Bioethics is Love of Life: An Alternative texbook

Darryl R. J. Macer, Ph.D.
Eubios Ethics Institute

Copyright 1998, Darryl R. J. Macer. All commercial rights reserved. This publication may be reproduced for limited educational or academic use, however please enquire with the author.

3. Theories of bioethics and love


In the past few decades there have been a number of theories expounded which claim to guide decision making for bioethical dilemmas we face. In this chapter I will review the theories of bioethics which exclude specific mention of love first, and then in the next section summarize those which have included love. Following that we are faced with the question why love has been neglected by most modern writers of bioethics.

3.1. Theories of bioethics

As discussed in chapter one, the term bioethics means the study of life ethics, but it has often been viewed only as a part. The concern with medical ethics has meant that most "bioethics committees" only consider medical ethics. Likewise, ecological and environmental ethics must include human-human interactions, as these interactions are one of the dominant ecological relationships in the world. Both extremes are incomplete perspectives, and many of the general theories can be useful in either domain if applied appropriately in a wide interpretation.

There is no one doctrine that is bioethics, neither is bioethics a campaign, rather it is a systematic process of reflection and discussion, in the tradition of Socrates rather than an a dogmatic system of beliefs. While some writers or protest campaigners use the term bioethics to promote particular viewpoints, there is a wide range of views on what bioethics is. It is both respect for life, and the process of making decisions that apply science and technology to life. It also has little difference from ethics in general, only that the subject matter is somewhat more focused on issues involving living organisms.

There are several basic theories of bioethics, and the simplest distinction that can be made is whether they focus on the action, the consequences, or the motives. Another separation that is used is deontological theories, which examine the concepts of rights and duties, and teleological ones, which are based on effects and consequences. If we use the image of walking along the path of life, a teleologist tries to look where decisions lead, whereas a deontologist follows a planned direction.

This separation is necessary to break down ethical dilemmas to manageable problems, but we still often have moral difficulties. For example, if we give a person dying of cancer marijuana to ease the pain, we can focus upon these three aspects, the action of giving the illegal drug, the consequences that the pain may be eased while using the drug, or the motive that we want to help. However, we can also focus on any of three aspects with a different view, for example, the action to give a drug that is not fully understood (if any are!), the consequence that others in the room may not like the smell, or the motive to respect the person's choice. The theories below focus on different parts of the total ethical equation needed to approach bioethics.

Aristotle in Nicomachean Ethics wrote that morality is the pursuit of a "final good" or "supreme good". This may be accepted, but the question is what this good is? The final good was often interpreted as happiness, which leads us to one of the main teleological theories, utilitarianism. Utilitarianism looks at the consequences of an action, and is based on the work of Jeremy Bentham (1748-1832) and John Stuart Mill (1806-1873). They could have been rediscovering what Mo Tzu had taught in China in the 6th century B.C. The principle of utility asserts that we ought always to produce the maximal balance of happiness/pleasure over pain, or good over harm, or positive value over disvalue. Initially they focused on the value of happiness, however recently other intrinsic values including friendship, knowledge, health, beauty, autonomy, achievement and success, understanding, enjoyment and deep personal relationships have been included (Beauchamp and Childress, 1994). Utilitarianism may appear cold and calculating, but it has been said by many (see section 2.2) to be an expression of brotherly love.

Utilitarianism is internally coherent, simple and comprehensive and can resolve dilemmas. We can also argue for the happiness of potential people, thus applying it to questions of human reproduction (Rachels, 1998). However, there are probably no pure consequentialists. If there is little difference in consequences, most people would consider it wrong to break a promise, and would decide based on that commitment. All societies accept some type of property rights, and most do not accept stealing from the rich to give to the poor, even though this would help more people. However, many societies accept differential tax scales, taxing the higher income earners increasingly more. Most people appreciate good motives over bad ones, although the consequences may be the same. Also it would allow violations of human rights, and could excessively limit autonomy.

Moral theories which focus on the act consider moral rules. There are different types of rules. Instrumental rules are those that prescribe an action believed to contribute to the attainment of a goal, for example, make sure you wash the vegetables well before eating them (so you do not get sick). When it comes to a restaurant however, the restaurant has to follow some instrumental rules prescribed by authority, for example, the toilet should not be in the kitchen. The problem is to decide which rules should be followed, as some rules do not bring benefit to anyone.

A rule utilitarian may use moral rules as authoritative instrumental rules, so the morally right action is conformity to a system of rules, and the criterion of the rightness of the rule is the production of as much general happiness as possible (Cox, 1968). For example, one moral rule used in medical research is that experiments on individual patients are justified only when the patients themselves stand to benefit, and not when the benefits go solely to third parties, even the entire human race. A rule utilitarian could claim this as a rule, and therefore it would still be within utilitarianism. Act utilitarians look at the particular act only, and say that moral rules are only approximate guides and may be broken if maximal good is not obtained. Most pragmatists would agree that sometimes obeying the rules is better than not have any. As Smart (1961) noted, selective obedience does not erode moral rules or general respect for morality. For them the only absolute principle is utility (Beauchamp and Childress, 1994). However, the demands of utility mean it is difficult to draw the line between morally obligatory actions and supererogatory actions (those that are more than moral obligation and performed for the sake of personal ideals).

If something is a moral obligation than society can impose it upon an individual, especially if that person aspires to belong to a professional society. The principle of doing good, expressed as always working for the patient's best interest for a health care worker, needs some practical guidance in the form of practice guidelines or medical association codes of conduct or rules. There are many rules of etiquette, which are not generally considered rules of ethics, but rather following a code of conduct that is appropriate to what one is doing. Sports games have rules which may not even be aimed at winning or enjoyment, but just occur, and by adoption of the rules of the game as a rule of the game in itself, then we follow them. Medical doctors may be told they should tell the truth to patients, or they should not sell drugs directly to patients, however, these rules are not universally regarded as absolute moral obligations.

Another problem of utilitarianism is that the interests of the majority outweigh the interests of a minority, because utility should be maximized. In this way it is consistent with democracy, and the system of referendums to decide public policy and law. Making most people happy most of the time is more important, even though a few persons or organisms may be unhappy. However, to make people happy is one of the central goals of love.

Aristotle and Thomas Aquinas (1225-1274) considered both the ends sought and the means of attaining them with reference to the nature of the human agents. Natural Law prescribes that good ends and means are those befitting the human agent, while bad ends and means are not (McInerny, 1987). They both considered an ultimate end to human actions and that people should act rationally. Thomas Aquinas held that there were very common guidelines of human action which are embedded in the very nature of the human agent known to all. Good is something then that we naturally desire, and was on the highest level. Prohibitions of murder, theft, adultery and lying are at a lower level, but Thomas argues that they are always and everywhere wrong because they are destructive of the good for man. He supported a positive law, but also motive. Good action is the product of character, character is formed by repeated acts of a given kind until our hearts are inclined to good action.

An alternative theory is based on obligations and is shaped from the work of Immanuel Kant (1724-1804). Kant argued in the Critique of Practical Reason that morality is grounded in pure reason, not in tradition, intuition, conscience, emotion or attitudes such as sympathy. We could see this as following the tradition of Francis Bacon, in Of Love, where he wrote "It is impossible to love and be wise". Kant regarded human beings as creatures with rational powers to resist desire, the freedom to resist desire, and the capacity to act by rational considerations. He said we must act for the sake of obligation and made categorical imperatives, one being "I ought never to act except in such a way that I can also will that my maxim become a universal law". In general, Kant has a problem with conflicting obligations, for example, between two promises if both are absolute.

The other famous imperative, "One must act to treat every person as an end and never as a means only" (Kant, see 1959), was also worded with love. In Doctrine of Virtue he restricts respect (Achtung) to a refusal to abase any other person as a mere means to my ends, and construes love as making other's ends my own. However, if someone agrees to do something for someone else, as in work, it is ethically accepted if the person is treated with respect. Kant considered beneficence more rational than love, in Foundations of the Metaphysics of Morals, he wrote, "...love as an inclination cannot be commanded. But beneficence from duty, also when no inclinations impels it and even when it is opposed by a natural and unconquerable aversion, is practical love, not pathological love; it resides in the will and not in the propensities of feeling, in principles of action and not in tender sympathy; and it alone can be commanded".

Martin Luther King, Jr. (1961) wrote regarding the non-violent struggle for civil rights, that "I would say that the first point or the first principle in the movement is the idea that means must be as pure as the end. This movement is based on the philosophy that ends and means must cohere". He argued that their movement would break with any ideological system that would argue that the ends justifies the means. This was a reason for the policy of non-injury, that protesters could not fight back, the same principle used also effectively by Gandhi in India.

The rule-based approach lies in the tradition of Thomistic natural law ethics, which says that practical moral judgment consists in the application of general moral standards to particular situations. Prudence is the kind of practical wisdom that directs the choice of means to ends, and it is necessary to apply the rules or principles to a particular case. The appropriate rules and principles must be applied, which can be called prudence, which itself is an intellectual virtue, which relies on good moral character or judgment at least.

An extension of obligations or duties is to reverse the moral focus, and say that someone has moral rights. If I have a right to freedom of speech, then the society has an obligation to let me speak. Rights protect people against moral abuse, and are very commonly used in ethics in especially Western countries. Although they are adopted in universal conventions on civil and political and cultural rights, there has been objection to the language of rights by some in Asia, particularly in countries which do not adopt full political democracy. This is due to the close attachment of rights to the idea of individual liberty, and which has modern origins with thinkers like Thomas Hobbes as a liberal individualism. This still leaves conflicts between individual and community which need to be resolved (Dworkin, 1977).

The language of rights is often expressed as legal rules. Some rights are judged to be absolute, like freedom of religious belief. The freedom of personal belief is supported in the Judeo-Christian-Islamic tradition as well as Buddhism, Confucianism, and Hinduism. Other rights are not absolute in all cases, even the right to life may be broken when another's life is in danger - and in some countries capital punishment means the right to life is broken as a punishment for some crime. The various rights of moral agents involved in a dilemma and its consequences, need to be balanced, as do the sets of primie facie principles that are used.

There are positive rights and negative rights used in medical ethics. The right to health care is a positive right, grounded in a claim of justice. The right to forgo a recommended surgical procedure is a negative right grounded in the principle of respect for autonomy. The US Supreme Court in the Roe versus Wade case in 1973 ruled that a woman's right to privacy gives her a right to have an abortion prior to fetal viability even if her life is not threatened, a negative right to limit social interference. However, it did not confer a positive right, that the governments have an obligation to fund such abortions (Beauchamp and Childress, 1994). However, we are still left to answer whether governments should fund abortions, and what is ethically correct. An outsiders observation of the abortion debate in the USA suggests the language of rights has led to strong conflicts between groups supporting different rights, such as a right to choose or a right to life. It can also be criticized how a right to life is argued for one person, and not for another, and how the concept of punishment in crime is given as a justification for loss of the right to life. Nevertheless, rights have increased the quality of life of minority groups and children and women, around the world since the Universal Declaration of Human Rights in 1948, fifty years ago.

Russell (1954) considered the question of whether ethical knowledge actually exists. While there are hopes and desires in ethics, and hopes and desires are subjective, there may still be ethical truths. We may all agree that people should be killed, but how is the concept of law developed. Russell wrote "laws are held to be good when they are "just", but "justice" is a concept which is very difficult to make precise...I think that in fact "justice" must be defined as "what most people think just"". He considered social ethics to be "a matter of give-and-take scarcely distinguishable from politics".

There are also theories of ethics based on community, which argue that individuality, autonomy or rights of a person, are not suited to the community structure of society. Communitarians argue that societies need a commitment to general welfare and common purpose, and this protects members against abuses of individualism, which could be equated with selfish pursuit of liberty. The question is what community we talk of, the individual family, the village, the state, country or region or global community. The family also has a range of definitions, but Haviland (1997) defined it as a group composed of a woman and her dependent children, with at least one adult male joined through marriage or blood relationship. There are also some families that do not have two adults and they may not be different sexes.

Some supporters of communitarianism include Aristotle, David Hume, W.F. Hegel, and Alastair MacIntyre. They have a variety of extremes. MacIntyre (1984) argues Aristotle considered that local community practices and their corresponding virtues should have primacy over ethical theory in normative decision making. These practices include parenting, teaching, governing, and healing. They would support the European approach to presumed consent in organ donation, rather than the individual libertarian view that everyone should specifically give consent for their organs to be used. Both individual and community need to be considered in ethics.

Above, I explained we could look at the actions, consequences or motives of a decision in ethical theory. We can ask whether there are some kinds of action which are intrinsically good or bad? Can we look at the moral quality of actions in this way? We could say that causing harm as an action is morally bad, but sometimes we may only know this after seeing the consequences. However, to kill is a morally wrong action given no other circumstances, the same as breaking a promise is intrinsically bad. There can be intrinsic parts of an action which make it morally right. Another way of looking at an action is extrinsically, as a expression of a virtue.

One of the fundamental debates inside ethics is whether it is universal or relative. There are two types of relativism: cultural and ethical. Cultural relativism is the view that ethical judgments supported by different individuals or groups are sometimes different and conflicting in a very fundamental way. Ethical relativism is the view that cultural relativism is true and that conflicting ethical judgments may be equally correct. Ethical relativism can also apply within one culture and between two individuals.

Beauchamp and Childress (1994) in Principles of Biomedical Ethics outline the most widely accepted theory of biomedical ethics, and the one most seen in textbooks. They defend the four principles approach, based on beneficence, non-maleficence, autonomy and justice. The same principles as I used above, and they write "Both the set of principles and the content ascribed to the principles are based on our attempts to put the common morality as a whole into a coherent package" (p. 37). Instead of restricting themselves to particular premises or principles, or categorical imperatives, they are pluralistic. They also include rules, rights and virtues but argue that principles provide the most abstract and comprehensive norms. The principles are derived from common morality as opposed to reason or natural law, but they still have deep justification in philosophy. It follows in the tradition of Jean-Jacques Rousseau and others who argued that a native moral sense is possessed by all persons and this is more important than the complicated systems of philosophers.

William Frankena (1973) extended the postulate of Hume that the two major principles of ethics are beneficence and justice. By beneficence he writes that we should maximize good over evil, and justice guides the distribution of good and evil. Beauchamp and Childress (1994) say that the author who had the greatest influence on their theory is W.D. Ross (1930), who listed obligations of self-improvement, justice, beneficence and non-maleficence. The principles are prima facie binding, meaning that they are not absolute, nor hierarchical, nor just rules of thumb. They are normative guidelines, but balancing should be performed. As Gillon (1986) says, these principles may not give us the answer to a particular moral problem but they do give a widely acceptable basis for trying to work out our answers more rigorously.

Personal autonomy is limited by respect for the autonomy of other individuals in the society. People's well-being should be promoted, and their values and choices respected, but equally, which places limits on the pursuit of individual autonomy. We should give every member in society equal and fair opportunities, this is justice (Rawls, 1971). Society should also include the future of society, future generations are also an essential part of society. Those who claim the individual autonomy comes above societal interests need to remember that at major part of protecting society is because it involves many lives, which must be respected. Individual freedom is limited by respect for the autonomy of other individuals in the society. People's well-being should be promoted, and their values and choice respected, but equally, which places limits on the pursuit of individual autonomy.

I would argue that these principles all derive from love. While it may still be useful to retain these principles, I would like to emphasize that they are all expressions deriving from love of life. The final sentence of Principles of Biomedical Ethics (Beauchamp and Childress, 1994) admits the requirement, "Almost all great ethical theories converge to the conclusion that the most important ingredient in a person's moral life is a developed character that provides the inner motivation and strength to do what is right and good" (p. 502). It is a suitable point to move to the place of love in theories of bioethics.

3.2. Love in theories of bioethics

The inner motivation and strength for ethical behaviour comes from love. Given the vast literature and familiarity with love, it is a wonder why so few of those people developing modern prescriptive bioethics have focused on it. Although the line of the Beatles song, "All you need is love" could summarize of the 1960s, the meaning of love in terms of being a practical guideline has not been fully explored. The principle of beneficence in ordinary English comes closest to love, but the former word is preferred over use of love because love has other meanings. Altruism, charity and humanity are also words related to love, but love is stronger. Because of the strength of love in positive obligations, it may be regarded as an ideal, something which cannot be attained.

Some ethical theories are based on virtues, or motives. A virtue is trait or character that is socially valued, and moral virtue is a trait that is morally valued. A moral virtue may be a disposition to act in accordance with moral principles, obligations, or ideals. Beauchamp and Childress (1994) made a list of principles of their theory of bioethics with corresponding virtues that allows comparisons:

Principles Corresponding Virtues

Respect for autonomy Respectfulness

Nonmaleficence Nonmalevolence

Beneficence Benevelonce

Justice Justice or Fairness

Rules Corresponding Virtues

Veracity Truthfulness

Confidentiality Confidentialness

Privacy Respect for Privacy

Fidelity Faithfulness

Ideals of Action Ideals of Virtue

Exceptional Forgiveness Exceptional Forgiveness

Exceptional Generosity Exceptional Generosity

Exceptional Compassion Exceptional Compassion

Exceptional Kindness Exceptional Kindness

They list four focal virtues, compassion, discernment, trustworthiness and integrity, for health care workers. There is difficulty to make virtues obligatory, but moral virtues like concern, compassion, and caring are widely recognized as signs of an ethical health care worker. Some other virtues have no parallel in the alternative theories of bioethics, including integrity, cheerfulness, sincerity, and commitment. We can compare to the 6th century B.C. virtues of Taoism, love, compassion, patience, meekness, tenderness, and unconditional generosity toward all living beings.

A criticism of virtue theory is that when strangers meet there may be little relationship between them (though love of our neighbour will be argued as applicable in this case also). Another criticism is that people of good character make mistakes and can perform wrong actions, therefore some account needs to be made for the mistakes we all make. Any moral theory will be more complete if virtues or motives are considered however, and they are often more important than the following of strict rules in ordinary life.

Fletcher (1968) gave the following example of the virtues in situationalism, "a loving but mistaken action is cause for regret; a loving but correct action is cause for joy; an unloving action, whether a correct or a mistaken reading of the situation, is cause for remorse. Thus remorse follows a betrayal or cheating of loving concern, while regret follows a cognitive but not moral failure". While "always act with love" is a universal formal ethical principle, it is on its own not substantive (it does not say what love is) and it is not normative (it does not tell us how we are to do it, and it is not prescriptive. The footmark is left to the situation and the decision-maker. Agape is a virtue, and Fletcher said "The imperative (love) combined with the indicative (empirical data) determines the normative (the good thing to do)".

Another of the debates over situationism is whether there are intrinsically wrong acts no matter what the circumstances. Situationalism would follow utilitarianism in arguing that there may not be any action which is absolutely wrong in all cases, unlike the arguments of absolute human rights which would say in no case an innocent person's human right to life, for example, may be violated. The extension of the ideal of love which gives us the principle of do no harm could also say there is no exception allowed under which we kill a human being, it is a matter of extension and application of the principle of love and respect.

Paul Tillich (1954) distinguished four forms of love, epithymia (desire), eros (the search for value), philia (friendship) and agape (the depth of love), which must all be present together otherwise they will be distorted. For Tillich, agape was a special form of love since it comes from God and is God. He treated the failure to love as a sin of estrangement or separation. He proposed the principle of love in terms of the Greek agape as the ultimate principle of ethics, which maintains "an eternal, unchangeable element, but makes its realization dependent on continuous acts of a creative intuition" (Tillich, 1963). He said love is above the legal law, natural law of Stoicism and supranatural law of Catholicism, and refused to define it saying "there was no higher principle by which it can be defined." He claimed backing from St. Paul and Martin Luther in the Christian tradition. The other principle he added was the Greek word, kairos, meaning apply it to the "right time", which is a principle needed to embody the love into practice and towards objects. His view of love was more than the equality seen in the Roman empire, when love was universally applied in a cool and abstract way, not warm. In Christianity the neighbour becomes a concrete object of the love which anyone can become. Tillich regarded law and institutions as necessary to embody love in a society.

Albert Schweitzer (1966) with Respect for Life could be said to have used the idea of love of life as a ground for respect of life, but he did not overtly use the term love - preferring respect or reverence. He argued for a reverence for all life. This approach makes no distinction between higher and lower life forms, saying that we can not judge other lifeforms in relation to ourselves. It makes the point that it is very difficult for us to understand or judge the importance of other living organisms in the natural order. The only reason for harming life he sees is necessity. However, what is "necessary" can vary widely between cultures.

One of the alternative theories of bioethics is termed ethics of care. Caring refers to emotional commitment to, and willingness to act on behalf of persons with whom one has a significant relationship. This ethic was recently revised in feminist writing, where it was argued that women predominantly display an ethic of care in contrast to men who predominantly exhibit an ethic of rights and obligations (Gilligan, 1982; Baier, 1985). Baier specifically thought of an ethic of love and trust, including human bonding and friendship, which is often involved in relationships of parents and children, friends, and physicians and patients. People often want to do something for others, because of their relationship, rather than any obligation or rational ethical decision making. However, often the ethics of care approach is developed without universal principles and therefore it has been considered opposed to universality. This criticism may assume that care is not universal, or that emotions vary between culture, however the emotions behind an ethic of care including love and interdependence are probably more universal than the idea of individual rights. The ethics of care has also been regarded as a way that women may continue to be dominated in a male-dominated system if it is gender-based (Sherwin, 1992).

Teilhard de Chardin considered love as the highest form of human energy (Grau, 1980). Love was mutually independent to intellectual energy, "A searching mind reveals what is lovable, while the loving mind is drawn on to search more. Teilhardian love was hopeful, moderating and controlling fear, and he asked how love can and should operate responsibly. Teilhard (1931) considered four fundamental aspects of love: attraction, affinity, sympathy and synthesizing energy. Attraction meant the drawing of elements of the world together among themselves, while affinity was a stronger term used for humans, as was sympathy. The synthetic energy of love was called the "totalizing principle of human energy".

Joseph Fletcher (1966) in Situation Ethics said love was the premier principle, and we should use case-based decision making to solve problems, always acting in love. There was strong reaction to that book and the ideas, especially among those in Christian ethics (Cox, 1968). It was called a new morality, and also an attempt at democratization of theology; making theological ethics understandable to all. He did not claim to be building a system of ethics, but rather a method of situational or contextual decision-making (Childress, 1992). Fletcher said that Christian moral judgments are decisions, not conclusions

Fletcher called love active goodwill toward the neighbour, calculating the best for the neighbour and it was not the same as emotional love. He considered four scales, ends, means, motives and consequences. Some theories of virtue ethics would also put good will or love as a premier motive in judging whether an action was ethical, but they consider the motives more, rather than all these other considerations, and Fletcher considered motives less than the other scales, and promoted ends and consequences as the main determinants. The value to be chosen as serving love the most, and the boundaries of each situation are two of the practical problems that were discussed in response to his theory. Are all consequences in the future relevant to the moral calculation?

The book The Gift Relationship by Richard Titmuss took the example of donating blood and called for a general social philosophy of giving in society. This is another form of practical love, which he called creative altruism. Campbell (1984b) argues that "eventually love cannot be moderate, if it will live in the world after Eden and professionalism must mean a risky professing, it will profess love". Love should be strong enough to demand our actions. We can see the expression of love in organ donation in Figure 3.

David Hume (1711-1776) considered that ability to reason was useful only for establishing the facts of a case and tracing the relationships between ideas, but a sentiment of approval or disapproval was necessary (Campbell, 1984). Hume believed, rightly I agree, that we approve of things that are beneficial to others just as much as we approve of things beneficial to ourselves. Hume in Enquiry into the Nature of Morals used the concept of humanity to explain why we are pleased to see others happy, "...the humanity of one man is the humanity of every one, and the same object touches the passion in all human creatures (p. 273).

Fletcher's Christian based approach based on love, was unusual still among Christian thinkers. Roman Catholic theology had argued in terms of natural law, rather than love, to support ethical decisions. Joseph Fletcher in an early book, Morals and Medicine (1954), used the arguments of rights, a stand which he moved from in Situation Ethics in 1966. Fletcher divided decision-making into three basic approaches,

1. antinomians, who reject rules as well as general principles of morality.

2. legalists, who think that some moral rules are absolute and inviolable no matter what the circumstances

3. situationists, who lie between, rejecting absolute moral rules but finding general moral principles to be helpful.

Using this analysis, some philosophers can be placed into two categories, for example, Immanuel Kant said "Treat people as ends and never as means", which would say a "moral wrong" is defined as treating persons as means, or using persons. However, many would place Kant as a legalist, allowing no exceptions for example in the case of telling a lie to save a life. Fletcher, as a situationist would say that since no kinds of acts are intrinsically good so we have to decide each case, considering the general principle that there is one intrinsic good, love, and one intrinsic evil, hate. As he wrote defending the theory, "The new morality, for which situation ethics is the appropriate method, follows love (freedom to put human need before anything else), staying as close to the law as possible but departing as far from it as need be." (Fletcher, 1968).

The legalist argument might say "It is always wrong to commit adultery", or "It is always wrong to kill a fetus", however, if we look at the specific circumstances we can always think of a case where it would be acting in love, or the lesser of two evils to do so. Fletcher said that the main thrust of situation ethics was a criticism of the legalism of some Christians who "hang on to certain eternally invariable rules of conduct as absolutely valid and universally obliging regardless of the situation. They think there are some things (allegedly learned directly from God) that are always right or wrong." (Fletcher, 1968). However, this vagueness has led to the rejection of situation ethics by the mainstream Christian ethical tradition. Roman Catholic ethics has developed the principle of double effect, to say that if the primary act is to save life and the secondary consequence is breaking one of the prohibitions it is allowable, as in the case of abortion to save the life of a mother. The point for us to consider is, whether any exception to a statement "It is always wrong to ..." means that we should give up that idea as a rule or law, and turn to situation ethics as a more consistent approach.

Martin Luther also wrote that law is not necessary if people act well, in Secular Authority, To What Extent It Should Be Obeyed, III, saying "If all the world were composed of Christians, that is, true believers, no prince, king, sword, or law would be needed". The problem is how do we know all the principles in which to act. John Robinson (1963) wrote that "such ethical [situationalism] cannot but rely, in deep humility, upon guiding rules, upon the cumulative experience of one's own and other people's obedience. It is this bank of experience which gives us our working rules of 'right' and 'wrong' and without them we could not but flounder". Karl Barth (1961) who writes of absolutely wrong actions allows for the ultima ratio, the outside chance that love in a particular situation might override the absolute, for example, in abortion.

Paul Tillich (1963) in Morality and Beyond discussed how pragmatists and positivists take their refuge in an ethical instinct that is supposed to lead to common sense. This common sense is secure if there is a society with a strong common belief and conventional morals, but is not effective when the harmony of the society dissolved. This is why principles like the Bill of Rights are useful in a changing world. At the same time as he wrote "Love alone can transform itself according to the concrete demands of every individual and social situation without losing its eternity and dignity and unconditional validity. Love can adapt itself to every phase of a changing world", he also concluded "no system of ethics can ever become an actual power without laws and institutions". Thus we can conclude that we do need a system of laws to empower the principle of love.

- The personal relationships of love can be extended to animals in a home farm in ways that cannot be experienced in the factory farm. No doubt both partners in the relationship benefit.

In this book I have reflected on the Christian tradition, due to its long dominance of Western thought, and that bioethics in the United States and the West in general has theological origins. Daniel Callahan (1990) and Leroy Walters (1980) have written historical accounts of the involvement of theology in the development of bioethics. Callahan noted that "The field has moved from one dominated by religious and medical traditions to one now increasingly shaped by philosophical and legal concepts." He continues however that "The consequence has been a mode of public discourse that emphasizes secular themes: universal rights, individual self-direction, procedural justice, and a systematic denial of either a common good or a transcendent individual good" (Callahan, 1990).

Another book exploring love as a basis for medical ethics is Moderated Love of Campbell (1984b). This book examined the professions of medicine, nursing and social work with a broad focus outside of Christian circles. These professions profess to love as a commitment to the service of humanity, and Campbell argued that love is a commandment beyond professional self-advancement. He cites the work of Paul Halmos (1970) in Personal Service Professions defined as a profession that aims to bring about changes in the body or personality of the client. In attempting to define love, Campbell includes brotherly love or philia (friendship based on mutual understanding and respect) and agape (concern for all humankind). Nurses have been associated more with the image of an Angel of Mercy, or of the care expressed in Motherly love and especially companionship. Love in social work is expressed as hopefulness, helping the depressed.

While situationalism may be more consistent as a theory of decision-making, there is still a need for a minimum standard to protect the weak. The law has proved necessary to prevent people and property and the environment from the worst abuses of lack of love. This book is written in the fiftieth anniversary year of the Declaration of Human Rights (1948). The Declaration and the subsequent Conventions which set out human rights, share many features seen in national constitutions of countries.

Casuistry is case-based reasoning and focuses on practical decision making in particular cases (Brody, 1988; Jonsen and Toulmin, 1988), and situation ethics is one form of it. They point out that rules, rights and theories cannot be divorced from history and circumstances. It looks at previous experience that is relevant to the ethical choice in this situation. From cases, extensions are made to principles, and Brody is positive to the development of ethical theory while some other proponents are not. They still differ from situation ethics that put love as the central principle.

Compassion has also been proposed as common ground for bioethics in a Thai Buddhist context (Boyd, 1998), and compassion can be considered as love as is discussed in the writings of Buddha. Generally compassion is focused on a particular context in suffering whereas social justice looks at inequality. In Theravada Buddhism the four prime virtues are mindfulness of friendliness (metta), compassion, joy and equanimity.

In Buddhism in general the self-less love is the bodhisattva in Mahayana Buddhism. The bodhisattva, by virtue of his decision to decline the rewards of nirvana, "until the last blade of grass has been liberated" is revered in Buddhism as the infinite and inexhaustible reservoir of compassion (karuna). The bodhisattva could have passed himself into eternal bliss, but remains in the mortal while other beings are bound by the triple evils of greed, hatred, and delusionment. The six Perfections are giving, morality, patience, vigor, meditation and wisdom) and other virtues include friendliness, good will, loving kindness, benevolence and sympathetic joy. Benevolence and altruism have broader meanings, not being restricted to suffering.

Sympathy is another word that is related to love, but it could be said to be a reaction to another's situation, as is compassion. Scheler (1954) saw sympathy as a preparation for love which is not a reaction but an action. He uses the term Mitgefhl or fellow-feeling, which if we have we will reach out to other people beyond self-centred motives.

One of the related virtues is hospitality or generousity, which is a virtue also seen in Islam. In a study of Sudanese ethics, Nordenstam (1968), said that hospitality expressed by Sudanese meant that the guest must always come first, and that urbanization where the frequency of guests increases may challenge the customs expressed as an outward virtue. The form of generosity which can be called charity (Arabic zakat and sadaqa) is one of five pillars of the Faith (others are praying, pilgrimage, fasting and profession of faith). If it is performed for religious salvation it may be less pure than from a concept of unconditional love. However, in the Western world the symbolism of hospitality may have become the opening of our privacy to chosen others, unlike the broader concept seen in many cultures (Mauss, 1970; Heal, 1990).

What is striking is that given all the popular support for the concept of love, why it is not the principle seen in textbooks of bioethics? I would suggest several reasons for this. First, the problem with case-by-case and situation ethics is that it is difficult to judge which is the best course of action in practice. However, this is not so obvious under other theories of bioethics as those authors would like us to believe.

A major problem has been the conflicting definitions and images of love. There are a variety of concepts included under the umbrella "love", as discussed above. Throughout this book, various definitions of love are described, but I also attempt in each chapter to show how these principles of love are not only consistent with bioethics, but are the bioethic we have.

Saint Augustine in the 4th century developed a doctrine of love, saying that love is to go beyond oneself and to fasten one's affection upon an object of love. Love is inevitable because humans are incomplete, and a person can love physical objects, other persons or themselves. Nothing is evil in itself, and moral problems come from the manner in which people attach themselves to the objects of their love and in expectations regarding the outcome of the love. Saint Augustine used four ideas under the term love (O'Donovan, 1980). Cosmic love was the attraction of objects for each other, in the Stoic tradition of natural philosophy and natural law, also including ideas that everyone loves peace. Positive love is the love based on desire from our will. Rational love was a more ordered love, admiring an appreciation of good, as an outsider of the relationship of love. Benevolent love was a term used for support given to an order which the person did not devise themselves. While every object can be loved, to love material objects for the goal of ultimate satisfaction will lead to dissatisfaction and discontent. He argued we had to reorder love so that first we love God, and then we can love others, and objects.

C.S. Lewis (1962) in the Four Loves, tried to analyze the different types of love, and at first distinguished "Gift-love" and "Need-love". Gift-love for example makes a parent work and plan and save for the future well-being of his family which they will die without sharing or seeing, while Need-love is when a baby comes to its mother from fear. He called gift-love divine as opposed to need-love, but emphasized that we still should call need-love, love. While need-love can be selfishly indulged, we do not call a child selfish if they seek comfort from their mother, nor a friend who seeks our company because they are lonely. He wrote "Need-love cries to God from our poverty; Gift-love longs to serve, or even to suffer for, God". Lewis actually identified four loves; appreciative love says: "We give thanks to thee for thy great glory". The most humblest of loves was affection (Greek, storge), which he says is a gift-love but it needs to be needed. Friendship was related to philia, and he called it the least instinctive, biological or necessary of the loves. Eros, or romantic love is necessary for our biological creation, and affection is necessary for our upbringing, but friendship is not needed, at least in most species. The fourth love, he called charity, agape. As discussed elsewhere in this book, there are distinctions among the four loves, but we still tend to avoid using the word love.

It is also not so clear why the term love is usually omitted from international law, whereas the concept of human dignity is often cited. Human dignity is arguably even more difficult to define than love. For example in the UNESCO Declaration on the Human Genome and Human Rights (11 Nov. 1997), Article 11 starts, "Practices which are contrary to human dignity, such as reproductive cloning of human beings, shall not be permitted". Why cloning is always against human dignity is not clear to me, for example, if it was the only way a family could have a genetically related child why is that against human dignity, when using donated sperm and eggs or a surrogate mother can be used, even for commercial contracts. Yet, at the time following the cloning of Dolly the sheep by nuclear transfer in February 1997, it became a popular call for many government leaders to say it was against human dignity. Therefore we have to look for other reasons why love is not popular.

Some attempt at showing practical applications of the principle of love are made in this book, however, it is still not considered a valid dismissal of a concept, that people may interpret the spirit of love to arrive at different decisions in the same circumstance. It does not hold that there is one good and proper decision to every question given the same circumstances, nor that people who make a different decision are unethical.

3.3. Academic snobbery

I would suggest that academics like to have a monopoly on prescriptive bioethics. I have found this in the strikingly hostile reactions to my book, Bioethics for the People by the People, expressed by one group of philosophers. This group of philosophers did not appreciate the idea of asking ordinary people to comment on bioethical questions, and then list these comments in a book. In the words of one philosopher, "So what, if people think that". This reaction is common among philosophers, who think that their arguments are correct and others are wrong if they disagree. To this group of philosophers there are two responses. One is descriptive bioethics has an important place in the science of bioethics, and we could also describe the views of any group as their bioethic. Another is that they can live in an ivory tower if they like (Figure 4), but do not expect everyone in the global community to follow their arguments, especially in a world which has often experienced the cultural imperialism of Western religion and philosophy.

There have also been writings about the origin of the academic field of bioethics in the United States (which may not be unique to that country), that philosophers found a new area of thought that would be given more prestige by the community and public, called bioethics. This allowed survival of philosophers, and has even resulted in a decade of plentiful funding of bioethics research with the bioethics programs attached to the Human Genome Project. However, tracing the origins of bioethics in the United States finds theologians also were initiators, who although they may have sought societal recognition did not have their livelihoods threatened because the Church supported them whatever. It is interesting to note that the book, Situation Ethics (Fletcher, 1966) discussed above was criticized also for making ethics simple for ordinary people to understand (Cox, 1968).

Even the book, Bioethics in High Schools in Australia, Japan and New Zealand, which included the comments and views of high school teachers received the comment that including the views of teachers was not useful. This book attempted to inform academics and other teachers about the views of about two thousand teachers who had responded to surveys on what bioethics is, and why they thought it was important, and practical issues of bioethics education. It suggests that some academics also did not want to listen to the views of teachers, revealing a little deeper academic snobbery than in the rejection of public views.

Another factor against love being included in bioethical approaches to life dilemmas is the general technocraticalization of society and of public expectations of what answers are needed to solve science and technology problems. The rapid change in society brought about by science and technology has had great impact on society. It is actually responsible for the globalization, with communications and transportation. More people will read this book through the Internet than on hard copy, and more people will be reading a copy downloaded from a computer than printed in a traditional way in a book printing press. People think that a new problem needs a new answer, however, what is needed is the application of old principles to new applications. This topic will be discussed at more length in the final chapter.

The general negative reaction to love comes from a longer philosophical tradition to dispense with emotion. Plato or Kant for example, have called emotions, feelings, passions and inclinations, distractions to moral judgment (Beauchamp and Childress, 1994). Those philosophers argue that action done from the desire to do good may not be morally good unless it comes from an appropriate cognitive framework. They argue that compassion may cloud judgment. The ethics of care can correct for this bias, but still has been at times somewhat non-democratic in the sense that it is defined as a theory. It also often was not impartial, saying that depending upon relationships, people will be treated in a different way. However, broad love for others should be impartial, and true compassion would not cloud judgment of what is best for the situation.

At the same time that some philosophers were rejecting the approach of descriptive bioethics, another group of equally regarded academics was accepting it. This was a pleasant surprise, as the first reaction was disappointing. Therefore expect to see more books written in this light, and more people trying to represent and learn from the arguments that there are in the community. It will be interesting in coming years how the bioethics community is divided up on the issue. For those with similar ideas, I hope that we will all learn many things from having open minds to people in all walks of life.

This approach to bioethics can also be seen in the approaches seen to the membership of ethics committees. Interestingly to my origins, and perhaps to my ideals of a society, my home country New Zealand is the most liberal in its idea of what a lay member to an ethics committee means. The law states that a majority of members of an ethics committee must be lay (non-academic or medical) and the chairperson should also be lay. This is a contrast to committees seen in Asia and Europe, where it is very rare or un-heard-of for a non-academic to be a member. The dean of a medical school is the chair, and there may be a token non-medical member of the committee. It is a fluid situation and only recently that lay members have been involved in ethics committees anywhere, but the idea is common to descriptive bioethics, that bioethics should be by the people not only for them.

3.4. Love as a basis for bioethics

In conclusion I beg us all to reconsider whether love does not share some of the features of a fundamental principle of bioethics. Firstly, as shown in the quotations it is universally recognized in both tradition and modern life as a good idea. It can also be seen to underlie basic primie facie principles commonly used in bioethics.

While some may criticize deciding each choice and case based on experience and love, rather than a formal set of principles, ethical experience has long been considered as the way to develop wisdom. In Christian theology the writings of people like Karl Barth moved attention away from experience to deontology, the Word of God and rules in the mid-twentieth century. Experience was given again as a basis for decisions by situation ethics. While humans are prone to self-deception, a trained mind sold be developed. Phenomenology is also an open ended method, supported by Martin Heidegger, Jean-Paul Satre, and also the concern of philosophers with everyday language shown by Wittgenstein (Cox, 1968). However, Satre disagrees with general principles of morality, not only rules, and the discussions above suggest that at least some principles based on love are common to human beings. Satre (1947) believed that truth and validity lie only in the individuals' experience and not apart from this (existentialism). Existentialism has been described as a philosophical ancestor of situationalism (Cunnigham, 1970). This means that ethical principles cannot be deduced from basic premises about the world, something which I disagree with.

To make love as the central virtue follows the moral theory of Aristotle, who argued that moral excellence should be a common goal. "Aristotle maintained that human virtues are dispositions to act, feel, and judge that are developed from an innate capacity by proper training and exercise" (Beauchamp and Childress, 1994). In Buddhist writings, the Mahayana, compassion (karuna) is emphasized as the necessary complement to wisdom (prajna) and as an essential ingredient in the perfection of the enlightened. Wisdom and compassion are compared to two wings with which one flies to the island of enlightenment (Bowker, 1997).

If we focus only on obligations, or the raw minimum, we have law, but not ethics. High moral ideals do not mean neglect of other parts of life, and self-love is necessary as discussed in the following chapter. People with a conscience and will should strive for moral excellence and development of character, this is also a universal goal seen in our global community. It is not enough to be content the way we are as no person or community is an island of themselves.

One point of view, which I share, is that moral saints who practice love like Mother Theresa are to not only be admired, but they are models for all of us to copy. For some people however, these saints are so different to the life that we have that they are beyond being a target for aspiration (Wolf, 1982). Freud (1930) in Civilization and Discontents rejected following the golden rule, "The commandment, 'Love they neighbour as thyself', is the strongest defense against human aggressiveness and an excellent example of the unpsychological proceedings of the cultural super-ego. The commandment is impossible to fulfil; such an enormous inflation of love can only lower its value, not get rid of the difficulty. Civilization pays no attention to all this; it merely admonishes us that the harder it is to obey a precept the more meritous it is to do so." This view that it is too idealistic has been more common in bioethics writings, but I this is due to the inability to accept that following a moral rule most of the time but sometime failing is better than nothing. it can also be argued from self-interest, as Mo Tzu wrote in 6th century B.C., the reason people think universal love is difficult is simply because they fail to recognize its benefit and understand its reason.

The only words against promoting love as the premier good are those who say that some competition is healthy for personal development and fulfillment. That people who work hard should be rewarded, and those who do not cannot expect to be supported by the rest of society. They also may say that natural selection suggests survival of the fittest is important. These issues will be discussed in the following chapters, as love for of our own life is, I agree, necessary to the person who tries to love others and understand others.


Figure 3: Expressions of love in bioethics

All IndiaIndia Institute of Medical Sciences, New Delhi

- A poster in the hospital grounds asks for the gift relationship to others, making the claim that sight is life.

Pet goats in home farmfarm

Figure 4: Academic snobbery

GandhiGandhi's Spinning Wheel, Ahmedabad, India

- By a philosophy of self-sufficiency to be one of the people, the great philosopher and activist Gandhi could make his ideas accessible to all.

King's College, Cambridge, EnglandEngland

- The continued tradition and dress-code and college rules, may make it more difficult for the academics in gowns to be seen to be the same as the townsfolk.


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