A "Handbook" for Many Hands

If you can call this a "handbook" with a straight face, you are either heavily into Germanic academic tradition, or you have big, strong hands. It's a tome. It's also a fine and extraordinarily helpful collection of thirty essays. Editor Bonnie Steinbock included both established and less known scholars, and the result works.

I cannot assess every essay, but I'd like to single out a few for comment. John Arras's chapter, "The Way We Reason Now: Reflective Equilibrium in Bioethics," focuses on "wide reflective equilibrium." Wide reflective equilibrium boils down to a coherence theory of justification, he argues. But reliance on coherence runs into trouble when confronted with corrupt coherence. And stressing coherence has certainly not produced consensus, as some had hoped it would. Reflective equilibrium, Arras concludes, is a helpful but unattainable regulative ideal for discussion in bioethics. It is no guarantor of moral truth, and we cannot assume it will resolve disagreement. Narrow reflective equilibrium can be remarkably helpful in the context of certain cases; theory is not a waste of time, but we don't have to have it straight in order to argue well about specific issues.

Some readers of this review will already be familiar with Daniel Sulmasy's work on double effect. If you are not, and you, like me, are hung up on this concept, his article on double effect is must reading. Making use of the work of Alan Donagan and others, Sulmasy offers a spirited—not to mention lengthy and carefully detailed—explication and defense of the rule, which basically provides a set of ethical criteria for deciding whether it is permissible to commit an act that will cause an effect one would normally be obliged to avoid. He also contends that the rule has often been misapplied, for example in the justification of some treatments for ectopic pregnancy. Some twentieth century Catholic theologians had argued that the death of embryos or fetuses occurring during operations to remove a Fallopian tube pregnancy were justified as "indirect effects." Sulmasy will have none of this sophistry. Although Daniel Sulmasy is a Franciscan, for better or worse his essay makes no use of theological premises—it is religious or theological only because it addresses a central concept in Roman Catholic medical ethics.

Soren Holm's essay on policy-making in pluralistic societies is comparatively short, clear as a bell, and serves the admirable purpose of beginning a conversation on considerations of political philosophy and bioethics. How should a pluralistic, democratic state legislate or otherwise act in the face of both moral and scientific uncertainty? He specifies the limits of appeals to liberty, noting that guarantees of my liberties require laws or other rules that may limit the liberties of others; for example, to assure the rights of surrogate parents, we may have to restrict the liberties of surrogates. He makes a case for deliberative democracy that depends on such principles as reciprocity and reasonableness in public discourse. This political acceptance of pluralism is to be contrasted with the scorched-earth form of political argument, in which other views are assumed to be unreasonable or just mistaken. Holm writes, "Attempting to reach a legitimate public policy in a morally pluralistic liberal democracy is not a social activity of the same kind as trying to win a philosophical argument." Decisions must be made, but they have to be seen as tentative; societies must come to agreement on policies that all find acceptable, but acceptability can include degrees of support ranging from enthusiastic advocacy to reserved judgment.

Feminist bioethics has been carefully studied by too few of my generation, and Carolyn McLeod's discussion of "dignity or money" and the commodification of women's reproductive labor was for that reason particularly helpful to me. The basic structure of the chapter is to compare two different schools of feminist writers—those who find selling reproductive services empowering, and those who argue that doing so is degrading. The language and arguments are clear and evenhanded, insights by the authors reviewed are celebrated, and McLeod's own arguments are deft. The debate over commodification, love, and money...