Allen Buchanan

Many philosophers invoke the "wisdom of nature" in arguing for varying degrees of caution in the development and use of genetic enhancement technologies. Because they view natural selection as akin to a master engineer that creates functionally and morally optimal design, these authors tend to regard genetic intervention with suspicion. In Part II, we examine and ultimately reject the evolutionary assumptions that underlie the master engineer analogy (MEA). By highlighting the constraints on ordinary unassisted evolution, we show how intentional genetic modification can overcome many of the natural impediments to the human good. Our contention is that genetic engineering offers a solution that is more eff icient, reliable, versatile, and morally palatable than the lumbering juggernaut of Darwinian evolution. In Part III, we evaluate a recent attempt to ground precautionary enhancement heuristics in adaptive etiology. Our problem with this approach is two-fold: first, it is based on the same "strong adaptationist" interpretation of evolution that motivates the flawed MEA, and second, the etiological concept of function on which it relies provides indirect and potentially misleading information about the likely consequences of genetic intervention. We offer instead enhancement criteria based on causal relationships in ontogeny. We conclude that rather than grounding a presumption against deliberate genetic modification, the causal structure of the living world gives us good moral reason to pursue it

All theories of the right to secede either understand the right as a remedial right only or also recognize a primary right to secede. By a right in this context is meant a general, not a special, right (one generated through promising, contract, or some special relationship). Remedial Right Only Theories assert that a group has a general right to secede if and only if it has suffered certain injustices, for which secession is the appropriate remedy of last resort.1 Different Remedial Right Only Theories identify different injustices as warranting the remedy of secession.

Much of the debate about the ethics of enhancement has proceeded according to two framing assumptions. The first is that although enhancement carries large social risks, the chief benefits of enhancement are to those who are enhanced (or their parents, in the case of enhancing the traits of children). The second is that, because we now understand the wrongs of state-driven eugenics, enhancements, at least in liberal societies, will be personal goods, chosen or not chosen in a market for enhancement services. This article argues that both framing assumptions must be rejected, once it is understood that some enhancements— especially those that are most likely to garner resources and become widespread— will increase human productivity. Once one appreciates the productivity-increasing potential of enhancements, one can begin to see that enhancement need not be primarily a zero sum affair, that the social costs of forgoing enhancements may be great, and that the state may well take an interest in facilitating biomedical enhancements, just as it does in facilitating education and other productivity-increasing traditional enhancements. Appreciating the productivity-increasing potential of enhancements also makes it possible to view the enhancement debate in a new light, through the lens of the ethics of development.

The distinctive aim of applied ethics is to provide guidance as to how we ought to act, as individuals and as shapers of social policies. In this essay, I argue that applied ethics as currently practiced is inadequate and ought to be transformed to incorporate what I shall call social moral epistemology. This is a branch of social epistemology, the study of the social practices and institutions that promote the formation, preservation, and transmission of true beliefs. For example, social epistemologists critically evaluate the comparative advantages of adversarial versus inquisitorial criminal proceedings as mechanisms for the discovery of truth.

While acknowledging the potential benefits of pharmacogenomics as a methodology, a number of comprehensive reports in the past several years examine a multitude of ethical, legal, and social factors that may limit the extent to which these benefits are realized — and realized in ethically acceptable ways. This article aims to identify and explore the most basic ethical and regulatory issues that are likely to arise if pharmacogenomics becomes widely enough used to have a significant impact on research and clinical practice. First, however, it addresses the question of whether pharmacogenomic tests are unique when compared to other genetic tests and thus deserving of more or less stringent ethical and regulatory requirements.

When advocates of insurance‐privatization consider whether private insurance‐dominated systems achieve justice at all, they tend to rely on an incomplete set of criteria for a just healthcare system. They also mistakenly assume that it is enough to show that justice is in principle achievable within a private insurance‐dominated system. This essay offers a more complete set of criteria for a just healthcare system. It then argues that the motivational assumptions needed to make insurance‐privatization at all plausible are inconsistent with the motivational assumptions needed to show that in practice a private insurance‐dominated system will achieve justice. A private insurance‐dominated system can be expected to satisfy the criteria for just healthcare only if there is extensive and effective regulation to constrain the normal competitive behavior of private insurers or if generous public funds are provided to fill the gaps in access left by the private insurance market. Yet the assumptions about the motivations and abilities of the public, regulators, and public officials needed to satisfy conditions or contradict the privatization advocate's explanations of how privatization will maximize efficiency, choice, and quality of care

Among analytic philosophers in the past few years there has been a growing commitment to taking Marx seriously. Since the publication in 1971 of John Rawls’ book A Theory of Justice there has been a growing commitment to taking problems of Justice and rights seriously. These two developments intersect in mutual criticism: Marx's radical critique challenges the resources of recent theories of rights and Justice, while the sophistication of recent theories raises the possibility that they escape Marx's most basic criticism.

Appeals to the idea of human nature are frequent in the voluminous literature on the ethics of enhancing human beings through biotechnology. Two chief concerns about the impact of enhancements on human nature have been voiced. The first is that enhancement may alter or destroy human nature. The second is that if enhancement alters or destroys human nature, this will undercut our ability to ascertain the good because, for us, the good is determined by our nature. The first concern assumes that altering or destroying human nature is in itself a bad thing. The second concern assumes that human nature provides a standard without which we cannot make coherent, defensible judgments about what is good. I will argue (1) that there is nothing wrong, per se, with altering or destroying human nature, because, on a plausible understanding of what human nature is, it contains bad as well as good characteristics and there is no reason to believe that eliminating some of the bad would so imperil the good as to make the elimination of the bad impermissible, and (2) that altering or destroying human nature need not result in the loss of our ability to make judgments about the good, because we possess a conception of the good by which we can and do evaluate human nature. I will argue that appeals to human nature tend to obscure rather than illuminate the debate over the ethics of enhancement and can be eliminated in favor of more cogent considerations.

This book is the most comprehensive treatment available of one of the most urgent - and yet in some respects most neglected - problems in bioethics: decision-making for incompetents. Part I develops a general theory for making treatment and care decisions for patients who are not competent to decide for themselves. It provides an in-depth analysis of competence, articulates and defends a coherent set of principles to specify suitable surrogate decisionmakers and to guide their choices, examines the value of advance directives, and investigates the role that considerations of cost ought to play in decisions concerning incompetents. Part II applies this theoretical framework to the distinctive problems of three important classes of individuals, many of whom are incompetent: minors, the elderly and psychiatric patients. The authors' approach combines a probing analysis of fundamental issues in ethical theory with a sensitive awareness of the concrete realities of health care institutions and the highly personal and individual character of difficult practical problems. Its broad scope will appeal to health professionals, moral philosophers and lawyers alike.

Our society has long sanctioned, at least tacitly, a degree of conflict of interest in medical practice and clinical research as an unavoidable consequence of the different interests of the physician or clinical investigator, the patient or clinical research subject, third party payers or research sponsors, the government, and society as a whole, to name a few. In the past, resolution of these conflicts has been left to the conscience of the individual physician or clinical investigator and to professional organizations. The public is no longer willing to allow health care providers to wholly govern their own conflicts of interest for several reasons. These include: new forms of health care financing and delivery that provide innovative and lucrative opportunities for physician or insurer enrichment at patient expense; the increased importance of commercial research support as peer-reviewed governmental research support has decreased; evidence that physicians and clinical investigators too frequently resolve conflicts of interest in their own favor; and a general societal mistrust of authority. This volume represents a multidisciplinary effort, drawing from philosophy, medicine, law, economics and public policy to identify and categorize conflicts of interest in medical practice and clinical research, and, where possible, to offer a mechanism for resolving them. Part I addresses conflicts of interest from a theoretical perspective, offering basic concepts and analytical frameworks. The second part discusses two topics prominent in current health care policy debates--self-referral and financial incentives to limit care. Part III examines conflicts of interest generated by pharmaceutical industry involvement in clinical practice and research. The final section deals with conflicts of interest in clinical research in several contexts, including institutional reviews boards, clinical trials, Cooperative Research and Development Agreements between government and private researchers, brokerage of research subjects by Contract Research Organizations, and cost-effectiveness studies.

: Two basic criticisms of managed care are that it erodes patient trust in physicians and subjects physicians to incentives and pressures that compromise the physician's fiduciary obligation to the patient. In this article, I first distinguish between status trust and merit trust, and then argue (1) that the value of status trust in physicians is probably over-rated and certainly underdocumented; (2) that erosion of status trust may not be detrimental if accompanied by an increase in well-founded merit trust; and (3) that under conditions of managed care the physician's commitment to traditional medical ethics cannot serve as an adequate basis for merit trust. Next, drawing on an analogy between managed care organizations and polities, I argue that (4) the most appropriate basis for merit trust in managed care is a conception of organizational legitimacy that includes procedural justice, empowerment of constructive criticism within the organization, and organizational accommodation of the noninstrumental commitment to patient well-being that is distinctive of medical professionalism. I then explore the conditions necessary for robust competition for merit trust among managed care organizations and indicate the kinds of public policies needed to facilitate such competition. Finally, I show how the account of organization-based merit trust can accommodate the special fiduciary obligation of medical professionals, without indulging in the delusion that it is the physician's fiduciary obligation always to provide all care that is expected to be of any net benefit to the patient.

This book, written by four internationally renowned bioethicists and first published in 2000, was the first systematic treatment of the fundamental ethical issues underlying the application of genetic technologies to human beings. Probing the implications of the remarkable advances in genetics, the authors ask how should these affect our understanding of distributive justice, equality of opportunity, the rights and obligations as parents, the meaning of disability, and the role of the concept of human nature in ethical theory and practice. The book offers a historical context to contemporary debate over the use of these technologies by examining the eugenics movement of the late nineteenth and early twentieth centuries. The questions raised in this book will be of interest to any reflective reader concerned about science and society and the rapid development of biotechnology, as well as to professionals in such areas as philosophy, bioethics, medical ethics, health management, law, and political science.

What limitations on intervention in support of democratic revolutions does proper regard for the collective right of self-determination impose? Some have held that if intervention in support of democratic revolutions is justified, it must cease once the authoritarian regime has been deposed—that any effort by the intervener to use force to shape the new political order would violate the people’s right of self-determination. This essay argues that proper regard for self-determination is compatible with much more extensive interventions