Zentrum für Medizinische Ethik

Zentrum für Medizinische Ethik
Hans-Martin Sass, Professor für Philosophie an der Ruhr Universität, 44780 Bochum, ist
Geschäftsführer des Bochumer Zentrum für Medizinische Ethik und Senior Research Scholar
am Kennedy Institute of Ethics, Georgetown University, Washington DC 20057.
Die Studie ist ein Beitrag zum Teilprojekt 'Gesundheitsmündigkeit - Health Literacy' einer
Forschergruppe 'Kulturübergreifende Bioethik' unter Leitung von Heiner Roetz (Bochum),
gefördert durch die Deutsche Forschungsgemeinschaft.
Herausgeber:
Prof. Dr. med. Burkard May
Prof. Dr. phil. Hans-Martin Sass
Prof. Dr. med. Herbert Viefhues
MEDIZINETHISCHE MATERIALIEN
Zentrum für Medizinische Ethik Bochum
Ruhr-Universität
Gebäude GA 3/53
44780 Bochum
TEL (0234) 32-22749/50
FAX +49 234 3214-598
Email: [email protected]
Internet: http://www.medizinethik-bochum.de
Heft 151
AMBIGUITIES IN BIOPOLITICS OF STEM CELL RESEARCH FOR THERAPY
Who cares for Gretchen Mueller?
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ZENTRUMS FÜR MEDIZINISCHE ETHIK BOCHUM. Er wird allein von den Autoren
verantwortet. Das Copyright liegt beim Autor.
© Hans-Martin Sass
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AMBIGUITIES IN BIOPOLITICS OF STEM CELL RESEARCH FOR THERAPY
naturales' maxims of avoiding extremes in Western cultures [Hartmann 2003; Sass 2004A].
Who cares for Gretchen Mueller?
Influential Chinese philosopher Mengzi holds, as Rousseau and others did in European
Hans-Martin Sass
enlightment culture, that 'being compassionate and act humanely .. is innate in everybody's
heart'. But in Asian as in Western philosophy, the nature of 'good morality' is controversial.
THE CASE: WHO CARES FOR GRETCHEN MUELLER?
While Mengzi (391-308 BC) grounds human morality in 'human nature' without much
Gretchen Mueller, 42 years old and a mother of 3, suffers from paralysis of her lower
metaphysical reasoning and calls for nurturing and practicing moral deeds to further self
limbs and trunk, associated with paralysis of her bladder and rectum, due to a car accident a
cultivation, Wang Yangming (1472-1529) presents a model of interacting macrocosms and
year ago. Her husband Carl, 48, an accountant, who had a heart attack 2 years ago resulting in
microcosms, calling on humans to avoid wickedness and evil and returning to original
substantial loss of left ventricular heart muscle, takes care of Gretchen and their children of 2,
goodness. For Mengzi the role model is the gardener caring, nurturing and beautifying the
4 and 7, as good as he can. New research in cloning and in reprogramming of human embryonic
garden, for Wang it is the cat and its innate (sometimes dormant, but never absent) nature to
and somatic stem-cells might offer therapies for re-growth of injured muscle and nerve cells
catch mice [Ivanhoe 2002:107f]. Controversies in European enlightment over the nature of
and eventually better or heal Gretchen's and Carl's health conditions and allow for improved
social contract between Rousseau, Hobbes and Locke resemble similar positions. Ratankul
individual and family life. But some governments have criminalized stem cell research, others
[1999, p. 19] describes it as Buddhist moral duty 'to practice morality (sila), mental discipline
have put more or less severe restrictions on human cloning, cell-reprogramming, and research
(samadhi) and wisdom (panna)'.
on embryonic constructs, in part due to a potential transfer of new therapeutic technologies into
St. Paul in his influential letter to the Romans argues that, while the Jews know what to
human reproduction; they seem to care more for zygotes and morulae than for citizens in need
do by revelation, the pagans have ample opportunity to learn about naturally good and bad by
of better medical care and caring governments.
studying the laws of nature. Religious commandments, such as fasting during Ramadan for
Muslims or obeying the sanctity of Sabbath for Jews, become less demanding and actually need
CARING FOR THE SICK IS A PRIME MORAL AND CULTURAL PRINCIPLE
to be disregarded, whenever there is need to balance those commandments against saving life
There are many differences in cultural traditions and professional cultures, representing
and fighting disease: saving life and fighting disease comes first [Sass 2003; 2004]. One of the
the richness of humankind's heritage and the diversity of priorities in expertise and ethics in
five central requirements for a Muslim is to support generously the poor and the sick [Ilkilic
professional ethics. But we rarely see much of a difference when it comes to moral obligations
2002]. The prophet Micah holds that are basically only three rules in obeying the Lord 'to do
towards the sick, the poor, those who are weak, in pain, in despair, and cannot help themselves.
justly, and to love mercy, and to walk humbly with your God' [Micah 6:8]. Jesus makes an even
A common moral prima-facie recognition of individual and communal responsibility toward
stronger appeal, suggesting God's appearance and image in the sick, the suffering and the poor:
the sick and the poor seems to be strongly supported by religious teaching, philosophical
'inasmuch as ye have done it unto one of the least of these my brethren, ye have done it unto
argumentation, and cultural tradition everywhere.
me' [Math 25:40]. Schueller SJ defines two 'golden rules' for Christians 'as God has loved us,
'Love your neighbor' is a basic commandment in most cultural and religious traditions
we should love one another; as God has forgiven us in Christ, so we should forgive one another
[Sass 1986; 2003A]. We find the Golden Rule 'do not do to others what you do not want to be
(Eph 4:32)'[1980, p. 212]; he calls this a general orientational model a norma normata, which
done to yourself' in Confucian teaching, in Jewish and Christian religion, in Kantian ethics [Qiu
needs to be differentiated by 'requirements of morality', as the norma normans, a decisionist
1988:298; Sass 2003A], even in extreme anarchist reasoning such as in Kropotkin's 'Mutual
position [Schueller 1980, p. 230] quite close to St. Thomas Aquinas insight that assessment and
Aid' [1902]. Avoiding extremes and helping others in doing so and in finding harmony and
justification of moral acts and those acts themselves need to be close to the situation: 'actiones
re-balancing mental and physical disorders is an essential insight in religions and philosophies
humanae secundum circumstantias sunt bone vel male' [S.Th.8I,II,q18,3]. Ivanhoe summarizes
of individual and social harmony, of harmonious interactions of microcosms and macrocosms,
a similar minimalistic view of applying general doctrines or principles to singular cases in
and of supporting the sick and the weak in spiritual and medical healing. Asian cultures of
situational ethics 'Mengzi vigorously attacked all attempts to ground morality in any "external"
orientation in harmony find responding cultures of the 'meson', the Golden rule and the 'res non
standard. No "teaching" or "doctrine" (yan) could ever replace the properly cultivated "heart
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and mind" (xin) as one's guide to moral action' [2002:35]. Asian cultures resemble the
two different models of certainty and insight.
Confucian notion of the larger family as the role model for moral obligations and rights, in
A-priori moral intuition based visions and principles allow for individual or
particular towards and of those members in need; from a Western point of view they probably
moral-community based personalized concepts of differences between good and evil. Those
would favor minimal-metaphysics Aristotelian reasoning over heavy-metaphysics Platonism.
sometimes different convictions and attitudes towards moral mid-level principles and their
Judaic and Muslim teachings have strong foundations in prioritizing the care for life and
implementation in day-to-day moral decision making depend on personal interpretation and
health over other religious commands. Christian theologians and churches have accepted
application of individually and culturally shaped values and visions. A-priori based scientific
cadaveric and life organ transplantation, blood donation, 'immortalization' of human cell lines,
experience allows for empirical scientific knowledge which can be verified by everyone using
cell-reprogramming of lung cells for the development and ongoing use of vaccination for
human rationality for scientific inquiry, independent of individually shaped prescientific
measles-mumps-rubella vaccination from aborted fetuses. As far as the acceptance of these
understandings or visions of the nature of nature.
practices by the Roman Catholic church is concerned, Kevin Fitzgerald SJ, priest and geneticist
The final system of reference for a-priori intuition is the individual conscience, taught
argues that benefits 'significantly outweighed the drawbacks of using aborted fetal cells'
and refined by parents, priest, and neighbors of a specific culture and its internal confirming or
[Argetsinger; Goldstein 2004].
critical forces in the implementation and development of moral culture and moral action and
Book-based Judaic, Christian, and Muslim religions, also non-book based systems of
interaction. A review of historical and contemporary moral positions towards helping fellow
reference such as Confucian, Daoist, Hindi, and Buddhists worldviews display quite variety
humans sick and poor on one side, and on issues such as moral duties towards unborn forms of
and flexibility in the history of ideas in their different branches and in bioethical positions on
human life, organ or blood exchange, merci-killing, demonstrate a widely shared common and
crucial issues today [ Nationaler Ethikrat 2003; Roetz 2004; Sass 2003A], but none of them
universal moral obligation for the former, but reasoned controversies among morally competent
does have any elasticity to disregard or actively violate the 'love your fellow-human', the
people on the latter; both positions are based on a-priori moral intuition, would not be possible
'solidarity' principle, in particular with the sick, the suffering and the poor. Gretchen and Carl
otherwise, and can be understood and assessed as such.
have heard the message of 'the good Samaritan', as told by Jesus, over and over again in many
sermons and other church teachings.
While the model of a-priori intuition may serve as a helpful conjecture and counterpart
to Kant's a-priori epistemology in continental European theory-based cultures, Veatch has
proposed a convincing model of 'common morality' within the Anglo-American theory-culture
THE A-PRIORI INTUITION AND OTHER MODELS TO BASE MORAL THEORY
of common sense and analytical philosophy: 'There is a universal inclination that life - at least
AND DIVERSITY
human life - is good and is to be preserved. Some slogans of professional ethics have have
When ethics is about making choices between good and evil, between being moral and
summarized that "the duty of the physician is to preserve life". Unless there is some good
being wicked, then the human capacity to make distinctions between good and evil, between
reason to act otherwise, we are naturally inclined and morally obligated to see that critically ill
morality and wickedness, must be an intuitive a-priori, which is different from an
people's lives are preserved' [2004]. Differences in opinion crossculturally or different
epistemological a-priori, as described by Kant [Sass 1986]. Both the inflexibility of certain
positions within one community or society might be solved or eased by what Rawls has called
non-controversial 'goods', such as the care for the sick and the needy, and the flexibility in
'considered moral judgment' and what Veatch defines as 'refined common morality', a
moral choice regarding controversial issues, as evidenced in the history of cultural and religious
reasonability standard holding that '"reasonable people" share a set of pre-theoretical moral
ideas and attitudes, give empirical support to the existence of an intuitive moral a-priori as the
insights - or would share them if they developed a set of considered moral judgments'[2004].
conditio sine qua non and per quam of ethical reasoning, moral conviction and value-based
While Veatch holds that 'almost all reasonable people agree or would agree to the claim
principled action. Kant's model of a-priori preconditions in epistemology - sine qua non and per
that there is a common morality', he argues that it is 'more difficult to confirm' the content of
quam - sets a conceptual framework for clear, reasonable, and undisputable consensus on
such a common morality 'if certain standard assessments were made to adjust and fine tune their
scientific knowledge by experience, a framework which ex post can be proven empirically
naive moral insight so that they became considered moral judgements'. The Hitlers and Stalins
again and again. A-priori based moral intuition and a-priori based scientific knowledge lead to
are not an issue of controversy in arguing even for naive moral insights into common morality.
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They do not represent soft or hard differences in moral intuition and implementation; they are
arguments only for legally tolerating the import of donated cadaveric organs from countries
the wicket adversaries and enemies of moral intuitions and differences in moral choice. But
such as Austria where consent-to-donate is the legal default position, if people actively by
there are, given the nature of moral intuition and moral choice, differences and ambiguities:
written statement have not opted out, but strong arguments for criminalizing the import of
'Words such as killing, murder, euthanasia, homicide, and allowing to die are complex terms
human organs from countries of questionable practice and no reliable legal standard and
that are defined differently by people in different religious and cultural groups even when they
oversight. He is aware that differentiating between ideals in bioethics and operational acts in
are all speaking English ... Learning that a priest in Rome holds that direct intended killing of
biopolitics does not serve the interest of fundamentalists nor the intentions of those who
the innocent is immoral does not necessarily conflict with the claim of the Chinese that
principled arguments are used in hermeneutics and politics and consensus formation.
In a model called differential ethics, I have suggested a minimal-theory operational
euthanasia is sometimes moral'.
As far as embryonic stem cell research or reprogramming of human cell lines in the
model, following methods used technology assessment for integrated value-and-technology
conduct of research for therapy is concerned, one could use Veatch' wording and formulate two
assessment of specific scenarios or singular cases [Sass 1999; 2003A]. This model
different positions in moral culture. (1.) 'Some reasonable people do or would agree that the
differentiates between basic moral commodities (liberty, security, dignity, fairness),
production of embryonic stem cells for therapeutic research and potential production of
semi-finished or amalgamated materials (freedom of expression, respect for privacy, social
therapies based on the use of such constructs is morally not acceptable and therefore sick people
security, informed consent), and end products (fine tuned principles as precision instruments
unfortunately need to be left to die or without adequate therapy'. (2.) 'Almost all reasonable
for managing single cases or scenarios of identical moral and technical challenges. Differential
people do or would agree that therapy for sick patients and saving of lives of people is a prime
ethics assumes that most mid-level principles are based on different revelational or
obligation in common morality, and that using embryonic stem cell lines or reprogramming
metaphysical insights promoting basic moral maxims, such as 'love your neighbor', and that
techniques for such a high moral goal is justified in particular when the destruction of embryos
differences among personal and collective understandings or priorities of mid-level principles
is not criminalized when performed by hormonal or mechanical antinidativa or early abortion
are best be solved by contracting, including contracts not to agree on or tolerate certain moral
for less commonly accepted purposes'. The difference in using 'some reasonable people' in
goals and deeds as long as others stakeholders in culture and community are not hurt.
sentence 1 and 'almost all reasonable people' in sentence 2 can be justified by most models of
Differential ethics refers in situations of ambiguous and complex technical and ethical decision
moral reasoning and would easily be supported by a vast majority of historical and
making to the grass-root level of allowing and entrusting the persons closest to the issue to be
contemporary moral, cultural, and religious positions.
the prime moral agent. It is not a utilitarian position, as it is not based on utility but on the very
Birnbacher understands bioethical maxims as ideals, not as prescriptions or rules for
nature of moral intuition and its respect. This position therefore suggests avoiding societal and
direct implementation [2004]. Using norms and maxims in bioethics as 'collective moral ideals'
cultural fight over words, beliefs, and truths by leaving final decisions to competent individuals
allows for understanding, accepting and supporting 'pluralism in bioethics'. Those ideals will
as prime moral agents of their beliefs and acts [Sass 1991; 2003A; 2003B].
have to be made operational in self-regulation, laws, regulation, also - as Asian traditions
Ivanhoe, in summarizing the mentioned differences in evaluating human nature and
tirelessly call for - in self-cultivation. When made operational in legislation ad regulation, the
human morality by Mengzi and Wang Yangming, underlines the point of consensus by both of
translation of ideals into the real world of real people, having real and quite often different
them, a consensus which might also be applicable to global crosscultural and innercultural
visions and values in ethics, need to meet high standards in legal and regulatory ethics. If
theoretical debates and moral actions: 'Mengzi and Wang offer profoundly moving examples of
underlying moral norms and visions are widely shared and non controversial, then justification
what it means to work at the improvement of both, self and society ... they also offer revealing
of laws and regulation in terms of legal and political ethics is not a problem. However, if such
examples of what it is to participate in an ethical tradition while working to adopt and transform
a cultural or moral consensus is not existent, such as in areas of abortion or embryo research,
its beliefs and practices to fit with the needs and assumptions of one's own age' [2002:142].
then such a justification is 'an issue of some complexity', in particular if governmental
Doering [2004] stresses the importance of 'self-perfection (xiu shen)' as a goal well known in
resolution occurs 'behind closed doors' and on issues which do not hurt anyone directly [2004].
Chinese as well as in Germany philosophy from Confucius and Plato to Kant and Zhu Xi; as
Birnbacher differentiates between 'soft refusal' and 'strong refusal' which e.g. gives soft
already mentioned, Buddhism calls for similar moral duties of self-perfection [Ratankul 1999,
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p. 19].
a defined and structured professional obligation in a particular field of human, societal, cultural
A-priori moral intuition and refinement and other models of presenting a plausible
and political service. The Western culture Hippocratic 'salus aegroti suprema lex' rule, i.e. to
theoretical foundation for understanding moral theories and actions in diversity cannot do so
make the benefit and sake of the patient the highest rule and law, even when in conflict with
without giving highest priority to individual challenge and personal choice between being good
political or other rules, is met by Asian traditions requiring the virtuous physician to be like a
or being wicked. The dignity of the individual conscience is the core of respect for human
brave, prudent and ingenious warrior. Most eminent and influential Chinese physician Yang
dignity and rights as civil rights. It can explain and support the diversity of moral cultures and
Chuan reminds people to only trust doctors 'who have the heart of humaneness and compassion,
actions within a framework of common morality or a-priori moral intuition. Veatch holds 'that
are clever and wise, sincere and honest' [Qiu 1988, p. 285f]. Doctor Gong Tingxian formulated
once one realizes that postmodern moral philosophy finds it possible for there to be different
interactive virtue rules for physicians and patients, stressing the treatment of the patient as a
accounts of the morality reality that are not incompatible even though they are
person and based on expertise and ethics and compliance of the patient and health competence
incommensurable, one discovers that the common sense belief in a universally held set of
in lifestyle decisions, a blue print for modern interactive maxims for patient-oriented
pretheoretical moral intuitions that become the raw data for theory construction more and more
individualized treatment [Sass 1994].
There is an ongoing debate in all cultures of healing and of expectating help and
plausible after all' [Veatch 2004].
Koch argues that a loose definition of 'embryo' has led to moral and legal confusion and
humaneness from experts and profesionals: Should professional health care fight nature or
mishandling of moral and legal assessment. When an embryo is a developing human organism
modify the course of nature? Of course, medicine is an action oriented profession determined to
from time of fertilization to the end of the eight week after fertilization, as defined by medical
safe life or to eliminate or alleviate pain and suffering against naturally progressing diseases
terminology, then the re-programming of stem cells, having the ability to give rise to more
and symptoms. Thus, medicine and health care is fighting 'nature' in the interest of 'life', but all
differentiated cells or tissue, and nuclear transfer in cloning technologies would not meet the
life is terminal, and all life is associated with some kind of hunger, pain, suffering. Roetz [2004]
definition of fertilization. In order to avoid fight over words, Koch suggests to reserve the term
points out that even in Chinese culture some schools exist, such as the one following
fertilization for the traditional 'integration of haploid sets of chromosomes by chance from
Confucian scholar Xunzi in the third century b. c., that similar to Baconian and Hobbesian
humans of different sex' [Koch 2003:113]. Elsewhere in science already the term 'embryonic
European traditions of fighting and overcoming cruel and immoral nature , do not see nature as
construct' has been used and accepted to define sets or conglomerates of totipotent cells derived
a role model for exemplary harmony [Sass 2004A] but as something that needs to be overcome:
from cloning or re-programming, not fertilization. Religious and cultural positions would find
man as co-creator of (a new) heaven and earth; Bacon's 'Novum Organum Scientiarum' sets the
such a definitional distinction helpful in evaluating and differentiating stem cell research for
new stage for making nature less cruel, more habitable, more cultivated.
therapy from making babies in vivo or in vitro.
Pellegrino and Thomasma, based in Western humanist and Christian traditions require
Gretchen and Carl know nothing about any of those and other models to base moral
of physicians to 'place the good of the patient at the center, possess and maintain competence in
theory and to argue for and to understand moral diversity between and among individuals,
knowledge and skill, recognize limitations, respect values and beliefs, care for all independent
moral communities and cultures. They are devoted Christians in the Roman-Catholic faith; they
of their ability to pay, assist patients to make choices, hold in confidence, never participate in
go to Holy Mass frequently and have followed instructions of their priest not to use IUD's or
killing, fulfill obligations to society, practice what you preach, teach and believe' [1988, p.205f].
hormonal contraceptives. Common sense, moral intuition, and civil sense tell them that
Understandable and acceptable by Westerners and Asians alike would be a set of virtues by the
authorities should support the improvement of medical care and the reduction of suffering and
Chinese Ministry of Health, neither making reference to specific Confucian or Western
pain by allowing - even promoting - the development of better medicine.
traditions, rather based in Marxist-Maoist reasoning of humanist solidarity and reciprocity:
'healing the wounded, rescue the dying, and practice socialist humanitarianism; keep the
CROSSCULTURAL PRIORITIES IN PROFESSIONAL HEALTH CARE ETHICS
interests of the patient in your mind and try everything to relieve patient suffering; show respect
Professional medical cultures everywhere have made it imperative to put the interest
for the patient's dignity and rights and treat all patients alike whatever their nationality, race, sex,
and the sake of the patient first, electing to make common morality and a-priori moral intuition
occupation, social position and economic status is, .. be honest in performing medical practice,
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keep secrets related to the patient's illness, be rigorous in learning and practicing, education on
and informed informed contracts with probands or patients, to have sexual relations with
medical ethics and the development of medical ethics must be part of managing and evaluating
patients, who are dependant on their physician or nurse, has been stigmatized by medical
hospitals' [Cao 1989:16f].
professional traditions and punished within professional organizations. In the commitment and
Originally developed in the research setting, now calling itself 'common morality', the
service of the healing profession for the best of the patient not everything goes, even though
influential Georgetown package 'autonomy, nonmaleficence, beneficence, justice' [Beauchamp,
other rules or laws, which will be respected in normal situations, may be violated in favor of a
Childress 2001] addresses the same issues as more detailed packages such as 'ahimsa
higher law, the 'salus aegroti' as the supreme law.
(nonmaleficence), compassion, respect, righteousness, dharma (responsibility)' by Michael Tai,
But there are medical situations where moral ambiguity rather than moral certainty or
a contemporary Chinese bioethicist [1999]. These and other traditions in medical professional
immorality are prevalent. There is, indeed, 'ambiguity in moral choice' as Richard McCormick
culture must be understood as expressions of a general intuitive moral a-priori defined and
SJ [1973] has assessed from the point of view of moral theology. Caesarian section, first
declared in codes of professional ethics, professional self-regulation and professional law. Only
performed in order to give birth to a successor to a throne while jeopardizing the life of the
in this specifically defined and executed form do they meet customer's and patient's
mother, was quite an ambiguous moral choice in feudal societies. Caesarian section or
expectations across different cultures and serve as the necessary foundation for trust based
pharmacologically induced delivery performed in modern hospitals in order to better schedule
communication and cooperation between providers and customers of professional health care
workforce, to improve risk-liability balance in certain jurisdictions, or to optimize financial
services.
rewards based on DRG schemes is questionable.
The principled dominance of the regulatory ideal of 'aegroti salus suprema lex' over
There is true technical and moral ambiguity and uncertainty in many medical decisions,
other moral ideals, even over public and personal obligations and interest, provide for an
in prescribing or not prescribing certain drugs, in in-situ surgical decision making, in framing
additional layer of moral identity and authenticity of individual health care experts and the
medical information in order to get patient's 'informed' consent when such a consent is legally
health profession [Sass 2003A; 2004A].
required but the medical situation does not allow for options. There are soft or hard differences
Those dominant professional traditions and expectations from patients or potential
and ambiguities in fine tuning moral intuition into real-life rules and acts representing the
patients in different cultures should give Gretchen and Carl hope that sooner or later treatments
cultural and historical richness in diversity of moral choice. These differences may not be
will be found and that politicians, lawyers, and theologians will stop 'playing doctor' and stop to
confused with true and evident immorality, wicket distortions of and hard contradictions
disappoint their and other patient's hopes and anticipations, that biopolitics will stop to deprive
towards each and any moral decision.
citizens of basic civil and human rights by not allowing or supporting the development of
Some, but not all, uncertainties and ambiguities, e.g. deciding whether or not to initiate
tube feeding or mechanical ventilation in terminally ill patients, best are dealt with by using the
medical treatment.
stakeholder model and including patients in making hard choices. Most issues of ambiguity in
MORAL AMBIGUITIES AND IMMORALITIES
moral and medical choice seem to occur in paternalistic decision making, 'medical experts'
While compassion and caritas and activities to serve the sick, the frail, and the poor are
following the 'book' or the DGR schemes, not providing individualized treatment. The
shared by all major cultures and therefore rightly may be called a cultural heritage of
traditional 'salus aegroti', good of the patient, need to be re-evaluated as 'salus ex voluntate
humankind, there are also actions clearly definable as immoral such as torturing and killing,
aegroti', the good as far as it is expressed by the patient or is in responding to the values, wishes
slavery, rape and exploitation. Medical codes of conduct have clear traditions and visions, strict
and visions of the individual patient. The 'salus ex voluntate aegroti suprema lex' maxim has
principles and virtues, delineating what might be acceptable or even mandatory in certain rare
become a global quality standard in contemporary medical ethics [Pellegrino, Thomasma 1988;
situations and what it is clearly not acceptable and immoral, even if lives would be saved,
Cao 1989; Ni 1999; HUGO 2003] and in interactive models of communication-in-trust and
diseases be healed, or suffering be ended. To catch people, slaughter them and sell their organs
cooperation-in-trust between experts and lay persons [Kielstein, Sass 2002; Sass 1994]. The
for saving the lives of others, to use fellow humans as guinea pigs in clinical research without
partnership model of moral reasoning runs against the deontological model of watertight
prior appropriate risk-benefit-uncertainty assessment and free and informed consent of or free
rational calculation and decision making by experts and related expert ethics.
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Non-book based moral reasoning but also strong fractions in monotheistic moral
prime moral intuition supported by many cultures and religions, is a maxim, not an inflexible
theology would agree with McCormick SJ [1973, p. 106] that 'moral awareness and judgments
fundamental rule, an 'ideal', as Birnbacher [2004] would say, a vision, which needs to be
are fuller and deeper than "rational arguments" and rational categories. They are the result of
taylored to the situation. There is a difference between breaking off a flower and throwing it
evidence in the broadest sense - which includes a good deal more than mere rational arguments.
away and breaking off a flower and giving it to a person one loves, and there are only a few
While moral judgment must continually be submitted to rational scrutiny in an effort to correct
among us who would not flowers to loved ones in respect for life. Killing flying insect just for
and nuance them, in the last analysis, rooting as they do in the intransigence and complexity of
fun, is not an expression of respecting life, but killing a mosquito on my skin who just starts or
reality, they remain deeper and more obscure than the systems and arguments we device to
has finished to bite protects me from nuisance and pain, sometimes even from the transmission
make them explicit'.
of infection. Killing large numbers of mosquitos by insecticides in order to prevent the
Communication-in-trust and cooperation-in-trust will allow for morally accepting
transmission of malaria or west nile virus infection has become a modern standard in hygiene
situations when medical treatment, even the saving of life is technically available, will be
and public health. Some worldviews hold that killing animals for protein intake is disrespectful
refused by patients based on their individual system of value-and-belief reference, such as
of life, and that enough non-animal protein is available for morally sensitive and cultivated
Jehovah's Witnesses refusing to accept blood infusions. It was a major moral and legal victory
people. Sources in Rabbinic tradition hold that killing a mosquito on Shabbat is a larger sin than
that most civilized hospital cultures and health care expert respect such a position, not shared
aborting a fetus. Killing a mosquito is not immoral, but depending on the situation is ambiguous
by many and widely seen as somewhat strange or even bizarre. This is an exemplary model for
and arguments pro and contra might be controversial. 'Killing' an embryonic construct cannot
defining the 'good of the patient' and for avoiding the moral 'evil', based on her or his
even be compared to the abortion of an embryo, and probably should not even be compared
'value-wish-and-vision profile: 'salus aegroti ex voluntate', determined by professionally
morally to the killing of a mosquito.
integrating a patient's value status and medical status.
Ethics is about making distinctions and basing moral intuition and interpretation on
Gretchen and Carl have among their friends followers of the Jehovah's Witness church;
differentiated analysis and evaluation of facts and scenarios. New scenarios require particularly
they intuitively feel that refusing other people's blood for saving life is somewhat strange, but
careful assessment of scientific facts and medical evidence without jumping to early
they respect their friend's position as a moral one in their own right. Recently, they read that a
conclusions. Recent longitudinal studies of humans born using in-vitro fertilization techniques
certain Dr Hwang in Seoul and his colleagues, some of them Christians, have derived a
confirm that genetic as well as environmental factors seem to influence genomic development
pluripotent embryonic stem cell line from a cloned human blastocyst, a scientific breakthrough
and the formation of active polymorphisms in individual DNA codes; thus in-vitro fertilization
which might lead to future therapy for both of them. They also read that Dr Hwang, a Korean in
has definite and certain shortcomings and contains health risks not associated with the natural
the Buddhist-Confucian tradition personally would be very reluctant to accept organs donated
way of 'making babies'; more 'natural ways' of assisted reproduction such in-vivo insemination
by others humans or donate organs of his own, as such a practice would be running against his
(GIFT and other methods) include less risk as the fallial tube environment is more 'natural' than
understanding that human bodies as a 'property' of ancestors are not for sale, not for donation
a petri dish. Animal studies have confirmed that DNA 'is both inherited and environmentally
[Hwang 2004; Faiola 2004]. While those anecdotes might or might not be true; Gretchen and
responsive. Behavior is orchestrated by an interplay between inherited and environmental
Carl find such arguments strange, but they are grateful that his cultural background and moral
influences acting on the same substrate, the genome' [Robinson 2004:397]. Daoists and
intuition seem to have motivated Dr Hwang to work on developing transgenic organs in
Western natural law philosophies rightly associate means of modifying, manipulating or even
animals for human transplantation and on cloning human cells for helping patients such as they
fighting and suppressing natural forces as having possible factual as well as moral risk. On the
are.
other hand, Western and Eastern worldviews also see the cruelty, immorality and inhumanity in
untamed natural forces, - a yet unsolved and probably unsolvable ideational battle and
DIVERSITY IN MORAL INTERPRETATION OF MEDICAL FACT AND EVIDENCE
dialectical challenge in most cultures [Sass 2004A; Roetz 2004].
Ethics is about making differences, making distinctions, making choices and avoiding moral
Opponents of embryonic stem cell research for therapy arguing that genetic code
asymmetry, also about differences in planning and judging moral actions. 'Respect for life', a
defines individuality and character, use an outdated model of individuality as recent scientific
13
14
evidence provides insight into an 'interplay of hereditary and environmental influences on
supplemented. Embryonic constructs produced by technologies and procedures existing today
genomic activity and individual behavior' already during very early stages of development and
are just transitory products for the farming and further developing embryonic stem cells; the
gestation [Robinson 2004:398; Jaenisch 2003]. Opponents of human cloning do not take into
only value and utility of those stem cells is for therapeutic purposes.
account the different environments of test tubes, petri dishes, fallial tubes and the uterus, nor do
they recognize the constructional shortcomings of cloning techniques.
Denker has summarized a number of insufficiently known facts about normal
Moral theology and philosophical arguments using natural law theory are cutting
conceptual and analytical corners, as they do not recognize different biological and associated
moral properties of embryonic constructs when compared to embryos derived with or without
embryogenesis and early pattern formation. We know much less about the formational
medical assistance, in vivo or in vitro, from two haploid sets of human DNA. As
properties of embryonic stem cells insolated in different types of nutrition medium in vitro:
reprogramming human cells has never been a scientific possibility and option until recently,
'Colonies of embryonic stem cells forming in vitro must be expected to lack, as a rule, the
cultural, philosophical and religious traditions do not provide ready-made concepts for cultural
simple but ordered asymmetries of the embryonic disc of normal embryos that are derived from
and ethical evaluation of cell reprogramming and cell cloning. Buddha, Lao Tse, Kant, Jesus,
the asymmetries of the egg and the zygote system' [2004:16]; but limited knowledge today
Mohammed or Plato had no reason nor a chance to think about it. Scientists so far agree that
cannot exclude that an early stage of further embryonic formation 'can start spontaneously as a
available methods of cloning embryos are not perfect and do produce 'embryonic constructs'
rare event even in standard cultures in human embryonic stem cells' [2004:18], comparable to
rather than embryos. Those embryonic constructs definitely do not qualify for reproduction, as
yet not well know developmental pattern resulting in twins or Siamese twins.
evidenced by animal studies. But as already mentioned, it is a worthwhile intellectual and
Enbryonic constructs, also called 'embroyid bodies' and 'coined for the mouse system
ethical exercise today to discuss medical, ethical, cultural and legal issues of prospective future
and refers to the fact that when mouse teratocarcinoma / embryonal carcinoma cells (EC) or
cloning techniques for human reproduction. Those techniques will have to be approved by
ESC's (embryonic stem cells) are kept in mouse ascites or in vitro'; they can develop into further
professional oversight bodies such as Chambers of Physicians, using existing and yet to be
developmental stages, but 'are lacking other extra-embryonic cells which play important roles
refined quality control and quality assurance standards. The features of such future quality
in embryo implantation and yolk sac formation' [Denker 2004:4]. Given these and other results
standards are not yet known and it might take another generation or two until those quality
from animal studies, one may safely argue that embryonic constructs or embroyid bodies or
requirements even can be formulated and guaranteed.
isolates embryonic stem cells derived from human blastocysts or blastocyst constructs in vitro
Also, humankind or some moral communities and national or international legislation
are not only biologically but also morally different from embryos in utero. Embryonic
might not accept cloning for human reproduction even though no medical harm would be
constructs were manipulated in vitro for further manipulation into tissue or other remedies.
involved. Existing technologies are only good enough for harvesting embryonic and other stem
They never will be aborted, i.e. by interventional means separated from a womb, from a mother,
cells for further scientific modification targeted at the development of certain cell lines or tissue
as they never had been in a womb. They do not have a mother or a father in the traditional
for therapeutic purposes. Of ethical importance in in-vitro cloning is the construction method,
biological and moral sense. They were constructed by transfering an entire somatic cell nucleus
the environment and the purpose. It is unscientific and irresponsible to just apply Newtonian
into the denucleid cytoplasm of a human oocyte in an artificial medium outside the womb for
laws of physics to specific issues in modern physics; it is similarly unprofessional and a logical
medical purposes and for healing, not for implantation and reproduction. Embryonic constructs
and moral malpractice to apply fundamental moral laws to each and every situation without
therefore are not embryos, neither in the biological nor in the moral sense. As they have no
specification, differentiation, and evaluation, to simply use the same arguments in evaluating
mother or father in the traditional sense, biologically by merging two haploid oocytes, morally
the moral recognition of embryonic constructs in vitro and of embryos in vivo.
by having genetic properties from two persons. How could one ever argue that they need to
Ethics is about making choices; there are easy choices and there some very hard choices
enjoy the protection and respect of genuine embryos whether created in vivo or, in case of
to be made by individuals or communities of different kind. Disputes on moral decision making
infertility, in vitro. These man-made constructs should not be allowed to be implanted into a
are already common in religiously and culturally homogeneous moral communities and legal
womb and criminal law in most civilized countries already makes such acts criminal deeds. If
systems; qualitatively and quantitatively they increase in dimension in pluralistic societies rich
existing laws to not outlaw reproductive cloning, then those laws should be modified or
in diverse individual and communal cultures and religious and humanist systems of reference
15
16
and belief. The already mentioned multitude of voices from different cultural and moral
and face [Mendelsohn 1819:201]. Ilkilic refers to Paret when similarly arguing that Muslims
traditions and a recent report of the German National Ethics Council [Nationaler Ethikrat 2003]
have seen the diversity of positions and fatwas in Islam as a special and particular blessing of
on cultural and moral diversity in the global cloning debate demonstrate quite clearly different
Islam by God [Ilkilic 2004].
cultural and religious attitudes and arguments in regard to re-programming of human cell lines,
Should a moral or could a legal request for abortion by a devoted Jewish female in her
cloning and the moral assessment of various forms of unborn human life, reincarnated human
fourth month of pregnancy be honored in a Frankfurt hospital in Germany, even if physicians
life or afterlife. The minutes of the Ethikrat also give a view into the variety of different
and nurses would be found, sharing her religious belief as expressed many times in Talmudic
positions within the same cultural or religious tradition, similar to differences in Christian
teaching that morally to be respected human life only begins after birth [1. Sabbath 107b; 9.
traditions.
Sabbath XIV,4; 1. Nidda 44b; 1. Sanhedrin 72b and VIII,9; also Exodus 21:22f]? Different
Respecting values and visions of individuals and moral communities and at the same
countries have different laws on abortion, based on legislative majority decisions or supreme
time agreeing on a consensus to accept dissensus in central matters of conviction, morals, is a
court rulings. In Germany, abortion is illegal because according to a supreme court decision all
challenge for everyone, in each and every culture and among cultures. In Europe, at last since
unborn human life shares the protection of the Constitution, but killings of early human life by
the Age of Reason, models of conflict solution have been introduced and in many areas
hormonal or mechanical antinidatives is not even discussed as possibly a criminal act, and
successfully used by applying principles of 'tolerance' and 'self-determination' together with
abortion of embryos up to three months will not be prosecuted if certain consultative and other
'respect for humans by respecting individual choice and conscience. Spinoza in 1670 argued
means recommended by the same court are fulfilled. It is a challenge to the moral and cultural
that law and order would not break down if individual systems of belief would be allowed;
environment and legal system of open societies to apply norms to facts and procedures without
rather, law and order and the shear existence of a peaceable and harmonious society would be
hurting individual judgment and conscience and without differentiation and situational
endangered if individual choice and conscience would not be respected in religious and moral
sensitivity and responsibility.
matters within an integrated framework of security and responsibility. We rightly would feel
In regard to evaluating facts and goals of stem cell research for therapeutic purposes,
severely violated in our individual civil and human rights if someone would request us to
Avram Steinberg summarized that Judaism had different legal approaches to moral issues and
believe that Jesus, indeed, walked on water or rose from the grave, that real trans-substantiation
does not accept absolute statements and judgments. To destroy a blastocyste is bad as it
of bread and wine into the blood and flesh of Jesus Christ occurs when Holy Supper is spend
destroys life, he holds. But when destroying a blastocyst in order to safe life, then one has to
under correct liturgical conditions. We today would find it not only uncivilized, but rude and
ponder whether or not the saving of life of a suffering patient is a virtue higher than the vice of
offensive, if someone would force Hindi to eat beef, or Jews and Muslims to eat pork, or
destructing a blastocyst. But the destruction of blastocysts for the production of cosmetics or
vegetarians to eat any animal products, competent adult Jehovah's Witnesses to forcefully
the development of biological weapons carries other moral cost-benefit risk [Nationaler
receive other people's blood.
Ethikrat 2004:31].
But there are not only modern post-enlightment arguments for respecting human dignity
Mary Mahowald recently argued that citizens have a basic right to 'self-preservation', i.e.
in honoring different values and visions of fellow humans of different tradition, religion, or
'preservation of one's own bodily integrity of life, provides a persuasive, but not necessarily
culture, there is also religious insight supporting value plurality and arguing for freedom of
adequate justification for cloning and embryo stem cell retrieval a negative moral right'
believe and for the exercise of related actions. It was Moses Mendelsohn, enlightened and
[2004:65]. She proposes a model of moral symmetry comparing embryonic constructs, at a
conservative Jewish rabbi, who grounded tolerance and individual moral autonomy and cultural
stage after embryonic stem cells have been harvested from the blastocyst, to 'surplus embryos'
and moral diversity in God's will and creation: 'Brethren, if you want true peacefulness in God
in infertility treatment or to ventilated brain dead organ donors after successful explanation and
(Gottseligkeit), let us not lie about consensus when plurality seems to have been the plan and
suggests they be 'allowed to die rather than actively terminated'.
the goal of providence. No one among us reasons and feels precisely the same way the
Ethics is about avoiding asymmetric moral judgment. Diversity in moral evaluation of
fellow-human does. Why do we hide from each other in masquerades (Mummerei) in the most
scientific facts and procedures also includes different moral approaches towards blastocysts
important issues of our lives, as God not without reason has given each of us his/her own image
depending on novelty of the situation and the role of biopolitics in bioethics. Human blastocysts
17
18
and morulae are destroyed at a rate of about 50% naturally; modern hormonal antinidatives, still
value-and-vision, but not the underling. However, in more liberal states the underling then and
called contraceptives, and intrauterine devices kill blastocysts, morulae and pre-embryos.
now was and is allowed to emigrate. It took a few centuries until such governmental tutelage
While the natural abortion rate of about 50% or higher can be understood as natural, the
disappeared on issues of trans-substantiation, not because the rulers gave in, but because no one
destruction of blastocysts by hormonal or technical devices is intentionally done by human
cared any more so much about whether or not the Holy Trinity was one person in three or three
intervention and is associated with enjoying unprotected sex. Opponents of embryonic stem
persons in one; thus, Spinoza's vision, Mendelsohn's belief, and the liberal tradition in Islam,
cell research for therapeutic purposes have yet to explain why they do not object as strongly
understanding differences of opinion as God's special blessing found a late real-life justification.
against women's choice in sexual activity and why they have not yet called for research
Today we have this kind of freedom of choice and following one's conscience for the rich and
programs to 'safe' early human life, i.e. blastocysts, from 'premature death'. Asymmetry in
well connected, not for the poor and the less flexible and less well connected. Gretchen and Carl
ethics is unethical and ruins moral judgment and moral behavior. Patients deprived of hope for
feel that it is not only unfortunate, but also unjust to live in a European country where
better remedies feel that moral asymmetry is applied to treat blastocysts used for potentially
therapeutic research on embryonic stem cells and constructs is severely restricted, if not illegal.
developing better medicine if compared to the fate of blastocysts intentionally aborted by
Given cultural diversities and moral convictions and visions in open, democratic and
hormonal or mechanical devices or 'naturally'. Asymmetry in moral argumentation occurs
pluralistic societies, the clash of cultures in controversial fields of morality, value, vision, and
easily when theory and real-life are distinctly separated from each other, when intellectual
belief is not so much the difference between traditional Christian, humanist, Jewish, Muslim,
debates lack virtues of care, love, solidarity, and respect for fellow humans. Real-life cases of
Hindi or Confucian cultures but the clash of conflict solution culture within each of these
patients in need of better medicines might break the cycles of academic disputes over theories
traditions, among them, and within the political and regulatory culture of dealing with issues of
and general principles, some of them controversial between cultures and within cultural
conflicting visions and values [Sass 2003B].
traditions and religious teachings. A paralyzed mother in a wheelchair in need of neurological
As pregnancy is part of nature, so are arguments, attitudes, and controversies over
treatment, a father who has lost substantial parts of his left ventricular heart muscle, these are
accepting, preventing, or terminating pregnancy a natural part of moral and legal discourse.
not theories, even not just 'cases'; these are not embryonic constructs in vitro, these are real-life
While only women can become pregnant, abortion decisions and judgments on the moral status
fellow humans, citizens caring for other fellow citizens and in need of better medicines and
of the fetus have been made by men, by societies, parliaments, courts, priests and philosophers,
better medical care [Sass 2004B].
at last by women. Attitudes by political or religious majority towards unborn human life have
been cast into state laws and regulations much too directly [Birnbacher 2004; Sass 1991]
STEM CELL CONTROVERSIES ALONG THE LINES OF THE ABORTION
instead of into religious teachings, sermons, and defined moral communities where they belong.
DEBATE
Individual choices and the self determination of women have been challenged and even broken
The actual debate on ambiguities surrounding human cloning and cell reprogramming
those laws and rules. The debate and the conflict is going on; pro-life activists kill abortion
occurs along the lines of controversy about the pro and contra of abortion [Walters 2004; Sass
performing physicians in the name of the right-to-life, pregnant women elect a pro-choice
1991]. In European countries, sharing a 'common moral heritage' as is often quoted by
position and exercise their perceived right-to-choose, i. e. autonomy and self determination. It
politicians and regulators, abortion legislation and practice is quite diverse. Pregnant citizens
has been mentioned that a woman's very personal decision to terminate a pregnancy lies beyond
requiring an abortion for whatever reasons and based on their religious or moral convictions
the effective control of criminal law, while others hold that the penal code has to protect human
may, if they are rich enough, travel to an neighboring country and get the service which is
life, born and unborn [Sass 1991]. It is well documented that the criminalization of abortion
refused in her home country. Similar differences exist for preimplantation services and other
does stop only some abortions, not all, and that it causes more unsafe abortions. From time
medical interventions.
immemorial and despite the penalties of criminal law and religious and societal discrimination,
It is a situation similar to the half-way solution of value-and-belief conflicts at the
many women have pursuit their reproductive choices against civil laws and religious teaching.
Muenster peace treaty of 1648 after 30 years of cruel battlings and killings all over central
Actual discussions, arguments, legal and societal conflicts in all cultures regarding the use of
Europe: cujus regio ejus religio', when the feudal sovereign was given freedom of
embryonic constructs and human stem cells in research for therapy represent the ongoing
19
20
debate between the individual's right to responsibly 'choose' and the state's perceived right to
'protect' the 'fruit of the womb' (Leibesfrucht) as the traditional German legal term for unborn
human life defines the embryo and the fetus.
of the egg) as theologically and morally binding for full moral recognition of human life.
Also, the principle of subsidiarity, teaching that decisions and responsibilities made by
individuals and small groups should be given precedence over rules and responsibilities of large
Richard McCormick SJ and Josef Fuchs SJ have pointed out, abortion is not only a
groups, states and courts, has served and might serve in the future to not eliminate, but to reduce
challenge to traditional Christian beliefs rooted in a particular moral faith, also a challenge to
conflicts between the individual conscience on one side and the institutional and societal level
secular humanism. For Fuchs, Christian morality 'is "human" not distinctly Christian' [1980:19],
on the other. Application of the subsidiarity principle, successful for centuries and recently in
while McCormick hints even stronger at a humanistic test for Christian ethics and actions: 'One
social ethics [Vatican 1931], in bioethics and biopolitics would find secular and theological
need not to be a Christian to be concerned with the poor, with health, with the food problems,
support from Spinoza, Mendelsohn, Muslim and other religious and secular positions. As has
and justice and rights. But if one is a Christian and is not so concerned, something is wrong with
been pointed out [Roetz 2004; Sass 1986; Sass 2003A] there is a certain elasticity in all
that Christianity. It has been ceased to be Christian because it has ceased to what his founder
authentic cultures and religious teachings (Roetz: dehnbare Lehren, elasticity in teachings);
was - human' [McCormick 1980:172].
Birnbacher calls it the difference between the 'ideal' and the real-life implementation of ideals
These various levels of moral reasoning and culture - the individual, the collective, the
theological, the societal and the different traditions in professional ethics - are not easily
[Birnbacher 2004], Veatch a 'common morality' which might lead to different refined and
reasoned arguments and acts [Veatch 2004].
reconciled, in part because traditions also change or are represented in different voices. A
Legislators and regulators have no mandate to fight the most common rights of humans,
century old Aristotelian and Thomist 'animation model', teaching that God personally after a
i.e. the right to have the dignity of their conscience be respected, as supported and called for by
period gestation gave his immortal soul into the developing unborn human life at the end of
a wide majority of positions in cultural and religious traditions and as expressed as a
organogenesis was only abandoned 150 years ago by the Roman Catholic church [Sass 1991].
fundamental vision for humanity in the 'Universal Declaration of Human Rights'. On the
As mentioned, in Jewish tradition the direct and individual ensoulment of each newborn by God,
contrary, the legislative and regulatory mandate is to support and to protect human rights of
as evidenced in sustained breathing after birth plays an important role in morally and spiritually
their citizens as civil rights. Solidarity in health care matters belongs to these fundamental civil
recognizing born people. In Islam, the animation theory also is of eminent importance in the
rights. Cultural traditions on abortion and the moral and legal recognition of unborn early
vast majority of historical and contemporary positions, giving different dates up to four months
human life, however, differ from culture to culture and within cultures. Biopolitics has to make
[Ilkilic 2004], which resembles Aristoteles' influential animation theory also in dominant
the not so complicated decision to honor the most basic human rights as civil rights first, while
Christian natural law theory up to the Vatican Council 150 years ago for the Roman-Catholic
been elastic and impartial towards competing worldviews on God, immortality, ensoulment,
branch of Christianity.
re-incarnation, and the spiritual value of cells and zygotes. These competing worldviews can
Mc Cormick stresses the importance of communication and acceptance over biological
and should be respected by conscience clauses and elastic laws in the direction pointed out by
stages of development in recognizing the moral standing of unborn human life. Similarily,
Spinoza and Mendelsohn in the European tradition and other authorities elsewhere. Such a
according to Qiu and Doering, Chinese tradition makes a difference between 'shengming', life
strong moral stand on human rights as civil rights for those most in need of help and protection,
in the biological sense, and 'shenghuo', life in a social sense:' there is no 'shenghuo' if there is
combined with elasticity and tolerance in theoretical matters, is what the most basic principles
no relationship between the one and the other; Confucians put greatest emphasis on those
of human decency and dignity would require of biopoliticians; setting political priorities and
interpersonal relationshsips and draw moral norms from them such as 'xiao' filial piety, 'ci'
political ethics right, could open a door of hope for better medical care in the future for
kindness between kids and parents, 'di' brotherly relation between brethren and sisters, 'xin'
Gretchen, Carl and all the others.
trustworthiness between and yi justice between friends, 'ren' humanness and 'hui' benevolence
between physicians and patients etc' [Doering 2004]. Only since the First Vatican Council 150
POLICY OPTIONS TO SUPPORT HEALTH CARE AND HUMAN DIGNITY
years ago has one of the major branches of Christianity, Roman Catholicism, rigorously
Saving life, alleviating pain and suffering, fighting disease and disability, protecting
defended a strictly biological stage in human development (defined as successful fertilization
health are generally non-controversial within different cultures and between cultures. But there
21
22
are quite a number of conflicting theological and philosophical positions in medical ethics,
which primarily are related to different theories and teachings regarding the beginning and the
improved information of and communication with citizens [2003:29ff]
Whenever and as long as philosophers, theologians, politicians and pressure groups
end of human life and afterlife, These are issues of contraception, abortion and various forms
fight over principles, theories and rules for action, the preferred course of biopolitical action
of withholding available life-prolonging treatment from terminally ill persons with or without
should be to refrain from legislative action by majority vote and make sure that the primary
their request. Some of these specific opinions and teachings have found their way into public
moral agent, i.e. the person closest to the moral challenge, be given the right to follow her or his
policy and regulation [Birnbacher 2004], even though citizens disagree deeply over the content
conscience and calling, and that individuals, families, neighborhoods and moral communities
and the right of such laws and regulations which do not express their own values and wishes and,
be given access to information and advice for making those responsible and well reasoned
in their eyes, disrespect the dignity of their conscience and their human and civil right to choose
choices of their own. The prudent and morally authentic response in political ethics would be
as long as other citizens are not hurt or harmed. As more and more so called leading cultures
the recognition that globalization of research, reasoning, services and production suggest that
(leitkulturen) loose the dominating power in traditionally geographically defined areas,
national legislation will be less and less efficacious and that coordinated trans-national
differences within cultures and among cultures become manifest everywhere associated with
legislation intertwined with legislative and cultural initiates in protecting individual choice,
the emancipation of individual visions and values and the forming of new moral communities
vision, values and wishes of citizens (as long as they do not hurt other citizens) would be the
everywhere, it becomes more and more a challenge to public culture and public policy to
politically and morally right thing to do. Elastic laws, at least allowing for conscience clauses
respect and to support the dignity of the individual conscience' choice and commitment.
for individuals or small moral communities to choose for themselves alternative moral and
If citizens disagree or if among a number of states, sharing same cultural traditions such
medical options, within the limits of human and civil rights not to be harmed by others, would
as in European states, and if there is disagreement on choosing the correct policy option to
be the most appropriate way to legislate controversial issues among citizens, who are different
provide an optimum of security and liberty to their citizens, then there are two options: If
in their visions and values not because one side is 'bad' or 'morally inferior' and the other side is
policies are different, but a dormant consent seems to be there, then the right course of action
'good' or 'morally superior', but because they have and are entitled to have different moral
would be to have public debates and formal procedures to come to consensus based legal and
intuitions and follow different religious or moral teachings [Sass 1991; 2003B]; some different
regulatory solutions, including escape clauses for conscientious objectors. But if differences
moral visions and acts are 'not incompatible even though they are incommensurable' but based
seem to be in different visions and values of individuals and moral and religious communities,
'in a universally held set of pretheoretical moral intuitions' [Veatch 2004].
then, in order to protect the dignity of the individual conscience and civil choice, formal
Different definitions of biological and medical terms in legal terminology in the
procedures to protect individual choice and conscience, peaceable public discourse, tolerance,
German Embryo Protection Law (1991), the recent Stem Cell Law (2002), and regulations
and information and counseling services to individuals would be the most favorable solution
regarding a central ethics commission for stem cell research (ZESV, 2002) would allow
[Sass 2003B:786]. An emancipation of political and regulatory ethics from biopolitical
Gretchen and Carl to produce an offspring by means of re-programming somatic stem cells, if
paternalism, recognizing the dignity of different systems of belief and the dignity of the
technically feasible, without any legal remedy, but they would not be allowed to use DNA
individual conscience, would respect citizen's moral intuitions and convictions in global world
transfer in cloning for reproductive purposes or therapeutic research, a logically, legally, and
of rich individual and collective cultural and moral traditions and values. Whichever
morally deficient platform to base trust into biolaw, biopolitics, and biopoliticians [Koch
biopolitical solution is found, it must include that free and informed consent of citizens to
2003:113-115].
accept or to refuse to take part in medical research of morally controversial and medically risky
Based on rulings of the European High Court in Luxembourg, beer brewed outside of
nature and to accept or refuse medication or medical treatment based on knowledge gained by
Germany not following century-old German beer-brewing regulations may nevertheless be sold
procedures judged as to be not acceptable or even immoral by the non-consenting person. A
as beer; since the 'Cassis de Dijon' decision [NJW 1979,1766;EuHC 20.2.1979;Art.30,37 EVG]
study by the European Academy in Bad Neuenahr-Ahrweiler on 'Embryo Research in
may be sold in other European states as fruit liqueur, even though the alcohol percentile is lower
Pluralistic Europe' proposed six procedural policy guidelines for promoting embryo research,
than requested in other states; similar court decisions and subsequent European regulations
including balancing potential benefits of positive outcomes of research for patients and
exist for pasta of different make. Why enjoys the conscience of individual European citizens
23
24
less freedom than making of wine, beer and pasta?
the evil caused to the value sought is partially determinative of the posture of the will (whether
Rich people may travel to other European countries where medical services are
intending or permitting)' [1973:72]. While helping and healing is a prime 'value' in all cultures,
provided which are illegal or criminalized in their own country, but that is not a solution for all
the dimensions of the 'evil' of omitting to save each and any fertilized human egg or of
[Sass 2003B:791] and these differences can be considered a moral and cultural harm to all
permitting to let early human life die or intentionally terminating its life by using antinidatives
Europeans the same way the European 'cujus region, ejus religio' solution in 1648 was a harm
is controversial among and within cultures and religions, but not an issue at all in some cultures.
to all European citizens. In an extended review of the legal situation in Germany,
Biopoliticians actively criminalizing therapeutic human embryonic stem cell research
commissioned by the Deutsche Forschungsgemeinschaft, Eser and Koch conclude that many
would need stronger arguments than those permitting research under existing or future
embryo research activities in Germany are illegal or will be punished by criminal law, including
professional self-regulation and ethics oversight bodies. Many classical positions in ethics
those done in cooperation with non-German research institutes outside of Germany [Eser, Koch
favor to withhold action, when information is not sufficient or outcome is not clear, rather than
2003:166-178]. While all kinds of beer may be sold in Germany, still only beer brewed under
acting by producing theories or laws or initiating action. Such a reasoning also would suggest
German brewing standard may be brewed in Germany. Prior to the Luxembourg court decision,
regulatory interventional minimalism rather than activism.
it had not been discussed whether or not Germans would have committed a crime when
Given the wide spectrum of book-based systems of belief on many ethical issues, over
drinking beer brewed under different than German standards on German soil. Eser and Koch
time and today, Torah and Talmud, Bible and Qur'an have served as guidance to be interpreted
have not been commissioned to answer the question whether Gretchen Mueller, given her
by individuals, communities and 'holy' persons, not as governance providing ready-made
finances would allow her to do so, would commit a crime punishable by German law on her
recipes for moral action. Non-book-based reference models tend to be less analytical and
return to German soil, if she someday would get successful medical treatment outside of
hermeneutical, concentrate more on general guidance and leave ample room for non-uniform
Germany or if today she would volunteer in embryonic stem cell research elsewhere.
personal or communal moral assessment and action. In general, all cultural positions - except
Walters, in a recent review of intercultural perspectives on human embryonic stem cell
the most bizarre and fundamentalist ones - allow, and historically have allowed, for modified
research discusses six policy options: (1) No human embryo research permitted; (2) research
positions [Nationaler Ethikrat 2003; Roetz 2004; Sass 2004A]. This makes cultural and
only existing stem cell lines, not on embryos; (3) research only on left-over embryos; (4)
religious traditions also a prime target for been exploited in party politics and in the halls of
research also on embryos created via IVF for research; (5) research only on embryos created via
political lobbying. Biopoliticians inviting experts in religious or cultural traditions for hearing
somatic cell nuclear transfer into human eggs or zygotes; (6) research also on embryos created
therefore should require that those experts present the full scale of positions within the tradition
via transfer of human somatic cell nuclei into non-human eggs. None of these options suggests
of their expertise not just one position which might have been the reason for their invitation in
to include potential recipients or beneficiaries of in shaping policy options, as Walters
the first place [Sass 2000]. Representatives of churches in political hearing, confusing basic
unfortunately could not find those policy options prominently present anywhere despite the fact
moral intuitions with their specific dogmatics, are quite often more a part of the problem than
that a conscience-clause option would be the logical consequence of respecting citizen's dignity
of a consensus oriented solution. Naturally, politicians must be and, indeed, are aware of the
over politician's authority. Gretchen and Carl, both German citizens and active members in the
political character of expert presentations, they choose to ask for; however, this is not an issue
German branch of the Roman-Catholic church, have not been consulted by either authority nor
of bioethics, but of ethics of biopolitics.
been given an opportunity to express their values, wishes and visions in regard to therapeutic
research which might hold some promise for their diseases and in regard to the question of how
to assess therapeutic cloning and re-programming of human cells in the presence of legally
permissible antinidativa and abortion at least within the first trimester.
WHO HAS ASKED GRETCHEN MUELLER ON OPTIONS IN BIOPOLITICS?
Political and biopolitical establishments have not yet asked Gretchen and Carl as
citizens and patients most close to the moral issue of stem cell research for therapeutic purposes,
European moral reasoning, similarly to other cultures, has made a distinction between
nor have they explained why they have not done so or why they seem to care more for zygotes
'omission' and 'commission'; according to McCormick 'there is a difference between an
than for people . So far only option 2, as described by Walters [2004], ambiguous and
intending and a permitting will' [McCormick 1973:70]: 'In a conflict situation, the relation of
questionable on bioethical and biopolitical terms, seems to be graciously accepted by majority
25
26
vote of German parliament [Eser; Koch 2003]. But this does not give citizens such as Gretchen
embryos carrying unknown and uncertain genetic risk factors, would not be 'hurt' by therapeutic
and Carl an opportunity to voice their conscience, values and wishes, and to get help. The
research as they are not intended to be 'born'. They would be 'hurt' less than oocytes, morulae
European Academy, Bad Neuenahr-Ahrweiler calls for more and better information of citizens
or fetuses, legally aborted within the first trimester or 'killed' legally by hormonal or mechanical
on scientific and related cultural and ethical issues of stem cell research, a goal previously
devices disallowing nidation, but not conception. According to Thomas Aquinas, moral acts
agreed upon by European governments and the European Commission but never or only
need to be judged according to the proportionality of balancing good and evil - 'recipiunt
meagerly implemented [2003].
speciem secundum id quod intenditur' [ThAq, STh II-II, q. 64, a. 7] -. The 'good' of therapeutic
While other citizens are 'allowed' to make personal choices on antinidativa, abortion,
research and medical therapy is uncontested, but the degree of 'evil' in human embryonic stem
and the moral value of primitive non-specialized human cells, zygotes, and morulae, Gretchen
cell research is controversial. Gretchen and Carl are hurt by the double-standard of politicians
is excluded from been given hope for progress in stem cell research and from making choices
choosing to care for zygotes and morulae more than for living citizens in need and for their
related to her health, wellbeing, even survival. To ask Gretchen and Carl, however, would be
families, i.e. caring less for those suffering from severe handicaps, weaknesses and limitations
of notable moral and legal importance in order not to hurt or harm them - 'primum nil nocere' in
in their lives and in caring for themselves and others.
political ethics. The 'do no harm' principle, a most eminent maxim in medical ethics, should not
been excluded from political ethics and its mandate.
In the presence of many legal and regulatory inconsistencies in the regulatory and moral
protection of different forms of unborn human life, of embryonic and somatic stem cells within
The 'subsidiarity' principle in political, social, and bio-ethics would suggest that
a given country or culture and among cultures and countries, Gretchen and Carl should be given
services would best be recognized and delivered at the grass-root level, in this case in the
the trust that their fate, their rights and expectations will not be regarded as inferior to the fate
research and clinical setting, not in consulting groups of legal and theological experts and in
of human cells or conglomerate of cells, stem-cells, embryonic or not.
political or parliamentary compromises. The subsidiarity principle would include that everyone
Gretchen and Carl recognize that others, healthy people, are enjoying life and using
be given the full right to refuse to be part of research or any other activity deemed to be of
IUD's and various other abortiva, do so without being criminalized or morally been
questionable moral or even immoral nature, or to accept treatment or medication based on
discriminated against. What Gretchen and Carl as patients request as a civil right, as a moral
questionable or even immoral research as judged by those individuals and taught by religious
priority in all cultures of authentic religious and philosophical reasoning, and as a human and
or moral groups, branches or communities.
political decency is less: the de-criminalization of cell-reprogramming and of embryonic stem
The European Academy in Bad Neuenahr-Ahrweiler's report on Embryo Research in
cell research for human therapy and the administration of modern medicine based on free and
Pluralistic Europe [2003:31] argues that 'research on embryos is not only morally permissible,
informed consent. They feel hurt that their government, many bioethicists and biopoliticians,
it can be morally mandated when legitimate interests of persons, suffering from non-treatable
theologians and judges playing doctors, and so-called experts of all sort, do not seem to honor
diseases and disorders .. outweigh the general interest of society to protect embryos'.
the most common moral principle to allow and to support the improvement of health care and
Gretchen and Carl are harmed and hurt, when research, potentially leading to remedy or
medical treatment for both of them, put theories over people, power over the health and
to alleviate their disabilities, would not be supported or accepted; they would be harmed even
conscience of people, moral tutelage of people over care for people, concern for cells, zygotes
more if such research would be prohibited or criminalized. Gretchen and Carl would be harmed,
and morulae over concern for citizens as patients.
if future treatment, developed on the basis of cloning or human embryonic stem cell research
elsewhere, would not be made available in their home country. Citizens richer than Gretchen
and Carl would have the moral and medical option to get treatment in Portugal, Israel, an Asian
country or wherever treatment is offered, but for financial reasons they most likely will not
have that option. Gretchen and Carl are also harmed by confusing and inconsistent legal
philosophy, wording, and rhetoric defining embryo, reprogramming, and cloning.
Reprogrammed cells, not intended to, but eventually capable of developing into
27
28
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31
32
Zentrum für Medizinische Ethik
Medizinethische Materialien
Die unterstrichenen Hefte sind derzeit leider vergriffen, können im Sonderfall aber als Kopie
oder e-file geliefert werden.
Heft 76: Sass, Hans-Martin; Kielstein, Rita: Die Wertanamnese. Methodische Überlegungen
und Bewertungsbogen für die Hand des Patienten. 2. überarb. Aufl. Dezember 1992.
Heft 77: Uhlenbruck, Wilhelm: Selbstbestimmung im Vorfeld des Sterbens - rechtliche und
medizinische Aspekte. September 1992.
Heft 78: Sass, Hans-Martin: Informierte Zustimmung als Vorstufe zur Autonomie des
Patienten. September 1992.
Heft 79: Tausch, Reinhard: Vergeben. Von der Bedeutung des Vergebens in
zwischenmenschlichen Beziehungen, auch in der Medizin. Mai 1993.
Heft 80: Schara, Joachim: Patientenaufklärung vor Krebsschmerztherapie. Juni 1993.
Heft 81: Sass, Hans-Martin; Kielstein, Rita: Wertanamnese und Betreuungsverfügung. 3.
überarb. Aufl. Juli 1995.
Heft 82: Kielstein, Rita: Klinik, Genetik und Ethik der autosomal dominant polyzystischen
Nierenerkrankung. 2. überab., erw. Aufl. März 1995.
Heft 83: Ilkilic, Ilhan: Der Bochumer Arbeitsbogen und der türkische Patient. Pratik Tip Etigi
Icin Bochum Calisma Tablosu Ve Türk Hastasi. Juli 1993.
Heft 84: Materialien zur Erstellung von wertanamnestischen Betreuungsverfügungen.
Eingeleitet und zusammengestellt von R. Kielstein, H.-M. Sass. Übersetzt von S.
Eschen. 3. Aufl. September 1995.
Heft 85: Timmermann, Jens: Das Thema Sterbehilfe in Thomas Morus' "Utopia". November
1993.
Heft 86: Tausch, Reinhard: Sinn-Erfahrungen. Förderung, Chancen und Grenzen bei
Betroffenen und Helfenden. November 1993.Heft 87:
Vliegen, Josef: Moderne
Psychiatrie und ihr Bild vom Menschen. Dezember 1993.
Heft 88: Hinrichsen, K.V. (Hg.): Sterben und Schwangerschaft. Mit Beiträgen von M.
Bissegger, K. Hinrichsen, E. Reichelt, H.-M. Sass, K.-E. Siegel, I. Wolf. 3. Aufl. Juni
1994.
Heft 89: Sass, Hans-Martin: Die Würde des Gewissens und die Diskussion um
Schwangerschaftsabbruch und Hirntodkriterien. 3. Aufl. Juni 1994.
Heft 90: Jakobs, Günther: Geschriebenes Recht und wirkliches Recht beim
Schwangerschaftsabbruch. März 1994.
Heft 91: Sass, Hans-Martin: Ethische und bioethische Herausforderungen
molekulargenetischer Prädiktion und Manipulation. 2. Aufl. Juni 1994.
Heft 92: Sass, Hans-Martin: Hippokratisches Ethos und Nachhippokratische Ethik. Juni 1994.
Heft 93: Koch, Hans-Georg; Sass, Hans-Martin; Meran, Johannes Gobertus:
Patientenverfügung und Stellvertretende Entscheidung in rechtlicher, medizinischer
und ethischer Sicht. 3. Auflage April 1996.
Heft 94: Fuchs, Christoph: Allokation der Mittel im Gesundheitswesen - Rationalisierung
versus Rationierung. Juni 1994.
Heft 95: Schroeder-Kurth, Traute: Das "Slippery Slope"- Argument in der Medizin und
Medizinethik. Dezember 1994.
Heft 96: Pohlmeier, Hermann: Selbstmordverhütung - Zur Ethik von Selbstbestimmung und
Fremdbestimmung. Dezember 1994.
Heft 97: Epplen, Jörg T.; Rieß, Angelika; Rieß, Olaf: DNA-Diagnostik in der Humangenetik:
Voraussetzungen und Tendenzen. März 1995.
Heft 98: Stotz, Gabriele: Theoretische und ethische Probleme der psychiatrischen Diagnose.
März 1995.
Heft 99: Vollmann, Jochen: Fürsorgen und Anteilnehmen: Ethics of Care. April 1995.
Heft 100: Hinrichsen, Klaus V.; Sass, Hans-Martin: 10 Jahre Zentrum für Medizinische Ethik.
Juni 1996.
Heft 101: Schreiber, Hans-Ludwig: Die Todesgrenze als juristisches Problem - Wann darf ein
Organ entnommen werden? Juli 1995.
Heft 102: Hartmann, Fritz: Lebens- und Hilfeleistungen im Sterben. 2. Aufl. Februar 1996.
Heft 103: Kielstein, Rita (Hg.): Ethische Aspekte in der Nephrologie. 2. Aufl. Februar 1995.
Heft 104: Bernat, Erwin: Antizipierte Erklärungen und das Recht auf einen selbstbestimmten
Tod. Januar 1996.
Heft 105: Richter, Gerd; Schmid, Roland M.: Ethische Perspektiven der Gentherapie 1995.
Januar 1996.
Heft 106: Bauer, Axel: Braucht die Medizin Werte? Gedanken über die methodologischen
Probleme einer „Bioethik“. März 1996.
Heft 107: Tausch, Reinhard: Empirische Untersuchungen zu Sinn-Erfahrungen und
Wertauffassungen. Juli 1996.
Heft 108: Sass, Hans-Martin: Ethik-Unterricht im Medizinstudium; Methoden, Modelle und
Ziele der Integration von Medizinethik in die medizinische Aus- und Fortbildung.
August 1996.
Heft 109: Meyer, Frank P.: Salus aegroti suprema lex; Probleme klinischer Studien aus der
Sicht eines Mitgliedes einer Ethikkommission - Schwerpunkt Onkologie. August
1996.
Heft 110: Sass, Hans-Martin: Reform von Gesundheitswesen und Krankenhäusern in
verantwortungsethischer Perspektive. August 1996.
Heft 111: Sass, Hans-Martin, Kielstein, Rita: Die medizinische Betreuungsverfügung in der
Praxis. Vorbereitungsmaterial, Modell einer Betreuungsverfügung, Hinweise für
Ärzte, Bevollmächtigte, Geistliche und Anwälte. 7. Auflage Dezember 2000.
Heft 112: Spittler, Johann F.: Sterbeprozess und Todeszeitpunkt - Die biologischen
Phänomene und ihre Beurteilung aus medizinischer Sicht. August 1996.
Heft 113: May, Arnd; Gawrich, Stefan; Stiegel, Katja: Empirische Erfahrungen mit
wertanamnestischen Betreuungsverfügungen. 2. Auflage Juli 1997.
Heft 114: Biller, Nikola: Der Personbegriff in der Reproduktionsmedizin. September 1997.
Heft 115: Kaminsky, Carmen: Gesagt, gemeint, verstanden? Zur Problematik der Validität
vorsorglicher Patientenverfügungen. Oktober 1997.
Heft 116: Baumann, Eva: Gesellschaftliche Konsensfindung und Humangenetik. Oktober
1997.
Heft 117: May, Arnd: Betreuungsrecht und Selbstbestimmung am Lebensende. September
1998.
Heft 118: Zülicke, Freddy: Chancen und Risiken von Gentechnik und Reproduktionsmedizin.
September 1998.
Heft 119: Meyer, Frank P.; Sass, Hans-Martin: Klinische Forschung 2000. Oktober 1998.
Heft 120: Grossmann, Wilfried; Maio, Giovanni, Weiberg, Anja: Ethik im Krankenhausalltag
- Theorie und Praxis. Oktober 1998.
Heft 121: Sponholz, Gerlinde; Allert, Gebhard; Keller, Frieder; Meier-Allmendinger, Diana;
Baitsch, Helmut: Das Ulmer Modell medizinethischer Lehre. Sequenzierte
Falldiskussion für die praxisnahe Vermittlung von medizinethischer Kompetenz
(Ethikfähigkeit); Uhl, Andreas; Lensing; Claudia: Perspektiven und Gedanken zur
medizinethischen Ausbildung. August 1999.
Heft 122: Schmitz, Dagmar; Bauer, Axel W.: Evolutionäre Ethik und ihre Rolle bei der
Begründung einer zukünftigen Medizin- und Bioethik. März 2000.
Heft 123: Hartmann, Fritz: Chronisch Kranksein als Grenzlage für Kranke und ihre Ärzte. März
2000.
Heft 124: Baberg, Henning T.; Kielstein, Rita; Sass, Hans-Martin (Hg.): Der
Behandlungsverzicht im Blick des Bochumer Inventars zur medizinischen Ethik
(BIME). April 2000.
Heft 125: Spittler, Johann F.: Locked-in-Syndrom und Bewusstsein – in dubio pro vita. August
2000.
Heft 126: Ilkiliç, Ilhan: Das muslimische Glaubensverständnis von Tod, Gericht, Gottesgnaden
und deren Bedeutung für die Medizinethik. September 2000.
Heft 127: Maio, Giovanni: Ethik und die Theorie des "minimalen Risikos" in der medizinischen
Forschung. September 2000.
Heft 128: Zenz, Michael; Illhardt, Franz Josef: Ethik in der Schmerztherapie. November 2000.
Heft 129: Godel-Ehrhardt, Petra; May, Arnd T.: Kommunikation und Qualitätssicherung im
Betreuungsrecht – Ergebnisse einer Befragung zur Mailingliste
[email protected]. März 2001.
Heft 130: Dabrock, Peter; Klinnert, Lars: Würde für verwaiste Embryonen? Ein Beitrag zur
ethischen Debatte um embryonale Stammzellen. Juli 2001.
Heft 131: Meyer, Frank P.: Ethik der Verantwortung. Verkommt »Evidence Based Medicine«
zu »Money Based Medicine«? März 2002.
Heft 132: Sass, Hans-Martin: Menschliche Ethik im Streit der Kulturen. 2. Auflage Januar
2003.
Heft 133: Knoepffler, Nikolaus: Menschenwürde als Konsensprinzip für bioethische
Konfliktfälle in einer pluralistischen Gesellschaft. März 2002.
Heft 134: Quante, Michael: Präimplantationsdiagnostik, Stammzellforschung und
Menschenwürde. März 2002.
Heft 135: Köchy, Kristian: Philosophische Grundlagenreflexion in der Bioethik. März 2002.
Heft 136: Hengelbrock, Jürgen: Ideengeschichtliche Anmerkungen zu einer Ethik des Sterbens.
Juli 2002.
Heft 137: Schröder, Peter: Vom Sprechzimmer ins Internetcafé: Medizinische Informationen
und ärztliche Beratung im 21. Jahrhundert. Juli 2002.
Heft 138: Zühlsdorf, Michael T.; Kuhlmann, Jochen: Klinische und ethische Aspekte der
Pharmakogenetik. August 2002.
Heft 139: Frey, Christofer; Dabrock, Peter: Tun und Unterlassen beim klinischen
Entscheidungskonfliktfall. Perspektiven einer (nicht nur) theologischen
Identitätsethik. August 2002.
Heft 140: Meyer, Frank P.: Placeboanwendung – die ethischen Perspektiven. März 2003.
Heft 141: Putz, Wolfgang; Geißendörfer, Sylke; May, Arnd: Therapieentscheidung am
Lebensende- Ein "Fall" für das Vormundschaftsgericht? 2. Auflage August 2003.
Heft 142: Neumann, Herbert A.; Hellwig, Andreas: Ethische und praktische Überlegungen zur
Einführung der Diagnosis Related Groups für die Finanzierung der Krankenhäuser.
Januar 2003.
Heft 143: Hartmann, Fritz: Der Beitrag erfahrungsgesicherter Therapie (EBM) zu einer
ärztlichen Indikationen-Lehre. August 2003.
Heft 144: Strätling, Meinolfus; Sedemund-Adib, Beate; Bax, Sönke; Scharf, Volker Edwin;
Fieber, Ulrich; Schmucker, Peter: Entscheidungen am Lebensende in Deutschland.
Zivilrechtliche Rahmenbedingungen, disziplinübergreifende Operationalisierung
und transparente Umsetzung. August 2003.
Heft 145: Hartmann, Fritz: Kranke als Gehilfen ihrer Ärzte. 2. Auflage Dezember 2003.
Heft 146: Sass, Hans-Martin: Angewandte Ethik in der Pharmaforschung. Januar 2004.
Heft 147: Joung, Phillan: Ethische Probleme der selektiven Abtreibung: Die Diskussion in
Südkorea. Januar 2004.
Heft 148: May, Arnd T; Brandenburg, Birgitta: Einstellungen medizinischer Laien zu
Behandlungsverfügungen. Januar 2004.
Heft 149: Hartmann, Fritz: Sterbens-Kunde als ärztliche Menschen-Kunde. Was heißt: In
Würde sterben und Sterben-Lassen? Januar 2004.
Heft 150: Reiter-Theil, Stella: Ethische Probleme der Beihilfe zum Suizid. Die Situation in
der Schweiz im Lichte internationaler Perspektiven. Februar 2004.
Heft 151: Ambiguities in Biopolitics of Stem Cell Resarch for Therapy. Who cares for
Gretchen Mueller. 2. Auflage Juni 2004.
Heft 152: Ilkilic, Ilhan: Gesundheitsverständnis und Gesundheitsmündigkeit in der
islamischen Tradition. April 2004.
Heft 153: Omonzejele, Peter F.: African Concepts of Health, Disease and Treatment [A
Future for Traditional Medicines and Spiritual Healings? A Postscript on Peter F
Omonzeleje by Hans-Martin Sass]. April 2004.
Heft 154: Lohmann, Ulrich: Die neuere standesethische und medizinrechtliche Entwicklung
in Deutschland – Wandel des Menschenbildes? Mai 2004.
Heft 155: Friebel, Henning; Krause, Dieter; Lohmann, Georg; Meyer, Frank P.:
Verantwortungsethik. Interessenkonflikte um das Medikament – Wo steht der
Patient? 2. Auflage Juni 2004.
Heft 156: Kreß, Hartmut: Sterbehilfe - Geltung und Reichweite des Selbstbestimmungsrechts
in ethischer und rechtspolitischer Sicht.1. Auflage September 2004, 3. Auflage März
2005.
Heft 157: Fröhlich, Günter und Rogler, Gerhard: Das Regensburger Modell zur Ausbildung in
klinischer Ethik. 1. Auflage Dezember 2004, 2. Auflage Februar 2005.
Heft 158: Ilkilic, Ilhan; Ince, Irfan und Pourgholam-Ernst, Azra: E-Health in muslimischen
Kulturen. Dezember 2004.
Heft 159: Lenk, Christian; Jakovljevic, Anna-Karina: Ethik und optimierende Eingriffe am
Menschen. 2.Auflage Februar 2005.
Heft 160: Ilkilic, Ilhan: Begegnung und Umgang mit muslimischen Patienten. Eine
Handreichung für die Gesundheitsberufe. 1. Auflage Juli 2003 (Tübingen), 5.
Auflage April 2005.
Heft 161: Hartmann, Fritz: Vom Diktat der Menschenverachtung 1946 zur "Medizin ohne
Menschlichkeit" 1960; Zur frühen Wirkungsgeschichte des Nürnberger
Ärzteprozesses. 1. Auflage Februar 2005, 2. Auflage März 2005.
Heft 162: Strätling, Meinolfus u.a.: Die gesetzliche Regelung der Patientenverfügung in
Deutschland. Juni 2005.
Heft 163: Sass, Hans- Martin: Abwägungsprinzipien zum Cloning menschlicher Zellen. Januar
2006.
Heft 164: Vollmann, Jochen: Klinische Ethikkomitees und klinische Ethikberatung im
Krankenhaus. Ein Praxisleitfaden über Strukturen, Aufgaben, Modellen und
Implementierungsschritte. 1. Auflage Januar 2006, 3. Auflage März 2006.
Heft 165: Sass, Hans- Martin: Medizinische Ethik bei Notstand, Krieg und Terror.
Verantwortungskulturen bei Triage, Endemien und Terror. 1. Auflage Februar 2006,
3. Auflage März 2006.
Heft 166: Sass, Hans-Martin: Gesundheitskulturen im Internet. E-Health-Möglichkeiten,
Leistungen und Risiken. 1. Auflage Februar 2006, 2. Auflage März 2006.
Bestellschein
An das
Zentrum für Medizinische Ethik
Ruhr-Universität Bochum
Gebäude GA 3/53
ZUSAMMENFASSUNG
Hans-Martin Sass unterscheidet in Unklarheiten in der Biopolitik therapeutischer
Stammzellforschung ein in allen Kulturen unkontroverses ethisches Primat der Hilfe für
Kranke und Leidende von kulturell und ethisch kontroversen Diskursen und Regelungen im
Umgang mit vorgeburtlichem Leben. Während Lebensrettung und Heilung oder Linderung von
Krankheit sich direkt auf eine a-priori moralische Intuition berufen können, sind ethische
44780 Bochum
Interpretationen des vorgeburtlichen Lebens zwangsläufig durch individuelles Gewissen und
unterschiedliche religiöse und moralische Kulturen geprägt. Er kritisiert obrigkeitliche Verbote
und Einschränkungen von Forschungen an embryonalen Stammzellen und empfiehlt der
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politischen Ethik und Praxis, Bürger und Patienten selbst entscheiden zu lassen, ob sie an
solchen Forschungen teilnehmen oder in der Zukunft durch solche Forschung gewonnene
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ABSTRACT
Name oder Institut:
In Ambiguities in Biopolitics of Stem Cell Research for Therapy Hans-Martin Sass
differentiates between a moral a-priori intuition directly calling to care for the sick and
Adresse:
suffering and an indirect application of a-priori moral intuition, refined and argued for by the
individual conscience and religious and philosophical traditions and cultures. While saving life
and healing or eliviating suffering is morally and culturally not controversial, differences in the
moral assessment of forms of early unborn human life are an indirect expression of genuine and
( ) Hiermit abonniere(n) wir/ich die Reihe MEDIZINETHISCHE MATERIALIEN zum
Sonderpreis von € 4,00 pro Stück ab Heft Nr.____. Dieser Preis schließt die Portokosten mit
ein.
authentic, but different moral visions and values, refined by individual conscience and different
traditions and teachings. In calling to respect the dignity of the individual conscience, he rejects
governmental moral tutilage and legal paternalism in criminalizing or severely limiting human
stem cell research; instead, he calls on political ethics and practice to let competent citizens and
( ) Hiermit bestelle(n) wir/ich die folgenden Einzelhefte der Reihe MEDIZINETHISCHE
MATERIALIEN zum Preis von € 6,00 (bei Abnahme von 10 und mehr Exemplaren € 4,00
pro Stück).
patients decide for themselves whether or not to take part in embryonic stem cell research or
accept future medical treatment based on such research.
Hefte Nummer: _____________________________________________
ISBN: 3-931993-32-9