Bioethics

There can be no libertarian bioethics without libertarian ethics. Once a libertarian approach to ethics is identified, resolving questions in bioethics involves little more than applying those principles to the sphere of human interaction specific to medicine and scientific innovation. For this reason, we must first touch on libertarianism as it relates to general theories of ethics before moving on to ethical theory with specific reference to bioethical questions.

Like the pursuit of liberty, bioethical questions have existed since the dawn of civilization, but the term bioethics and its emergence as an academic and clinical discipline first occurred in the 1970s. Then as now, some of the more theoretical topics include defining illness, patients’ rights, medical professional integrity, human dignity, competency, research ethics, self-​ownership, medical resource allocation, and social responsibility.

All ethical theories, of course, are intended to provide practical guidance for human interaction. A complete theory of ethics must do two things. First, it must provide a framework of rules intended to ensure peaceable interaction within a community; this framing is the purview of theories of justice. Second, it must provide guidance for individuals who wish to become morally better people; this guidance is the purview of theories of personal morality. Libertarian theories of justice are well documented and do not need further explanation. Suffice it to say that, unlike many theories of justice, libertarian theories are procedural rather than prescriptive in nature. The libertarian principle of equal freedom is illustrative: “Everyone has the right to live their life as they choose as long as in so doing they do not violate another’s equal right to do the same.”

Unfortunately, little attention has been given to libertarian theories of personal morality, particularly not from the perspective of ethical theory. At the end of the 19th century, Herbert Spencer, in his book, The Principles of Ethics, tried to provide a scientific foundation for a libertarian ethics. However, since then, there has been no such comprehensive effort. Both Murray Rothbard in The Ethics of Liberty and H. Tristram Engelhardt, Jr. in The Foundations of Bioethics provide fundamental theories of justice, not comprehensive theories of ethics. Others, such as Tibor Machan in Generosity and Ayn Rand in The Virtue of Selfishness, focus on analyzing a particular moral principle and do not provide a theoretical foundation for an entire libertarian theory of personal morality, although Rand clearly thinks she does.

What, then, would the theoretical foundations of a libertarian personal morality look like? First, like libertarian theories of justice, liberty would have to occupy a place of paramount importance. Several well-​known ethical theorists, albeit not libertarians, make liberty central to their theories of personal morality. Aristotle, John Stuart Mill, and Immanuel Kant are among the most famous moral philosophers to stress that, without freedom, including the freedom to make mistakes, there can be no true moral conduct. Without choice, there is no morally blameworthy or praiseworthy actions, no good or bad conduct, no good or bad people. There is only more or less determined action, with little room for the intentional internalization of a moral code or personal moral growth. In addition, each of these great philosophers also stipulated what they believed that personal code should be.

Aristotle put forward a theory known as “virtue ethics.” In the Nicomachean Ethics, written as a practical guide for his son, Aristotle stressed both that human beings naturally strove to better themselves and that virtue was the path to moral goodness. Aristotle argued that the good person is one who intentionally chooses to make practical wisdom and virtue habitual. The virtues at issue were temperance, courage, pride, truthfulness, fairness, and friendliness, among others.

John Stuart Mill, the most famous proponent of utilitarian ethics, argued that actions should be judged as right or wrong based on how well they contributed to the aggregate good of society, usually expressed in terms of the maximization of happiness. As he contended in On Liberty: “I regard utility as the ultimate appeal on all ethical questions; but it must be utility in the largest sense, grounded on the permanent interest of man as a progressive being.…”

Immanuel Kant is known as the father of rationally based deontological theories of ethics. Most deontological or duty-​based systems of ethics are theological, but Kant’s Enlightenment version claims its foundation in reason. Kant held that ethics provided the laws of freedom, the way physics provided the laws of nature. “Nothing in the world—indeed nothing even beyond the world—can possibly be conceived which could be called ‘good’ without qualification except a good will.”

Kant proffered a rule, a categorical imperative, in which he argued that appeals should be made to common human reason: “Can I will that my maxim becomes a universal law?” This one simple sentence is the rational foundation of all moral conduct, Kant argued. Morally correct actions are conduct that one would find reasonable for everyone. The nonaggression axiom, embraced by libertarians, fits Kant’s categorical imperative perfectly. It is logical not to aggress against others because, were everyone to do so, there would be chaos. With the help of Kant’s categorical imperative and its corollary maxim of “respect for persons” as a precondition of liberty, an individual is set to cultivate a good will and become a better person. Although controversial, this assertion is all but self-​evident given the history and theoretical foundations of libertarianism.

Many argue that there is something fundamentally unlibertarian about the concept of the aggregate good, which is inherent in all utilitarian theories, from the utilitarian theory of Mill to the social contract theories of Rousseau and Rawls. Individual freedom is not something that should be tolerated (or extolled) because of its utility, nor is it something to be traded for a promise that basic material needs will be met. Liberty is important in and of itself, not simply as a means to an end. For many libertarians, individual freedom is of such paramount importance that, even if it could be proven that liberty did not further the general interests of society, they would not be willing to give it up.

One way out of this utilitarian dilemma is to root the primacy of liberty in an Aristotelian ethics or a Lockean notion of natural rights. Aristotelian ethics has rightfully been criticized as subjective and culture-​bound and can really only be redeemed by grounding it further in either natural law or reason.

Under natural rights theories, freedom is either a Godgiven right or an inherent aspect of human nature. The problem with this type of theory is that some libertarians do not believe in God or God-​given rights, and others have misgivings about the scope of natural rights. Who is to say what qualifies as a natural right and on what grounds? Perhaps the answer lies in what is reasonable. If that is the case, then we need not rely on natural rights at all—and can simply make reason the foundation of liberty. We are thus brought back to the Enlightenment notion that reason can lead to right action in the same way that it can lead to a just system of government.

One theory that grounds liberty in reason was put forth by Kant in his book, Foundations of the Metaphysics of Morals. Libertarians who embrace this approach argue that rational beings do not want others interfering in their decision making, either public or private, economic or moral. In short, respect for others necessitates the primacy of liberty. Once it is clear that liberty is a necessary precondition of any libertarian theory of ethics and that reason is the only sufficient guide for libertarian moral conduct, it becomes all but self-​evident what a libertarian theory of bioethics would look like.

Not uniquely libertarian, but important to any theoretical discussion of bioethics, are the four fundamental principles of bioethics described by Tom Beauchamp and James Childress in Principles of Biomedical Ethics, first published in 1979. These principles are respect for autonomy, nonmaleficence, beneficence, and justice. Beauchamp and Childress argue that it is the balancing and prioritizing of these four principles that is at the heart of bioethics.

Three other important concepts that touch on ethics as it relates to medical questions are paternalism, human dignity, and informed consent. Paternalism has reference to the principle at work when, in a conflict between beneficence and autonomy, beneficence takes precedence. From a libertarian perspective, paternalism is ethically suspect unless there is definitive proof that a person is mentally compromised. Unfortunately, the phrase human dignity in many bioethics discussions does not include respect for autonomy, but rather implies the imposition of one group of individuals’ values on others. Finally, informed consent is a concept essential to autonomous decision making. It requires that a person be mentally competent, that he gives consent and does so voluntarily, and that he comprehend what is being decided. To help ensure comprehension, the person must have received a legally determined minimum amount of information necessary to make a well-​reasoned decision and must be given an opportunity to request additional information. Finally, the information provided must be directed to the questions asked and do so accurately.

It should not be surprising that “respect for autonomy” and “informed consent” play crucial roles in a libertarian theory of bioethics. The other principles are generally only relevant to libertarian bioethics insofar as they relate to autonomous consent.

Consider how a libertarian theory of ethics would resolve a current-​day bioethical dilemma. Is it ethical to let people sell their organs? The sale of organs is currently illegal in the United States, in part because legislators were swayed by concerns that the commodification of body parts is an affront to human dignity. The libertarian approach to this problem emphasizes that competent adults can make their own determinations as to what is an affront to their dignity and that they have the right to enter informed voluntary agreements for the sale of body parts if they so choose. In a libertarian society, the law should be concerned that such agreements are voluntary, that no fraud or deception is involved, and that, once legally entered into, contracts are upheld. But unlike current law, such arrangements would be legal.

A libertarian might well recognize the rights protected by law, but nevertheless suggest that certain motives for entering such arrangements are more or less praiseworthy and that certain conduct is more or less required by the imperative of respect for others. Value judgments are inherent to personal moral theory. Consider the moral status of the following motives: the gift of an organ simply to save a life, the sale of an organ to benefit the donor’s children, the sale of an organ to rectify some wrong committed by the donor (e.g., to repair a borrowed car that was destroyed), and the sale of an organ to purchase something the donor desires. Libertarians would argue that all of these motives should be equally legal, but are not necessarily equally praiseworthy. In descending order, from the first to the last, they reflect a diminution of moral self-​awareness, good will, virtue, and/​or respect for persons.

Prescriptions for conduct also are inherent to personal moral theory. Consider the following questions: Would it be appropriate for an organ recipient, realizing that the donor is in great financial need, to offer barely more than the donor’s cost associated with the donation? In other words, would it be moral to take advantage of a donor’s weak economic bargaining position? Conversely, assuming a scarcity of organs available for transplantation, should the donor set a price so high that the recipient ends up alive but destitute? In other words, is it moral to exploit the recipient’s desperate situation? Should organ recipients pay contractually unanticipated transplant-​related expenses incurred by donors? Finally, should organ donors notify recipients if sometime after the transplant they develop an illness that may affect the ultimate success of the transplant even if not obligated by law or contract to do so? Arguably, the application of the categorical imperative and the principle of respect for persons would necessitate answering the first two sets of questions in the negative and the latter two in the affirmative.

A libertarian system of justice would not obligate the actors in any of these scenarios in one way or another. However, a libertarian theory of personal morality would provide both a means of judging the morality of conduct and prescriptions for being moral.

Further Readings

Aristotle. Nicomachean Ethics. Introduction to Aristotle. Richard McKeon, ed. New York: Random House, 1947.

Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. 3rd ed. New York: Oxford University Press, 1989.

Engelhardt, H. Tristram, Jr. The Foundations of Bioethics. New York: Oxford University Press, 1986.

Kant, Immanuel. Foundations of the Metaphysics of Morals and What Is Enlightenment? Lewis White Beck, trans. Indianapolis, IN: Bobbs-​Merrill Educational Publishing, 1981.

Machan, Tibor R. Generosity: Virtue in Civil Society. Washington, DC: Cato Institute, 1998.

———. Individuals and Their Rights, a Primer on Ethics. Chicago: Open Court Publishing, 1989.

Mill, John Stuart. On Liberty. New York: W. W. Norton, 1975.