Autonomy, Responsibility, and Health Care - Critical Reflections potx

Autonomy, Responsibility,

and Health Care

Autonomy, Responsibility,

and Health Care

Critical Reflections

edited by Bogdan Olaru

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¤

www.zetabooks.com

Bucharest, 2008

Cover design : Paul Balogh

DTP : Paul Balogh

Copyright belongs to the authors.

First published in printed and electronic format 2008.

This book was funded by CNCSIS, under the research project “Biopolitics”

(193/2006-07). To read more about this project please visit the webpage:

http://www.romanian-philosophy.ro/person/Bogdan.Olaru or write to:

[email protected]

ISBN: 978-973-1997-16-2 (paperback)

ISBN: 978-973-1997-17-9 (eBook)

Table of Contents

notes on contributors. . . . . . . . . . . . . . . . . . . . . . vii

Foreword. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1. Autonomy and Embodiment. The Way Back

to the Unavailability of the Body

Autonomy: as Self-determination against, or as Self-transcendence

to Others? Anthropological Reflections on the Background of Bioethics

Regine Kather, Freiburg University (Germany). . . . . . . . . . 15

Why the Way we Consider the Body Matters:

Reflections on four Bioethical Perspectives on the Human Body

Silke Schicktanz, University Medical Center

Göttingen (Germany) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

2. Autonomy and Care from the Perspective

of End-of-Life Decision-Making

Autonomie als Selbstbestimmung und Fürsorge:

aufgezeigt am Beispiel der Sterbehilfe

Karl-Wilhelm Merks, Tilburg University (Netherlands) . . . 79

Autonomie und Fürsorge. Die Perspektive des Rechts

Volker Lipp, Göttingen University (Germany) . . . . . . . . . 95

3. Peculiar Forms of Responsibility?

The Limits of Discourse Ethics Concerning the Responsibility

toward Nature, Nonhuman Animals, and Future Generations

Nicolae Morar, Purdue University (USA) . . . . . . . . . . . . 129

Toward an Ethics of Species. Is there a Responsibility

to Preserve the Integrity of (Human) Species?

Bogdan Olaru, Jassy Institute for Economic

and Social Research (Romania) . . . . . . . . . . . . . . . . . . . . 159

The Principle of Responsibility for Illness and its Application

in the Allocation of Health Care: A Critical Analysis

Eugen Huzum, Jassy Institute for Economic

and Social Research (Romania) . . . . . . . . . . . . . . . . . . . . 191

Index of Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221

Index of Names. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227

Notes on Contributors

Eugen Huzum lives in Jassy, Romania, where he studied philoso￾phy and political science. He now works as a researcher at the Jassy

Institute for Economic and Social Research. His interest fields include

foundationalism, metaethics, theory of social justice, and multicultur￾alism. His last research project dealt with the politics of recognition

and distributive justice.

RegineKather is professor at the University of Freiburg (Germany).

She was associate professor at the University of Bucharest and visiting

professor at the University of Cluj-Napoca (Romania). Regine Kather’s

work is mainly in philosophy of nature and in philosophical anthro￾pology. She is author of Was ist ‘Leben’? Philosophische Positionen und

Perspektiven (Darmstadt, 2003) and Person. Die Begründung menschli￾cher Identität (Darmstadt, 2007).

Volker Lipp is professor of civil law, law of civil procedure, and

comparative law at the University of Göttingen (Germany), and was,

inter alia, visiting fellow at the Institute of Advanced Legal Studies,

University of London. He has written on subjects in bioethics, with spe￾cific interests in the legal and policy issues. His more recent books are

Patientenautonomie und Lebensschutz. Zur Diskussion um eine gesetzli￾che Regelung der ‘Sterbehilfe’ (Göttingen, 2005) and Familienrechtlicher

Status und Solidarität (co-authored with Anne  Röthel and Peter

A. Windel, Tübingen, 2008)

Karl-Wilhelm Merks is member of the Scientific Advice Council

of the Centre for Intercultural Ethics at the University of Tilbug

(Netherlands). He is author of Verantwortung – Ende oder Wandlungen

einer Vorstellung?: Orte und Funktionen der Ethik in unserer Gesellschaft

(Münster, 2001), Gott und die Moral: Theologische Ethik heute (Münster,

viii notes on contributors

1998), and co-editor, with Frans Vosman, of Aiming at Happiness: The

Moral Teaching in the Catechism of the Catholic Church (Kampen,

1996).

Nicolae Morar is a PhD student at Purdue University, USA.

He received his Master degree in 2005 from Lyon III “Jean Moulin”

University with a thesis entitled “Les enjeux de la médicine reproduc￾tive aux Etats-Unis: entre Ethique et Politique.” He is interested in

Continental Philosophy, especially Foucault, Deleuze, Agamben, and

Sloterdijk and its connections with applied ethics (genetic testing/ bio￾power). He is also the founder and the co-organizer of the Bioethics

Seminar Lectures at Purdue University.

Bogdan Olaru has studied philosophy at Alexandru Ioan Cuza

University of Jassy (Romania) and Humboldt University of Berlin. He

worked for nine years as a researcher at the Jassy Institute for Economic

and Social Research. His primary areas of interest currently include

bioethics, ethical theory, and phenomenology. He has edited Current

Ethical Controversies in Biotechnology: Individual Autonomy and Social

Responsibility (Jassy, 2008), and his most recent publications address

assisted reproductive technologies and stem-cell research.

Silke Schicktanz is professor at the University of Göttingen

(Germany), where she teaches in the Department of Medical Ethics

and History of Medicine. Her research and teaching interests include

organ transplantation, xenotransplantation, and ethical and socio-cul￾tural aspects of human reproduction and sexuality. She took part in

the EU-Research Project “Challenges of Biomedicine—Socio-Cultural

Contexts, European Governance and Bioethics” which focused on

the socio-cultural background of modern biomedicine in different

European countries. She has published numerous articles and co-edited

several books on ethical and social issues in health care.

Foreword

This book brings before the readers’ eyes the work of a group of ded￾icated researchers whose interest lies in moral philosophy and applied

ethics. The contributors had the liberty to choose the application fields

and the examples that best illustrate their arguments. Nevertheless,

they all put the main stress on two issues which seems to be the key to

understand many of the today’s bioethical challenges: the autonomy

claim and the question of moral responsibility arising in various fields

of applied medical research.

The book addresses some classical questions such as: what is the

meaning of autonomy? What justifies it? How come infringements

against the autonomy claim make sense sometimes? How do we rec￾ognize overriding moral demands? Still, these questions are far from

being fully answered here. The natural way to tackle these issues is to

put the claim of personal autonomy in some kind of balance with other

values, and to weigh the relative importance of different imperatives

which (seem to) conflict with one another. Thus, we usually lose our

aim in philosophical quarrels, because we face conceptual patterns

which seem to be irreconcilable: autonomy and care, autonomy and

justice, autonomy and solidarity, autonomy and trust, etc. Last in this

series, for instance, constitutes the focus of a recent book by Onora

O’Neill,1

in which she describes in quite a straightforward manner, the

conflict between autonomy, as precondition for individual liberty, on

the one hand, and trust, as basis for social cooperation and solidarity,

on the other. The other way to think about this is to see the clashing

claims as moral demands which complement one another, and, if truth

be told, this is what we expect and how things really work. We do

justice only when and if, we really consider what people’s wishes look

1 Onora O’Neill, Autonomy and Trust in Bioethics (Cambridge

University Press, 2002).

2 bogdan olaru

like, and we show respect for their wishes especially when we take care

of them. Or, to put it another way, to care about someone generally

means to respect his or her wish to make decisions for him or herself.

As a matter of fact, most of us expect the others to practice precisely

this form of care, especially in matters such as reproductive issues or

end-of-life decisions.

But this is not the end of the story. In most cases, we manage

to recognize the individual responsibility that goes together with the

exercise of free choice and autonomous action. Yet, there are times

when we fail to do so. Let us consider this well-known example: We

have an obligation not to make use of our environment as we please,

that is, for instance, not to use the natural resources irrespective of

what would benefit or harm the next generations. But it is difficult to

point to a particular entity in charge of this form of ecological respon￾sibility. Individuals as well as institutions, life-style as well as cultural

habits, have a part to play in shaping this special form of responsibil￾ity. Let’s take another example: active family planning and responsible

parenthood. We usually think of the decision to have a child as the

very expression of free choice and prize this as the genuine illustra￾tion of the autonomy claim. We should think so irrespective of how

old the parents are, and we would never allow anyone to set the right

time for parenthood on our behalf. Then why should we dismiss as

weird or even ‘abnormal’ the wish to have a child when it comes from

a sixty-year-old woman or even older? What makes such a decision

look so peculiar? Is it not because we only point to her age over and

over? But does her wish to have a child differ substantially from the

same wish of other women, apart from the fact that the latter would

eventually want the same at earlier ages? It seems that there are deeply

rooted boundaries about these things and that most people find no dif￾ficulty in addressing them when it comes to actions which don’t fit into

traditional patterns. Perhaps these boundaries are not only cultural,

but also anthropologically given, and therefore, we must include the

anthropological dimension in a more comprehensive understanding of

foreword 3

the autonomy concept. Only then, the charge of border-crossing could

eventually make sense (if ever)—not because of some kind of incom￾patibility between one’s age and what he or she wants to achieve in

some circumstances, but because of the gap between the self-assumed

decisions and the responsibility which follows from them.

One of the most difficult questions is, then, how to link human

responsibility to those consequences of action which no one can fully

foresee but, nevertheless, which no one can afford to neglect. Many

biotechnological challenges are of the same nature. We just cannot

foresee the complete range of virtual social and moral costs of genetic

screening for reproductive purposes or of human germline engineering

and gene therapy for humans or animals. This is why we must explore

special obligations grasped under peculiar formulae like ‘genetic

responsibility’2

or ‘responsibility for the species integrity.’3 In arguing

about such new obligations, the big unknown variable is whether we

really identify and describe genuine responsibilities or only inflate the

field upon which we just want to extend our control. We see ourselves

nowadays confronted with strong and even more unusual autonomy

claims (the wish of a Finnish lesbian couple to have a child could

be another such example), while the solution to conflicting demands

becomes increasingly fuzzy and parochial. I believe we face here a cir￾cular, but non-vicious, legitimating process that any autonomy claim

inevitably goes through: If autonomy makes up the necessary condi￾tion to take responsibility and if the latter functions as a factual limit

for the former, we stand before a process of mutual justification and,

possibly, of mutual limitation. I hope that this book will bring some

insights into this process.

2 Thomas Lemke, Veranlagung und Verantwortung. Genetische

Diagnostik zwischen Selbstbestimmung und Schicksal (Bielefeld: Transcript,

2004).

3 Jürgen Habermas, Die Zukunft der menschlichen Natur. Auf dem Weg

zu einer liberalen Eugenik? (Frankfurt/M.: Suhrkamp, 2001).