove frontiere per Vuomo, 2nd ed., Piemme, Casale
Monferrato.
Toulmin, S.: 1981, 'The Tyranny of Principles', Hastings Center Report 11,31-39.
Toulmin, S.: 1982, 'How Medicine Saved the Life of Ethics', Perspectives in Biology
and Medicine 25, 736-750, reprinted in J.P. De Marco - R.M. Fox (eds.): 1986,
New Directions in Ethics. The Challenge of Applied Ethics, Routledge and Kegan
Paul, New York-London, pp. 265-282.
Veatch, R.: 1981, A Theory of Medical Ethics, Basic Books, New York.
Veatch, R.: 1987, The Patient as Partner, Indiana University Press, Bloomington,
Indianapolis.
Viafora, C: 1989, Fondamenti di Bioetica, Ambrosiana, Milano.
Wear, S.: 1991, 'The Irreducibly Clinical Character of Bioethics', The Journal of
Medicine and Philosophy 16,53-70.