Review of

Playing God? Human Genetic Engineering and

the Rationalization of Public Bioethical Debate

BY JOHN H. EVANS

Introduction by John Berkman

In January 2003, at the Society of Christian Ethics (SCE) meeting in Pitts­burgh, Pennsylvania, a panel consisting of Stanley Hauerwas, Jeffrey Stout, Gilbert Meilaender, and James Childress was convened to discuss a recent book by John H. Evans. Playing God?, a revision of Evans's doctoral dissertation, was published by the University of Chicago Press in late 2001. Evans, an assistant professor of sociology at the University of California, San Diego, was also pres­ent to respond to the panel.

Evans's book is worthy of reflection by members of the SCE for many rea­sons, not least of which is that it is a rare example of a true "outsider" to the so­ciety (a sociologist, no less) choosing to write a book about an American public policy debate in which past and present members of the SCE have played sig­nificant roles. Evans's book is especially welcome; for in his drama, theological ethicists are not merely buffoons and sideline attractions, but rather rise to the level of authentic heroes and villains.

The focus of Evans's book is the evolving debate over genetic engineering and related biomedical questions, but the book is also a commentary on the evolution of different conceptions of moral discourse in the public realm over the past forty years. Evans analyzes the form of moral discourse in terms of its relative "thickness" or "thinness," its propensity to be "substantively rational" or "formally rational," whether it is almost exclusively "means-oriented" or also "ends-oriented," and so forth. With regard to the issue of genetic engineering, Evans's work focuses on the language of morality that functions on presidential and other government commissions addressing bioethical matters.

Since Evans addresses the possibility of theological voices participating in public debates, and specifically looks at this possibility in the context of Ameri­can bioethical commissions, panelists whose work is well-known in one or both of these areas were invited to respond to Evans's book. Hauerwas and Stout are well-known commentators on the possibility and desirability of distinctively

Journal of the Society of Christian Ethics, 24,1 (2004): 183-217

184 · Stanley Hauerwas

theological voices speaking in the American public square. Meilaender and Childress are well-known for their work in biomedical ethics and share the distinction of being invited to serve on a presidential bioethics commission (Childress under President Clinton and Meilaender under President George W. Bush).

On the day the panel was convened, the four respondents gave short presen­tations and Evans responded, and this was followed by general discussion and questions from the floor. After the session, all four panelists agreed to write up and submit their responses to the jfSCE, and those formal responses are pre­sented here. Evans was given copies of the responses, and his formal reply to the respondents appears at the end of this piece.

While valuable and important in their own right, the formal responses pub­lished here do not entirely capture the drama and humor of the day. Evans's book elicited not only appreciation, but also passion, sharp criticism, and hu­morous responses. Our guild is not used to an outsider examining our work in terms of its empirically verifiable "influence," or making generalizations based on empirically dominant perspectives. Evans approaches our work in ways akin to the stereotypical anthropologist. He seeks to discover what we, the "natives," are up to. The goal, however, is not to understand all the perspectives, but to as­certain which are influential, at least in relation to other authors in the field. This led to a rather humorous moment, when Evans informed our distin­guished panelists that, while all of them showed up in his data set, only one of them "made the cut." For purposes of publishing responses, however, all of our panelists easily made the cut. Enjoy.

Comments by Stanley Hauerwas

Reading Dr. Evans's very informative book reminded me of Mr. Gustafson's de­scription of a sociologist: "A sociologist is someone who takes $50,000 of foun­dation money to find out where the local whorehouse is when for $10 he could have asked any cab driver." Such a comment is not really fair to John Evans's fine book, but I make it nonetheless to confess that I somehow knew the story he tells before I read it. I found the story quite revealing, but I suppose I think most of us who have been engaged in issues now described as "bioethical" for the last thirty years were aware that the theological voice increasingly became muted. Dr. Ev­ans may or may not have shown he can provide empirical confirmation of the loss of the theological voice, but (as I will suggest below) it is not clear to me if his "empirical evidence" is more compelling than what we already knew.

The only qualification I might have to make to the story that Dr. Evans tells is that the muting of the theological voice was not the result of the rise of bioethics as a field. Rather, the theological voice had long learned to police itself

Book Review · 185

in the interests of being a player in democratic public policy issues. Paul Ramsey, of blessed memory, was not entirely free from that process. Evans quotes Steve Long's characterization of Ramsey's emphasis on consent as the crucial criteria for determining the Tightness or wrongness of experimentation. Long observes that Ramsey focused on consent because he "sought to find a language accessible to as many people as possible despite their theological convictions, and 'consent' appeared to cross over communities and traditions" (65). But Evans nonetheless makes Ramsey the theological hero of his book for maintaining a substantive ethic against the increasing proceduralism of the bioethicists.

Long, I suspect, would think his characterization of Ramsey in this quota­tion, as isolated from his richer account of Ramsey, could give the wrong im­pression. The quotation suggests that Ramsey was looking for a way to translate his substantive theological commitments into concepts that would be more widely accepted. Yet Ramsey did not think he was translating: he was trying to articulate the fundamental commitments Christians had made to Western civi­lization. For Ramsey, covenant named the moral resources found in the funda­mental institutions of Western civilization that were the result of Christian in­fluence. Accordingly, Ramsey thought any qualification or abandonment of the respect due to each of God's creatures risked leaving us morally at sea.

I quite agree that Ramsey was heroic in his interventions concerning human genetic engineering experimentation, but I think the very way Ramsey ap­proached these issues presents a problem for Dr. Evans's account. Evans quite rightly notes that after the rise of bioethics, teleological questions tended to be bracketed. But Ramsey also had a problem providing an account of teleological reasoning. Ramsey, I suspect, thought utilitarianism was so institutionalized into our habits of thought that any attempt to raise issues of ends would have results he wanted to keep at bay. I think his stress on questions of discrimination in just war reflects this tendency in his thought. I have nothing but admiration for Paul Ramsey's commitment to shaping public policy, but I think some of the problems Evans attributes to the rise of bioethics were present in Ramsey's work.

I should also like to raise a question about Evans's understanding of the rise of bioethics. If I understand Evans aright, he is at least suggesting that some philos­ophers and theologians became bioethicists because a commission was estab­lished that needed such a beast. He notes: "[F]irst came government advisory commissions, which needed a formally rational type of argumentation, and the overlapping consensus model, which is a close relative of formal rationality" (175), and then came the bioethicist. The latter, moreover, become shills for the scientists who want to avoid democratic debates in favor of commissions that are then used to educate the public to accept the scientists' understanding of why this or that form of experimentation is a very good thing. At least it was a very good thing for the scientist who wanted to do such experimentation. As a result,

186 · Stanley Hauerwas

bioethicists become experts who can then rule substantive considerations out of order because anyone raising substantive considerations must be a theologian and theology cannot be part of the public discussion.

John Fletcher and Al Jonsen seem to be the main two characters represent­ing bioethics in Evans's account. I suppose Childress and Beauchamp are also cast in the paradigmatic role of villains. Since I am a theologian, I have some sympathy with Evans's account of this development. But I think I should at least note that I did testify before the Ethics Advisory Board of the Department of Health, Education, and Welfare sometime in the 1980s on in vitro fertiliza­tion. In my testimony (which as a student of Ramsey's dictum "Never waste a word" I published in Suffering Presence), I raised some of the issues about the policing effect public policy has on genuine exploration of differences.1 I then proceeded to make a theological argument about how and why Christians think children should be welcomed into the world that I thought made in vitro fertilization quite problematic. I do not think anything I said made its way into the advisory board's report, but it is at least an instance when theology was not disqualified.

However, my concern about how Fletcher, Jonsen, Childress, and Beau-champ are narrated by Evans is not about the role he thinks they have played in making bioethics a field; my aim, rather, is to raise a question about his method. I simply find myself unpersuaded by Evans's attempt to be empirical by catego­rizing and clustering influential authors. Surely something has gone wrong when Jeremy Rifkin is identified as a theologian (156). Which leads me to sug­gest that it might have been useful if Evans had thought to interview Fletcher and Jonsen to get their understanding of what they thought they were doing when and if they became bioethicists rather than theologians. After such inter­views Evans may well think his story holds up; but I think it never does any harm to ask.

This finally brings me to what I regard is Evans's most important concern, that is, whether formal modes of rationality are the inevitable product of mod­ernization. He, of course, wants to argue against Weber that thin accounts of rationality are not inevitable in modernity. He may be right, but I am not sure how one might find out one way or the other. I did find it curious, however, that Evans did not make use of Alasdair Maclntyre's account in After Virtue of the rise of the "expert" in modernity.2 Maclntyre quite rightly reminds us that the distinction between "facts" and "values" is not an epistemological necessity, but is rather a necessary fiction to underwrite the authority of the scientist. Of course, if Evans had used Maclntyre to sustain his account, he would have had to raise questions about his own concerns with empirical verification.

In his conclusion, Evans quotes Habermas 's observation that the problem of modern society is the "colonization" of the life-world of the state and the

Book Review · 187

market, in which substantive rational discourse is replaced by formal and proce­dural considerations (182). Evans notes that Habermas was not conducting em­pirical research, and thus that much needs to be explained about how such a process works. I assume that Evans thinks his book provides the kind of work he believes is necessary to explain Habermas-like observations. I think he has been successful, but not because he has supplied the necessary empirical confirma­tion. Rather, he has told a story that many of us have lived. That is no small achievement.

Comments by Jeffrey Stout

John Evans claims that the debate over human genetic engineering has become disturbingly thin. His account of this in Playing God? has two parts: a narrative of events and a sociological explanation of those events. Neither of these strikes me as entirely satisfactory, so I will try to recast them a bit. But it is because I think Evans has his finger on something important that I want to get the details right.

The narrative seems to imply that there was one thing—"the debate"—that changed over time. But it is not clear that "the debate" remains defined in the same way throughout the analysis. Evans starts out referring to the debate in a very general way. Anyone qualifies as a participant in it insofar as he or she ad­dresses the topic of human genetic engineering and reaches a public audience. But once the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research begins meeting in the early 1980s, Evans narrows his focus considerably to concentrate on what is said in and immediately around the commission. Narrowing the focus in this way en­tails, for example, that Stanley Hauerwas's critique of bioethics receives no at­tention in this book.

So perhaps Evans isn't (or shouldn't be) trying to explain why a single thing called "the debate" became thinned out. His database actually sheds light on something more specific: the forms of discourse that are produced in and around legislatures and commissions of certain kinds. It is plausible to suppose that the broader debate continued in the background culture even after the President's Commission began to have an impact. That this broader debate did not become completely thinned out is clear from the case of Jeremy Rifkin, whom Evans discusses briefly. But Hauerwas could be used to make the same point, and so could Gilbert Meilaender.

It is true, however, that the range of voices and considerations likely to have direct influence on policy decreased drastically when the political struggle over human genetic engineering (HGE) shifted from a legislative context to the commission. This is the real nub of Evans's story—the thing that actually

188 · Jeffrey Stout

requires explanation. How, then, does Evans propose to explain this important development? His answer draws on the Weberian notion of rationalization.

Classical Weberians had a large-scale story to tell about the "process of ratio­nalization" in modernity. Evans is aware, however, that such a story is hard to square with the facts. He therefore follows Weberian revisionists who see ratio­nalization as a much more delimited affair, to be explained by features of specific institutions and groups rather than by a teleological conception of modernity.

The details relevant to HGE mainly have to do with competition for author­ity among professional groups and with the creation of a commission to study the issue. According to Evans, the debate over HGE became "rationalized" as a result of these factors. Bioethics rapidly found its niche as the profession autho­rized to adjudicate conflict within the newly rationalized discursive framework. Theologians found their voices ignored unless they were prepared to adopt this framework, to speak the thinned-out language of bioethics.

I have no doubt that this more delimited sort of explanation is more promis­ing than Weber's large-scale story about modernity. But I suspect that Evans remains too indebted to Weber in his understanding of rationalization. A de­bate is thin, for Evans, to the extent that it is carried out in formal, as opposed to substantive, terms. A debate is carried out in substantive terms if it pays atten­tion to questions concerning ends. A debate is formal insofar as it takes ends for granted and focuses instead on questions about the instrumental advantages and disadvantages of possible means toward those ends. A debate largely about the ends to be pursued in some domain of society is termed "substantively rational." A debate exclusively confined to the selection of efficient means for the achieve­ment of taken-for-granted ends is termed "instrumentally rational."

Thus, the metaphor of "thinning out" is explicated as a process in which sub­stantive rationality gives way to instrumental rationality. The trouble is that this way of thinking about rationalization creates confusion. It conflates three dis­tinctions that are not equivalent: thin and thick, formal and substantive, means-oriented and ends-oriented.

The President's Commission did foster formal discourse in one sense, be­cause it aspired to state its policy recommendations explicitly as rules or princi­ples for the conduct of future research. Reasoning about cases in terms of such rules is a formal affair. Explicitly stated rules allow us to formulate practical ar­guments that can be judged as formally valid or invalid—where formal validity means that if the premises of the argument are correct, the conclusion is also correct. When running an institution, it is often wise to adopt rules so as to fos­ter relatively transparent formal reasoning of this sort. No rules, no policy. Policymaking begets formal reasoning.

The notion of formal inference I have just introduced is not defined in rela­tion to the distinction between reasoning focused solely on the selection of

Book Review · 189

means and reasoning that includes reflection on the acceptability of ends. What means one should adopt and what ends one should have are both substantive questions. And the reasoning one engages in concerning either of these questions can be either formal or material, depending on the degree of explicitness one is looking for.

To see what I am driving at, consider Evans's account of Paul Ramsey and Joseph Fletcher. He treats Ramsey's contributions to the debate as examples of substantive rationality and Fletcher's contributions as examples of formal ratio­nality. Ramsey had argued, against Fletcher, that some means are absolutely unacceptable in principle. He proposed rules to place constraints on the selec­tion of means. Ramsey's reasoning was every bit as formal as Fletcher's was. They disagreed mainly about whether the rules should take the form of deonto-logical side-constraints or consequentialist rules of thumb.

To make Ramsey's way of talking fit into his Weberian story about increas­ing rationalization, Evans translates Ramsey's means-oriented point into a point about the acceptability of ends. This is ironic, given Evans's displeasure with the similar process of translation practiced by the commission.

It is a mistake to identify rationalization with instrumental reasoning. The bureaucratic settings that Weber associated with rationalization are often pre­occupied with the adjudication of rights-claims—that is, with explicitly formu­lated side-constraints intended to establish limits for instrumental reasoning. And the report of the President's Commission does not, in any event, appear to exclude deontological considerations from its reasoning. Deontological and in­strumental forms of ethical reasoning are both formalistic, and both have been defended in theological as well as in secular terms.

I have said that the real issue Evans identifies is that once the commission was created, theological and other comprehensive considerations were squeezed out of the discussion most directly affecting policy. Why were they squeezed out? Not because they pertained to ends, and not because they were inherently infor­mal or substantive. They were squeezed out because they were controversial. If the commission was going to achieve consensus on a single set of policy recom­mendations and justify those recommendations in a single voice, neither the rec­ommendations nor the arguments for them could take highly controversial pre­mises for granted. Theological premises are highly controversial.

That the commission was charged to produce a consensus report was crucial. A commission with a different charge might have had different effects. A com­mission charged with giving expression to the full range of public opinion, and explicitly cautioned against boiling down arguments into a common vocabu­lary, would have behaved differently. If commissioners had been encouraged to submit minority reports instead of feeling bound to reach consensus, they would have been less inclined to ignore or play down theological arguments.

190 · Jeffrey Stout

The resulting debate would indeed have been thicker, simply in the sense of providing fuller expression to a wider range of outlooks. And that would have been a good thing for democracy as well as for theology.

There is a stiff price to be paid, however, whenever poUcymaking is trans­ferred from the legislature to a body of experts. Some sorts of commissions are more likely than others to be responsive to the full range of comprehensive views held by the citizens of a modern democracy. But panels of experts are not representative in the way that legislatures are. That is why they are attractive to political leaders who want to insulate policymaking from the vicissitudes of freewheeling democratic debate.

As Oliver O'Donovan has pointed out, what makes modern democracies dis­tinctive in institutional terms is the expectation that rulers should be responsive to representative legislatures. A legislature is essentially unlike a feudal council, which serves at the ruler's pleasure. A representative congress or parliament de­liberates "in response to a wider context of deliberation, open to all, to which it must be attending carefully."3

The influence of big money and corporate power over the electoral process has, of course, rendered legislatures less representative than a democratic public would want them to be. A full-scale democratic critique of our institutions would not merely cast suspicion on commissions; it would also seek to enhance the representative function of legislatures, not least by fostering campaign-fi­nance reform. Even in their currently deformed condition, however, legisla­tures tend to be more representative than commissions. Otherwise, commis­sions would not be so attractive to the politicians who create them.

Many of today's commissions are the modern, bureaucratic equivalent of feudal councils, with professionals in place of noblemen. Their actual effect— and often their intended purpose—is to insulate policymaking from a wider context of public deliberation in which everyone feels free to express their com­prehensive views in full. Nowadays, when rulers do not want freewheeling dem­ocratic discussion to take its course, they appoint a commission. Those who care about democracy therefore have every reason to look on government com­missions with suspicion, regardless of the good will of those who serve on them and regardless of what they eventually say.

My hope is that Evans's book will lead to fresh critical thinking not only about the antidemocratic function of such commissions, but also about the roles that bioethicists, medical ethicists, and ethicists in general are increasingly be­ing asked to play by governments, courts, hospitals, universities, and the press. What sort of expertise or authority is one claiming to have when one accepts these roles? Who is supposed to defer to the ethicist's findings and for what rea­sons? What sort of society are we becoming complicit in when we encourage our fellow citizens to defer to our alleged expertise? It would seem to be a soci­ety in which the new professional class exercises authority over the people. It

Book Review · 191

would seem to be a society in the process of undermining its democratic habits and institutions.

Comments by Gilbert Meilaender

If we place the origins of bioethics in this country somewhere in the 1960s, it should not surprise us that the last decade has seen the beginning of efforts to take stock of its emergence and gradual maturation. Probably the two most well-known book-length attempts to do this are David Rothman's Strangers at the Bedside (1991) and Albert Jonsen's The Birth of Bioethics (1998).4 Alongside these books we must now place John Evans's Playing God?, and it is a worthy ad­dition and competitor.

It may be useful, first, simply to summarize the organization of the book's chapters, for the storyline of the work is carefully plotted. Chapter 1 outlines and explains Evans's method of analysis. Chapter 7 offers his concluding reflec­tions and suggestions. That leaves five chapters in between, of which chapter 4 is not just the midpoint but the centerpiece. It discusses in detail Splicing Life, the 1983 report on human germline genetic engineering (HGE) produced by the President's Commission.5 (This chapter draws on archival research in tran­scripts of commission deliberations and on oral interviews with many of the central participants. Nor should one ignore the extensive and informative foot­notes to the chapter.) Chapters 2 and 3 chart developments in the periods that led up to the report (1959-74 and 1975-84). Chapters 5 and 6 trace the juris­dictional competition among professions in the periods following the report (1985-91 and 1992-95). It captures the gist of Evans's narrative—though by no means does justice to its interest and complexity—to say that his storyline be­gins at a time when public debate about HGE focused on what ends or goals it was appropriate to pursue and concludes at a time when a few ends were largely assumed and debate focused on what means would best serve to attain those ends. Debate that focuses on ends cannot easily work by calculation, since it is hard to find the scale on which ends can be weighed. Hence, if our aim is to achieve some kind of public policy consensus or recommendation, we are likely to prefer to assume the acceptability of a few ends and, then, confine our debate largely to questions of means. "Substantive" rationality, in Evans's account, considers ends and means together; a means may be rejected not because it is inefficient but because the end it serves is judged unworthy or immoral. "For­mal" rationality seeks to calculate the most effective means to some already as­sumed and accepted end. Thus, we can also describe Evans's storyline as a movement from substantive to formal rationality in bioethics.

Even so basic a description of Evans's thesis allows us to place his telling of this story in relation to earlier ones by Jonsen and Rothman. Jonsen's book

192 · Gilbert Meilaender

contains a wealth of detail (though the reader must accept a quirky tendency to tell the story of bioethics as, in part, the story of the author's life). Whereas for Jonsen the rise of public bioethics in the form of national commissions and eth­ics committees is largely a narrative of progress, for Rothman and now for Ev­ans the picture is much more mixed. For Rothman the transition from bedside ethics to bioethics—as doctors were nudged from the bedside and replaced by "strangers" such as bioethicists—was a very mixed blessing indeed, as "one more aspect of modern life has become contractual, prescribed, and uniform."6

Evans also narrates a transition, but a different one. He examines the nudg­ing aside not of doctors but of theologians. His is a sociological account of pro­fessions competing in an environment for jurisdiction. By focusing in particular on human germline genetic engineering and the course of debate about it in the United States, he weaves his narrative of a movement from "thick" to "thin" re­flection in the gradually developing profession of bioethics. His story is in many respects one of a rise and fall, of a "diinning out" of bioethical discourse. Just as science advances to a point where "the public needs to make crucial decisions about whether our society should engage in various types of HGE, the structure of the debate among the professionals has been eviscerated" (4). (Although I have considerable sympathy for Evans's account, his focus on HGE may lead him to overstate somewhat the "thinness" of bioethics. Surely in one area— namely, research on human subjects, at least when those subjects have com­pleted the process of gestation and birth—the developing discipline of bioethics has not always been the abject servant of research interests. Quite the contrary, in fact.)

Evans is certainly not the first or the only one to note the thinning of bioethics. What gives his book its special character, however, is the depth of its sociological analysis (with his theory of professions competing for jurisdiction) and its critique of competing explanations. Some have tried to account for this development by means of an "expanding democracy" explanation. That is, an increasingly pluralistic society found it necessary, so the argument goes, to make use of government commissions committed to seeking overlapping con­sensus (which is necessarily "thin"). Evans argues quite convincingly that the order of events was actually the reverse. First came the decision—for strategic reasons aimed at preserving research from public oversight—to locate the HGE debate in advisory commissions. Then, when these bodies committed themselves to formal rather than substantive modes of argument, the nature of bioethics discourse changed. (Evans's critique of this explanation is, in effect, a direct refutation of Jonsen's account of the rise of bioethics.) Others explain the rise of a thin bioethics by appeal to a macrohistorical process, as if a turn to for­mal reasoning were an inevitable result of modernization. Here again, Evans's entire narrative is designed to demonstrate that there was nothing necessary or inevitable about the transformation.

Book Review · 193

His account begins at a time when HGE was little more than a gleam in the eye of some eugenicists, who were quite willing to argue in substantively ratio­nal fashion that HGE would serve desirable ends such as reducing the genetic load or, more important, providing a new quasireligious vision of the meaning of human life in a world from which God was thought to be absent. The chal­lenge to this eugenic vision came in large measure from theologians, who by training and inclination were prepared to debate ends, to argue about what would or would not constitute a good human life and praiseworthy social aims. (Evans's categories are sometimes stretched a bit—as when, for instance, in the early years he places Leon Kass within the "theological community." This works only if we mean by this a community of those interested in broader, metaphysical questions about ends.) Moreover, in these initial decades of bio­ethical argument, it was the theologians who were more in step with public sen­timent. And, after all, since substantively rational argument considers the ends of human life generally, there would seem to be every reason to take public sen­timent seriously.

Precisely that, Evans argues, was what the scientists feared. To avoid the es­tablishment of regulatory commissions that might actually place limits on the means deemed acceptable for work in HGE, the scientists suggested the cre­ation of advisory commissions. Thus, the birth of the bioethics profession with the establishment (in 1973) of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, far from being a promising achievement, was a device to keep science free of public regulation. Through the commission, the public's concern would be represented by being mediated through the variety of professions competing for jurisdiction with the scientists. Three principles—respect for persons, beneficence, and justice—es­tablished the ends to be promoted. What remained—what became the work of the new bioethics profession—was discourse in search of consensus about how best to attain those ends. Moreover, what had begun as a method for thinking about moral issues in experimentation soon ballooned into the basic mode of deliberation in bioethics generally.

The deliberate shift from substantive to formal rationality became apparent in the Asilomar controversy, which is still often depicted as a paradigm of wise self-governance by the scientific community. Early attempts to splice and re-combine DNA in ways that crossed species lines raised questions about possible safety hazards. Lest the public become aware of such biohazards and assert its right to control scientific research, scientists sought to limit argument to means, not ends. That is, they wanted the argument to focus solely on questions of safety and not on "contested jurisdictional arenas, such as whether DNA should be moved between species at all. . . . That is, the scientists tried hard to make this a debate about the efficacy of means for forwarding set ends, not a substantively rational debate about ends themselves" (96-97). By narrowing the

194 · Gilbert Meilaender

debate in this manner, advocates of research confined it to a realm in which sci­entists clearly had jurisdiction. In the light of Evans's sociological analysis, therefore, Asilomar becomes not a triumph of scientific self-governance but a political victory for scientific researchers in a battle of competing jurisdictions. (I note in passing that Evans's case is powerfully argued here and ought to invite more thoughtful and less self-congratulatory invocations of Asilomar in bio­ethical discourse.)

The second important national bioethics commission, the President's Com­mission for the Study of Ethical Problems in Medicine and Biomedical and Be­havioral Research, had a broader mandate than the first, as its name—which did not confine its attention to the ethics of research—made clear. In 1980, after the Supreme Court's Chakrabarty decision permitting the patenting of geneti­cally engineered life-forms, a broad array of religious leaders wrote President Carter expressing apprehension about emerging genetic technologies. Their concerns were wide-ranging, exemplifying a willingness to speak in substan­tively rational, and not merely formally rational, terms. They asked for greater public oversight of HGE research, oversight that would resist any temptation to "play God." The president, in turn, requested a report from the President's Commission, which (after several years' work) produced Splicing Life, "which was essentially a repudiation of the way the religious leaders had described the problems" (101).

Evans characterizes this report as the "fulcrum" of the HGE debate, and he devotes the whole of chapter 4 to unraveling the process by which the report was produced. This is a fascinating and instructive chapter. Its depth and com­plexity resist summary here, but for anyone interested in thinking about how bioethical reflection can best serve our society, it is essential reading. Several commitments and decisions made by the commissioners (and their influential staff) determined the ultimate character of the report. They were determined that research must be permitted to move forward. And they aimed to produce among themselves consensus (as opposed, for example, to compromise). This necessitated a thinning out of the ends sought, a focus on formal rather than substantive modes of reasoning. "In sum," Evans writes, "the commission served as a buffer between the concerns of the citizens and the scientists, reduc­ing the threat to the scientists' jurisdiction and advancing the jurisdiction of the bioethicists" (102). In order to win their jurisdictional competition with the theologians and thereby avoid impediments to research, scientists ceded some jurisdictional ground to the newly emerging profession of bioethics (which seemed quite prepared to support the cause of advancing science).

In a very interesting concluding chapter, Evans suggests that we might be better served if we were to have both "ends commissions" and "means to ends commissions" (the one to engage in substantively rational deliberation, the other in formally rational deliberation). He argues that we should "be very

Book Review · 195

cautious about having government advisory commissions—or any organization distant from democratic legitimation—orchestrate a deliberation over ends" (201). The irony of his suggestion is that—as Evans himself fully understands— "we already have the equivalent of ends commissions, called legislatures" (203). They ought not, he suggests, yield ground to government advisory commis­sions. It follows, of course, that rather than criticizing interest-group politics and the compromise it entails, we should prefer it—at least in bioethics—to a search for consensus within advisory commissions. We should not want our elected representatives to be replaced by unelected government commissions. Rather, we should want them to argue about the sort of questions that involve the very meaning of our humanity. Moreover, it is when they do so that the concerns of religious believers are most likely to find their way into the debate.

We must grant, of course, that elected representatives are often all too eager not to take up such questions. They prefer to toss hot-button issues into the lap of an appointed commission, and, of course, when they do themselves take up such issues, they may not always do it wisely or well. That, however, is simply the nature of democratic discourse, and it still provides the best avenue for con­cerns of religious believers to have an impact on public debate and decision.

If we expect there to be such debate—and probably some compromise as a result—we will not think it necessary, or even perhaps desirable, that advisory commissions reach consensus recommendations. They may serve us best when they are not expected to reach consensus, when they are free to play out the ar­guments, free not to forge a lowest-common-denominator recommendation that will inevitably bracket the deepest concerns of religious believers (and some others as well). I take it that, from Evans's perspective, such a role for ad­visory commissions would be a desirable next chapter in the story he has told.

Comments by James F. Childress

Playing God offers a very important and illuminating interpretation and critique of public bioethics, despite some conceptual, methodological, and analytic flaws. In this critical response, I will focus on three major themes: Evans's crite­ria for bioethics/bioethicists, his interpretation and critique of principlism, and his understanding of public bioethics, specifically the role and function of bioethics commissions.

Bioethics and Bioethicists

Evans argues that debates about human genetic engineering (HGE) and a num­ber of other bioethical issues are now generally "thin" (formally rational) rather than "thick" (substantively rational) in that they calculate effective and efficient

196 · James F. Childress

means to assumed ends that are few in number and are considered commensu­rable and universal. This shift from substantive rationality to formal rationality in bioethical debates resulted from the competition of professions, not from democratic pluralism or a process of modernization. More specifically, it re­sulted from the emergence and increasing power of the profession of bioethics in the struggle for jurisdiction over the definition of the ethics of HGE. The profession of bioethics, with its distinctive mode of argumentation (princi-plism), benefited in this competition from the removal of bioethical debate from the public and legislative realm and its reassignment to the state bureau­cracy operating through government advisory commissions, a relocation that was supported by scientists seeking to protect their freedom. In this process, the bioethics profession displaced the theological community as a primary influ­ence on public bioethics.

This interesting thesis hinges, in part, on Evans's criteria for identifying bioethicists and distinguishing them from others who may also engage in bioethics. In popular parlance, people who participate in bioethical debates are often called "bioethicists," but Evans restricts the term "bioethicist" to those who are members of the "bioethics profession." However, even though the field of bioethics is flourishing, it is not clear to many that bioethics is, or even should be, a profession. Unfortunately, Evans's implicit and explicit criteria for identifying bioethicists are problematic in part because a person doing bioethics may satisfy one but not another, thereby complicating Evans's classification and argument.

At least three criteria play some role in Evans's discussion. First, being a bioethicist may be a matter of self-designation or self-identification—someone may simply claim, "I am a bioethicist." At one point Evans writes about those "who called themselves bioethicists—rather than theologians, philosophers, or members of any other existing profession" (35). However, this first criterion is not as significant in his analysis as the other two criteria.

Second, Evens holds that "'bioethicists' are those authors whose primary identification [also called primary academic appointment] is with a 'bioethics' or 'medical ethics' department or center, whether within a medical school or out­side it" (211, emphasis added). He points to John C. Fletcher as a prime exam­ple because of Fletcher's pivotal role in the debate about human genetic engi­neering. Using this second criterion, Evans can say that Fletcher moved from being a theology professional to a bioethics professional when he moved to the National Institutes of Health and subsequently to the University of Virginia. However, the limitations of this criterion are evident when we observe that, in fact, Fletcher's appointment to the faculty of the University of Virginia in the late 1980s was evenly split between the Department of Religious Studies in the College of Arts and Sciences and the School of Medicine, where he established the new Center for Biomedical Ethics.

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Or, to speak personally, I write in the field of bioethics, but do not consider myself to be a bioethicist. And my primary academic appointment is in the De­partment of Religious Studies, rather than in a bioethics or medical ethics de­partment or center. So I do not satisfy either of Evans's first two criteria. And yet Evans views Pnnciples of Biomedical Ethics? which I coauthored with Tom Beauchamp (whose primary academic appointment is in a department of phi­losophy), as a crucial text for his interpretation of bioethicists' mode of argu­mentation. As it turns out, then, "primary identification" with "a 'bioethics' or 'medical ethics' department or center" may not be as clear-cut, helpful, or in­clusive as Evans supposes. It may reflect historical accidents, such as available opportunities or sources of funding.

But Evans also has a third criterion: "the only professionals considered to be bioethicists are those who use the profession's form of argumentation" (35). This criterion reflects an interpretation of profession that differs from ordinary discourse, which tends to focus on a special educational degree or organization. And it is also in tension with the first two criteria. According to Evans, we should define a profession "by the abstract knowledge that it uses in its work" (29). By this criterion, people are bioethicists based on their mode of argumen­tation, whatever their self-designation or affiliation. Evans claims that his "em­pirical research finds that those whom [he identifies] as bioethicists do use a dif­ferent form of argumentation than the members of other professions. In short, members of other professions participate in public bioethical debate, but they are not bioethicists unless they use the system of argumentation of the bioethics profession" (35). According to Evans, some people who called themselves bioethicists "created a distinct form of argumentation for this [public bioethical debate]. In so doing they also created a profession, making distinctly different arguments than other professions did" (3 5). Despite Evans's claim, many of us considered ourselves to be philosophers, theologians, or ethicists, rather than bioethicists.

Before exploring this putatively distinctive mode of argumentation, I would stress the tension among Evans's criteria for bioethicists. For instance, he claims that "it seems unlikely that the bioethics profession will move away from a formally rational type of argumentation, because its core jurisdiction of clini­cal bioethics now depends upon it" (194). This claim is odd, given Evans's link between the profession and its "abstract knowledge." If the bioethics profession is defined by a formally rational type of argumentation, and moves away from that type of abstract knowledge, the logic of Evans's argument is that it would cease to be the bioethics profession. We could, of course, avoid this logical im­plication by employing one or both of the other two criteria. We could then say that the bioethics profession had changed its "abstract knowledge," instead of ceasing to exist. This example points to the confusion that plagues Evans's criteria.

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Principlism as Bioethicists' Mode of Argumentation

What is the form of argumentation that Evans believes he finds among bio­ethicists? It is what came to be called "principlism," and Evans greatly oversim­plifies it and exaggerates its role and influence.

First, Evans takes what may have been the most prominent and even the most prevalent bioethical framework since the late 1970s and identifies it as the exclusive framework for bioethics: One is a bioethicist, according to the third criterion, if and only if one uses that framework. However, this argument has the odd consequence that those who are bioethics professionals, according to his definition of "primary appointment," cease to be such if they employ a case-oriented framework, such as the influential framework offered by Albert Jonsen, Mark Siegler, and William Winslade in their various editions of Clinical Ethics, a work missing from Evans's bibliography even though he makes claims about principlism as the dominant framework in clinical ethics.8

Second, Evans greatly oversimplifies principlism. His analysis tends to con­flate the Belmont Report of the National Commission for the Protection of Hu­man Subjects of Biomedical and Behavioral Research (1979)9 with the princi­ples presented in various editions of Beauchamp and Childress, Principles of Biomedical Ethics. The Belmont Report's three principles (respect for persons, be­neficence, and justice) are similar to Beauchamp and Childress's four principles (respect for autonomy, beneficence, nonmaleficence, and justice). But there are important differences in content, some of which emerge in the latter's presenta­tion of their principles for bioethics as a whole, not merely for research involv­ing human subjects (the topic for the Belmont Report). Other differences include derivative principles or rules such as truthfulness and fidelity that are featured in Principles of Biomedical Ethics.

Third, Evans distorts many, perhaps most, versions of principlism by filter­ing it through his ends/means analytic categories. These categories fail to cap­ture the nuances of positions that have broader or, dare I say, richer and thicker frameworks of moral, social, and political reasoning about science and other matters. Part of the ambiguity concerns "means," which sometimes refers to technologies and sometimes to actions toward ends. For instance, Evans notes that the thin ends favored by the principlists "could be applied to every poten­tial debate about a technological means, such as HGE, abortion, or the cessation of life support" (18, emphasis added). But then he writes that "for the formally rational debater, no means is inherently wrong, but is only wrong if it does not maximize the end pursued" (21). Few principlists would hold that "technologi­cal means" such as H G E are inherently wrong, but they can and often do con­sider some actions morally unjustifiable not because they fail as means to realize an end or produce good consequences but because of their inherent or intrinsic features.

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Principlists may hold utilitarian, deontological, or mixed views. Most prin­ciplists, unless they are thoroughgoing utilitarians, hold that some features of acts tend to make them right or wrong, independent of agents' ends and of ac­tions' consequences. Such a view does not necessarily commit principlists to saying that acts with those features are absolutely wrong, and never justified, since those features could conceivably be overridden by other features of those acts. Nevertheless, for most principlists, "respect for autonomy" is a strong (even if prima facie) constraint, a limiting principle, not merely an end. A simi­lar point holds for justice—hence, for most principlists, an act can be wrong be­cause it involves the exploitation of individuals. And deception is at least prima facie wrong. These examples are sufficient to indicate that Evans's means/ends analytic framework fails to illuminate most principlist positions.

Indeed, Evans tends to reduce formal rationality, attributed to principlism, to consequentialist reasoning. Consequentialist reasoning is a "hallmark of for­mal rationality" (15). Because of his reductionist interpretation of principlism, Evans can use the metaphor of calculation to replace the principlists' metaphors of weighing and balancing principles. In short, Evans's analysis oversimplifies and distorts by making formal rationality consequentialist and then assimilating principlism to this model.

Fourth, Evans fails to see how significant alternatives to principlism function in public bioethics. For instance, Albert Jonsen and Stephen Toulmin (the for­mer a member of the National Commission for the Protection of Human Sub­jects, and the latter a member of that commission's staff) have argued that the commissioners reached their judgments about such topics as research involving children through their ethical analysis of types of cases without recourse to principles and that the Belmont principles emerged late in their discussion, to­ward the end of the commission's term, in part because of a mandate in the original legislation. Jonsen and Toulmin write: "the locus of certitude in the commissioners' discussions did not lie in an agreed set of intrinsically convinc­ing general rules or principles, as they shared no commitment to any such body of agreed principles. Rather, it lay in a shared perception of what was specifi­cally at stake in the particular kinds of human situations."10 Whether we agree or disagree with Jonsen and Toulmin's claim—and I would dispute some of their overall argument—their claim needs to be considered, because casuistry may have functioned more than principlism in some governmental bioethics commissions.

Evans's Normative Stance on Public Discourse and Governmental Bioethics Bodies

Evans takes a "normative position," influenced by Jürgen Habermas, that "the public debate about HGE should not be artificially limited when such limitation

200 · James F. Childress

favors the interest of one group over others," and he understands a group's in­terest in public bioethics as the promotion of that group's moral vision against what it considers to be other groups' bad arguments (5). Evans has another nor­mative claim, made in passing rather than argued for, that "visceral reactions" represent "unarticulated wisdom from which we can learn" (3). Given these points, it is not surprising that he contends that the public bioethics debate in the U.S. has been "eviscerated" or that "a bigger, deeper, more fundamental, or 'thicker' debate has been replaced by a smaller, shallower, more superficial, or 'thinner' one" (4). While conceding that a thin morality may have a place in pub­lic debates, Evans fails to consider why it might sometimes become dominant apart from particular professional groups' interests. Indeed, at times and for var­ious reasons, the public may prefer a thin debate rather than a thick one. Perhaps public policy in a democracy even depends more on the breadth of argument among the populace than on depth of argument among debaters. Even though Evans notes what he believes his book "has shown about how people should make collective moral decisions in pluralistic societies" (9, emphasis added), he has not made a complete or convincing argument for such "collective moral decisions" on all bioethical issues, much less an argument for why public bioethics commis­sions should be construed only as "means commissions," given their limited authority.

Three observations may be pertinent. First, a range of bioethical issues could receive attention, but it is not clear that all of them—or which ones—should be subjected to thick rather than thin debate. Evans apparently believes that hu­man genetic engineering should have been a matter of thick debate, but it is not clear why. At other points he seems to suggest that issues that evoke strong emotional reactions should be subjected to thick debate, but this point also needs further development.

Second, even those who might argue for thin debate in some contexts oí pub­lic policy usually recognize the place and importance of thick debate in the public culture, which often has an impact on public policy. According to Evans, the shift of public bioethics to governmental advisory commissions, away from the public and legislatures, led to the exclusion of theologians (196, et passim). However, theologians have remained active in the shaping of public culture, and they have not been ignored in public policy, as I will note below. It is diffi­cult to establish that the emergence of governmental bioethics commissions or the profession of bioethics undermined their role—indeed, evidence suggests a resurgence of interest in religiously based bioethics.

Third, bioethical debates may focus on acts and practices, on the one hand, or on public policies, on the other hand. Public policies typically concern whether to permit, prohibit, or regulate acts or practices or whether to with­hold or provide governmental funds, and within what limits, as debates about both human cloning and human embryonic stem cell research indicate. In

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debates about coercive public policies, which regulate or prohibit acts, certain moral presumptions are built into our society's constitution, laws, and policies, and they provide starting points for the arguments that occur. Arguments have to rebut those presumptions, for example, about scientific freedom or repro­ductive liberty.

A failure to recognize such points may in part account for Evans's inade­quate account of public bioethics commissions, but his account suffers from other conceptual and empirical problems. Having served on such commissions, including the National Bioethics Advisory Commission (1996-2001), as well as several more specific bodies, such as the Human Fetal Tissue Transplantation Research Panel, the National Organ Transplantation Task Force, and the Re­combinant DNA Advisory Committee (RAC), I believe that Evans's interpreta­tion of bioethics advisory commissions and their function is seriously flawed in ways that damage his analysis.

First, he uses the language of "decide" or "decision" over and over again for what these bioethics bodies do—he views these "commissions as decision-mak­ers" (3 7 et passim). Of course, they "decide" and make "decisions" in a certain but very limited sense—that is, they decide to make recommendations to policy­makers. But for the most part they do not make policy decisions—in general, just as he proposes, accountable public officials make policy decisions, and they may or may not heed the recommendations offered by bioethics bodies. Bioethics bodies have to present analyses and arguments that are convincing to those in po­sitions of accountability. Evans seems to recognize this in his language of "advi­sory commissions," but if bioethics commissions only have an advisory role, then some of his interpretations and judgments require more qualification.

Evans could respond that his points hold for bioethics commissions that ad­vise the bureaucracy—for instance, the Recombinant DNA Advisory Commit­tee—but in fact he focuses mainly on the work of the President's Commission and also attends in his final chapter to the recent National Bioethics Advisory Commission (NBAC), another body accountable to the White House. In short, Evans provides no evidence for his claim that "advisory commissions became the ultimate arbiter of whether HGE was ethical and thus whether it would oc­cur" (6, emphasis added).

Just as Evans's analysis distorts what public bioethics commissions do, and can do, it also distorts the major counterexample he offers: abortion. Several times he refers to the "thick" debate about abortion as a counterexample to the "thin" debate about human genetic engineering. The latter, he contends, was shifted away from the public "toward government advisory commissions," while the former, abortion, remains in the public's domain: "the abortion de­bate has retained the public as the ultimate decision-maker and the HGE de­bate has not" (178). That analysis is seriously misleading because, as a matter of fact, the U.S. Supreme Court in Roe v. Wade in 1973 preempted evolving state

202 · James F. Childress

decisions about abortion, thereby taking much of the decision making about abortion laws out of the hands of state legislatures and thus away from the pub­lic. This court decision, many argue, truncated the public debate about abortion laws, one result being the emergence of a vigorous right-to-life movement. De­spite shifts among justices on the Supreme Court, different rationales in subse­quent decisions, and other changes in legal rules surrounding women's abortion decisions, the core of Roe v. Wade still holds. Of course, this core could change because of changes in the Supreme Court.

The U.S. Congress's recent legislation on so-called partial-birth abortions is marginal to the overall public policy and practice of abortion. For instance, ac­cording to some reports, the new law would affect approximately 1,500 of the 1.5 million abortions each year in the United States. And even that legislation is subject to being overturned by the Supreme Court.

Furthermore, Evans is able to claim that the public is still "the ultimate deci­sion-maker" about abortion only by expanding his interpretation of democratic decision making: "politicians at the state and federal levels determine whether abortion is going to occur—whether through votes or the appointment of jus­tices" (178). If Evans can accommodate "the appointment of justices" in the ex­ercise of democratic authority, accountable to the public, then he can surely ac­commodate the appointment of bioethics advisory commissions that have no power other than to offer advice, which accountable agents, such as legislatures and presidents, can choose to follow or not.

The debates about abortion and about HGE are also not fully comparable in part because of the central place of the embryo/fetus in the abortion debate (and its marginal role in the debate about HGE) and, I might add, in the de­bates about human embryonic stem cell research over the last few years. This central place requires judgments about moral status, which cannot be resolved through moral principles. Instead, judgments about moral status determine how principles, such as respect for persons and nonmaleficence, are applied; they cannot themselves resolve moral status.

In his final chapter, Evans discusses "the 1997 debate over human cloning and how the process of the cloning debate provides further evidence for the claims made in this book" (9). Although he concedes that, at first glance, the furor over human cloning might appear to "contradict" his findings (169), he claims that there is no contradiction: "The answer is that, for this issue, and unlike most other decisions by government advisory commissions, the ultimate arbiter of the ethical decision was the public" (189). In short, some "democratically elected of­ficial would be held accountable for the decision on this issue—be it the president or the Congress" (169). But that point would hold for most bioethical debates, in­cluding HGE—the public may choose to hold officials accountable.

Some of Evans's observations about the context, process, and content of NBAC's 1997 report Cloning Humansneed qualification.11 He notes that NBAC

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invited several theologians and philosophers, among others, to testify in what amounted to a thick discussion, but he seems to suppose that the theologians were invited because the public had defined the problem through its expression of repugnance over the prospect of human reproductive cloning (191). It is a ma­jor mistake to contend as Evans does that "theologians were no longer seen as serious contributors to the debate itself but rather served as spokespersons for communities within a pluralistic public that was closely watching the cloning de­bate" (189). There was serious interest among commissioners in these theologi­cal positions, in part because over the previous twenty-five or so years theolo­gians had debated human cloning more than philosophers had. Furthermore, in a couple of places in the report, NBAC gives several reasons for attending to po­sitions taken by thinkers within religious communities and traditions.

Despite NBAC's incorporation of theological perspectives into its delibera­tive process, Evans contends that NBAC's report is not as "thick" as it first ap­pears: "[W]hen it came to actually reaching ethical conclusions about what to do about cloning, the broader, substantive debate receded into the background" (191). In fact, NBAC unanimously recommended a federal ban of three to five years on efforts to clone human beings and, at the same time, called for an ex­tended national dialogue ("widespread and continuing deliberation") on human cloning about precisely the kinds of issues that Evans wants debated:

The Commission concludes that at this time it is morally unacceptable for anyone in the public or private sector, whether in a research or clinical set­ting, to attempt to create a child using somatic cell nuclear transfer cloning. The Commission reached a consensus on this point because current scientific information indicates that this technique is not safe to use in humans at this point. Indeed, the Commission believes that it would violate important ethi­cal obligations were clinicians or researchers to attempt to create a child using these particular technologies, which are likely to involve unacceptable risks to the fetus and/or potential child. Moreover, in addition to safety concerns, many other serious ethical concerns have been identified which require much more widespread and careful public deliberation before this technology may be used.12

It is important to distinguish what NBAC offered as reasons for its recom­mendations from what individual commissioners may have considered their reasons. All agreed that safety was relevant; perhaps it was sufficient for most to reach the unanimous recommendation—certainly it was for me; but some com­missioners may have found the other reasons about individuality, threats to the family, etc., to be persuasive. And these reasons require broad public attention.

Although some states have banned human reproductive cloning, there is no federal ban, perhaps in part because of continuing "thick" debates in which a number of participants, including a majority in the House of Representatives,

204 · John H. Evans

propose at the same time to ban human cloning for research purposes. There is widespread agreement among the public and legislators that we should ban hu­man cloning to produce children—there is an overlapping consensus about eth­ical public policy based on a variety of reasons. However, the thick debate about the moral status of the early embryo, in the context of cloning-for-research, re­veals deep and perhaps irreconcilable differences among religious communities and traditions, as well as the public at large.

In conclusion, even though Evans's interpretation of public bioethical dis­course provides valuable insights, it will, I am sure, provoke vigorous responses and critiques. In my judgment, his analysis and critique are not fully cogent be­cause of several conceptual, methodological, and analytic flaws, some of which I have identified. However, I hope he will continue his examination of public bioethics, perhaps less constrained by his heavy and problematic social scientific apparatus (e.g., the use of the citation index). In particular, I look forward to his examination of the work of the current President's Council on Bioethics re­garding human cloning, in part because its chair contends that it is not a council of bioethicists but a council on bioethics.

John H. Evans Responds

I am honored to have such a distinguished panel of scholars of religion and the­ology read and comment upon my work. I must start with a critical admission: I am a sociologist of religion, not a theologian. My theological training consists of paying attention in church. Like many sociologists, I have selected a commu­nity to study, a community to which I am an outsider. There is a certain danger in returning to the community under study—a certain danger in letting the na­tives talk back.

A famous incident in the history of sociology offers the appropriate warn­ing. In the 1950s, sociologist Arthur Vidich moved to Candor, New York, pop­ulation 2,500, to conduct an in-depth community study. A few years later, he published his work in The Small Town in Mass Society, which soon became a best-seller in Candor.13 Although he used fake names for the town and all of the people in it, with only 2,500 people it was apparently quite clear who all the characters were, and they were not happy. From their perspective, Vidich had not described their town accurately. While the Society of Christian Ethics has been gracious in allowing me to return to the community I have studied, Vidich was not so lucky. The citizens of Candor were so enraged by his book that he was hung in effigy in the town square, and the fourth of July parade in­cluded a float with an image of him bending over a manure spreader. Since I encountered no rope or manure spreaders during my talk in Pittsburgh, I as­sume it is safe to respond to the natives. I want to argue that I did describe the

Book Review · 205

town accurately, although at points I might not have been as clear as I could have been.

Professor Childress, while not armed with a rope, is the "native" with the most critical and detailed response to my analysis. I will therefore organize my response following his critique, and work in the comments from Professors Hauerwas, Stout, and Meilaender. By way of foreshadowing, I can say that most, although not all, of the criticism of my book results from theology and philosophy being more precise than social science. This is not how these fields are usually portrayed, but I mean something distinctive here. Social science is less precise because it tries to make grand claims where precision is impossible, such as "the debate about HGE changed from substantively rational to formally rational from the 1950s to the 1990s." Theology and philosophy typically do not try to make such claims, and instead are more likely to conduct close read­ings of texts, avoiding generalization. See, for example, Professor Stout's exact­ing examination of James Gustafson.14 In contrast to Stout, due to my different concerns, I would have classified all of James Gustafson's work into a one-word category. In engaging in such generalization, I take on the language of proba­bility: "theologians like Gustafson tend to write in such a manner"; "the deci­sions of government advisory commissions have a very strong influence on what actually occurs with HGE"; "bioethicists are more likely than others to use principlism to make their arguments."

Part of the misunderstanding of my book derives from the fact that I often as­sume this perspective in my writing and do not add qualifiers such as "tend to," assuming that the reader understands that my claims should be qualified in this way. This works among my immediate colleagues, but I have learned that if I want to continue to engage in crossdisciplinary conversation I need to do a better job of emphasizing the probabilistic nature of my claims. I recognize that my say­ing that the criticisms of my book stem from a misunderstanding of social science can be seen as an attempt to quash criticism by returning the debate to my juris­diction—analyzing data—in the same way I accuse scientists in my book of trying to make the HGE debate turn on the calculation of risk because this is what they are good at doing. That is, turning the discussion back to my jurisdiction makes it difficult for those outside of the jurisdiction to question my response. To avoid shutting down conversation, I will try also to focus upon the criticisms of my book that are based on conceptual issues, issues that are more squarely in the ju­risdiction of philosophers and theologians than of social scientists.

On Method and Data

I think that the greatest amount of confusion over my book has resulted from the method that I use to make my claims, and particularly the limitations that this method put upon me. We must start with what it was that I wanted to do. I

206 · John H. Evans

wanted to make claims about the academic debate over human genetic engi­neering (HGE) from the 1950s to the present. I also wanted to examine the de­bate as it actually occurred, and not how people had learned that it occurred. I wanted to avoid reading history through the eyes of the present. This is an im­portant point and an important trade-off to other concerns. A quick aside to one of the points made by one of my critics: Professor Hauerwas says that he knew this story before I told it, without all of the sociological methods, because he had lived it. It turns out that Hauerwas's writings about the change in these debates were generally right, but I did not want people to have to take his word on it. T o sound like more of a scientist than I actually am, I wanted people to have more objective "proof of why things changed, from someone who was not a participant.

How would one conduct research to achieve these goals? Interviewing peo­ple who had been through the debate as the exclusive method was generally not acceptable, because those people had learned or had an interest in a particular account of this history. Opinion polls and the like do not exist that far back into history. Instead, the only data source was the texts that comprised the debate. So, as I outline in the methodological appendix to the book, I created a list of 1,465 texts that had been published on the topic of the ethics of H G E between 1959 and 1995—and defined it as "the debate"—a list that I consider to be fairly exhaustive. (Of course, there are other debates I could have looked at, such as in novels, movies, and public conversation.)

One approach at this point would be to read all of these texts, and then write the book. There are two reasons why I did not do this. First, methodological canons in my field require that I not only read texts, but "code" them, essen­tially categorizing paragraphs as referring to certain themes, in order to look for insights in the relationships between paragraphs and between texts. Coding all 1,465 texts would have been far too time-consuming. Second, and more impor­tantly, not all of these texts were influential to the debate. A chapter in an edited volume is rarely as influential as an article in the New England Journal of Medi­cine—which is distributed to tens of thousands of people.

I decided to look at both the "common" or average authors (the writers of the 1,465 texts) and the "most influential" authors in the debate. How could one figure out who was an influential author? "Quality" does not matter here, because "quality" is in the eye of the beholder. Nor does the fact that the author later on became influential, or that he or she is influential in other debates. It does not matter if the author's work is well-respected at the flagship research centers. What was important to me was that the author was influential among those writing about the ethics of HGE at that time.

The only avenue available was to see who the writers of the common texts (the 1,465) thought was influential to their ideas as they were writing. Inter­views would have been preferable, but unworkable. Instead, I relied upon a

Book Review · 207

method whose validity is well-demonstrated in the sociology of science—exam­ining the citations of those 1,465 texts to see who their authors thought was influential.

It is at this point that I can hear the collective chortle coming from the col­lective readership of this journal, and mutterings of "That's why I didn't be­come a sociologist." What a ridiculous assumption, people will say, that we cite texts only because they are influential to our writing. The last paragraph of Childress's response makes the general point by simply calling it "problematic." W e think of our own writing and come up with numerous objections. W e say that the greatest influences upon us are so ingrained that they are not refer­enced, or that we reference texts all the time that are of minor importance to our thinking. As one information scientist put it, who we decide to cite is essen­tially subjective, with people citing each other as an acknowledgment of intel­lectual influence, as a form of reward or income, as a way to settle priority claims, or as a tool of persuasion. Citations can be affirmative or negational, or­ganic or perfunctory, evolutionary or juxtapositional, conceptual or opera­tional.15

Before defending the citation, I must raise a critical point that addresses cita­tion gathering and many of the other critiques of my book—the concept of a generalization. Consider a public opinion poll that you would read in the news­paper that says, "People in the South attend church more regularly than do people in the North." However, your brother lives in the South, and he never goes to church, so how could this statement be true? What the statement should actually say is that "on average" this statement is true. Social science is based upon claims like this, and my book is no exception.

A related concept could be called the "signal to noise" ratio, probably taken from electronics. The "signal" is that average we just mentioned: that, for ex­ample, 64 percent of Southerners attend church weekly. The "noise" is how many cases do not fit into the signal—your poorly attending brother, for exam­ple. W e can always come up with an average, but if most people are nowhere near the "signal," we have very "noisy" data indeed. With surveys, "noise" is lessened by surveying more people. (The "margin of error," usually mentioned in such newspaper articles, is largely a function of how many people the poll­sters interviewed.)

T o return to the methodological story about citations, I would be wary of in­terpreting the citations from a single text, without much additional work. But when you average the citations of hundreds of texts, idiosyncratic reasons to cite someone become noise, with the reason that we thought a text was important to our writing remaining as signal. Idiosyncrasies are just that, and your idiosyn­crasies will not be shared by another, and will just become random noise. For example, in the texts I sampled to write the book, there were citations to novels and country music songs, children's stories, Greek mythology, physics, the

208 · John H. Evans

founding fathers, science fiction novels, and so on. But each of them remained an isolated reference—idiosyncratic—whereas the works of people like Ram­sey, John Fletcher, and LeRoy Walters were referenced time and time again. (For methodological studies of this aspect of citation measures, see the appen­dix to my book).

To return to how I wrote the book, the most heavily cited authors in each of four time periods were labeled the most influential. I obtained the most cited text from each most cited author and interpretively read and coded it as de­scribed above, focusing on the substantively/formally rational distinction that my critics have described so well above. I formed these authors into communi­ties by looking at which influential authors were cited together. Studies have shown that if Ramsey and Kass tend to be cited together, they are more alike than Ramsey and Peter Singer. Once again, this is a generalization with some noise, but not that much more noise than the public opinion polls we read.

I went further and classified each common and influential author as being a member of one of fifteen different professions. I could then make claims such as "the common authors who were theologians tended to look to Jeremy Rifkin as one of their influential authors." Here I must express regret that I did not move part of endnote 2 on page 233 into the body of the text to clear up a confusion I caused for Professors Hauerwas and Meilaender, as well as others who have read the book. The figures that show the communities of influential authors in each time period (located on pages 46, 75, 138, and 156) have a label that I as­signed to each community. For example, on page 156,1 describe the "commu­nity" of "theologians" as Leon Kass, Paul Ramsey, Joseph Fletcher, and Jeremy Rifkin because they were more likely to be cited by theologians than they were likely to be cited with any of the other influential authors. Hauerwas interprets this as my saying that Rifkin is a theologian, which he is not. Rather, what this means is that Rifkin was a favorite author of the theologians, more than he was a favorite author of any other type of writer. Hauerwas could say that what has "gone wrong" is not my method but the theologians of the era who looked to Rifkin for inspiration. (I generate similar confusion for Meilaender as well with regard to Kass.) Hopefully if there is a second printing the publisher will allow me to clarify this.

To finish my summary of methods, I also conducted a case study of the for­mation of an ethical text by the President's Commission where I analyzed the text more like scholars in the humanities do. I also examined the archives of the commission and interviewed key participants. This chapter was designed to provide greater detail about the process of the debate than the more generalized claims I had to make when looking at influential texts.

This entire approach is a trade-off, requiring me to make many generaliza­tions, but I believe the trade-offs are worth it. There is no other way to look at the debate as it was evolving. There is no other way to conduct this research if

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one is concerned with making representative claims such as: "If I define the de­bate in such a manner, this is what I found." However, I will be the first to ac­knowledge that these concerns come at a price—as my critics have noted in many instances.

Identifying Bioethicists and Theologians

To the first criticism. Once one analyzes a large number of texts, simplified classification is necessary. (As an aside, I agree it is ironic that this method, as well as sociology itself, is part of the rationalist impulse of modernity, as Hauerwas points out.) Professor Childress states that my thesis hinges on being able to identify people as bioethicists, theologians, scientists, and so on. Of the three criteria he identifies, the first was just rhetorical on my part, the second is what I used to classify people, and the third was my actual definition. That is, you are a member of a profession if you use its form of argumentation, and since I demonstrated that people who were identified through my second criteria used the form of argumentation, I used the second criteria in practice. For ex­ample, an author was a bioethicist if he had a primary appointment in a bioethics department, medical ethics center, and so on. To get right to the best counterexample: what about James Childress, whose work embodies what I de­scribe as the form of argumentation of the bioethics profession? He has a pri­mary appointment in a department of religious studies, and would therefore be classified as a theologian. Indeed, Professor Childress was one of the "common authors" in the data (just falling short of being an "influential" author—at least for the HGE debate), and I classified him as a "theologian."

Once again, this is noise in the data. It is due to idiosyncrasies of history, as he suggests, and would probably not happen again. True, the two foremost pro­ponents of the form of argumentation in the bioethics profession as I have de­fined it (Beauchamp and Childress) are not in bioethics departments, but that is merely because they invented the form of argumentation before there were very many bioethics departments. When the mantle gets handed down to the next generation, members of that generation will most likely be in bioethics depart­ments. Imagine this thought experiment: If Beauchamp and Childress went on the job market right now, which academic units would be clamoring to hire them? Philosophy and religious studies, or bioethics?

Moreover, Childress points out the issue of joint appointments, with some authors (John Fletcher comes to mind) being sometimes classified as theolo­gians because they list their religious studies appointment first and their bio­ethics appointment second (and may even reverse the order on different occa­sions). More noise. Also, as noise goes, there was little noise in defining people in established professions like medicine, biological sciences, sociology, and the­ology. Bioethics was much noisier, because as Childress rightfully points out,

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particularly in the early years, people who were writing using the bioethics form of argumentation (or were writing about bioethical topics, the formulation that I think he would prefer) were scattered throughout academia.

What he is saying, in my terms, is that there is no signal in the noise, or that the signal is so weak that the noise overwhelms. If that were the case, then why does the book find empirical differences in the arguments used by people I call "bioethicists"? Why do bioethicists I identify in this admittedly "noisy" way tend to use principlism while theologians do not? Why are bioethicists con­cerned with some sorts of technologies and theologians with others? If it were all noise, there would be, as we say in the business, "no pattern in the data." But the data is highly patterned by profession, in the same way in analysis after anal­ysis, time period after time period, and in a manner that coincides with what is known about these professions. I would argue that with less noise in the data, I would have needed to analyze fewer texts to get the same amount of precision or could have used the same number of texts and obtained even stronger results.

What h Principlism?

The next criticism is partly an empirical dispute and partly a misunderstanding that results from my methods. Childress states that I greatly oversimplify principlism and exaggerate its role and influence. I respond that I am just re­porting what I see among the common and influential writers in the debate about HGE. One of the reasons I set up my research as I did, with such concern for representativeness of texts in the debate, was to be able to respond to criti­cisms such as this.

First, he says that principlism may be "the most prominent and even the most prevalent bioethical framework." I agree, so what is the dispute? I think Childress does not accept the notion of generalization I outline above. The competitor he cites, the case-oriented framework of Jonsen, Siegler, and Winslade is—with no disrespect intended—noise in the data. I do not doubt that there are people who consider themselves to be doing bioethics who are following this framework (and would then not be bioethicists by my definition), but they are few compared to those who are following principlism. Returning after many years to the raw data I used to write the book, I find that Beauchamp and Childress are cited ten times, despite the fact that people rarely cite the methodological canon they are operat­ing with. The book by Jonsen, Siegler, and Winslade that he refers to is not men­tioned anywhere in any book or article I examined, and I have never heard of it until this moment.

There is other evidence that principlism is dominant and the other systems are marginal. This week I am also submitting an application to the Institutional Review Board (IRB) of my university to get approval to "conduct research on human subjects" by asking members of churches and synagogues what they

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think about reproductive genetic technologies. The primary concern of the IRB is whether I will be harming the church members by asking them these ques­tions, whether their participation is truly voluntary, whether my project will give a benefit to either the respondent or society, and whether I have consid­ered the inclusion of all types of people. These are the four principles of principlism: nonmaleficence, autonomy, beneficence, and justice. I support these principles in this case (as a start; these are not all that should be consid­ered). I also use this example to argue that principlism has been institutionalized into public law and into the very way that academics think about all research. In sum, principlism is dominant among bioethicists and in "bioethical debate."

Childress later states that other systems, like casuistry, may have been used by government advisory commissions, citing the claims of Jonsen and Toulmin. Childress says he disputes some of their overall argument, and I do too. How­ever, even if casuistry is operating in the commissioners' minds—a notion for which I saw no evidence—what gets put to paper is principlism. In terms of in­fluencing a debate, what is important is what is printed.

I also agree that I oversimplify principlism, at least as principlism is intended to be used by its theoreticians such as Beauchamp and Childress, because a sim­plified version is what the average writer in bioethics uses. Empirically, the common contributor to debates about HGE does not use principlism in the more sophisticated way that Childress does. The claims Childress makes about the richness of principlism in use do not come through from looking at average writers. Of course, there may be something particular to the HGE debate that results in this conclusion, and principlism may operate in a richer way in de­bates I have not examined.

Conceptual Troubles: What Is a Profession?

Childress sees a conceptual problem in my definition of a profession. I follow the sociology of professions literature, particularly the work of Andrew Abbott in defining a profession by its system of knowledge,16 not by its organizational base, such as the American Medical Association, or by an educational credential such as having an advanced degree in theology. For example, the system of ab­stract knowledge of medicine is that body of knowledge that physicians use to engage in their primary task—making bodies function properly—and includes knowledge about anatomy, biology, circulation, and so on. The system of ab­stract knowledge for bioethics is the system that bioethicists use to conduct their work, writing about the ethics of science and medicine. The abstract knowledge of professions such as medicine has changed on many occasions. I show in my book that the abstract knowledge of scientists has changed since the 1950s. Does this mean that the medical or scientific professions have ceased to exist? No, they just changed. Think of the "system of professions" as a snapshot

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of a given year, say 1979. We can make generalizations of the collective snap­shots and give them labels ("bioethics"), or describe how they change in more detail. I do not see how this causes great troubles for my argument.

On Rationality

Stout suggests a conceptual confusion that results from my use of the Weberian tradition's discussion of rationalization, and that "it is a mistake to identify ra­tionalization with instrumental reasoning." This is critical, because this distinc­tion is central to the entire book. I am definitely following the mainstream so­ciological interpretations of Weber and rationalization, and I had not thought of the more fine-grained distinction Stout makes.

I tliink my response is best discussed through Stout's example of my treat­ment of Ramsey. First, to return to the limitations of the probabilistic approach I have taken, I only analyzed the writings of Ramsey that the common authors in the HGE debate thought were important, so I am making claims about "this Ramsey," not the one who wrote about just war and other issues. If one were in­terested in what Ramsey really thought, this would be unacceptable. If one is in­terested, as I am, in how Ramsey's writing changed the HGE debate, then it is preferable. While I recognize Stout's description of Ramsey, it does not come out quite so strongly in "the Ramsey" I am making claims about—the one who wrote Fabricated Man.11

I am also making generalizations about Ramsey's writings. No figure in my book is a pure-type, although some reside closer to the pure categories than others. Ramsey lies close to my "substantively rational" category, as I defined it, but he did make statements that could be considered formally rational. For ex­ample, when he thought that he had the ends figured out for some problem, his discussions of what means to employ became somewhat formal by my terms. I am thinking here of the ethics of human experimentation.

Similarly, Hauerwas also says that Ramsey—a central figure in the book—is not the ideal-type substantively rational author I make him out to be. Indeed, as Protestantism has been said to carry the seeds of its own destruction, Ramsey ironically carried the germ for formally rational bioethics. Hauerwas would know this better than I, given that some of my information about Ramsey comes from reprinted correspondence between him and Ramsey. However, I would say that of all the influential authors in the HGE debate, Ramsey was one of the most substantively rational.

To return to Stout's critique, he says that I have folded three concepts into my substantive rationality concept, resulting in confusion. Stout says that Ram­sey was opposed to some means "in principle," wanting to create rules about means. So Ramsey did want to create formalistic rules. But I want to emphasize the "in principle" part here. Ramsey's opposition was "in principle" or

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deontological, which I define as substantive. I would need to give this much more thought, but Stout's three pieces strike me as empirically being three overlapping circles in a Venn diagram. I described the overlap of the circles, but Stout says I would do better to look at the circles separately. If I were to write another book on rationalization, I would certainly consider whether creating three categories out of the one I used would create a more accurate depiction of what has occurred.

Differing Interpretations: Why Theology Got Squeezed

In the book I say that theological and other comprehensive perspectives were squeezed out of the debate that had influence on what actually happened with HGE because the proponents of these perspectives wanted to discuss ends. Professor Stout says that they were squeezed out because they were controver­sial, and consensus cannot be reached about controversial ends. I would not so much disagree with this as I would say that the squeezing out of controversial ends is the more micro-level mechanism of what I describe. The bureaucratic state cannot have debates about ends, because then they would be seen as set­ting ends or values, and setting ends or values is controversial.

When Should We Have Thick Debates, When Should We Have Thin Debates?

Childress asks when and on what issues we should have thick debates and when and on what issues we should have thin debates. My general orientation is that we should have the more efficient "thin" debates when there is public consensus about ends. If eradicating infectious diseases is the consensual goal of society, then we should have a "thin" debate about the most efficacious means of achiev­ing that goal. I do not think there are many issues in bioethical debate that come close to having this degree of consensus, although some are closer than others (perhaps the ethics of human experimentation). The general point is that I am aware of no evidence that we have reached consensus that the four principles of principlism are the only principles that should apply to these issues.

The first government bioethics commission proposed three principles for human experimentation that became public law through the actions of executive branch officials at the National Institutes of Health (NIH) and elsewhere. Yes, the president of the U.S. is an elected official and is officially responsible for all executive branch decisions, but there are so many issues in a presidential election that these issues are generally overlooked. Would it not have been more demo­cratic—and resulted in a more accurate depiction of the public's principles—to have the debate over these principles conducted by a more closely representative group of public officials like the House of Representatives?

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What Power Does an Advisory Commission Have?

Childress might say that this makes no sense, because Congress has actual power, and government bioethics commissions and bioethicists just get to ad­vise those with power. How could government advisory commissions have power?

Childress says that I write as if I think bioethics advisory commissions have direct regulatory power. However, I acknowledge throughout the book that they do not have this power. For example, I write on page 83 that Senator Ken­nedy failed in the early 1970s to create regulatory commissions and instead set­tled for advisory commissions. I do use the language of "decision makers" throughout the book to describe what these commissions do. I mean that these commissions were the "decision makers" in the entire debate over what is ethi­cal. They became the group that was looked to by governmental officials for a conclusion on the ethics of some situation. They are not decision makers about policy, by and large.

But Childress could respond that even if this were true, these commissions do not become "the arbiter" of whether H G E will occur, as I claim, because ei­ther they have no power or others hold the actual power to stop them if they wish to. Does one need to have direct regulatory control to be "the arbiter?" This raises the basic question of what power is. In his seminal study, aptly called Power, Steven Lukes outlines three types of power.18 The first is the classic po­litical science view of power, which is the ability to make someone do some­thing they otherwise would not do. This is probably how power is thought of by most of the public—we would otherwise not pay our taxes if there weren't someone with power making us do it, and, more on point, some scientists would perform a dangerous experiment on healthy babies if there weren't some power forcing them not to. Childress seems to believe that this is the only power that really matters, and since bioethics commissions lack this power, their decisions lack power. The second type of power is the ability to control the options avail­able in the policy process.

In my book I consider Lukes's third type of power, which he considers the greatest, to be most important. This is the ability to control the agenda of the people battling for the first type of power by defining the very terms of the de­bate. It would be an act of type 1 power for generals to stop lower-ranking offi­cers who want to conduct humanitarian activities in war zones. It is a more ef­fective act of (type 3) power to control military education in such a way as to convince junior officers that humanitarian activities are a waste of time or are dangerous. The most effective form of power is that which does not appear to have been exercised.

Government advisory commissions have this type 3 "convincing" power, and are therefore powerful. By and large, they do not have type 1 power

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(although some, like the commission Childress was on that drafted the proto­cols for the first HGE experiments, come close). Rather, these commissions have this agenda-setting power. I chronicle in the beginning of chapter 5 the in­fluence of the report of the President's Commission in setting the agenda at the NIH when creating the research protocols for the first HGE experiments.

Upon reflection, this notion of power is largely implicit in the book, because it is such a background assumption in sociology that I unfortunately did not ex­plicate it. Such a perspective on power is implicit in the very topic of study: why should we care about this intellectual debate about HGE if it did not have some sort of power? I should have made this clearer in the introduction.

To return to the critique, the next question is whether this more diffuse third type of power should be in the hands of government advisory commis­sions as currently constituted. True, people with type 1 power have the ability to ignore the message coming from the commission with type 3 power. But why do we give these groups the ability that others do not have to transmit their message to those with type 1 power? It does matter who gets to define what is ethical, because this definition defines the terms of the type 1 debate that occurs in places like the Congress. Why have these groups at all? There are valid rea­sons. However, their power does suggest that we pay attention to whether or not they exclude certain perspectives that are held by members of the popula­tion, and I would suggest that they do frame the type 1 debates in particular ways.

On Comparison to the Abortion Debate

I conclude with two responses that do not fit elsewhere, but that I want to in­clude. I compare the HGE debate to the abortion debate, which I consider to be more substantive or "thick." Childress does not contest that it is thicker, just that it is in the control of the people. Childress claims that the Roe v. Wade deci­sion made abortion not a matter of public debate, but rather a matter of deci­sions by judges. As a pragmatic matter of the practice of abortion in the U.S., this is true. However, the debate about whether abortion is moral, and the de­bate over whether it should be legal, have not been limited by the Roe decision. If they were, why would there be such a "vigorous right-to-life movement" as Childress says? This right-to-life movement is trying to elect public officials that agree with their views, and to pass a constitutional amendment to overturn the Roe decision.

On the National Bioethics Advisory Commission (NBAC)

Professor Childress was a member of the NBAC proceedings. Indeed, it is my impression that he was responsible for inviting the religious voices to the table,

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and is obviously one of those who feel that religious voices are important. I stated that "obviously some commissioners thought that the theologians pro­vided insight" (189), but I also claimed that theologians were not taken to be se­rious contributors to the debate. I am not the only one with this impression. In the line before the one that Childress quotes from my book, I quote a consul­tant to the commission who reached essentially the same conclusion as I did. And, once again, what is important is what was put on paper, not what was in in­dividual minds.

Conclusion

Once again, I am flattered to be the subject of this criticism, and hope that my response has been adequate. I end with an unresolvable point mentioned by Hauerwas. He rightly points out that my most important concern is whether formal modes of rationality are the inevitable product of modernization. I do want to argue that the "iron cage" of formal rationality is not inevitable. He is right that with one case study I have no definitive evidence about the trend of modernity. I will go further—I could have simply observed a speed bump on the inevitable roadway to the perfectly rationalized world. I will stand with the view that such a world where everything is a matter of cold, hard calculation should be avoided if possible.

Notes

1. Stanley Hauerwas, Suffering Presence: Theological Reflections on Medicine, the Mentally Handi­capped, and the Church (Notre Dame, Ind.: University of Notre Dame Press, 1986).

2. Alasdair Maclntyre, After Virtue, 2d ed. (Notre Dame, Ind.: University of Notre Dame Press, 1984).

3. Oliver O'Donovan, The Desire of the Nations: Rediscovering the Roots of Political Theology (Cambridge: Cambridge University Press, 1996), 270.

4. David Rothman, Strangers at the Bedside (New York: Basic Books, 1991); Albert Jonsen, The Birth of Bioethics (New York: Oxford University Press, 1998).

5. President's Commission for die Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Splicing Life: A Report on the Social and Ethical Issues of Genetic En­gineering with Human Beings (Washington, D.C.: Government Printing Office, 1983).

6. Rothman, Strangers at the Bedside, 261.

7. James F. Childress and Tom Beauchamp, Principles of Biomedical Ethics, 5th ed. (Oxford: Oxford University Press, 2001).

8. Albert Jonsen, Mark Siegler, and William Winslade, Clinical Ethics: A Practical Approach to Ethics Decisions in Clinical Medicine, 5th ed. (New York: McGraw-Hill, 2002).

9. The National Commission for the Protection of Human Subjects of Biomedical and Be­havioral Research, The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research (Washington, D.C.: Government Printing Office, 1978).

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10. Albert Jonsen and Stephen Toulmin, Abuse of Casuistry: A History of Moral Reasoning (Berkeley: University of California Press, 1990), 18.

11. National Bioethics Advisory Commission, Cloning Humans: Report and Recommendation of the National Bioethics Advisory Commission (Rockville, Md., 1997).

12. Ibid., iii.

13. Arthur Vidich and Joseph Bensman, The Small Town in Mass Society (Garden City, N.J.: Doubleday, 1960).

14. Jeffrey Stout, Ethics after Babel (Boston, Mass.: Beacon Press, 1988), 167-88.

15. John H. Evans, Playing God? Human Genetic Engineering and the Rationalization of Public Bioethical Debate (Chicago: University of Chicago Press, 2002), 206.

16. Andrew Abbott, The System of Professions (Chicago: University of Chicago Press, 1988).

17. Paul Ramsey, Fabricated Man (New Haven, Conn.: Yale University Press, 1970).

18. Steven Lukes, Power (New York: Macmillan, 1974).