Bioethical Prescriptions: To Create, End, Choose, and Improve Lives by F. M. Kamm (review)

F. M. Kamm’s latest book is no stylish page-turner, but it has something in common with good psychological thrillers: plenty of unexpected twists and turns. They surprise you at first, but in the end you appreciate the author’s design. If you pay close attention, you may even be able to predict some of the twists.

Kamm’s work requires concentration, but rewards the effort. She focuses intently on getting the right answer, which for her means a theory that coheres with and explains the presumptive moral judgments of her reasonable readers (or at least herself) concerning various imaginative thought experiments. To this end, she gleefully draws whatever distinctions she finds necessary, testing and modifying principles at a dizzying pace. Deep in the dialectic, you may lose track of her point, but she always has one. I can reassure wary readers that Bioethical Prescriptions (BP) provides a more accessible introduction to Kamm’s philosophical enterprise than does her work in pure normative-ethical theory, such as Intricate Ethics (2007) and the two-volume Morality, Mortality (1993/1996). The essays in BP grip the reader more firmly because the discussion is usually anchored in a concrete bioethical issue and each essay stands on its own.

BP collects twenty-seven papers by an eminent bioethicist and moral philosopher. Twenty-three are squarely on biomedical ethics, the remaining four on methodology. The material was published in the last twenty-five years and has been revised by the author. A few arguments and illustrations are repeated, but it is helpful to have the papers available as an organized whole.

The basic headlines are these. Kamm is pro-choice on abortion. She supports genetic enhancement, physician-assisted suicide, voluntary active euthanasia, and biomedical research on human embryos. She opposes certain resource-allocation policies that disfavor persons with disabilities. Given such imprecise characterizations of Kamm’s positions, each is predictable in a liberal nonconsequentialist. But the devil is in the details. Kamm’s moral conclusions are too specific and imaginative to be [End Page E-1] inferred from the mere fact that she is a liberal nonconsequentialist (as are many biomedical ethicists). You have to read the book. It is profoundly thought-provoking—as painstakingly careful a work of applied ethics as I have found.

The papers in BP fall naturally into five parts: (1) Death and Dying, (2) Early Life, (3) Genetic and Other Enhancements, (4) Allocating Scarce Resources, and (5) Methodology. Relatively self-contained chapters challenge the arguments of Baruch Brody on euthanasia (chapter 6), J. David Velleman on assisted suicide (chapter 5), Jeff McMahan on the ethics of killing in marginal-life cases (chapter 13), and Ronald Dworkin on abortion (chapter 11). There are also worthwhile excursions on dementia and advance directives (chapter 7), brain death (chapter 8), and Münchausen syndrome by proxy (chapter 14).

Kamm’s work on the subjects in parts one and two is especially wellknown. Many of the papers in these parts were published in prominent venues. Therefore, I shall focus more on parts three and four, which have received less attention and are less readily available.

Kamm wages bioethical battles on several fronts, facing a diverse set of philosophical opponents. On one front, her opponents are consequentialists, typified by Peter Singer and health economists who claim that maximizing quality-adjusted life years (QALYs) is the most (if not the only) important social value to serve when allocating healthcare resources. On another front, Kamm challenges “conservative” opponents of human embryo research (Leon Kass), human genetic enhancement (Michael Sandel), and abortion. In a third theater, Kamm confronts some of the stronger positions associated with advocacy for persons with disabilities.

Kamm’s method involves formulating mid-level moral principles, testing them with thought experiments, and refining them accordingly. She invents principles that are entirely her own. She states her positions with a degree of precision invariably exceeding that of her opponents. Kamm prizes consistency, but she never claims that her principles will (or will...