Matthew Shea

Unrepresented patients cannot make their own medical decisions and do not have any surrogate decision-maker. This patient population is highly vulnerable to being harmed, wronged, ignored, and exploited. But the ethical issues related to their care have gotten little attention from Christian bioethicists, which is problematic in light of Christianity’s concern for the poor, the needy, and the vulnerable. This article claims that Christian bioethicists must address these issues, and that Christian morality demands an approach that is different from the status quo. First, it lays out moral principles pertaining to the care of unrepresented patients, focusing on the special obligation to prioritize and protect the vulnerable. Second, it applies these principles to one major ethical problem—the appropriate decision-maker for unrepresented patients—arguing that Christians should favor institutional committees instead of the conventional practices of courts and clinicians.

The value of human life has a central importance in bioethics and in the Thomistic natural law tradition, but its meaning is often ambiguous. It can refer to the value of human _life itself_, the value of a person’s _life_, or the value of _the person_ whose life it is. These are different kinds of value, but they are often overlooked or conflated in the literature. This article aims to clarify and develop natural law ethics by analyzing two goods associated with the value of life: well-being and dignity. It critiques the mainstream welfarist axiology that makes well-being the sole fundamental good, and it proposes an alternative axiology consisting of two intrinsic goods: well-being and dignity. It argues that this dual value theory is a better account of the value of life, the value of persons, the moral equality of human beings, and the metaphysics of goodness.

Tom Beauchamp’s contributions to the field of bioethics are as influential as they are numerous. Here we reflect on his intellectual legacy, specifically his role in establishing principlism as a method of bioethical analysis. Despite its prominence in medical ethics education, in our experience as clinical ethicists and researchers, we rarely analyze ethical issues the way principlism suggests, either in the clinic or our scholarship. In this paper, we consider the complex ways in which principlism may fruitfully relate to other approaches to ethical analysis in clinical ethics (e.g., the four-box method) as well as its relative strengths and drawbacks pedagogically, explanatorily, and translationally. We conclude with some reflections about the intellectual flexibility of principlism and its role in fostering interdisciplinary bioethics.

Thomas Aquinas was one of the greatest philosophers and theologians of the medieval period, and his account of happiness is one of the most influential in the Western tradition. For Aquinas, happiness is the final end and highest good that all of us seek in life. But not everyone agrees about what makes human beings happy. This piece is an exposition and commentary on Aquinas’s Summa Theologiae, Part I-II, Question 2, which asks the question: What does happiness consist in? What is the final end and highest good that fulfills our human nature and satisfies our desires? Aquinas examines various answers, including wealth, honor, fame, glory, power, pleasure, life, health, knowledge, and virtue. He argues that none of these things can make us perfectly happy, and that true and perfect happiness is found in God alone.

This book explores the connection between God and happiness, with happiness understood as a life of well-being or flourishing that goes well for the one living it. It provides a historical and contemporary survey of philosophical questions, theories, and debates about happiness, and it asks how they should be answered and evaluated from a theistic perspective. The central topics it covers are the nature of happiness (what is it?), the content of happiness (what are the constituents of a happy life?), the structure of happiness (is there a hierarchy of goods?), and the possibility of happiness (can we be happy?). It argues that God's existence has significant, positive, and desirable implications for human happiness.

The concept ethics defines health care ethics as a professional practice. Yet the meaning of “ethics” is often unclear in the theory and practice of clinical ethics. Clarity on this matter is crucial for understanding the nature of clinical ethics and for debates about the professional identity and proper role of ethicists, the sort of training and skills they should possess, and whether they have ethics expertise. This article examines two different ways the ethics of clinical ethics can be understood: Real Ethics, which consists of objective moral norms grounded in moral truth; and Conventional Ethics, which consists of conventional norms grounded in bioethical consensus. Drawing on the bioethics literature and features of professional practice, it shows that Conventional Ethics is the dominant paradigm. Then it presents a critique of Conventional Ethics, arguing that it cannot avoid the challenge of moral pluralism, it fails to address vitally important moral questions, and it is incapable of providing an essential service to the people ethicists aim to help. It ends with suggestions about how the practice of clinical ethics might overcome these problems.

There has been increasing awareness of the medical and moral challenges in the care of unrepresented patients: those who cannot make their own medical decisions, do not have any surrogate decision maker, and have not indicated their treatment preferences. Most discussions have focused on procedural questions such as who should make decisions for these patients. An issue that has not gotten enough attention is the ethical standard that should govern medical decision making. I explore the question of which ethical standard provides better justification for end-of-life decisions for unrepresented patients. Two options are considered: the conventional and less demanding best interest standard, and the novel and more demanding medical futility standard. I explain the similarities and differences between these two standards, examine arguments for and against each one, and suggest that the medical futility standard is ethically superior and should replace the established best interest standard.

The foundation of natural law ethics is a set of basic human goods, such as life and health, knowledge, work and play, appreciation of beauty, friendship, and religion. A disputed question among natural law theorists is whether the basic goods are “incommensurable.” But there is widespread ambiguity in the natural law literature about what incommensurability means, which makes it unclear how this disagreement should be understood and resolved. First, I clear up this ambiguity by distinguishing between incommensurability and incomparability. I show that proponents of New Natural Law Theory hold that basic goods are both incommensurable and incomparable, whereas proponents of Classical Natural Law Theory hold that basic goods are incommensurable but comparable. Second, I critique the leading New Natural Law arguments for the incomparability of basic goods. Throughout the article, I explain why value incommensurability is an essential feature of natural law ethics but value incomparability is not.

The foundation of natural law ethics is a set of basic human goods, such as life and health, knowledge, work and play, the appreciation of beauty, friendship, and religion. A disputed question among natural law theorists is whether the basic goods can be measured or compared in terms of their value. Proponents of New Natural Law Theory, the best-known version in the contemporary literature, hold that basic goods are both incommensurable and incomparable. Proponents of Classical Natural Law Theory, the historically mainstream version, maintain that basic goods are incommensurable but comparable. I make a case for the comparability of basic goods, arguing that commonsense moral intuitions about human flourishing and analysis of how we resolve moral conflicts provide good reasons to affirm that basic goods are comparable and that some goods are more valuable than others.

Perfectionism is the view that what is intrinsically good is the fulfillment of human nature or the development and exercise of the characteristic human capacities. An important objection to the theory is what Gwen Bradford calls the “Deep Problem”: explaining why nature-fulfillment is good. We argue that situating perfectionism within a Thomistic metaethical framework and adopting Aquinas's account of the metaphysical “convertibility” of being and goodness gives us a solution to the Deep Problem. In short, the fulfillment of human nature consists in the actualization of human potentialities or fullness of human being, and because being is ultimately the same thing as goodness, the fulfillment of human nature is good. We show that Thomistic perfectionism meets the requirements for an answer to the Deep Problem, provides the best explanation possible for the goodness of nature fulfillment, and is a natural foundation for perfectionist theories of value.

When decisionally incapable patients need a surrogate to make medical decisions for them, sometimes the patient has not appointed a healthcare agent and there is intractable disagreement among potential surrogates of equal priority, legal rank, or relation to the patient (e.g., child vs. child, sibling vs. sibling). There is no ethical, legal, or professional consensus about how to identify the appropriate surrogate in such circumstances. This article presents a case study involving an elderly female patient whose four children disagree about whether to continue life-sustaining treatment for their mother, along with an ethical analysis of various strategies for selecting the appropriate surrogate in cases of conflicting equal-rank family members. It critically examines three different strategies—chance, majority rules, and quality of relationship with the patient—and defends the third approach.

Principlism, the bioethical theory championed by Tom Beauchamp and James Childress, is centered on the four moral principles of beneficence, non-maleficence, respect for autonomy, and justice. Two key processes related to these principles are specification—adding specific content to general principles—and balancing—determining the relative weight of conflicting principles. I argue that both of these processes necessarily involve an appeal to human goods and evils, and therefore require a theory of the good. A significant problem with principlism is that it lacks a theory of the good and consequently does not have an adequate solution to the problems of specification and balancing. My conclusion is that principlism must adopt some account of human well-being in order to be a satisfactory bioethical framework.

This special issue commemorates the 40th anniversary of Tom Beauchamp and James Childress’s Principles of Biomedical Ethics with a collection of original essays addressing some of the major themes in the book. It opens with intellectual autobiographies by Beauchamp and Childress themselves. Subsequent articles explore the topics of common morality, specification and balancing of moral principles, virtue, moral status, autonomy, and lists of bioethical principles. The issue closes with a reply by Beauchamp and Childress to the other authors.

This paper explores the relationship between disability and quality of life and some of its implications for bioethics and healthcare. It focuses on the neglected perfectionist approach that ties well-being to the flourishing of human nature, which provides the strongest support for the common view of disability as a harm. After critiquing the traditional Aristotelian version of perfectionism, which excludes the disabled from flourishing by prioritizing rationalistic goods, I defend a new version that prioritizes the social capacities of human nature and the goods of personal relationship. This relationship-centered perfectionism is able to accommodate and explain disabled thriving. I also show how these issues have important implications for specific bioethical debates and clinical practices, using a cluster of issues related to Down syndrome as timely illustrations. My goal is to sketch a perfectionist theory that gives a more plausible account of the relationship between disability and well-being, and that provides better practical guidance in cases involving judgments about the quality of disabled lives.

In a recent paper, Alvin Plantinga defends occasionalism against an important moral objection: if God is the sole direct cause of all the suffering that results from immoral human choices, this causal role is difficult to reconcile with God’s perfect goodness. Plantinga argues that this problem is no worse for occasionalism than for any of the competing views of divine causality; in particular, there is no morally relevant difference between God directly causing suffering and God indirectly causing it. First, we examine Plantinga’s moral parity argument in detail and offer a critical evaluation of it. Then we provide a positive argument, based on the doctrine of doing and allowing, to show why there is a morally relevant difference between God’s direct and indirect causation of suffering.

A serious challenge to religious believers in the Abrahamic traditions is that the God of the Old Testament seems to command immoral actions. Thomas Aquinas addresses this objection using the biblical story of God ordering the Israelites to plunder the Egyptians, which threatens to create an inconsistency among four of Aquinas’s views: God did indeed command this action; God is perfectly good and cannot command any evil actions; the objective moral goodness or badness of actions is not based on arbitrary divine commands; and the prohibition of theft is an immutable principle of the natural moral law. I examine Aquinas’s views on metaethics, stealing, justice, property, and collective responsibility to show that there is not a genuine inconsistency in his position, and that his strategy provides a helpful model for responding to the objection from divinely-sanctioned evil.

I propose and defend a new combination of natural law ethics and virtue epistemology. While all contemporary natural law theories recognize knowledge as one of the basic human goods, none of them provide a detailed explanation for the value of knowledge, which would greatly enrich such theories. I show that virtue epistemology is able to deliver the required solution to the value problem, which makes this combination project very attractive. I also address two major worries about this approach: it commits one to a type of virtue ethics that is incompatible with natural law theory; and it results in a fragmented, pluralistic account of normativity. I attempt to alleviate both worries, arguing that the first is unfounded and the second, while true, is not a genuine cause for concern because the combination of natural law ethics and virtue epistemology is more unified than it may appear.

The articles in this issue cover a wide range of topics, including the moral status of human embryos and human-animal chimeras and hybrids, the determination of death, theories of human cognition, and policies on the identity of mitochondrial donors. Despite this variety, there are two underlying questions that tie the articles together: what is a human being? And, what is the basis of moral status? First, I discuss these two questions and why they are important for bioethics. Then I provide summaries of the six articles in this issue and explain how each of them is connected to the questions of human nature and moral status.

In contemporary discussions of human well-being, well-being is typically understood in secular terms. Analogously, most contemporary discussions of eudaimonistic virtue ethics, influenced by Aristotle, take human flourishing to be a matter of living virtuously, where flourishing and virtue are both secular notions. For many religious believers, however, well-being and virtuous activity involve not just ethical dispositions and actions, but primarily relationship to God. In this paper, I present an alternative eudaimonistic account of well-being that is theological in nature. This view, which I call Thomistic eudaimonism, makes a strong connection between flourishing, virtuous activity, and relationship with God. What is worth considering about this account is that it is able to avoid one of the worst problems for secular, Aristotelian eudaimonism, namely that flourishing and virtue seem to come apart. This is a major strength of Thomistic eudaimonism and a reason to consider it as a theory of well-being.