I begin with the self portrait of our great dinner, one of the greatest artists of the German Renaissance.
As you can see, he was a very fine painter and an even finer printmaker, as you will later see.
He travelled throughout his life, taking up inspiration abroad as well as a few clients.
His second major trip took him across the Alps to Venice,
where he studied the sculptural nudes of Andrea, Montana and the Madonnas of Giovanni Bellini.
While there, he wrote home to me on bail in southern Germany.
And in. One of his letters, we read the following sentence If you can have the high temperature here in a foreign land, I'm treated like a Lord.
Whereas at home, like a parasite. Well, I am myself a foreigner here in terms of my passport.
I think where a centre for practical ethics and at the Ethos Centre, I'm also a foreigner in another sense.
I'm not a bioethicist, let alone a biologist.
I teach political theory. Yet both centres have treated me as an active, I might say, like a Lord.
So I think both centres for the opportunity to learn a little bit about bioethics at Oxford this year.
And for the opportunity this evening to share some of my preliminary thoughts with you.
I argue that private ethics is politics.
Bioethics belongs to the political sphere.
As it involves decisions that cannot be correct but can be procedurally legitimate, as I will explain.
I also argue that we should approach bioethical questions politically in terms of procedural design,
and I argue that two procedures in particular can deliver legitimate bioethical decisions.
I advance my argument in three steps.
First, I develop the thesis with the example of human germline gene editing.
Second, I propose a general understanding of procedurals toward coping with the bioethical questions raised by germline engineering.
Third, I combine two types of procedural.
Expert bioethics committees. And deliberative democracy.
I argue that bioethics is politics, not in the agreeable sense of a triumphal march toward an ever better society and ever greater justice.
But in the disquieting sense of competition.
Competition among value commitments, competition without end by politics.
In this context, I mean disagreement.
In the public sphere about issues that require decision for regulation, for legislation.
For public policy. Perhaps no answer to a bioethical question can claim universal validity.
In as much as bioethical questions are matters of normative preference.
Socially constructed and historically contingent.
Normative preferences differ within communities.
And among them. Competing viewpoints rarely converge.
The existence of stable disagreements does not necessarily show that there is no truth.
Rather, it shows that even if there is truth in this sphere, we have never been able to recognise it.
Which is why, of course, the disagreements are stable.
In natural science. By contrast, questions are assumed to have one answer, and any answer is a claim to truth.
To explore the political quality.
Bioethical claims.
I will look at genetic technologies able to make heritable changes to the human germline that is able to alter the DNA sequences of embryos.
How could such technologies may have unintended consequences given limits to our knowledge of human genetics,
gene environment interactions and the pathways of disease,
including the interplay between one disease and other conditions or diseases in the same patient.
A bio ethical perspective then seeks to balance interventions in the present.
With future consequences that cannot be foreseen, or at least not entirely.
I draw first on a 2017 article by Kim, Gil Douglas and Saba Lesko.
They note. That roughly 6% of all babies born have a serious birth defect.
Of genetic or partially genetic origin.
And they advocate germline engineering to prevent genetic disease with the qualification if proven acceptably safe.
Engineering seeks to prevent disease in future people.
Toward that goal. Germline gene editing may offer a novel treatment for single gene disorders and contribute to overcoming polygenic disease.
It offers some couples the only way to avoid passing on single gene disorders.
In cases where neither in-vitro fertilisation or IVF nor pre-implantation genetic diagnosis for PGD is possible,
PGD is a procedure used prior to implantation to help identify genetic defects within
embryos so as to prevent certain genetic diseases from being passed on to the child.
The embryos used in PGD are usually created during the process of.
By the. Whereas PGD and IVF are not powerful enough to select against polygenic diseases.
Germline gene editing allows multiple changes to be made.
To a single entry. And thus may target many different genes simultaneously.
This is important because the majority of common diseases result not from single gene mutations,
but from a poorly genetic disposition together with environmental influences.
Thus, diabetes involves at least 44 genes in common cancers.
More than 300. We observe a political dimension in this context where Gyngell and colleagues simply dismiss
the possibility that deploying the technology to escape genetic disease might generate.
New forms of inequality, discrimination and societal conflict.
Consider access to technology. Access that is unequal because not everyone can afford.
In that case, not the technology.
But unequal access to it. May generate various forms of discrimination compared with persons who have no access to it.
Persons who do maybe better off along several interrelated dimensions health, ability to work, socioeconomic status and so forth.
Those who do have access likely are more strongly positioned in society to begin with, which may be why they have access in the first place.
Under these social conditions,
access to the technology may only reinforce the social position of those who are better situated and discriminated against.
Those who are weakly situated. We see another political dimension in the fact that many technologies of therapy
that is treating an illness or disease can equally be technologies of enhancement.
Enhancement means improving on a condition not deficient.
For example, losing eye surgery, pre-implantation genetic diagnosis and plastic surgery.
This ambivalent quality of technology deployment would seem to undermine the position of people who oppose using technology
for the purpose of enhancing individuals who are not ill or deceased and yet who advocate its use toward therapeutic ends.
That position would seem to be undermined by the perspectival quality of determining whether deploying such technologies is morally desirable.
Or morally objectionable. We observe another political dimension in the author's claim that it is doubtful that the embryo
is the type of entity that can be harmed or at least harmed in a morally significant way.
The embryo does not have experiences or desires and on some accounts of well-being.
Entities that lack experiences and desires have no well-being and thus cannot be harmed.
Yet. Morally significant harm can be configured in many different ways.
The Catholic Church, to take a prominent example, has a view very different from Dingell and colleagues.
It regards the embryo as morally vulnerable to almost any intervention.
So the task lies not in the question.
What set of reasons can bridge this difference?
The task here, rather, is political.
Any public policy decision? Must choose among incompatible alternatives and do so as a matter of normative preference.
Normative preferences are political when they reflect competition that matters in the formation of regulation or public policy.
In setting public policy. The competition.
With this, with the greatest influence, is often that among elites, the doctrine makers of a world religion constitute one kind of elite.
The European Parliament is a different kind.
It has the authority to pronounce on behalf of all EU citizens.
In doing so, it may sometimes project one particular value commitment.
And a very heterogeneous population.
A 1997 resolution states that the cloning of human beings constitutes a serious violation
of fundamental human rights and is contrary to the principle of equality of human beings,
as it permits a eugenic selection of the human race and offends against human dignity.
The Parliament also declared that the individual has a right to his or her own genetic identity.
A scientific elite differs from both religious and political elites.
With whom? Scientific fact. Does not necessarily carry weight in all cases, as the following examples show.
As background. I begin with a 2016 article in which John Harris notes that one in every 270 births is an identical twin.
A twin is a kind of natural clone, and as such would seem to violate every set of twins putative equal right to his or her unique genetic identity.
In 1998, another eight.
The Council of Europe declared a prohibition of human cloning.
But the Council nowhere explained how or why its prohibition can possibly be based on what the Council referred to as.
Human rights. Human dignity. And genetic identity.
These terms are quite indeterminate in meaning, as Harris asks rhetorically,
if embryo splitting that is the deliberate creation of monocyte like twins proved to confer immunity to some lethal genetic diseases.
Would we ban this deliberate cloning? Another example.
In 1997, UNESCO's bioethics committee proclaimed a moral imperative that the human genome must be preserved as the.
Common heritage of humanity. But how can something be preserved in this case, the human genome,
when it is a product of evolutionary change and exists only within the ongoing phenomenon of evolution?
UNESCO's committee would seem to be advocating the.
Freezing of the human genome at its current state of evolutionary history.
This viewpoint is hostile to the very idea of intervening in the germline of humans to modify,
if not human nature, then at least the genetic endowment of some humans.
The idea of somehow freezing the evolutionary development of the human genome at any point in time.
Is misguided. All genomes change over time.
A simple example of this is the spread of lactose tolerance among different human populations.
In human infants. The lactase gene is expressed once the baby is weaned.
This gene shuts down the introduction of milk into the ordinary diet of some human populations.
Through the domestication of milk, producing animals favoured those adults who carry the lactase enzyme.
Now they had a new food source. And over time, 80% of the European population became lactose intolerant.
This example shows how this or that concept of nature made selfie kind of political bioethics.
Can this or that concept offer some kind of normative standard for making bioethical decisions?
From a Catholic perspective, nature does seem to be a standard, but from other perspectives, we might well reject nature as a standard.
Consider if sexual reproduction were in fact not natural, but somehow a human artefact,
it would hardly satisfy today's regulatory bodies that monitor medical procedures given the incidence of sexually transmitted disease.
The high abnormality rate in the resulting children and the gross inefficiency in terms
of the death and destruction of embryos estimated to be one in three deaths per life.
Birth to one in five deaths. I offer one last example of a political dimension within a bilateral by bioethical issue.
The claim that parents are morally obligated to create the biologically best child possible.
Best possible. As defined by what standard nature functions as a positive standard.
When humans value their evolved biology and diagnosed some variations as abnormalities or illnesses as unwelcome deviations from the standard.
And nature functions as a negative standard whenever humans would engineer their species in ways that seek improvements upon our evolved biology.
Political. Is the choice of a particular notion of nature.
So is the particular perspective from which one evaluates the merits and demerits of evolved human biology.
So is the choice of criteria that would define any given concept of improvement.
We come now to part two. Procedural ism offers one way of coping with some of these challenges.
It might secure agreement under conditions that otherwise discourage.
General agreement on political and social norms is unlikely, where norms calling for deep commitment are not shared within the community.
But if normative differences preclude agreement on many issues.
They need not preclude agreement on procedural rules for coping with difference.
Procedural ism is the notion that no rule is acceptable apart from a formal method, and that the acceptable method yields an acceptable rule.
A rule is acceptable by virtue of being the outcome of an agreed upon procedure.
And the rule in this context would be the answer to a particular bioethical issue or question.
In a liberal democratic tolerant of.
Value pluralism. Procedural ism makes collective action possible despite enduring differences in the values commitments of its various members.
It makes agreement possible because it aspires not to consensus on substance, but rather to legitimacy in form.
Even those persons whose preference did not succeed in the latest procedural decision may regard the outcome as legitimate.
Those who disagree with the winning position may continue to argue against it and to marshal support for their preferred alternative.
And they may even prevail in the future. Procedural exercise.
And political community, then, through majoritarian democratic institutions,
can move forward in the name of all members, even under conditions of disagreement.
I address now two features of procedural ism first, its normative thinness, and second, constraints on it.
A procedure is normatively thin. If it does not affect the content of the procedure.
For example, voting in a democratic election is a kind of procedure.
The content of this procedure comes from the particular policy, commitment and values of each of the political parties fighting for votes.
In a fair system of voting, a procedure establishes which party has received the most votes without influencing that outcome.
Each political party, for its part, is normatively think it has particular commitments,
which it offers voters commitments that compete with those of other parties.
This notion of thick and thin norms is a bit tricky, so an additional example might help.
The Constitution of a modern liberal democracy guarantees its citizens the freedom of religious belief in practice.
Any particular faith is normatively thick as a particular belief system.
Thus, in a nation state where to require all citizens to adopt one particular religion.
Doing so would violate the sick norms of all citizens of other faiths because each has its own belief system,
even as some of them overlap in some ways.
Guaranteeing the equal freedom of all faiths, neither favours nor dis favours any one faith or no faith at all.
In that sense, the rule of freedom. Of belief. It's normal to believe in.
A legal rule that allows members of each faith an equal right to practice their faith freely does not violate the norms of any of those faiths.
Indeed, that normatively thin rule facilitates their peaceful coexistence despite differences in their respective sets of faith norms.
In this sense, the norms can facilitate life within normatively heterogeneous communities by means of its normative thinness.
Procedural ism allows for reaching decisions that are binding on members of a community.
To do so, it need not presuppose some end or value prior to or independent of the goals of the instant case.
To be sure, procedural wisdom allowed facilitates outcomes that are thick nothin but participants need not identify in any way with
the thick norms they nonetheless recognise as legitimate because they can recognise those norms as having been selected.
On a legitimate basis. That's the idea of the losing party, recognising the winning party's right to form a government.
That's the idea of recognising the legitimacy of a judicial system, even when one disagrees with a particular judicial holding or interpretation.
The normative identities of groups and individuals, as I've said, are things.
In modern pluralist societies and of course, across different societies,
groups and individuals regularly need to be able to act on a normatively thin basis.
The normative diversity within the population or across different populations in many cases is quite irrelevant to the tasks of modern life.
Here. People are functionally inter-related, yet in many respects normatively autonomous of each other.
The notion of autonomy is a core feature of political liberalism.
It values the individual's uniqueness of all other persons.
The bioethical notion of patient autonomy reflects this value.
Autonomy here doesn't mean separation from others.
It means rather an appreciation of how the individual is both inflected in various group memberships and is reducible to not.
Medical practice and biomedical research may,
in some cases consider persons as isolated individuals who consent or refuse to consent to participate in research.
In other cases, it may regard them as members of various non-governmental.
Groups. Such as the family or racial and ethnic communities.
How do we best conceive of patient autonomy?
This, too, is a political question. A normatively thin standpoint does not regard the individual in terms of her communal memberships,
or at least it does not attempt to determine her wishes and choices.
By simply reading them off community traditions, beliefs and values.
Rather it views patient autonomy in terms of uncommercial choice in accordance with the individual's subjective perception.
A for particular interests. Likely any bioethics regards the individual as a distinct locus of moral value.
In most cases,
the individual's interests would take precedence over the interests of the wider community and over those of scientific and medical research.
But maybe not in all cases. And if so, then no single understanding of patient autonomy can be the best one for all persons.
In all cases. One familiar question about patient O'Connor.
It concerns the relationship between professional expertise and its individual addressee, as in the doctor patient relationship.
On the one hand, the patient may need and want professional expertise in the interests of her health.
On the other hand, she is vulnerable to medical paternalism because she lacks professional expertise.
Patient autonomy seeks to protect and preserve the vulnerable individuals freedom vis a vis the power of professional knowledge and practical skill.
Bioethics might frame this issue as one of balancing patient Aponte and medical expertise.
Balancing here is not a matter of objective measurement.
Determining the acceptable level of risk or a necessary level of safety is contingent context relative and depends on value commitments.
Consider chemical therapies to treat cancer.
How is the risk of their high toxicity best balanced against their power to subdue cancer?
The risk is so great that, unlike most other pharmaceuticals licensed for human use,
chemical therapies have never been tested on healthy adults before clinical adoption.
Yet there are benefits measured against the lethal nature of cancer.
May persuade some patients and some clinicians that the risks are acceptable.
But not all patients and physicians will be so persuaded.
Persons of different think values will balance the risks and benefits differently.
Consider another example. Mitochondrial disease causes conditions like leis disease, a fatal infant encephalopathy.
And it's common and it causes other diseases that waste muscles or cause diabetes and deafness,
mitochondrial replacement therapy or M or T in search of the healthy mitochondria of
an unrelated person into an embryo containing the nuclear DNA of two other people.
In one estimate, NRT will enable some 2500 women in the UK to have children genetically related to them while avoiding terrible diseases.
But risk benefit analysis in this context must address the fact that currently there
is no alternative for women who want their own genetically related offspring,
and that many women will continue to desire their own genetically related children and will continue to have them, if denied or unable to access.
M are key and that with out NRT, these women will perpetuate the occurrence of disease.
Again, we observe balance as a matter of competing values that different people will weigh differently.
In this sense, again, it is political. I turn now to ways in which procedural ism is constrained.
After all, the thin normativity of procedural ism does not mark the absence of all normativity whatsoever.
Thinness is not neutrality, nor is it indeterminacy.
Procedural ism must be sufficiently thick normatively to generate answers to difficult questions about the good, the right and the just.
Yet it must be sufficiently thin to appeal to people who disagree about the nature of the good, the right, and the just.
For that reason, no procedural ism can operate without introducing into itself at least a few substantive norms.
First of all, a commitment to procedural ism is not itself normatively neutral.
Procedural ism is itself a norm, one that entails and often the obligation to recognise and abide by its outcomes.
This is a significant obligation normatively, because procedural ism does not generate normatively neutral outcomes.
Any procedure that has winners and losers is hardly neutral in its results.
So an obligation to recognise and abide by procedural rules is an obligation to respect some norms that one does not share.
Further procedural ism entails various norms of fairness, including fair access to participation,
fair conditions of participation and the sincerity of participant behaviour.
The norm of fairness gives the individual reason to trust the group or institution in which the procedure is embedded.
A patient's informed consent is a matter of fairness, a matter of the patient's being able to participate in making some relevant decisions.
This fairness gives the patient reason to trust the medical research professionals.
What about the interests of third parties? For example, the patient's parents or spouse or children.
How are these third party interests to be balanced against the patient's interests?
In many cases, we would expect them to be subordinated to the patient's interests, but maybe not in all cases.
For example, with respect to infants in intensive care, how are its best interests balanced against those of the family?
The infant cannot participate, of course, but the question still poses itself where a proxy defines and advocates for the child's best interests.
The attending doctors might be such a proxy where decisional autonomy lies not with the parents,
but with medical professionals who, let's say in this instance,
do not share the family's view of the child's best interests with the family takes to be the child's best interests,
contrast with what the medical profession believes those best interests to be.
Each side may then view the other side as subordinating the patient's interests in this case.
In some cases,
procedural ism involves substituted judgement where another must represent the economy of the so who cannot choose and act independently.
Issues involving future children, such as those subjected to germline gene editing,
require substituted judgement in lieu of the affected persons consent.
Do the benefits enjoyed by the individuals once born way heavier than the risks to which the procedure exposed them?
Not if germline gene editing causes side effects so severe as to make an individual's life not worth living.
But the question of what makes an individual's life not worth living is political.
Any given answer will depend on very particular value commitments that compete with those held by others.
I come now to the third and final part of my talk.
Here, I propose combining two types of procedural ism in mutually reinforcing ways.
The procedural ism of expert committees or commissions,
and the procedural ism of deliberative democracy then carefully and systematically renders late opinion better informed.
And more thoughtful. I begin with bioethics committees.
They claim a special expertise in making normative decisions that endow their recommendations with normative authority.
But I would claim public commissions cannot operate on a plane above politics.
To clarify this claim, I draw on a 27 article in which she and.
Michael Dunn and so on, located an expert committee's authority partly in the political community's stake in scientific research.
According to these authors, it is this stake that justifies a classical framework for research governance.
They regard this stake as fundamentally democratic, situating an inquiry and research within the grasp of society rather than removed from.
Yet they caution that a specifically democratic location misses something important about the nature of inquiry, something that transcends politics.
She and and colleagues argue that insofar as the committee members operate within this framework,
there is no distinctive ethical expertise relevant to the justification or practice of ethics review that exists independently of this process.
Thus, it is the decision making process that is authoritative, not the committee.
Indeed, they argue any committee member or social researcher who put themselves forward as an ethics expert in
this context would be at risk of undermining the legitimacy of a fair process model of research ethics.
Governance. In fact, to say that procedural isms authority comes in part from the institutional status of the committee itself,
both as a process and in the appointment of its individual members,
obscures the political element here the presence of different persons in the committee,
accompanied by their respective value commitments which may marry and compete with each other.
Expert bioethics committees are political, among other dimensions,
as well as a particular commitment to procedural ism as a means of public policy formation.
In selecting the criteria of membership appointment and in choices choices about who might to provide testimonials.
These criteria displayed political sensitivities, such as seeking a range of viewpoints.
I turn now to deliberative democracy.
I think the procedural wisdom of expert committees needs to be supplemented with an integrated into another kind of procedural ism,
one that generates informed and reflected non-expert opinion.
Deliberative democracy. Deliberative democracy chooses participants randomly rather than selecting for affinity.
It allows participants to draw on balanced expert information toward vetting competing perspectives carefully perspectives both of
scientific research and of ethical reasoning by consulting with experts representing diverse viewpoints and deliberations with peers.
Participants develop, examine and challenge their own views while mutually influencing each other by reasoned argument that they themselves evaluate.
This procedure encourages discursive argument based on views informed by exposure
to scientific fact as well as exposure to a range of normative thinking.
Like expert bioethics committees, the deliberative process begins with certain norms, norms that can always be placed into question.
Earlier, I examined a couple of these kinds of norms,
the risk benefit analysis to minimise patient harm and informed consent to provide decisional autonomy to the patient.
The deliverable, the deliberative process also begins with another, more commitment to deliberation on terms of mutual respect.
And that commitment reduces the range of possible, relevant reasons to only those that can be accepted by others on terms that all can accept.
To be sure, reasons acceptable to other persons may often be difficult to identify where.
The reason in question is an artefact of contested background assumptions such
as what constitutes the good life or how political community is best organised.
An approach based on giving and evaluating reasons makes definite demands on the participants.
It requires that they be able to change their minds based on giving reasons and evaluating the reasons of others.
It requires that they be able to consider trade-offs that are necessary in public policy,
rather than assuming that their role is to only and always protect and preserve their own personal interests.
And it requires participants to be respectful of minority views.
I come now to my conclusion political bioethics is less plausible the more it presupposes shared common values.
By contrast,
political bioethics is plausible by means of decisions that are acceptable to all participants and affected persons and to the community as a whole,
because they are legitimate and bioethical decisions, are political, is made on the basis of procedural legitimacy.
In this way, political bioethics views the lack of convergence among moral experts as inherently political, inherently political means.
There is no particular method of moral reasoning that can eliminate the political quality of bioethical issues.
There is no external standpoint that would allow one to adjudicate in a manner objective or neutral or disinterested.
Among the competing bioethical presuppositions and understandings.
Thus reasoned debate by itself all too often will fail to generate an answer equally acceptable to all participants and affected persons.
To view bioethics as politics is to take a viewpoint that is morally ambiguous.
The potential wisdom and insights of bioethical analysis cannot escape this ambiguity.
Given disagreement in the public sphere about ethical issues that require decision for regulation,
legislation or public policy, how should bioethical questions be decided?
On what basis in liberal Democratic community?
It should be a heightened form of opinion. A heightened forum means informed by expert opinion of committees,
as well as by input from the general populace that has benefited from democratic deliberation.
Basing political, legal or regulatory answers on expert opinion may not always be easy,
and basing them also on democratic opinion is surely very difficult.
So what difference does the adjective political make when conceptualising bioethics?
What practical difference would it make if a community were to adopt a viewpoint of political bioethics?
It might make a practical difference. After all, if bioethics is fundamentally political,
then it matters what kind of politics we actually practice in any given community toward bioethical regulation,
toward bioethical legislation, and toward bioethical public policy.
If we prefer political liberalism to say authoritarianism,
then we will want to attempt to extend the discussion and the decision making to the general public to the extent possible at any given time.
Again, that goal is difficult indeed, and it is fraught with obvious dangers.
It may never be more than modestly successful, if even.
That. But a goal impossible to meet may still function in a regulative sense.
It may provide us practical orientation,
and that orientation should be in a democratic spirit to extend the discussion and
the decision making to the general public to the extent possible at any given time,
and hopefully to ever greater extents.
Over time. The promised print.
Thank you very much.