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 Bioethics
Principles, Issues, and Cases
Fifh Edition

Lewis Vaughn
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 B R I E F CO N T E N T S

Preface xii

Part 1. Principles and Theories 1

Chapter 1 moral reasoning in bioethics 3
Chapter 2 bioethics and moral theories 38

Part 2. Medical Professional and Patient 95

Chapter 3 paternalism and patient autonomy 97
Chapter 4 truth-telling and confidentiality 170
Chapter 5 informed consent 200
Chapter 6 human research 238

Part 3. Life and Death 303

Chapter 7 abortion 305
Chapter 8 reproductive technology 391
Chapter 9 genetic choices 466
Chapter 10 euthanasia and physician-assisted suicide 551

Part 4. Justice and Health Care 629

Chapter 11 dividing up health care resources 631
Chapter 12 pandemic ethics 697
Chapter 13 race, racial bias, and health care 725

Appendix 749
Glossary 751
Index 755

v
 CO N T E N T S

Preface xii Summary 34

Argument Exercises 35
Part 1. Principles and Theories 1 Further Reading 36
Notes 37
Chapter 1
moral reasoning in bioethics 3 Chapter 2
Ethics and Bioethics 3 bioethics and moral
Ethics and the Moral Life 5 theories 38
In Depth: Morality and the Law 7
Te Nature of Moral Teories 38
Moral Principles in Bioethics 8
Infuential Moral Teories 39
Autonomy 9
Utilitarianism 40
Nonmalefcence 10
In Depth: Utilitarianism and the Golden
Benefcence 10 Rule 42
Utility 11 Kantian Ethics 42
Justice 12 Principlism 44
Ethical Relativism 13 Natural Law Teory 45
In Depth: Anthropology and Moral Diversity 14 Rawls’s Contract Teory 47
Ethics and Religion 17 Virtue Ethics 49
Moral Arguments 19 In Depth: Can Virtue Be Taught? 50
Argument Fundamentals 19 Te Ethics of Care 50
Patterns of Moral Arguments 22 Feminist Ethics 51
Review: Valid and Invalid Argument Forms 23 Casuistry 52
In Depth: Fallacies in Moral Reasoning 24 Criteria for Judging Moral Teories 53
Evaluating Premises 26 Review: Evaluating Moral Teories: Criteria of
Assessing Whole Arguments 28 Adequacy 54
Obstacles to Critical Reasoning 29 Applying the Criteria 54
Denying Contrary Evidence 30 Utilitarianism 55
Looking for Confrming Evidence 30 Kant’s Teory 56
Motivated Reasoning 31 Key Terms 57
Preferring Available Evidence 32 Summary 57
Te Dunning-Kruger Efect 33 Further Reading 58
Key Terms 34 Notes 58
 Contents vii

readings 59 “Confronting Death: Who Chooses, Who

“Utilitarianism,” John Stuart Mill 59 Controls? A Dialogue Between Dax Cowart
“Te Moral Law,” Immanuel Kant 62 and Robert Burt,” Dax Cowart and Robert
Nicomachean Ethics, Aristotle 67 Burt 146
“Te Need for More Tan Justice,” Annette C. Bouvia v. Superior Court, California Court of
Baier 78 Appeal 156
“Moral Saints,” Susan Wolf 86 “Fundamental Elements of the Patient-Physician
Relationship,” AMA Council on Ethical and
Part 2. Medical Professional and Patient 95 Judicial Afairs 161
“Advocacy or Subservience for the Sake of
Chapter 3
Patients?” Helga Kuhse 162
paternalism and patient
autonomy 97 Chapter 4
Shades of Autonomy and Paternalism 97 truth-telling and
Refusing Treatment 98 confidentiality 170
In Depth: Physician Autonomy 100
Paternalism and Deception 170
Futile Treatment 100
In Depth: Do Patients Want the Truth? Do
Legal Brief: Advance Directives 101 Physicians Tell It? 171
Legal Brief: Refusing Treatment for Children on Confdential Truths 173
Religious Grounds 102
Legal Brief: Confdentiality and a Duty to
In Depth: CPR and DNR 103 Warn 174
In Depth: Moral Conficts in Nursing 103 In Depth: Truth-Telling and Cultural
Classic Case File: Elizabeth Bouvia 104 Diversity 175
Applying Major Teories 105 Classic Case File: Carlos R. 176
Key Terms 106 Applying Major Teories 177
Summary 106 Key Terms 178
Cases for Evaluation 107 Summary 178
Further Reading 109 Cases for Evaluation 178
Notes 110 Further Reading 180
Notes 180
readings 110
“Paternalism,” Gerald Dworkin 110 readings 181
“Te Refutation of Medical Paternalism,” Alan “On Telling Patients the Truth,” Mack Lipkin 181
Goldman 120 “Is It Ever OK to Lie to Patients?” Shelly K.
“Why Doctors Should Intervene,” Terrence F. Schwartz 183
Ackerman 126 “Why Privacy Is Important,” James Rachels 186
“Autonomy, Futility, and the Limits of Medicine,” “Confdentiality in Medicine—A Decrepit
Robert L. Schwartz 131 Concept,” Mark Siegler 192
“Four Models of the Physician-Patient Relationship,” Tarasof v. Regents of the University of California,
Ezekiel J. Emanuel and Linda L. Emanuel 136 Supreme Court of California 195
viii Contents

Chapter 5 Classic Case File: Te UCLA Schizophrenia

informed consent 200 Study 252
Cases for Evaluation 253
Autonomy and Consent 200
Further Reading 257
Conditions of Informed Consent 201
Notes 257
In Depth: Decision-Making Capacity 203
In Depth: Two Views of Informed Consent 205 readings 258
Legal Brief: Important Informed Consent Te Nuremberg Code 258
Cases 206 Declaration of Helsinki: Ethical Principles for
Applying Major Teories 207 Medical Research Involving Human Subjects,
Classic Case File: Jerry Canterbury 208 World Medical Association 259
Key Terms 209 “Te Belmont Report,” Te National Commission
Summary 209 for the Protection of Human Subjects of
Cases for Evaluation 210 Biomedical and Behavioral Research 262
Further Reading 212 “Final Report: Human Radiation Experiments,”
Notes 212 Advisory Committee on Human Radiation
Experiments 265
readings 212
“Of Mice but Not Men: Problems of the
“Te Concept of Informed Consent,” Ruth R. Faden
Randomized Clinical Trial,” Samuel Hellman
and Tom L. Beauchamp 212
and Deborah S. Hellman 271
“Informed Consent—Must It Remain a Fairy Tale?”
“A Response to a Purported Ethical Difculty with
Jay Katz 217
Randomized Clinical Trials Involving Cancer
“Transparency: Informed Consent in Primary
Patients,” Benjamin Freedman 277
Care,” Howard Brody 227
“Racism and Research: Te Case of the Tuskegee
Canterbury v. Spence, United States Court of
Syphilis Study,” Allan M. Brandt 281
Appeals 234
“Te Ethics of Clinical Research in the Tird
World,” Marcia Angell 293
Chapter 6
“Ethical Issues in Clinical Trials in Developing
human research 238 Countries,” Baruch Brody 297
Te Science of Clinical Trials 239
In Depth: Te Tuskegee Tragedy 240 Part 3. Life and Death 303
Benefcence, Science, and Placebos 241
Chapter 7
Science and Informed Consent 244
In Depth: Women in Clinical Trials 245 abortion 305
Research on the Vulnerable 246 Starting Point: Te Basics 305
In Depth: Why Enter a Clinical Trial? 247 Fact File: U.S. Abortions 306
Applying Major Teories 250 In Depth: Abortion and Public Opinion
Key Terms 251 2021 309
Summary 251 Te Legal Struggle 310
In Depth: Abortions Performed Later in
Pregnancy 311
 Contents ix

Persons and Rights 312 Cases for Evaluation 407

In Depth: Does a Fetus Feel Pain? 315 Further Reading 409
Applying Major Teories 316 Notes 410
Key Terms 317
Summary 317 readings 411
“IVF: Te Simple Case,” Peter Singer 411
Classic Case File: Nancy Klein 318
“Te Presumptive Primacy of Procreative Liberty,”
Cases for Evaluation 319
John A. Robertson 415
Further Reading 322
“Surrogate Mothering: Exploitation or
Notes 322
Empowerment?” Laura M. Purdy 422
readings 323 “Is Women’s Labor a Commodity?” Elizabeth S.
“A Defense of Abortion,” Judith Jarvis Tomson 323 Anderson 432
“Why Abortion Is Immoral,” Don Marquis 334 “Egg Donation and Commodifcation,” Bonnie
“On the Moral and Legal Status of Abortion,” Mary Steinbock 445
Anne Warren 346 “Cloning Human Beings: An Assessment of the
“Abortion and the Concept of a Person,” Jane Ethical Issues Pro and Con,” Dan W. Brock 454
English 357
“Abortion,” Margaret Olivia Little 364 Chapter 9
“Abortion Trough a Feminist Ethics Lens,” Susan genetic choices 466
Sherwin 369
Genes and Genomes 466
Roe v. Wade, United States Supreme Court 378
Genetic Testing 467
Planned Parenthood of Southeastern Pennsylvania v.
Gene Terapy 473
Casey, United States Supreme Court 384
Fact File: Genetic Testing for Cancer Risk 475
Stem Cells 478
Chapter 8
Fact File: New Developments in Gene Terapy 479
reproductive technology 391 Applying Major Teories 481
In Vitro Fertilization 391 Classic Case File: Te Kingsburys 482
Fact File: Assisted Reproduction 392 Key Terms 483
In Depth: “Savior Siblings” 395 Summary 483
Surrogacy 397 Cases for Evaluation 483
In Depth: IVF and Children’s Future Further Reading 486
Children 398 Notes 486
Cloning 400
In Depth: Cloning Time Line 403 readings 487
Applying Major Teories 404 “Genetics and Reproductive Risk: Can Having
Key Terms 404 Children Be Immoral?” Laura M. Purdy 487
In Depth: Sherri Shepherd: How Surrogacy Can “Te Morality of Screening for Disability,” Jef
Go Wrong 405 McMahan 494
Summary 405 “Genetic Dilemmas and the Child’s Right to an
Classic Case File: Baby M 406 Open Future,” Dena S. Davis 498
x Contents

“Disowning Knowledge: Issues in Genetic Testing,” readings 568

Robert Wachbroit 509 “Death and Dignity: A Case of Individualized
“Te Non-Identity Problem and Genetic Harms— Decision Making,” Timothy E. Quill 568
Te Case of Wrongful Handicaps,” Dan W. “Voluntary Active Euthanasia,” Dan W. Brock 572
Brock 513 “When Self-Determination Runs Amok,” Daniel
“Is Gene Terapy a Form of Eugenics?” John Callahan 584
Harris 518 “Active and Passive Euthanasia,” James
“Genetic Enhancement,” Walter Glannon 524 Rachels 589
“Genetic Interventions and the Ethics of “Dying at the Right Time: Refections on (Un)
Enhancement of Human Beings,” Julian Assisted Suicide,” John Hardwig 593
Savulescu 529 “Te Philosophers’ Brief,” Ronald Dworkin, Tomas
“Germ-Line Gene Terapy,” LeRoy Walters and Nagel, Robert Nozick, John Rawls, Tomas
Julie Gage Palmer 538 Scanlon, and Judith Jarvis Tomson 604
“What Does ‘Respect for Embryos’ Mean in the “Legalizing Assisted Dying Is Dangerous for
Context of Stem Cell Research?” Bonnie Disabled People,” Liz Carr 613
Steinbock 546 “‘For Now Have I My Death’ 1: Te ‘Duty to Die’
Declaration on the Production and the Scientifc and Versus the Duty to Help the Ill Stay Alive,”
Terapeutic Use of Human Embryonic Stem Felicia Ackerman 615
Cells, Pontifcal Academy for Life 549 Vacco v. Quill, United States Supreme Court 626

Chapter 10 Part 4. Justice and Health Care 629

euthanasia and physician- Chapter 11
assisted suicide 551
dividing up health care
Deciding Life and Death 552
resources 631
Legal Brief: Euthanasia and Assisted Suicide:
Major Developments 554 Health Care in Trouble 631
In Depth: Assisted Suicide: What Do Doctors Fact File: U.S. Health Care 634
Tink? 555 Teories of Justice 635
Autonomy, Mercy, and Harm 556 In Depth: Comparing Health Care Systems:
In Depth: Oregon’s Death with Dignity Act 558 United States, Canada, and Germany 636
In Depth: End-of-Life Decisions in the A Right to Health Care 638
Netherlands 560 In Depth: Public Health and Bioethics 639
Applying Major Teories 560 Te Ethics of Rationing 640
In Depth: Physician-Assisted Suicide and Public Classic Case File: Christine deMeurers 642
Opinion 561 Key Terms 644
Classic Case File: Nancy Cruzan 562 Summary 644
Key Terms 563 Cases for Evaluation 645
Summary 563 Further Reading 648
Cases for Evaluation 564 Notes 648
Further Reading 567
Notes 568
 Contents xi

readings 649 readings 712

“Is Tere a Right to Health Care and, If So, What “Why Some Americans Refuse to Social Distance
Does It Encompass?,” Norman Daniels 649 and Wear Masks,” Michael Sandel with Colleen
“Te Right to a Decent Minimum of Health Care,” Walsh 712
Allen E. Buchanan 656 “Fair Allocation of Scarce Medical Resources in the
“Rights to Health Care, Social Justice, and Fairness Time of Covid-19,” Ezekiel J. Emanuel, Govind
in Health Care Allocations: Frustrations in the Persad, Ross Upshur, et al. 715
Face of Finitude,” H. Tristram Engelhardt, “ICU Triage: How Many Lives or Whose Lives?”
Jr. 662 Angela Ballantyne 722
“Mirror, Mirror 2017: International Comparison
Refects Flaws and Opportunities for Better U.S. Chapter 13
Health Care,” Eric C. Schneider, Dana O. race, racial bias, and health
Sarnak, David Squires, et al. 670 care 725
“Public Health Ethics: Mapping the Terrain,” James
Race and Racism 725
F. Childress, Ruth R. Faden, Ruth D. Gaare,
Health Disparities and Race 731
et al. 675
Implicit Bias in Health Care 733
“Human Rights Approach to Public Health Policy,”
In Depth: Can Implicit Biases Be Changed? 735
D. Tarantola and S. Gruskin 686
Racial Profling in Medicine 735
Key Terms 737
Chapter 12
Summary 737
pandemic ethics 697 Cases for Evaluation 738
Pandemic Facts 698 Further Reading 739
When Resources Are Scarce 699 Notes 739
Personal Choices 702
reading 740
In Depth: Te Privilege of Social
Distancing 704 “Racial Profling in Medicine,” Michael Root 740

COVID Falsehoods 705 Appendix 749

In Depth: Against Pandemic Falsehoods 707 Glossary 751
Key Terms 708 Index 755
Summary 708
Cases for Evaluation 709
Further Reading 711
Notes 711
 P R E FAC E

Tis ffh edition of Bioethics embodies all the 6. Writing that strives hard for clarity and
features that have made it a best-selling text- concision to convey both the excitement
book and includes all the most important and complexity of issues without
changes and improvements that dozens of sacrifcing accuracy
teachers have asked for recently and over the
years. Te book is, therefore, better than ever. topics and readings
And if it isn’t, let even more good teachers say so Eleven chapters cover many of the most contro-
and let the corrections and enhancements con- versial issues in bioethics, detailing the main
tinue. And may the book remain, as so many arguments and flling out the discussions with
teachers have said, exactly suitable to their background on the latest medical, legal, and
teaching approach. social developments. Te main issues include
Bioethics provides in-depth discussions of paternalism and patient autonomy, truth-tell-
the philosophical, medical, scientifc, social, and ing, confdentiality, informed consent, research
legal aspects of controversial bioethical issues ethics, clinical trials, abortion, assisted repro-
and combines this material with a varied collec- duction, surrogacy, cloning, genetic testing,
tion of thought-provoking readings. But on this gene therapy, stem cells, euthanasia, physician-
foundation are laid elements that other texts assisted suicide, the just allocation of health
sometimes forgo: care, pandemic ethics, and racial bias in health
and medicine.
1. An extensive introduction to ethics,
Every issues chapter contains one to twelve
bioethics, moral principles, critical
readings, with each selection prefaced by a brief
thinking, and moral reasoning
summary. Te articles—old standards as well as
2. Full coverage of infuential moral theories,
new ones—refect the major arguments and
including criteria and guidelines for
latest thinking in each debate. Tey present a di-
evaluating them (the focus is on
versity of perspectives on each topic, with pro
utilitarianism, Kantian ethics, natural law
and con positions well represented. In most
theory, Rawls’s contract theory,
cases, the relevant court rulings are also
principlism, virtue ethics, the ethics of
included.
care, and feminist ethics)
3. Detailed examinations of the classic cases
special features
that have helped shape debate in major
A two-chapter introduction to bioethics, moral
issues
reasoning, moral theories, and critical think-
4. Collections of current, news-making cases
ing. Tese chapters are designed not only to in-
for evaluation
troduce the subject matter of bioethics but also
5. Many pedagogical features to engage
to add coherence to subsequent chapter material
students and reinforce lessons in the main
and to provide the student with a framework for
text
thinking critically about issues and cases.
 Preface xiii

Chapter 1 is an introduction to basic ethical A diverse package of pedagogical aids. Each

concepts, the feld of bioethics, moral principles issues chapter contains a chapter summary, sug-
and judgments, moral reasoning and argu- gestions for further reading, and a variety of
ments, the challenges of relativism, and the rela- text boxes. Te boxes are mainly of three types:
tionship between ethics and both religion and
1. “In Depth”—additional information,
the law. Chapter 2 explores moral theory, shows
illustrations, or analyses of matters
how theories relate to moral principles and
touched on in the main text.
judgments, examines infuential theories (in-
2. “Fact File”—statistics on the social,
cluding virtue ethics, the ethics of care, and
medical, and scientifc aspects of the
feminist ethics), and demonstrates how they can
chapter’s topic.
be applied to moral problems. It also explains
3. “Legal Brief”—summaries of important
how to evaluate moral theories using plausible
court rulings or updates on the status of
criteria of adequacy.
legislation.
Helpful chapter elements. Each issues chap-
ter contains:
new to this edition
1. Analyses of the most important arguments A Chapter on Pandemic Ethics
ofered by the various parties to the Chapter 12 covers many of the most important
debate. Tey reinforce and illustrate the life-and-death issues and moral debates that
lessons on moral reasoning in Chapter 1. have occurred during the COVID-19 pandemic:
2. A section called “Applying Major emergency triage and the allocation of scarce
Teories” showing how the moral theories medical resources (ICU beds, ventilators, medi-
can be applied to the issues. It ties the cations, vaccines), the safety and welfare of
discussions of moral theories in Chapter 2 health care workers, disparities in health care
to the moral problems and illustrates the for racial and ethnic minorities, personal mo-
theories’ relevance. rality (whether to wear a mask, practice social
3. A section labeled “Classic Case File” that distancing, get vaccinated, and self-isolate), the
examines in detail a famous bioethics spreading of pandemic misinformation, cutting
case. Te stories covered in these sections corners in coronavirus research, and contact
include those of Elizabeth Bouvia, Jerry tracing versus privacy rights.
Canterbury, Nancy Klein, Baby M, Nancy
Cruzan, the Kingsburys, Christine A Chapter on Race, Racial Bias, and
deMeurers, and the UCLA Schizophrenia Health Care
Study. Tese are in addition to many other Chapter 13 delves into the insidious efects of
controversial cases covered elsewhere in racial and ethnic bias on the health status of mi-
the book—for example, the Terri Schiavo norities and on nearly every facet of health care.
controversy, the Tuskegee tragedy, the It discusses prevailing misconceptions about
Willowbrook experiments, and the U.S. race and provides philosophically sound defni-
government’s human radiation studies. tions of racism (both individual and structural),
4. A bank of “Cases for Evaluation” at the racial prejudice, and racial discrimination. It
end of each chapter. Tese are recent news debunks the myth that racism and racial dis-
stories followed by discussion questions. crimination are things of the past, shows how
Tey give students the chance to test their structural racism has caused large-scale racial
moral reasoning on challenging new inequalities in society, and documents the
scenarios that range across a broad health disparities—the diferences in mortality
spectrum of current topics. and disease—between Whites and minorities.
xiv Preface

It examines the evidence of widespread racial University Press—especially my editor Andrew

and ethnic bias in health care, explores the pow- Blitzer, assistant editors Rachel Boland and
erful efects of implicit bias in clinical practice, Lacey Harvey—and many reviewers:
and surveys the problem of racial profling in
Keith Abney, Polytechnic State University at
diagnosis and treatment.
San Luis Obispo
Kim Amer, DePaul University
Updates
Jami L. Anderson, University of Michigan
• Abortion and public opinion (survey)
Carol Isaacson Barash, Boston University
• Abortions performed later in pregnancy
Deb Bennett-Woods, Regis University
• Statistics on assisted reproduction
Don Berkich, Texas A&M University
• “Savior siblings”
Stephan Blatti, University of Memphis
• New developments in gene therapy
William Bondeson, University of Missouri,
• Te fve main ways to do gene therapy
Columbia
• Genetic testing for cancer risk
Lori Brown, Eastern Michigan University
• Euthanasia and assisted suicide: major
Paul Benjamin Cherlin, Minneapolis College
developments
David W. Concepción, Ball State University
• Oregon’s Death with Dignity Act
Catherine Coverston, Brigham Young
• U.S. health care: the uninsured, per capita
University
spending, and health care quality
Russell DiSilvestro, California State
• Comparing health care systems: U.S.,
University, Sacramento
Canada, and Germany
John Doris, Washington University in
St. Louis
New Readings
Denise Dudzinski, University of Washington
• Michael Sandel with Colleen Walsh, “Why
School of Medicine
Some Americans Refuse to Social Distance
Craig Duncan, Ithaca College
and Wear Masks”
Anne Edwards, Austin Peay State University
• Ezekiel J. Emanuel, Govind Persad, Ross
John Elia, University of Georgia
Upshur, et al., “Fair Allocation of Scarce
Christy Flanagan-Feddon, Regis University
Medical Resources in the Time of Covid-19”
Jacqueline Fox, University of South Carolina
• Angela Ballantyne, “ICU Triage: How
School of Law
Many Lives or Whose Lives?”
Leslie P. Francis, University of Utah
• Michael Root, “Racial Profling in Medicine”
Devin Frank, University of Missouri–
Columbia
ancillaries Kathryn M. Ganske, Shenandoah University
Te Oxford University Press Learning Link houses Martin Gunderson, Macalester College
a wealth of instructor and student resources, in- Helen Habermann, University of Arizona
cluding an Instructor’s Manual, Test Bank, and Stephen Hanson, University of Louisville
both Lecture and Art PowerPoint Presentations Karey Harwood, North Carolina State
for instructor use. Te site also includes Self- University
Quizzes, Videos and Video Quizzes, and Flash- Sheila R. Hollander, University of Memphis
cards for student use. Please visit www.oup.com/ Chad Horne, Northwestern University
he/vaughn-bioethics5e to access these resources. Scott James, University of North Carolina,
Wilmington
acknowledgments James Joiner, Northern Arizona University
Tis edition of the text is measurably better than William P. Kabasenche, Washington State
the frst, thanks to the good people at Oxford University