Jeffrey Bishop

Erratum to: Echo Calling Narcissus: What Exceeds the Gaze of Clinical Ethics Consultation? Content Type Journal Article Pages 171-171 DOI 10.1007/s10730-010-9132-7 Authors Jeffrey P. Bishop, Saint Louis University Tenet Chair of Health Care Ethics, Albert Gnaegi Center for Health Care Ethics Salus Center, Room 527, 3545 Lafayette Ave St. Louis MO 63104-1314 USA Joseph B. Fanning, Vanderbilt University Center for Biomedical Ethics and Society 2525 West End Ave., 4th Floor, Suite 400 Nashville TN 37203 USA Mark J. Bliton, Vanderbilt University Center for Biomedical Ethics and Society 2525 West End Ave., 4th Floor, Suite 400 Nashville TN 37203 USA Journal HEC Forum Online ISSN 1572-8498 Print ISSN 0956-2737 Journal Volume Volume 22 Journal Issue Volume 22, Number 2

Compelled by recent public and politicized cases in which withdrawal of nutrition and hydration were at issue, this essay examines recent Church statements and argues that the distinction between private and public forms of human life is being lost. Effacing the distinction between the sphere of the home (oikos), where the maintenance of life (zoē) occurs, and the city (polis), where political and public life (bios) occurs, may have unforeseen and unwanted consequences. Through their well-intentioned efforts to preserve the sanctity of life, certain bishops and the Congregation for the Doctrine of the Faith have unfortunately brought political considerations into the home, taking decision-making authority away from those most intimately related to the patient. Thus, the question of removing nutrition and hydration in the case of patients such as Schiavo and Englaro becomes politicized and abstract, in contrast with the Church's previous positions on the importance of proportionate means in the maintenance of life, local decision making, and its recognition of life as a penultimate end

This paper examines the historical rise of both cardiopulmonary resuscitation and the do-not-resuscitate order and the wisdom of their continuing status in U.S. hospital practice and policy. The practice of universal presumed consent to CPR and the resulting DNR policy are the products of a particular time and were responses to particular problems. In order to keep the excesses of technology in check, the DNR policies emerged as a response to the in-hospital universal presumed consent to CPR. We live with this historical concretion, which seems to perpetuate a false culture that the patient's wishes must be followed. The authors are critical of the current U.S. climate, where CPR and DNR are viewed as two among a panoply of patient choices, and point to UK practice as an alternative. They conclude that physicians in the United States should radically rethink approaches to CPR and DNR.

In the mid-1970s, the biomedical model of medicine gave way to the biopsychosocial model of medicine; it was billed as a more comprehensive and compassionate model of medicine. After more than a century of disentangling medicine from religion, the medicine and spirituality movement is attempting to bring religion and spirituality back into medicine. It is doing so under a biopsychosociospiritual model. I unpack one model for allowing religion back into medicine called the RCOPE. RCOPE is an instrument designed to categorize religion and spirituality as psychological coping mechanisms. I explore how such instruments are related to the history of statistical measurement and demonstrate the political impetus that governs such enterprises. The biopsychosociospiritual medicine is billed as a more holistic and comprehensive model. This new model of medicine offers total care. However, I demonstrate how this total care becomes totalizing, indeed totalitarian, admitting religion and spirituality back into the fold of medicine under a new secularized medical control

Tolerance is at the heart of Western liberalism, permitting mutually exclusive ideas and practices to coexist peacefully with one another, without the proponents of the differing ideas and practices killing one another. Yet, nothing challenges tolerance like the practice of sunna, female circumcision, clitorectomy, or genital mutilation. In this essay, I critique the Western critics of the practices, not in order to defend these practices, but rather to show that Western liberalism itself does not offer transcultural and transtemporal principles, for these principles only cohere within the tradition of liberalism. The Western critique of sunna often maps onto the bodies of African women Western symbolic notions of sexual and political freedom, as symbolized in the clitoris. The practices of sunna cohere within the web of beliefs, the tradition, of those who practice them and, thus, are rationally justified within those traditions. I offer Alasdair MacIntyre's notion of moral inquiry as a guide through the complex world of cultural and moral dialogue between differing traditions.

Of Goals and Goods and Floundering About: A Dissensus Report on Clinical Ethics Consultation Content Type Journal Article Pages 275-291 DOI 10.1007/s10730-009-9101-1 Authors Jeffrey P. Bishop, Vanderbilt University Center for Biomedical Ethics and Society 2525 West End Avenue, Suite 400 Nashville Tennessee 37203 USA Joseph B. Fanning, Vanderbilt University Center for Biomedical Ethics and Society 2525 West End Avenue, Suite 400 Nashville Tennessee 37203 USA Mark J. Bliton, Vanderbilt University Center for Biomedical Ethics and Society 2525 West End Avenue, Suite 400 Nashville Tennessee 37203 USA Journal HEC Forum Online ISSN 1572-8498 Print ISSN 0956-2737 Journal Volume Volume 21 Journal Issue Volume 21, Number 3

The call for a narrative medicine has been touted as the cure-all for an increasingly mechanical medicine. It has been claimed that the humanities might create more empathic, reflective, professional and trustworthy doctors. In other words, we can once again humanise medicine through the addition of humanities. In this essay, I explore how the humanities, particularly narrative medicine, appeals to the metaphysical commitments of the medical institution in order to find its justification, and in so doing, perpetuates a dualism of humanity that would have humanism as the counterpoint to the biopsychosociologisms of our day

The doctrine of the mature minor began as an emergency exception to the rule of parental consent. Over time, the doctrine crept into cases that were non-emergent. In this essay, we show how the doctrine also developed in the context of the latter part of the 20th century, at the same time that the sexual revolution, the pill, and sexual liberation came to be seen as important symbols of female liberation—liberation that required that female minors be granted the status of a mature minor. To do so moves sexual morality out of the domain of the family, where it had always been situated, and into the domain of the state. We also show how a phenomenological account of the care of the body in the family conforms to the latest in neuroscientific understandings of adolescent brain development. The family attenuates the dependency of adolescents and provides an important social contextualization for the care of the body, including the inculcation of sexual mores in adolescence. We conclude that the drive to push sexual decision making as a matter of state concern further undermines the foundations of the moral meanings of sex and sexuality

Humanity does not gradually progress from combat to combat until it arrives at universal reciprocity, where the rule of law finally replaces warfare; humanity installs each of its violences in a system of rules and thus proceeds from domination to domination. (Foucault, 1984, 85)In this essay, I take a note from Michel Foucault regarding the notion of biopolitics. For Foucault, biopolitics has both repressive and constitutive properties. Foucault's claim is that with the rise of modern government, the state became exceedingly concerned about the body politic, the bodies that make up the polis, including the health of those bodies. However, Giorgio Agamben claims that Foucault and all western political philosophy misses the relationship between power and Sovereignty, with disastrous results and totalizing tendencies. I explore the case of Terri Schiavo claiming that the social conservatives have attempted to politicize bare life in its legal maneuverings, but I also show how the social liberals open an uncontrollable space between life and death. Both the left and the right miss the aporia at the heart of western political philosophy, and bioethics is complicit in the totalizing effects of contemporary medicine

Voluntary active euthanasia and physician assisted suicide should not be legalised because too much that is important about living and dying will be lostIn the first of this two part series, I unpack the historical philosophical distinction between killing and allowing a patient to die in order to clear up the confusion that exists. Historically speaking the two kinds of actions are morally distinct because of older notions of causality and human agency. We no longer understand that distinction primarily because we have shifted our notions of causality from a traditional formulation to a modern formulation of causality and thus of moral assessment that focuses on the effects of an action. In this essay, I prepare the ground for a companion essay by showing that the traditional formulation allows us to maintain notions of meaning and purpose to human living and dying that are precluded in the efficiency paradigm of modernity. Taken together with the companion essay, I am claiming that voluntary active euthanasia and physician assisted suicide should not be legalised because too much that is important about dying and living will be lost.TWO LIESIt would be naïve to think that euthanasia, in either the VAE sense, or in the more passive sense of PAS, does not happen. It would even be naïve to think that it does not occur in a non-voluntary form. It would be equally naïve, however, to think it could be controlled through governmental regulation. The real question with regard to PAS/VAE, put so eloquently by Martha Minow, is which lie do you countenance: the lie that euthanasia does not already happen, or the lie that it can be controlled without having repercussions well beyond the limits of procedural mastery?1 With this two part paper series, I will argue that the …

This paper examines the historical rise of both cardiopulmonary resuscitation and the do-not-resuscitate order and the wisdom of their continuing status in U.S. hospital practice and policy. The practice of universal presumed consent to CPR and the resulting DNR policy are the products of a particular time and were responses to particular problems. In order to keep the excesses of technology in check, the DNR policies emerged as a response to the in-hospital universal presumed consent to CPR. We live with this historical concretion, which seems to perpetuate a false culture that the patient's wishes must be followed. The authors are critical of the current U.S. climate, where CPR and DNR are viewed as two among a panoply of patient choices, and point to UK practice as an alternative. They conclude that physicians in the United States should radically rethink approaches to CPR and DNR.

This essay places Foucault's work into a philosophical context, recognizing that Foucault is difficult to place and demonstrates that Foucault remains in the Kantian tradition of philosophy, even if he sits at the margins of that tradition. For Kant, the forms of intuition—space and time—are the a priori conditions of the possibility of human experience and knowledge. For Foucault, the a priori conditions are political space and historical time. Foucault sees political space as central to understanding both the subject and objects of medicine, psychiatry, and the social sciences. Through this analysis one can see that medicine's metaphysics is a metaphysics of efficient causation, where medicine's objects are subjected to mechanisms of efficient control

Guiding our response in this essay is our view that current efforts to demarcate the role of the clinical ethicist risk reducing its complex network of authorizations to sites of power and payment. In turn, the role becomes susceptible to various ideologies—individualisms, proceduralisms, secularisms—that further divide the body from the web of significances that matter to that body, where only she, the patient, is located. The security of policy, standards, and employment will pull against and eventually sever the authorization secured by authentic moral inquiry. Instead of asking “What do I need to know?”, the question animating the drive to standardize will be “What is the policy or standard?” The claims of the authors in this issue of HEC Forum confirm these suspicions.

Death cannot be mastered through a metaphysics of efficiency that interprets all actions in terms only of cause and effect, but it can be transcended if we leave the frame open to death’s ambiguityIn the second of this two part series, I describe how in shifting our frames from one of human purpose and meaning to one of efficiency, we shift the possible answers we get to our questions about voluntary active euthanasia and physician assisted suicide . Thus, by placing VAE/PAS within the frame of efficiency, we narrow our focus to the final effect in the world of cause and effect—namely death. Thus, in ensconcing euthanasia within a legal framework meant to instrumentally and efficiently control euthanasia, we are in fact narrowing our focus on death. Thus, in legalising VAE/PAS we are not just adding one choice to a panoply of other choices, we are in fact changing the nature of all choices, for each choice conditions all others. We should therefore live with the lie that VAE/PAS do not happen as opposed to living with the lie that through efficient legal control we protect patients from medical dominance.AN ANECDOTESeveral years ago an acquaintance told me about a terrible situation in which he found himself during the Vietnam war. He was Green Beret—one of the elite special forces corps of the US army. He was in an area that was officially off limits to the US. His unit came under heavy fire and a buddy was shot in several places but was still alive. His comrade was in serious pain, but what scared him the most was that he might die in the jungle, be eaten by a wild animal, or be captured by the enemy. There was no way to get him out. The wounded soldier …

Technology is evolving at a rate faster than human evolution, especially human moral evolution. There are those who claim that we must morally bioenhance the human due to existential threats (such as climate change and the looming possibility of cognitive enhancement) and due to the fact that the human animal has a weak moral will. To address these existential threats, we must design human morality into human beings technologically. By moral bioenhancement, these authors mean that we must intervene technologically in the biology of the human animal in order to get it to behave morally to address these existential threats. I will bring the idea of moral bioenhancement into conversation with two philosophers of technology. Bernard Stiegler has argued that technology and culture, and thus technology and human beings, have always evolved hand in hand. Peter-Paul Verbeek notes that we have always designed morality into technology, and thus he sees technology as mediating human morality. When we offload human intentionality onto technology, Verbeek argues, technological objects and systems participate in shaping the moral subjectivity of the human actor. I will show that modern technological bioenhancement obliterates human being. Whereas in the past, human culture was handed from generation to generation through the mediation of technology, in the modern era, the human becomes the raw material upon which a technological will (imperative) rides.

What is morality? Is “morality” something that admits of technological enhancement? What could it possibly mean for a society to have a moral imperative to morally enhance? We are compelled to take up questions like these as we move into the future of moral bioenhancement. Each article in this issue of the Journal of Medicine and Philosophy attempts to bring some clarity as to what is meant by morality, such that one could be morally obligated to morally enhance. These articles broaden the scope of the question as to the nature of human morality, what might and what might not be permitted in terms of moral bioenhancement, and explore the nature of the kinds of beings humans might become—whether human or post-human—and the moral obligations that may exist toward them.

E. Haavi Morreim's book, Holding Health Care Accountable , insightfully describes several features of the current crisis in malpractice in relation to the health care marketplace. In this essay, I delineate the key and eminently practical guide for reform that she lays out. I argue that her insights bring us to more fundamental aspects than immanent medical economy and accountability - aspects that are ignored at present. I describe the features of immanent economy and how they tend to cover over epistemological and existential finitude in medicine, show how economy can in fact create new medical knowledge, and show that necessary error is a real feature of day-to-day medical practice. The current system, even with Morreim's reforms, remains at the level of immanent economy, but with modifications may point to the features of medicine that transcend medical knowledge and economy. The gifts of medicine cannot be reduced to the immanent medical economy, and any attempt to do so results in crisis. A health care that points to finitude and fallibility is one that points to the mystery of human existence and mortality. Any health care financing system that helps to delineate finitude - both epistemological and existential - is one that will give patients a new lease on living and dying.

The essays in this issue of JMP are devoted to critical engagement of my book, The Anticipatory Corpse. The essays, for the most part, accept the main thrust of my critique of medicine. The main thrust of the criticism is whether the scope of the critique is too totalizing, and whether the proposed remedy is sufficient. I greatly appreciate these interventions because they allow me this occasion to respond and clarify, and to even further extend the argument of my book. In this response essay, I maintain that the regnant social imaginary of medicine is the regnant social imaginary of our time. It is grounded in a specific ontotheology: where ontology is a power ontology; where material is malleable to the open-ended organization of power and dependent only on working out the efficient mechanisms of its enactment; where ethically it is oriented only to the immanent telos of utility maximization in the short run, and ultimately to some posthuman future in the long run. This ontotheology originates in the anticipatory corpse and is ordered toward some god-like posthuman being. The entire ontotheology finds enactment through the political economy of neoliberalism. This social imaginary constantly works to insulate itself from other social imaginaries through the use of its institutional power, through marginalization, circumscription, or absorption. The modern social imaginary of neoliberal societies marginalizes and politically isolates other social imaginaries, or transforms them into something acceptable to the neoliberal imaginary. Yet, these other social imaginaries could influence the larger social imaginary in novel ways, sometimes through withdrawal and sometimes through challenges. These other practices—again, usually practices ordered according to different ontological and teleological purposes—might serve as a source of renewal and transformation, but only if the practitioners of these other social imaginaries understand the ontotheological powers that they are up against.

Full-Blooded religion is not acceptable in mainstream bioethics. This article excavates the cultural history that led to the suppression of religion in bioethics. Bioethicists typically fall into one of the following camps. 1) The irreligious, who advocate for suppressing religion, as do Timothy F. Murphy, Sam Harris, and Richard Dawkins. This irreligious camp assumes American Fundamentalist Protestantism is the real substance of all religions. 2) Religious bioethicists, who defend religion by emphasizing its functions and diminishing its metaphysical commitments. Religious defenders empty religion of its theology to present its feel-good functions in a way that is acceptable to the irreligious. However, religion reduced to its functions dissolves into a counter-culture that may counteract materialism but lacks the power to motivate much more. This article criticizes both camps, as both presume Enlightenment myths and consequently neuter religion. Both irreligious and religious bioethicists commonly presume Enlightenment myths about secularity and religion. Secularity is presumed neutral and rational. Religion is presumed divisive and irrational. This myth provides built-in value-judgements; we have already judged secularity as good and religion as bad. Much of the debate over religion in bioethics is arguing over false stereotypes of religion. Consequently, mainstream bioethics neuters religion, while the irreligious are gifted political power to define the field.