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. Downloaded from http://jmp.oxfordjournals.org/ at Fondazione Centro S. Raffaele del Monte Tabor on June 27, 2012 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. 80 Massimo Reichlin 1. THE APPLIED ETHICS PATTERN Downloaded from http://jmp.oxfordjournals.org/ at Fondazione Centro S. Raffaele del Monte Tabor on June 27, 2012 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 81 Downloaded from http://jmp.oxfordjournals.org/ at Fondazione Centro S. Raffaele del Monte Tabor on June 27, 2012 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 82 Massimo Reichlin 1.1 Some distinctions in the applied ethics pattern Many authors within the applied ethics pattern have suggested Downloaded from http://jmp.oxfordjournals.org/ at Fondazione Centro S. Raffaele del Monte Tabor on June 27, 2012 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 Downloaded from http://jmp.oxfordjournals.org/ at Fondazione Centro S. Raffaele del Monte Tabor on June 27, 2012 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 84 Massimo Reichlin 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 Downloaded from http://jmp.oxfordjournals.org/ at Fondazione Centro S. Raffaele del Monte Tabor on June 27, 2012 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 85 Downloaded from http://jmp.oxfordjournals.org/ at Fondazione Centro S. Raffaele del Monte Tabor on June 27, 2012 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- 86 Massimo Reichlin 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 Downloaded from http://jmp.oxfordjournals.org/ at Fondazione Centro S. Raffaele del Monte Tabor on June 27, 2012 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- Downloaded from http://jmp.oxfordjournals.org/ at Fondazione Centro S. Raffaele del Monte Tabor on June 27, 2012 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). 88 Massimo Reichlin Downloaded from http://jmp.oxfordjournals.org/ at Fondazione Centro S. Raffaele del Monte Tabor on June 27, 2012 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 Downloaded from http://jmp.oxfordjournals.org/ at Fondazione Centro S. Raffaele del Monte Tabor on June 27, 2012 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. 90 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 Downloaded from http://jmp.oxfordjournals.org/ at Fondazione Centro S. Raffaele del Monte Tabor on June 27, 2012 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 Downloaded from http://jmp.oxfordjournals.org/ at Fondazione Centro S. Raffaele del Monte Tabor on June 27, 2012 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: r ajaAre • u jo a§.reip aip piOAe oj SinXxj j[tjs ' -uauiajduiOD ajqissod iraip Supsa§§ns suoiindo snotreA aip Suoure saDiiaiajjip aip jaidiaiui oj a>[ij pjnoM ayv\ sDxipaoiq jo snjejs reD -iSojouiajsida aip jo anssj aijj ipiM. pauiaDiioD uaaq 3AEIJ OIJM asoip A*q pjaijdn suonndo jo A^ij^jnjd dm pazireumms Downloaded from http://jmp.oxfordjournals.org/ at Fondazione Centro S. Raffaele del Monte Tabor on June 27, 2012 IVSIVHddV IVDIUHD V '£ Di}STATpnpap-uou pire B p moAej ur paDnpai ;ui{Mainos ajopjaip ST sauoavp jo ajoj aqx saseD jo u o p n p s aip in ; p s a j ;eip sanj^A UOUIUIOD jpijdun asoip jo uotjiu§o3aj aip s>pas ;T fsaDijDUjd jepos jno in pappaquia Xjpn^De aie ;eq; sSimreaui p i o u i aip jo -jajin avp pue sisXpire a ^ o;in pauin; snq; si uoisuainrp ai[X 'papunoiS Apuaiajjrp 's^uasuoD Xireui siavpuS ;eip uoispap 0} uoisaijpe p u o s i a d B a^A^oin oj japio in Ajuo aAispap uajjo saurp ^uajajjrp ;u jireAajai sa^dpinid snoiSijai ' d\]\ :saseD aj§urs aip jo STSAJBUE a^aiDuoD ai sajnj pue sajdpinid aip n p sinjsp XjsnoiAajd o; ajqissodun si DijjDads pure suoruido su{ I^TM sa;nqixjuoD o; ssaDOjd D^nauainian ire q§noji{; dou\d sa>[e; jepos aip jo ;uauissassc jeioin aip "MaiA siq; uj -sDnpaoiq jo ijireuTjdpsTpiajin am SUTUIJIJJB stsaip aip o; aDuaiajaj jo ^inod pD -xipa^aui lua^srsuoD e saAiS ipeojdde Di^smsPD aip 'uoisnpuoD uj '(9£ ' d 1661 'SBJJJV) ^^ajipdun gurpeijsqi?, aip JOJ saDTAap Diuouiainn Xpueij JO sapu pa;cj;snnj ajaui ajoui vjDnui die saseD 'sjsmsBD J O JuotjDnnsi • n jo poi{;aui ^ spuuuiap Xj^smsED 'umnDBA jEDxpeid e in ;q§np; aq pniOD sajdpinid asoijM 'MB^ ireuio^j pire uisiAipnpap o; XrcijuoD,, ' s e u y Xq pa^ou s y sas^D j^piDT;jEd in saSpnf jo suoispap ppipnf snoiAajd 04 siajai ;nq '(ajduiexa JOJ 'Xje^i in asBD aip si SE) paijdde aq 04 SA\UJ aq; jo aip sure^uoD ipiijM. apoD e Xq paiuaAoS jou ST UT MV\ ireUIO^[ JO }Flfl. iflTM S^SeXlUOD Saj uoxes-ojSuy atp jo Auouiixied uounnoD aip jo uia^ed aq; SMOJJOJ uoTjeTnuiioj 3AT;EUIJOU -siuaumSje A\au pire aSpajMOiDj Mau 'saDuauadxa Mau jo jirSij aip in uopB^ajdia^inaj pire uoisiAai o; uado XTjextuDnj^s die aAiiap Xaip sajdpinjd aip 'sauoaip rejauaS jo uopppunua 3ip oj ireip jaijrej 'sas^D jo sisXreire aip o; pa;oAap Xpadojd -saixjunoD ;uajajjrp aip jo 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 Downloaded from http://jmp.oxfordjournals.org/ at Fondazione Centro S. Raffaele del Monte Tabor on June 27, 2012 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. 94 Massimo Reichlin Downloaded from http://jmp.oxfordjournals.org/ at Fondazione Centro S. Raffaele del Monte Tabor on June 27, 2012 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 Downloaded from http://jmp.oxfordjournals.org/ at Fondazione Centro S. Raffaele del Monte Tabor on June 27, 2012 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 96 Massimo Reichlin those who specifically and professionally deal with moral philosophy. 3.2 The clinical side Downloaded from http://jmp.oxfordjournals.org/ at Fondazione Centro S. Raffaele del Monte Tabor on June 27, 2012 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 97 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 Downloaded from http://jmp.oxfordjournals.org/ at Fondazione Centro S. Raffaele del Monte Tabor on June 27, 2012 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. 98 Massimo Reichlin Downloaded from http://jmp.oxfordjournals.org/ at Fondazione Centro S. Raffaele del Monte Tabor on June 27, 2012 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 Downloaded from http://jmp.oxfordjournals.org/ at Fondazione Centro S. Raffaele del Monte Tabor on June 27, 2012 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. 100 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. Downloaded from http://jmp.oxfordjournals.org/ at Fondazione Centro S. Raffaele del Monte Tabor on June 27, 2012 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.