This chapter explores the nature of individual well-being. Our preferred approach is a type of subjective theory according to which both enjoyment (positively experienced mental states) and the satisfaction of narrative-relevant desires (desires whose satisfaction makes a difference to one’s life story) are prudentially good for an individual. Suffering and the frustration of narrative-relevant desires are prudentially bad. Contact with reality plays an amplifying role. Enjoyment is better for someone when they are taking pleasure in something real. Likewise, the fulfillment of desires is prudentially better when those desires are informed and rational. Enjoyment and desire-satisfaction are unified in a single coherent account of well-being in that both reflect the lived, self-caring perspective of a conscious subject. The chapter’s final three sections address (1) the relationship between disability and well-being, (2) decision-making for impaired newborns, and (3) decision-making for patients in irreversibly unconscious states.

We begin by deriving a negative right to procreative autonomy from autonomous agents’ right to control their own bodies. Turning to the ethics of deciding who will come into existence, we distinguish fixed-identity decisions, which address whether or not to bring a specific individual into being, and identity-determining decisions, which determine which of several possible individuals will come into existence. Regarding fixed-identity decisions, we defend a liberal view of abortion based primarily on the thesis that death does not harm pre-sentient fetuses. An example will help to clarify the less familiar category of identity-determining decisions: a couple might attempt to get pregnant now or – concerned about an outbreak of an infectious disease that might damage a fetus – wait several months, thereby determining which of two possible individuals will later exist. We argue that in at least some of these “nonidentity” cases, it is permissible to cause to exist someone whose life is expected to go worse than that of another possible individual. Finally, we apply our theoretical conclusions to two practical issues: the use of medical technologies in sex selection and public health measures in the context of a Zika virus outbreak.

This chapter provides background about the concept of bioethics and the history of the discipline, explaining the motivations for the book and outlining the subsequent chapters. A satisfactory work in bioethical theory, as we intend to provide, would accomplish three aims: (1) provide a high-quality discussion of ethical theory and methodology in ethics, (2) avoid the narrowness of normative vision that one finds in some theories (e.g., on hypothetical agreement in contract theory, on liberty in libertarianism, on moral rules in a rule-based approach), and (3) integrate areas of philosophical theory that are often neglected in theories of bioethics such as the nature of harm, the nature of well-being, models of moral status, personal identity theory, and the “nonidentity problem.”

This chapter explores distributive justice and beneficence. Justice involves giving individuals what they are due. Distributive justice governs the distribution of valuable resources and of burdens, and the granting of certain legal rights. Beneficence concerns agents’ duties to benefit other individuals. The chapter highlights distinctions (1) between the ideal and the nonideal and (2) between how institutions should be arranged and how individuals should act. We understand nonideal theory to address what particular actors – both states and persons – should do in the actual world today. Regarding institutions, domestically, we defend a liberal egalitarian view about distributive justice: unchosen differences in individual advantage within a society are prima facie unjust. Globally, we endorse cosmopolitanism: similar principles of justice apply internationally as apply domestically. Regarding individuals’ obligations, we defend moderately extensive duties of beneficence. We argue that national governments should ensure that all their residents have access to affordable health care and that the international community ought to amend the global intellectual property regime that governs pharmaceutical patents.

The focus in modern bioethics on the importance of patient autonomy – with its emphasis on informed consent and patient rights – has transformed medical practice and clinical research. We analyze the concept of autonomy and distinguish two ways in which autonomy is morally important for bioethical questions. We discuss respect for autonomy and its relationship to rights before delineating a taxonomy of ways in which someone’s autonomy can be interfered with. We evaluate two justifications for interfering with someone’s actions: paternalistic justifications and prevention of harm to others. Respect for autonomy grounds the requirement to obtain consent from competent patients and research participants. We provide a detailed analysis of the conditions for valid consent. The last part of our ethical analysis discusses surrogate decision-making for those who lack competence to decide for themselves. Finally, we apply our theory to the right to refuse medical treatment and the ethics of direct-to-consumer advertising of pharmaceuticals.

This chapter outlines our dual value theory. At the most general level, the theory consists of two substantive values, a formal distributive principle, and a scope determining the set of beings with moral status. The two values are well-being and respect for rights-holders. The distributive principle is equal consideration for all beings with moral status. And the scope is the set of sentient beings. Although our approach confers equal moral consideration on all sentient beings, it does not regard all sentient beings as rights-holders. On the basis of these ideas, we specify mid-level principles pertaining to nonmaleficence, beneficence, distributive justice, and autonomy rights. We also explain the key respects in which our theory differs from the principle-based approach of Tom Beauchamp and James Childress, and comment on other types of ethical theory.

This chapter explores four approaches to personal identity in terms of numerical identity: person-based accounts, a biological account, a mind-based account, and a social account. We also introduce the concept of narrative identity, which involves a person’s self-conception or self-told story about their life. We argue, first, that person-based accounts and the social account are implausible accounts of numerical identity and, second, that both the mind-based and biological accounts are plausible. This motivates a pluralistic approach to personal identity in the sense that policies and practices should be consistent with both accounts. With these theoretical resources, we turn to three practical issues. First, we neutralize some concerns about human enhancement through biomedical means. Second, we investigate and ultimately vindicate the authority of advance directives in cases of severe dementia. Finally, we address the definition of death and associated questions about unilateral discontinuation of life support and vital organ procurement. Proper resolution of these issues turns primarily on practical considerations other than the nature of death.

This book has covered a lot of ground. We began with the development of our theory of bioethics at a very abstract level. It is an ethical theory that recognizes two fundamental values – well-being and respect for rights-holders – along with a formal principle of equal consideration. At this level, it is easy to state, but it is not immediately obvious how to apply it to problems in bioethics. Much of the book has therefore involved specifying the theory at a level of detail that allows us to apply it to real-world questions. Given that well-being is a fundamental value, we need to know what well-being consists in, what it is to harm and to benefit someone, and who has a welfare that matters morally. Given that respect for rights-holders is a fundamental value, we need to know who has rights, what they are rights to, and so forth. Development and application of the theory go hand-in-hand.

Our methodology is a version of the method of reflective equilibrium that is widely used in philosophy and bioethics. This methodology gives a prominent place to our considered judgments about ethics and to the demands of maintaining a coherent overall set of beliefs. We describe some methodologies for normative theorizing in bioethics that are often advanced as alternatives to reflective equilibrium. Some, such as casuistry, we think are better understood as versions of the method of reflective equilibrium, at least as they are typically practiced. Others, such as particularism and foundationalism, we reject. We defend the method of reflective equilibrium against some prominent criticisms, including skeptical reactions about the use of intuitions motivated by recent work in experimental philosophy. Finally, we turn to metaethics and clarify what we are, and are not, assuming about the nature and foundation of ethics. Although we make no specific assumptions about the foundations of ethics, we assume that people’s beliefs about ethical matters, especially upon reflection and when informed about relevant facts, provide the appropriate starting point for ethical inquiry.

The principle of nonmaleficence states a prohibition on causing harm to others in the absence of justifying circumstances. After surveying some prominent accounts of the nature of harm, we defend a counterfactual account: you harm someone if and only if you make them worse off than they would have been in the absence of your intervention. Using this account we specify nonmaleficence into several general moral rules corresponding to ways in which individuals can be harmed. These foundational reflections are followed by discussions of three areas of ethical concern in which rules concerning harm are prominent: (1) the ethics of torture, including health professionals’ involvement in torture; (2) the limits of permissible risk in pediatric research; and (3) the ethics of medical assistance-in-dying. We argue for a prohibition of torture, a specific risk ceiling for pediatric research, and a liberal approach, with various safeguards, to medical assistance-in-dying.

Our account of moral status embraces equal consequentialist consideration for all sentient beings while ascribing the stronger protection of rights to those with narrative capacity. Individuals with the capacity to have narrative self-conceptions or identities have full-strength rights, while individuals with nontrivial temporal self-awareness that falls short of narrative capacity have partial-strength rights. This account of moral status is neutral with respect to species, which means that membership in Homo sapiens is neither necessary nor sufficient for moral status or rights. The final three sections explore ethical implications for research involving human embryos, rodents, and great apes. We defend a very liberal position with respect to embryo research, a relatively restrictive approach to rodent research (granting equal consequentialist consideration to rodents’ interests while permitting their use on utilitarian grounds), and a prohibition of invasive, nontherapeutic research involving great apes.