Mark Fox

In “Harmful Choices, the Case of C, and Decision-Making Competence,” Pickering and colleagues advance an argument in favor of externalism, a view in which the competence of a decision maker is judged relative to factors external to their cognition. In advancing this argument, Pickering and colleagues focus on the external factor of harm: In their view, it is the harmfulness of a considered or chosen action that provides evidence against the competence of the decision maker. However, the proper identification of harmful choices and outcomes remains a demanding task, largely because our understanding of what harm is remains deeply incomplete. Despite 50 years of tempestuous debate, the metaphysics of harm remains an unsettled question. The existence of such a debate does not, in and of itself, provide evidence against the externalist position; rather, it is the theories of harm themselves that pose meaningful challenges for the externalist. Our purpose, here, is to illuminate these challenges.

Clinical bioethics is big business. There are now hundreds of people who bioethics in community and university hospitals, nursing homes, rehabilitation and home care settings, and some who play the role of clinical ethics consultant to transplant teams, managed care companies, and genetic testing firms. Still, there is as much speculation about what clinically active bioethicists actually do as there was ten years ago. Various commentators have pondered the need for training standards, credentials, exams, and malpractice insurance for ethicists engaged in clinical consultation. Much of the discussion seems to accept an implicit presumption that all clinical ethics consultation practices look pretty much alike. But is this accurate? What do clinical ethicists do, how and where do they do it, and what kind of clinical ethics is useful in the hospital and in other settings?

Transplantation has long been recognized as a value-laden enterprise. Consequently, the rhetoric of transplantation has been dominated by a potent moral vocabulary. The themes of gift, altruism, and stewardship are commonly invoked in transplantation practice and policy. These themes have been appropriated by the transplant community with little critical analysis. In light of the historical evolution of transplantation, an evaluation of these themes is warranted, to determine whether they offer substantive insights into contemporary practice. ;This dissertation undertakes such an appraisal, proceeding by way of a phenomenological explication of the operative values shaping transplantation policy and practice. The central contention of this dissertation is that much of the moral language of transplantation is rooted in an experience of transplantation that differs in significant and relevant ways from contemporary practice. The development of an increasingly sophisticated system of organ procurement and sharing presents a profound challenge to the implementation of a stewardship model for organ allocation. Likewise, the structural dichotomy between organ donation and allocation dramatically alters the gift-exchange aspects of organ donation. Ultimately, the uncritical acceptance of the traditional moral vocabulary of transplantation has largely obscured the moral import of transplantation policy and practice