Review

Reviewed Work(s): Practical Reasoning in Bioethics by James F. Childress

Review by: Sharon E. Sytsma
Source: Politics and the Life Sciences, Vol. 17, No. 1 (Mar., 1998), pp. 93-95
Published by: Cambridge University Press
Stable URL: https://www.jstor.org/stable/4236421
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 Book Reviews

language involves the left hemisphere. Speeches of three
presidents and of Nixon's staff were analyzed for words
assumed to reflect right or left hemisphere processing, and
the hemispheric lateralization of the individuals was thereby
inferred. The authors recognize that there are severe limita-
tions to inferences about brain function from such behavioral
analyses.
With regard to mechanism, Masters and Way also suggest
that the behavior-activating system plays more of a role than
does the behavior-inhibiting system of the brain in effects of
positive mood on reinforcement of prior attitudes toward a
political speechmaker. With regard to biological function,
Losco reviews concepts from sociobiology, arguments for
their application to political behavior, and results from a few
studies. For example, one study cited suggests that castra-
tion, celibacy, kidnapping, and adoption in preindustrial
societies may free individuals to serve the reproductive
fitness of unrelated leaders, and that many practices in the
modem state and private bureaucracies may serve similar
biological functions. Another study cited suggests that sex
differences in fitness strategies may have resulted in differ-
enees between males and females in processing of political
stimuli. Such differences have been reported. Even so, Losco
concludes that, unfortunately, very few studies in biopolitics
are based on a consideration of hypotheses about evolved
functions of political behaviors.
This book will be extremely valuable for those interested
in using observational methods to study behaviors of indi-
viduals or small groups that are relevant to political science.
The methods are accurately described and critically evalu-
ated. The literature citations in each chapter should also be
useful. However, I am somewhat disappointed by how little
there is in each chapter actually relating the observational
methods to the asking and answering of biological questions
about political behavior. Biopolitics is no longer a young
field. It should no longer be sufficient just to claim, as is
often done in this volume, that biology is relevant to political
behavior. Now, biological hypotheses about political behav-
ior should be developed, and these should be tested by
observation and experiment. Two areas of psychology could
serve as models for this enterprise?behavioral neurosci-
ence and evolutionary psychology.

Practical Reasoning in Bioethics

James F. Childress
Bloomington, IN: Indiana University Press, 1997, 385 pp. US$39.95 cloth. ISBN 0-25 3-33218-4. Indiana Unive
Press, 601 N. Morton St., Bloomington, IN 47404-3797, USA.

Sharon E. Sytsma Northern Illinois University, USA

Practical Reasoning in Bioethics is a collection of sixteencal reflections on practical reasoning. In the first, and in my
previously published essays and articles written or co-writ-
view most interesting chapter, Childress examines the role
ten by James Childress. The essays are grouped into fiveof imagination, metaphor, analogy, and symbolism in ethical
parts: Principles, Metaphors, and Analogies; Respect for reasoning. We speak of medicine using the metaphor of war,
Autonomy: Its Implications and Limitations; Termination or of as a business, or as part of a system of ecology; and we
Life-Sustaining Treatment; Allocation of Health Care; and use metaphors (as further discussed in Chapter 3 on medical
Obtaining Organs and Tissues for Transplantation. Except models) when we think of health care professionals as tech-
for the most recently written, the articles have been revised
nical engineers, advocates, colleagues, contractual partners,
or updated for this publication. Anyone concerned with parents, priests, or as God. Analogical reasoning guides our
ethical issues in medical decision-making will find this book
thinking about issues: euthanasia is compared to Nazi exter-
comprehensible, engaging, sensitive, thoughtful, and very minations in order to examine its putative moral equiva-
worth reading. lence, abortions where the mother's life is threatened is
Appropriately, the first section, "Principles, Metaphors,
compared to self-defense, and women are called "fetal con-
and Analogies," contains rich and illuminating philosophi-
tainers" in response to the prospect of enforced cesareans for
fetal benefit in order to highlight the neglect of a woman's
autonomy. Policies are often justified or criticized because
Sharon Sytsma is Assistant Professor of Philosophy at Northern
of the symbolic meanings they carry, a factor even utilitari-
Illinois University, DeKalb, IL 60115, USA, where she regularly
teaches a course in biomedicai ethics. She is the author of articles ans need to consider in their calculations. Childress wisely
on biomedicai ethics and on ethical theory, especially Kantian observes that these "aesthetic" arguments, while instructive,
ethics and theories of moral motivation. should not be seen as determinators of moral judgments,

Politics and the Life Sciences March 1998 93

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Book Reviews
since metaphors can be bad, analogies inaccurate, and sym-
bols limited.
Childress here responds to criticisms of his "princi-
plism"1?the method of moral decision-making based on the
prima facie binding principles (autonomy, beneficence, non-
maleficence, and justice) identified and developed in his
previous well-known work, Principles of Biomedicai Ethics,
coauthored with Tom L. Beauchamp (Beauchamp and
Childress, 1994). Criticisms raised by casuists, feminists,
and virtue theorists are all treated deftly and fairly. Childress
recognizes the value and contribution of the other ethical
approaches, but insists that they rely fundamentally on the
four basic principles. However, his response to the criticisms
of ethical theorists is less satisfying.
Ethical theorists (Gert and Clouser) criticize principlism
for not providing a meaningful normative guide, because the
principles lack unification within a theory, leaving us
clueless when principles conflict, and therefore prone to
arbitrary, spurious, and relativistic solutions (Clouser and
Gert, 1990). Echoing Aristotle, Childress happily "pleads
guilty" (p. 31) to the charge that principles do not fully
determine morality and of imprecision?believing that we
ought not to demand precision and direction when there is
none to be had. Childress counters that when principles
conflict, decisions are not arbitrary, but rather must conform
to the logic of prima facie duties: infringements thereof must
be necessary, proportional, efficient, and realistic about
achieving goals.
These responses are reasonable, but not so his further
claim that the "theory"' approach oversimplifies moral ex-
perience by implying that conflicts can always be resolved
on the basis of theory, thus failing to accommodate and
explain the inevitable tragedy of irresolvable dilemmas.
However, the claim that theory can provide direction when
principles conflict does not entail that theory always does so.
Further, while Childress correctly holds that "a theory is not
needed to establish these principles as binding" (p. 32), he
dismisses too readily the value of theoretical ethical inquiry.
He allows that his approach "involves a dialectic between
theory, principles, mies, and particular judgments... with a
reflective equilibrium operating at each level as well as
between levels" (p. 32), without ever himself consulting
traditional theories, or attempting to devise a new one, or a
synthesis of several. A more honest response requires admit-
ting that he is not a theorist, but that he is addressing
important problems that cannot wait for the achievement of
a completely satisfying, universally accepted moral theory,
and must leave the task of theory to others.
Section 2 deals with problems and clarifications on the
Principle of Respect for Autonomy. While painstakingly
meticulous and somewhat redundant, the attempts to deal
with the case of an elderly nursing home resident who
refuses to rise for breakfast, and the question of the entail-
ments of this principle for cancer patients, demonstrates
balanced judgment and highlights Childress's ethical gifts
of imagination, sensitivity, and flexibility. Also insightful is
94 Politics and the Life
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his argument that mandatory HIV screening and testing
policies violate autonomy and respect for persons. Applying
the logic of prima facie duties, Childress carefully and
convincingly concludes that no mandatory policies for HIV
screening fulfill all these conditions, and hence that no
mandatory policies can be justified.
Part 3, entitled "Termination of Life-Sustaining Treat-
ment," deals with decisions to withhold medical treatment
in general, and artificial nutrition and hydration (ANH) in
particular, and further extends the discussion of the impor-
tance and difficulty of respecting autonomy. The chapter
devoted to Dax Cowart presents Childress's well-balanced
and finely tuned account of this classic case originally pub-
lished in 1989, along with an interesting updated commen-
tary. Two chapters address the problem of withholding and
withdrawing ANH, the first of which has most often been
anthologized as "Must Patients Always be Given Food and
Water" (with JoAnne Lynn; 1983), and the second written
three years later. Both chapters address and criticize the
common arguments against ever withholding or withdraw-
ing artificial nutrition and hydration and identify situations
where such decisions are morally permissible. However, the
second chapter includes two case studies and a more elabo-
rate treatment of the "symbolic argument" against withhold-
ing and withdrawing ANH?that we should always provide
ANH because doing so is symbolic of care and compassion,
and because the sentiments of repulsion or repugnance at the
prospect of a patient's "starving to death" protect and en-
hance the well-being of society. Childress highlights a com-
mon problem with symbolic arguments: they tend to violate
the principles of beneficence and autonomy, supporting
symbolic values "at the expense of actual patients" (p. 160).
Yet a stronger response is available. Policies that are sup-
posed to symbolize caring and compassion cannot survive
as effective symbols. Given evidence that dehydration eases
pain in the dying process, and given that all forms of ANH
involve discomfort, risks, and indignities, it could not be
long before they will come to signify coarseness and lack of
concern.
The ethical allocation of health care resources is t
of the fourth section. Childress argues that in
involving scarce resources, patients should first b
in terms of "medical utility" (likelihood of medic
and that the final selection should be determined
form of a lottery method. He defends the ethical s
of the lottery method over social utility, on the gr
it best respects and best symbolizes the equality an
worth of individuals, since no consensus is lik
reached about the relative social worth of per
postscript written twenty-five years after the orig
Childress finds his view vindicated in the movement of
pharmaceutical companies in the last few years toward mak-
ing new or scarce drugs available by lottery, and in the
acceptance by the public of the lottery system as a just one.
Childress's concern for equal respect for persons and the
negative utility of a policy permitting evaluations of social
Sciences March 1998
 Book Reviews

utility is laudable. However, his exception in the case of a and includes his retrospections of 1995. He rejects argu-
political figure on whom social stability depends is based on ments against fetal tissue transplants that assert that the use
reasoning that could justify other exceptions, and yet still be of such tissue symbolically conveys approval of, and even
fully in keeping with his ideals. Since no reasonable person collaboration in, abortion, arguing that a policy can be
would object to giving preference to an important political formulated that discourages this symbolic message, and that
figure on whom social stability depends, no one would obdurate insistence that the message of approval will be sent
perceive the preferential treatment as unfair. But the same is at best speculative, and therefore insufficient to outweigh
holds true when comparing the social utility of a healthy the great good that fetal tissue transplants can certainly
retarded adult with a mentality of a two-year-old, and a effect. Unfortunately omitted from discussion in these es-
highly talented, bright, energetic, community-minded par- says is the recent controversy over the use of non-heartbeat-
ent?even one whose death would not invite social disaster. ing cadavers. Also, although Childress admirably argues
The disparity is so great that granting the scarce resource to against adopting a market approach in our culture, he does
the parent would hardly evoke perceptions of unfairness. not come to grips with the inevitable injustice resulting from
Taken together, the chapters on health care distribution its acceptance in other countries.
culminate in a searing criticism of our health care system, Despite these criticisms and the redundancy typical of
and of managed care programs as the solution to them. After collections of previously published essays, this book is a
noting the several opportunities for injustice in organ distri- worthy one. The conscious recognition of the importance,
bution, Childress informs us that "ability to pay" still is the inevitability, and the fallibility of the use of metaphor,
most relevant determining factor in who "gets" the organs, symbols, and analogies considerably enhances and enriches
and claims that it is unfair and exploitive to request organ Childress's "principlism." The reader concerned with poli-
donation from the poor, who are not likely to be organ tics and the life sciences can only benefit from the example
recipients. Managed care programs may result in lowering of Childress's dedication and active participation in
health care costs, but only at the expense of reducing trust biomedicai ethics as educator, as researcher, as congres-
between patients and health care providers, and only by sional consultant, and as philosopher.
limiting patient and doctor autonomy. Giving financial in-
centives to doctors for limiting access to health care encour-
ages lack of disclosure, undermining ideals of informed
consent. Managed care also exasperates the plight of the Notes
indigent, offering no means of compensation for their
treatment. 1. This term was applied to Beauchamp and Childress's approach
by his critics, K. Danner Clouser and Bernard Gert (1990).
The fifth section addresses distributive problems specifi-
cally in organ and tissue transplantation policies. Alternative
policies and their possible modifications receive careful
examination in terms of efficacy (established or specula- References
tive), morality, and symbolic meaning. Childress convinc-
ingly concludes that the "gift model" best ensures publicBeauchamp, T.L. and J.F. Childress (1994). Principles of Biomedicai
trust and the viability of organ transplantation, even while Ethics. 4th edition. New York: Oxford University Press.
Childress, J. and J. Lynn (1983). "Must Patients Always Be Given
limiting available organs. The chapter on fetal tissue trans-
Food and Water." Hastings Center Report 13 (October): 17-21.
plants recounts Childress's experience and participation inClouser, K.D. and B. Gert (1990). "A Critique of Principlism." Journal
the Human Fetal Tissue Transplant Research Panel in 1988, of Medicine and Philosophy 15:219-36.

Politics and the Life Sciences March 1998 95

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