“I fear that my child’s organs will be harvested without my permission.”“But it is for a very good purpose, and, besides, the child is dead.”

Philosophical bioethics traditionally centres on arguments. When Judith Jarvis Thomson published her article “A defense of abortion” in 1971, she presented several arguments against restrictive abortion policies.¹ Similarly, when Peter Singer published his “Animal liberation” in 1973,² John Harris his “The survival lottery” in 1975,³ and Philippa Foot her “Euthanasia” in 1977,⁴ they all concentrated on the logical and conceptual inferences that can be made from certain attitudes and states of affairs to the desirability of definite courses of action and inaction. And when other philosophers have responded to these contributions, they have tried to show flaws in the original deductions, and they have tried to produce better arguments for or against the normative conclusions reached by the original authors.

Bioethics as it is currently understood, however, lays more stress on concerns. Onora O’Neill, for instance, has recently expressed concerns about the erosion of trust in the medical and health services of modern welfare states.⁵ This erosion is partly due to the inability of the national system to address more particular concerns. In the Alder Hey Children’s Hospital case, for instance, the original anxiety was that organs were removed from dead children without their or their parents’ consent. Another class of more particular anxieties is caused by terminations of pregnancy based on prenatal diagnoses. Some people see abortions based on genetic features as a threat to themselves, and react accordingly.

VOICING, CLARIFYING, AND CREATING CONCERNS

The connection between arguments and concerns, if any, is largely unclear. Some arguments can, of course, be seen to voice or to clarify certain concerns. O’Neill’s account of trust, for instance, is presumably an attempt to explicate a widespread and generic notion held by individuals, interest groups, and the media. Also seen like this, we can say that Thomson voiced certain liberal or moderate concerns about abortion laws; Singer expressed his unease about the treatment of non-human animals; Harris stated his irritation in the face of conservative organ donation policies, and Foot verbalised the apprehension many of us feel when we think about the prolongation of a miserable and undignified human life.

Other arguments can be seen to create concerns, which might not have been there without their initial philosophical expressions. Søren Holm’s 1998 modern classic “A life in the shadow: one reason why we should not clone humans” could be a case in point.⁶ I am not sure that members of the general public had any particular anxieties about the life of clones as being “biologically prelived” before his article was published in the Cambridge Quarterly of Healthcare Ethics. Several reprints and a few plagiarisms down the line, however, the concern now seems to be squarely rooted in the collective mentality—as evidenced by at least one recent book review in The Guardian and by the numerous sites to be found by an internet search on the word combination life/shadow/cloning.^7,8

None of these arguments, however, seem to address concerns in any useful sense. By a “useful sense” I mean a sense in which philosophers could be said to come up with workablesolutions or credible responses to popular anxieties, whether spontaneous or manufactured. Part of the promise of bioethics to society as a whole seems to be that philosophers can deliver such solutions and responses. But I doubt, that we can—or, indeed, that we should.

TACKLING CONCERNS

Philosophers can, of course, trytotackle concerns with arguments. This seems like a particularly natural course of action when the concerns arise from, or are expressed in terms of, arguments to begin with. For instance, all the philosophical irritations I have listed so far can, in theory, be countered by one argument—the argument that the irrevocable and inalienable sanctity and uniqueness of every human life trumps all lesser ethical concerns.

Thomson tried to show that abortions are sometimes justified—but they cannot be, if every human life has absolute value. Singer maintained, among other things, that research on animals is wrong—but if it saves human lives, this cannot be true. Harris seemed to argue that consenting people should be chopped up and used as organ donors for others—but this cannot be right, if the ones consenting have no right to give up their lives. Foot stated that prolonged existence without the essential features of a human life can be worse than death—but this must be wrong, since all human existence is valuable. And Holm said that clones would have to live in the shadow of their parents—but how can this be, when everyone is, by definition, unique?

Philosophical reactions like this do not, however, properly address the concerns formulated in the arguments. They work by asserting a moral starting point, and by declaring that all anxieties and intuitions raised by it can be brushed aside. At best, they offer an alternative ethical universe where the original concerns can be forgotten. Since, however, people have in most cases already decided what their preferred ethical universe is, this is not a very credible response or workable solution.

PARTICIPATING IN CONCERNED ARGUMENTATION

Since people live in their predefined moral realms, the concerns they voice are often argumentative in nature. The opinions and beliefs individuals express as concerns can be based on reasons shared by their peers. When this is the case, can philosophers participate in the discussion on the quality of these opinions and beliefs in a useful way?

I think that to a certain extent they can. In addition to clarifying lines of thought, and showing their historical and cultural connections, academics from many fields who trade in well formulated arguments can expose logical and factual errors in public debates. If views are based on contradictory or clearly empirically false premises, the claim can reasonably be made that they should not be taken seriously into account in any ensuing practical decisions.⁹

There is, however, a serious limitation to this. The reasons on which opinions and beliefs are based can include moral, cultural, and emotional norms, as well as values and expectations that are logically consistent and irreducible to empirical facts.⁹ Can philosophers then claim authority in settling the issues on hand? I do not think so.

PARTICIPATING IN CONSENSUS FORMATION

Bioethics is not only about people’s concerns. It is also about making decisions in pluralistic and multicultural societies, where everybody’s original views cannot always in the end be fully accommodated. What is the role of philosophers in the process of making such decisions?

Many academics in the field have developed ideas of communicative action and consensus formation to address the need to determine public policies on questions in which opinions initially differ. They have emphasised, among other things, the significance of openness, transparency, wide participation, and the acceptability of the process itself to all those involved.^9–14

The quest for tenable ways of reaching consensus is, no doubt, a worthwhile activity, but it does not remove the need to consider people’s spontaneous concerns and the ability of arguments to address them. When individuals and groups have worries about concrete actions by professionals and authorities, their reservations do not automatically go away with widely accepted policy decisions. This fact is well recognised by experts on opinion formation, for whom the residual anxieties are an unavoidable side product of good democratic decision making. However, the question of the significance of these actual concerns remains.

SPONTANEOUS CASES

Can philosophers, or others formulating arguments, usefully address people’s spontaneous doubts?

Let me start with the type of case where mothers and fathers want to protect the dignity of their children. What can be said—credibly and to any effect—to parents who are concerned that their dead children’s organs will be used for medical research? One option is to argue that medical research is enormously useful, and it will, in the long run, benefit many people, including children who would otherwise die prematurely. An additional argument could be that people who are dead do not really have interests in their bodies anyway, so the children are in no way harmed by harvesting their organs before cremation or burial. The question is, however, would philosophical ruminations like these have an effect on the parents? Would they not just be more infuriated by such attempts to whitewash actions and policies they see as outrageous?

The situation may be even worse when it comes to cases where people are concerned about their own safety and dignity. “People like me should not be aborted” is a fairly typical rhetorical statement from people with minor or major inborn disabilities. (The quotation is from an interview with the Rev Joanna Jepson in the Northwestern edition of Metro.¹⁵) It voices a concern that abortions based on prenatal tests are an instance of, or contribute to, discrimination against certain individuals and groups in our modern societies. One philosophical response to this is to argue that abortions are not about existing, adult individuals who can ask the question. At the time of the choice, no one exists, and no one can be harmed by the decision to abort. Children and adults with disabilities can, of course, be harmed, but that would be wrong. So, keeping the two things apart from each other, we can both condone the terminations, if the parents so choose, and agree that people’s needs should be met, whatever they are. Unfortunately, however, it is clear from public debates that arguments like this do not even begin to alleviate or remove the concerns people have.

REASSURANCES AND ACTIONS

Concerns can be addressed by reassurances and actions. When people are worried about genetic discrimination or posthumous organ retrievals, their apprehensions can be relieved by bans, restrictions, and regulations, and by promises to plan or implement them. Since promises and reassurances are in the majority of cases cheaper than regulative actions, they are often the route preferred by public authorities. One simple reason for the erosion of trust in the public health care system is, of course, that the promises do not always lead to planning, and planning does not always lead to visible regulation.

It would, however, be simplistic to say that unkept promises made under political pressure are the only, or even the main, explanation for public distrust. This is because conflicting concerns make it genuinely difficult for public authorities to decide what action to take. While some citizens are concerned that abortions are allowed on flimsy grounds, others—like Thomson—have been more worried about restrictions on them. The same observation applies to all my examples: some people—like Singer—are troubled by animal research, others by its prohibition; some people worry about organ harvesting, others—like Harris—about its restrictions; some have anxieties about euthanasia, others—like Foot—about keeping people alive against their wishes. Not all of these pairs of concerns are truly contradictory—some of them can, no doubt, be reconciled—but others are.

CLARIFICATION AND RANKING

These considerations bring us to the philosophers’ last resort. Although arguments cannot be employed to address people’s concerns directly, what about using them indirectly, to sort out which concerns can be reconciled, and which of the conflicting concerns are the most important to address? This would give philosophers an indispensable role in clarifying issues to all decision makers, public and private. It would also show that arguments can address concerns, or be used in addressing concerns, after all.

So the question is: “Can (philosophical) arguments help in the clarification and ethical ranking of concerns?” I have two answers to this question, namely “Yes, but not necessarily” and “I doubt it.”

I believe that, sensitively used, conceptual arguments can clarify and explicate concerns held by philosophers and non-philosophers alike. This is shown by the contributions of Thomson, Singer, Harris, Foot, and Holm that I have referred to here. However, sophisticated arguments can also add to the general confusion in many ways. For instance, incompletely digested by professional groups, the media, the authorities, or the general public, sustained ethical arguments often start to produce their own realities—realities where champions of consequentialism kill children, defenders of deontological theories are determined to become concentration camp guards, and supporters of teleological doctrines believe in natural slavery and the intellectual infirmity of women.

So my first answer is that arguments can help in the clarification of concerns, but that this is by no means inevitable. And I doubt that philosophical arguments can help in any general way in the ethicalranking of concerns. If the philosophers doing the ranking know what the moral values of the decision makers or agents are, then they can give them moral reasons for certain priorities. If on the other hand they know what the values and interests of the other groups affected by the decisions are, they can give the decision makers prudential reasons for certain, possibly different, priorities.

Philosophers can, in other words, provide agents with arguments for and against some specified choices. But can they—can we—produce valid arguments for or against the eventual choice of these arguments? I have my qualms.

RATIONALITY

I am fully aware that some philosopher colleagues would, at this point, like to say something about the rationality of the arguments we use and the concerns we should address.

I have a lot of sympathy with this approach. It would, no doubt, be rational to prefer rational arguments and to prioritise rational concerns. But which arguments and concerns are rational? When it comes to logical consistency and empirical facts, some good answers can be given to this question. Proper responses are, however, more difficult to come by in the case of moral, cultural, and emotional norms and expectations. Which values and courses of action are more rational than others? Some say the ones that are consonant with the natural law, others prefer those that are consistent with our freedom as moral agents, one group is committed to those that aim at the greatest happiness of the greatest number, and another group says it does not matter, because reason died of its own contradictions two hundred years ago, and left its legacy to art and politics. So the colleagues who would like to make use of rationality in our present context will have to tell me which account should be taken on, and how the choice can be justified.

REHEARSING ARGUMENTS, ADDRESSING CONCERNS

In sum, then, what can be said about the interplay of arguments and concerns in bioethics in the light of my observations?

Arguments can voice, clarify, create, and tackle concerns. If the concerns in question are philosophical, they can be conceptually addressed and, in so far as theoretical consensus can be reached, settled. When the concerns under scrutiny are argumentative, and when they embody logical and empirical reasons for or against definite policies, arguments can demonstrate their rationality or irrationality, and consequently suggest that they should or should not be intellectually accepted.

In the case of concerns which involve moral, cultural, or emotional norms, values, or expectations, arguments can, and probably should, be rehearsed to make explicit the underlying ethical assumptions. The eventual choice between these assumptions falls, however, outside the scope of arguments, understood as attempts to arrive, by the use of words, at universally acceptable solutions.

The concerns that remain can be addressed by reassurances and actions. The actions available to authorities include, in addition to promises and regulations, efforts to communicate with the public and to prompt consensus formation. Philosophical reflections and arguments can have a legitimate role in these activities. If the decisions reached are truly acceptable to all those involved, the initial concerns have effectively been accounted for. But if some, or many, people are still concerned, repeated or additional philosophical arguments are not the answer. Perhaps others can suggest what is.