Robert Baker

The central thesis of this article is that by anchoring bioethics' core conceptual armamentarium in a four-principled theory emphasizing autonomy and treating justice as a principle of allocation, theorists inadvertently biased 20th-century bioethical scholarship against addressing such subjects as ableism, anti-Black racism, classism, and other forms of discrimination, placing them outside of the scope of bioethics research and scholarship. It is also claimed that these scope limitations can be traced to the displacement of the nascent concept of respect for persons—a concept designed to address classist and racist discrimination—with the morally solipsistic concept of autonomy.

: Medical ethics often is treated as applied ethics, that is, the application of moral philosophy to ethical issues in medicine. In an earlier paper, we examined instances of moral philosophy's influence on medical ethics. We found the applied ethics model inadequate and sketched an alternative model. On this model, practitioners seeking to change morality "appropriate" concepts and theory fragments from moral philosophy to valorize and justify their innovations. Goldilocks-like, five commentators tasted our offerings. Some found them too cold, since they had already abandoned applied ethics; others too hot, since they still find the applied ethics model to their taste. We reply that the appropriation model offers an empirically testable account of the historical relationship between moral philosophy and medical ethics that explains why practitioners appropriate concepts and fragments from moral philosophy. In contrast, the now fashionable common morality theory neither explains moral change nor why practitioners turn to moral philosophy

In lieu of an abstract, here is a brief excerpt of the content:Negotiating International Bioethics: A Response to Tom Beauchamp and Ruth MacklinRobert Baker (bio)AbstractCan the bioethical theories that have served American bioethics so well, serve international bioethics as well? In two papers in the previous issue of the Kennedy Institute of Ethics Journal, I contend that the form of principlist fundamentalism endorsed by American bioethicists like Tom Beauchamp and Ruth Macklin will not play on an international stage. Deploying techniques of postmodern scholarship, I argue that principlist fundamentalism justifies neither the condemnation of the Nazi doctors at Nuremberg, nor, as the Report of the Advisory Committee on the Human Radiation Experiments (ACHRE) demonstrates, condemnation of Cold War radiation researchers. Principlist fundamentalism thus appears to be philosophically bankrupt. In this issue of the Journal, Beauchamp and Macklin reject this claim, arguing that I have misread the ACHRE report and misunderstood Nazism. They also argue that the form of post-postmodern negotiated human rights theory that I proffer is adequate only insofar as it is itself really fundamentalist; insofar as I take postmodernism seriously, however, I mire international bioethics in relativism. In this response, I reaffirm my anti-fundamentalism, provide further evidence in support of my reading of the ACHRE report, and defend my post-postmodern version of rights theory. I also develop criteria for a minimally adequate theoretical framework for international bioethics.Universal Morality Reconsidered 1Paradoxically, the need for content-full universal moral principles tends to be most deeply felt and most adamantly asserted in the face of striking evidence of their absence. People are inspired to claim that Nazis must accept the universal principle that doing harm is wrong because they are appalled by the horror of the Holocaust. Yet the event itself provides palpable evidence that the Nazis saw no wrong in doing harm. One has the suspicion that claims of universalism [End Page 423] confound philosophical aspirations with empirical observations. This distinction makes a significant difference because empirical claims can be disconfirmed by data, whereas philosophical claims can only be challenged on the level of theory.I am, like Tom Beauchamp and James Childress, a common morality theorist. Thus, I believe, as they do, that ethics “relies heavily on ordinary shared moral beliefs for its content, rather than relying on pure reason, natural law, a special moral sense, and the like” (Beauchamp and Childress 1994, p. 100). For most of human history sexism and slavery were considered moral. They certainly were the norm. Thus, if one looks to common morality as the source of moral content, empirical claims of moral universalism appear suspect. Insofar as one would condemn sexism and slavery, one needs to find some theoretical justification for condemnation that goes beyond a consensus on moral content (hence my embrace of the structural analogue of human rights theory).Beauchamp, however, takes a very different view. He asserts in his critique of my position, that: “it is an institutional fact about the substance of morality (not merely [as Baker claims] the formal features of the concept of morality and not merely my view of it) that it contains fundamental and shared precepts. It is by appeal to this shared moral substance that persons are enabled to make justifiable cross-temporal and cross-cultural judgments” (Beauchamp 1998, p. 395). Beauchamp is thus claiming that it is both an empirical and a conceptual truth there is common core underlying the morality of all societies. He fleshes this claim out in another passage.[T]he term morality refers to norms about right and wrong human conduct that are so widely shared that they form a stable... communal consensus.... These standards sometimes vary from society to society, but embedded in the beliefs of all moral societies are the core dimensions of morality: Persons must keep their promises, must respect the rights of others, must not kill or cause harm to innocent persons, must not abuse children, and the like. All morally committed persons are comfortable with these norms and do not doubt their relevance and importance.(Beauchamp 1998, p. 394)Insofar as Beauchamp is making an empirical claim in this passage, the examples cited are problematic. “Promise keeping,” for example, cannot be a cultural universal because the practice is...

Philosophy textbooks typically treat bioethics as a form of "applied ethics"-i.e., an attempt to apply a moral theory, like utilitarianism, to controversial ethical issues in biology and medicine. Historians, however, can find virtually no cases in which applied philosophical moral theory influenced ethical practice in biology or medicine. In light of the absence of historical evidence, the authors of this paper advance an alternative model of the historical relationship between philosophical ethics and medical ethics, the appropriation model. They offer two historical case studies to illustrate the ways in which physicians have "appropriated" concepts and theory fragments from philosophers, and demonstrate how appropriated moral philosophy profoundly influenced the way medical morality was conceived and practiced

In lieu of an abstract, here is a brief excerpt of the content:Medical Ethics in a Time of De-CommunizationRobert Baker (bio)Ethics is often treated as a matter of ethereal principles abstracted from the particulars of time and place. A natural correlate of this approach is the attempt to measure actual codes of ethics in terms of basic principles. Such an exercise can be illuminating, but it can also obscure the circumstances that make a particular codification of morality a meaningful response to specific historic circumstances. This is particularly true of the codes of medical ethics beginning to emerge from the post-Communist societies of Eastern Europe, which are, perhaps, best understood as artifacts of an era, rather than as expressions of abstract principles.The era in question is post-Communist. It is an era informed by a reaction to decades of Communism, which, of course, was more than an economic system or even an ideology; it was a form of life that permeated every aspect of civil society—advertising, art, literature, music. Medicine was not exempt. I recall entering an oncology ward in East Berlin and finding the patients seated around a large table making posters. Wondering whether this was a form of art therapy, I asked the head nurse what the patients were doing. She replied: it is "Party time—the portion of each week every citizen donates to the people and the Party." I looked again at the posters and saw that they honored Karl Marx on the 100th anniversary of his death: "1883-1983, The Struggle Goes On." The Party, the struggle, the people, were everywhere, and they penetrated and informed daily life even for terminal patients on a cancer ward.The interweaving of Communist practices into the warp and woof of daily life has profound implications for the post-Communist era. It means that East Europeans cannot simply rebuild; they must unweave Communist thought patterns—what might be called the ideostructure of Communism—from the fabric of their lives through a deliberate process of deCommunization. What remains after de-Communization depends upon [End Page 363] the historical relationship each country had with Communism. In Russia, removing Communist ideostructure sets the conceptual calendar back to 1918. For the Czechs, the calendar advances to the 1930s, leaving them with thought patterns that are Western, industrial, and democratic. In the rest of Eastern Europe the conceptual clock also tends to turn back to the 1930s, but at that time the conceptual frameworks were nationalist, anti-Western, and frequently fascist, or even Nazi.In Poland the situation is different. World War II opened with the Nazi invasion of the country—which Hitler (later joined by Stalin) subsequently occupied. After the war, the Soviet army controlled the country, which became a captive player in the Soviet sphere of influence (aptly denominated, "the Warsaw Pact"). Poland's pre-Communist thought patterns are nationalist, West-leaning, accepting of parliamentary structures, but also of authoritarian government. They are also Catholic.Catholicism to Poles is not merely a religion, it is a posture of opposition to their German (Nazi, antichristian) and Russian (Orthodox or atheist) occupiers. I toured Polish hospitals several times during the Communist period —always accompanied by one or more "tour guides." (Westerners were not allowed to roam Communist countries unescorted.) Almost all of my guides wore little pins adorned with the face of Lenin (not the hammer and sickle—a symbol of Soviet occupation). Most doctors and nurses, however, adorned themselves with Catholic icons—typically a crucifix. Their conspicuously displayed crosses symbolized less their embrace of Catholicism than their rejection of Communism. Catholicism, in the Polish context, was thus an affirmation of individual and national independence.De-Communizing Polish Medical Ethics: The Abortion ControversyIn Poland, de-Communization was initiated through a series of negotiations between Lech Walensa's Solidarity and the Communist Government. The Polish Code of Medical Ethics is an indirect consequence of these negotiations, which stipulated the dissolution of Communist medical organizations. They were to be replaced by a Polish Medical Chamber—a type of quasi-governmental body, common in Eastern Europe, which combines the functions of a governmental licensing agency with those of a national medical association. Medical chambers also set standards of professional conduct and (unlike...

In lieu of an abstract, here is a brief excerpt of the content:A Theory of International Bioethics: Multiculturalism, Postmodernism, and the Bankruptcy of Fundamentalism 1Robert Baker (bio)AbstractThis first of two articles analyzing the justifiability of international bioethical codes and of cross-cultural moral judgments reviews “moral fundamentalism,” the theory that cross-cultural moral judgments and international bioethical codes are justified by certain “basic” or “fundamental” moral principles that are universally accepted in all cultures and eras. Initially propounded by the judges at the 1947 Nuremberg Tribunal, moral fundamentalism has become the received justification of international bioethics, and of cross-temporal and cross-cultural moral judgments. Yet today we are said to live in a multicultural and postmodern world. This article assesses the challenges that multiculturalism and postmodernism pose to fundamentalism and concludes that these challenges render the position philosophically untenable, thereby undermining the received conception of the foundations of international bioethics. The second article, which follows, offers an alternative model—a model of negotiated moral order—as a viable justification for international bioethics and for transcultural and transtemporal moral judgments.Man in the Twentieth Century can not be circumscribed by the standards of any single culture.American Anthropological Association (1948) in a statement officially denouncing the 1948 United Nation’s Declaration of Human Rights.Recently... so-called “liberal” medicine has revived the old rights of a clinic understood in terms of a special contract, a tacit pact made between one man and another. This patient gaze has even been attributed the power of assuming [a role in clinical decision making].Miracles are not so easy to come by....Michel Foucault (1975, p. 5) [End Page 201]An Overview of the AnalysisInternational bioethics originated in the trauma of the Holocaust, specifically, in the 1946–1947 Nuremberg “Doctors Trial” when a tribunal of three American judges convicted Nazi medical researchers of “crimes against humanity.” In justifying their judgment, the Nuremberg Tribunal cited 10 principles for morally permissible research, which, they claimed, were based on “fundamental” principles that civilized societies “all agree” upon and accept as the foundations of their “moral, ethical, and legal” norms. Foremost among the principles was one stating that morally permissible human experiments require the informed voluntary consent of the subject. The Nuremberg judgment soon became associated with the ideal of human rights declared in the 1948 United Nations Charter. These two ideas—fundamental principles of morality and human rights—have been linked in all major formulations of international bioethics promulgated in the past 50 years, including the Council of Europe’s 1997 Convention for the Protection of Human Rights and Dignity of the Human Being with Regard to the Application of Biology and Biomedicine (Council of Europe 1997; Dommel and Alexander 1997). In this paper, I explore the received justification for international bioethics—the idea that it is grounded in fundamental principles accepted in all societies—tracing it from its initial, almost off-hand, promulgation by the Nuremberg Tribunal, through its more thoughtful development by such bioethicists as Ruth Macklin, to its more complex use by the President’s Advisory Committee on Human Radiation Experiments.After a brief review of the evolution of the received justification, I discuss the viability of this justification in the face of the critique implicit in two important intellectual movements: multiculturalism and postmodernism. In the international context, multiculturalism asserts the claim that there are no common moral principles shared by all cultures. Postmodernism asserts a similar claim against all universal standards, moral and nonmoral. In the 1990s, bioethicists have attempted to respond to these claims in various ways. These responses are documented, analyzed, and then shown to be “bankrupt,” in the sense that they undercut the most important objective of moral fundamentalism: the justification of transcultural moral judgments, such as the condemnation of the Nazi doctors.A second article, which follows the present one in the same issue of the Kennedy Institute of Ethics Journal, revisits the contractarian tradition [End Page 202] of Hobbes and Locke, as it has been reinterpreted by David Gauthier (1986), John Rawls (1971, 1993), and Robert Nozick (1974), to develop the idea of negotiated moral order as the basis of international bioethics. When conceptualized as a negotiated moral order, international bioethics can accept the genuine insights...

In lieu of an abstract, here is a brief excerpt of the content:A Theory of International Bioethics: The Negotiable and the Non-NegotiableRobert Baker (bio)AbstractThe preceding article in this issue of the Kennedy Institute of Ethics Journal presents the argument that “moral fundamentalism,” the position that international bioethics rests on “basic” or “fundamental” moral principles that are universally accepted in all eras and cultures, collapses under a variety of multicultural and postmodern critiques. The present article looks to the contractarian tradition of Hobbes and Locke—as reinterpreted by David Gauthier, Robert Nozick, and John Rawls—for an alternative justification for international bioethics. Drawing on the central themes of this tradition, it is argued that international bioethics can be rationally reconstructed as a negotiated moral order that respects culturally and individually defined areas of nonnegotiability. Further, the theory of a negotiated moral order is consistent with traditional ideals about human rights, is flexible enough to absorb the genuine insights of multiculturalism and postmodernism, and yet is strong enough to justify transcultural and transtemporal moral judgments, including the condemnation of the Nazi doctors at Nuremberg. This theory also is consistent with the history of the ethics of human subjects experimentation and offers insights into current controversies such as the controversy over changing the consent rule for experiments in emergency medicine and the controversy over exempting certain clinical trials of inexpensive treatments for preventing the perinatal transmission of AIDS from the ethical standards of the sponsoring country.The Preamble to the Council of Europe’s (1997) Convention on Human Rights and Biomedicine, the most recently ratified code of international bioethics, is noteworthy because it never mentions “principles,” the concept most frequently cited by the fundamentalists as basic to international bioethics. Instead it stresses rights, a concept that has been utterly ignored by the fundamentalist theorists of international bioethics. The Preamble exemplifies a conception of international [End Page 233] bioethics as an ethics of covenants and conventions grounded in human rights. In the full text of the Preamble, the term “rights” appears eight times and the expressions “convention” and “covenant” are used six times; the term “principle” does not appear at all. In this essay, I develop a theoretical framework for international bioethics based on conventions, covenants, and areas of “nonnegotiability”—a concept that serves as a functional analogue to the traditional notion of “human rights.” I also shall argue that, unlike the theory of basic principles central to moral fundamentalism, the theory of negotiated morality appears immune to the multicultural and postmodern critiques of international bioethics that were analyzed in the preceding article in this issue of the Kennedy Institute of Ethics Journal (Baker 1998).Negotiated Moral Order: A Model for International BioethicsReconsidering ContractarianismThe linkage of “conventions” and “covenants” with human rights that is evident in the Council of Europe’s Convention on Human Rights and Biomedicine traces back directly to the moral and political theories of Thomas Hobbes and John Locke. Such philosophers as David Gauthier (1986), Robert Nozick (1974), and John Rawls (1971, 1993) recently have reinvigorated this classic contractarian line of analysis. In this section, I shall reconsider classical contractarian theory from a perspective informed by these more recent analyses.The most riveting feature of all forms of contractarian theory is the metaphor of the contract itself, particularly the legitimating role it accords to assent. Because contractarians look to the assent of those who would be bound by a moral norm as ultimately the sole source of a norm’s legitimacy, the most important corollary of contractarian moral theory is that moral norms are illegitimate insofar as agents either in principle could not, hypothetically would not, or actually will not rationally assent to be bound by them. Contractarians also argue that because legal norms are legitimated by acceptance of the authority of those who promulgate them, the authority of such norms is bounded by the actual or hypothetical assent of the governed. These features of contractarian analysis generate the correlative concepts of human rights and civil rights.Less often remarked, but nonetheless integral to the metaphor of the social contract, is the contractarian recognition that the interests of the [End Page 234] parties who contract to form civil society are naturally in conflict (or, as Hobbes put...

In ‘New Threats to Academic Freedom’ Francesca Minerva argues that anonymity for the authors of controversial articles is a prerequisite for academic freedom in the Internet age. This argument draws its intellectual and emotional power from the author's account of the reaction to the on-line publication of ‘ After-birth abortion: why should the baby live?’ – an article that provoked cascades of hostile postings and e-mails. Reflecting on these events, Minerva proposes that publishers should offer the authors of controversial articles the option of publishing their articles anonymously. This response reviews the history of anonymous publication and concludes that its reintroduction in the Internet era would recreate problems similar to those that led print journals to abandon the practice: corruption of scholarly discourse by invective and hate speech, masked conflicts of interest, and a diminution of editorial accountability. It also contends that Minerva misreads the intent of the hostile e-mails provoked by ‘After-birth abortion,’ and that ethicists who publish controversial articles should take responsibility by dialoguing with their critics – even those whose critiques are emotionally charged and hostile

The British National Health Service (BNHS) was founded, to quote Minister of Health Aneurin Bevan, to ‘universalise the best’. Over time, however, financial constraints forced the BNHS to turn to incrementalist budgeting, to rationalise care and to ask its practitioners to act as gatekeepers. Seeking a way to ration scarce tertiary care resources, BNHS gatekeepers began to use chronological age as a rationing criterion. Age-rationing became the ‘done thing’ without explicit policy directives and in a manner largely invisible to patients, to Parliament, and to the public. The invisibility of the practice, however, violates the publicity principle that John Rawls and other philosophers believe essential to fairness. BNHS invisible age-rationing practices are thus a test case of the principle that fairness presupposes publicity; they raise the question: is it possible to preserve equitability in a system that uses non-public criteria to allocate scarce resources? To seek an answer, published data on access to end-stage renal disease (ESRD) treatment in Britain and the European Community (EC) are analysed. Among the findings are: that BNHS age-rationing acts as an excuse for denying care to those most likely to need ESRD treatment; and is, moreover, arbitrary and inequitable. It is further argued that no age-rationing policy can sustain visibility, and that, if the BNHS is to be fair to its patients, it must reform its present age-rationing practices, replacing them by a publicly visible, outcome-based rationing policy that rations either in terms of QALYs or triage categories

The American Medical Association enacted its Code of Ethics in 1847, the first such national codification. In this volume, a distinguished group of experts from the fields of medicine, bioethics, and history of medicine reflect on the development of medical ethics in the United States, using historical analyses as a springboard for discussions of the problems of the present, including what the editors call "a sense of moral crisis precipitated by the shift from a system of fee-for-service medicine to a system of fee-for-system medicine, better known as 'managed care.'" The authors begin with a look at how the medical profession began to consider ethical issues in the 1800s and subsequent developments in the 1900s. They then address the sociological, historical, ethical, and legal aspects of the practice of medicine. Later chapters discuss current and future challenges to medical ethics and professional values. Appendixes display various versions of the AMA's Code of Ethics as it has evolved over time. Contributors: George J. Annas, J.D., M.P.H., Arthur Isak Applbaum, Ph.D., Robert B. Baker, Ph.D., Chester R. Burns, M.D., Ph.D., Arthur L. Caplan, Ph.D., Alexander Morgan Capron, J.D., Christine K. Cassel, M.D., Linda L. Emanuel, M.D., Ph.D., Eliot L. Freidson, Ph.D., Albert R. Jonsen, Ph.D., Stephen R. Latham, J.D., Ph.D., Susan E. Lederer, Ph.D., Florencia Luna, Ph.D., Edmund D. Pellegrino, M.D., Charles E. Rosenberg, Ph.D., Mark Siegler, M.D., Rosemary A. Stevens, Ph.D., Robert M. Tenery, Jr., M.D., Robert M. Veatch, Ph.D., John Harley Warner, Ph.D., Paul Root Wolpe, Ph.D.

I was the graduate student that Albert Jonsen so aptly describes. Bronx born and educated at the City College of New York, I emigrated to the Midwest to study at the Minnesota Center for the Philosophy of Science, where May Brodbeck, Herbert Feigl and other “logical positivists” were engaging in an ongoing dialogue with postpositivists like Paul Feyerabend and Karl Popper. In this environment, I studied philosophy of science, epistemology, and metaethics—the epistemology and logic of ethical concepts and language. I even wrote my thesis on the ur-text of the metaethical turn, G. E. Moore's Principia Ethica. Then, like other epistemologists and metaethicists, “a public disaster, the American military involvement in Southeast Asia,” as well as the burgeoning civil rights movement, drew me into the sphere of public debate

The Cambridge World History of Medical Ethics is the first comprehensive scholarly account of the global history of medical ethics. Offering original interpretations of the field by leading bioethicists and historians of medicine, it will serve as the essential point of departure for future scholarship in the field. The volumes reconceptualize the history of medical ethics through the creation of new categories, including the life cycle; discourses of religion, philosophy, and bioethics; and the relationship between medical ethics and the state, which includes a historical reexamination of the ethics of apartheid, colonialism, communism, health policy, imperialism, militarism, Nazi medicine, Nazi "medical ethics," and research ethics. Also included are the first global chronology of persons and texts; the first concise biographies of major figures in medical ethics; and the first comprehensive bibliography of the history of medical ethics. An extensive index guides readers to topics, texts, and proper names