As the chapters in this collection show, naturalizing bioethics is a dynamic business: it requires us to move continually from theory to practice and back again. Theory is overhauled, adjusted, and fine-tuned in the light of practice and practice in the light of theory, and justification rests on the norms that have been tested and found good in critical and self-reflexive deployments of this process. The essays gathered here offer many examples of how bioethicists might build better theory by understanding individuals in context, attending to the web of relationships in which we all live, appreciating the reality of power, and — a not unimportant point to which we will return — situating themselves within their own work. But what does all this mean for bioethicists in clinical settings? In this epilogue, written specifically for bioethicists working in health care institutions, we set out an agenda for a naturalized bioethics in practice.

The agenda can be thought of as a call for three closely interconnected kinds of change. First, bioethicists will have to alter how they engage in — and teach clinicians to engage in — moral deliberation. Second, because working conditions greatly affect how well health care professionals can exercise their moral agency, bioethicists may need to initiate changes in those conditions. Third, bioethicists will have to change how they understand their own role in the clinical setting. We take up each of these in turn.

When infant patients and their parents tumble into the world of liver transplantation, they are not as lighthearted and curious as Alice — the hospital is not a Wonderland. However, they do discover, as she does, that they are leaving the ordinary life they shared behind. The geography lessons that Alice learned in school have become somewhat pointless; they do not seem to tell her where she is. The same happens with family habits and self-understandings when a child is threatened by disease and the need for liver transplantation. In retrospective interviews with parents about their child's liver transplantation, the time leading up to the transplantation is depicted as a period of transition. Their child's threatening disease has abruptly interrupted their lives, and indeed, many parents indicate that somehow their life stopped in this period: “Your life comes to a halt,” as one of our respondents put it.

Feminist care-ethics makes a difference when analysing and discussing healthcare issues. As a specific moral perspective it frames moral questions in healthcare in terms of responsibilities and is concerned more about the dangers of abandonment than the dangers of interference. The care perspective also invites us to re-examine and re-evaluate current conceptions of autonomy and moral relationships. In this chapter I shall try to show that care-ethics, as a relational ethics, makes a difference in the moral reading of problems arising in the use of genetics. In arguing this, I will start by presenting the main characteristics of care-ethics. I will then go on to discuss the issue of whether care-ethics can be seen as a feminist ethical perspective. In the final part of the chapter I will show how care ethics can make a difference to the discussion of ethical issues in genetics. In particular, I shall concentrate on the tension between responsibility toward others and the value of personal autonomy.

Care ethics

In 1982, Carol Gilligan published In a Different Voice, in which she put forward the thesis that a so-called ethics of justice gives only a partial voice to the moral experiences of men and especially of women. An ethics of justice, needs to be complemented by an ethics of care that is capable of articulating the moral values of nurturing and caring. In developing this care perspective Gilligan challenged the idea that abstract and universalistic moral reasoning was the best way of thinking about moral problems.

Medical ethics has had a rich and complex history over the past 40 years. It has been transformed from a rather clear and straightforward set of rules and attitudes, shaped largely by the medical profession itself, into a major field of academic and social inquiry. Contemporary work in medical ethics can be divided into three parts: ethical analysis and arguments of large-scale issues in science, practice and policy (such as consideration of the ethical issues concerning cloning or resource allocation); theoretical inquiry into the foundations of medical ethics; and practical analysis of particular dilemmas in clinical practice. This last area in medical ethics is normally referred to as clinical ethics, and is in many respects the most important and vibrant part of medical ethics today. It lives through its intimate connection with clinical practice and medical and healthcare education, the ways in which suggestions made by practitioners of clinical ethics are rapidly tested in clinical reality, and the growth of a practical field of work in which ‘ethicists’ support patients, professionals and ethics committees in making good decisions in difficult circumstances.

For all this vibrant growth, there has been some unease with the way clinical ethics has developed. Healthcare professionals are sometimes baffled by the argumentative curlicues of the philosophers; patients and activists are often suspicious that all this ‘ethics’ is just a way of reinforcing existing professional attitudes and authority, and that ethicists are just as blind to patients' concerns as the medical professionals; and philosophers are generally infuriated by the apparent laziness and lack of rigour of their ‘applied’ colleagues.

Much writing and thinking in bioethics takes the form of a kind of Calvinesque speculative architecture. Our aim in this book and in the particular way in which it has been created has been to do something different. We wanted, in particular, to encourage the contributors to engage with one another and with the case to a degree unusual in bioethics practice. Behind this intention is something like a commitment to the idea that moral development, the growth of moral understanding and the emergence of moral practice in medicine (and in bioethics) can be facilitated by encouraging moral philosophers and health professionals to engage with one another in a focused and reasonably structured setting. More broadly it is to argue that conversation is a developmental fundamental of human experience (Parker 1995).