Four years ago The Hastings Center initiated a “pluralism project.” That project gave the Center staff a chance to explore one swath of the theoretical literature concerning how members of democratic regimes ought to think about and respond to the differences among themselves. Much of that literature, produced by philosophers like Charles Taylor, Martha Nussbaum, and John Kekes, is wonderfully articulate about difference in general. But it is nearly silent about how particular categories of difference actually make a difference in the lives of particular individuals negotiating particular institutions.

It has become a commonplace to observe that the people of the world will soon be divided into two classes—the technologically literate and everyone else. While such a situation certainly has unfortunate economic effects—for everyone else—how much worse it would be if we made a slight alteration in our description. How much worse it would be if the vast majority of people were possessed of too little information to allow them to make informed decisions about their own lives, health, and genetic inheritance. Unfortunately, this is the reality. And as scientific advances rocket far ahead of both our bemused journalistic establishment and our limping regulatory apparatus, the reality becomes ever more pernicious.

Sometimes evil is simply the good that oversteps boundaries and has gone too far. It is this sort of evil that is hardest to perceive and is the most pernicious in its power to harm. In Western mythology the image of Lucifer, the “Being of light” who becomes Satan, “the fallen angel,” applies here. In that story Lucifer, once the most favored, is so convinced of his goodness he thinks he is the Supreme Being himself. He oversteps his created limits.

In modern industrial society the issue of access to healthcare is inseparable from the question of whether there is a right to healthcare and whether government has the correlative duty to assure a minimum level of care to all citizens. While discussion in terms of rights and duties tends to direct our attention to broader, more theoretical ethical issues, discussion in terms of ‘access’ invites consideration of more practical concerns. The news media rarely report in terms of whether a citizen's right to healthcare has been abridged or disregarded, but rather offers tales of people being denied access. Advocacy groups for specific illnesses do not necessarily argue for universal health insurance, but rather press that certain conditions, such as renal failure requiring dialysis, receive unlimited insurance coverage and that people with the condition be given automatic access to care.

Dolly, as we all know, is a sheep. And a very remarkable sheep. Not because of what she is, but because of the mode by which she appeared in our midst. Dolly was cloned in a laboratory by a technique called nuclear transfer; she is virtually genetically identical to a sheep born six years before she was. And we—and the ways in which we view the world and each other—will never be the same again.

Critics from a variety of camps have argued that bioethics has suffered an indifference to “difference.” Cases have been described as thin and the selves inhabiting them hollow. This criticism has been driven at least in part by a reworked conception of the self. The rational and autonomous self that once dominated bioethics discourse has been replaced with a more “textured” self, a self embedded in stories, relationships, families, communities, cultures, and other “thick” particularity—such as race, ethnicity, gender, sexual orientation, religion, and experience generally. The import of such a self is not simply descriptive accuracy; these contextual details—these differences—matter. They matter because they figure importantly into our ethical analyses of cases, affecting, for example, how we interact with and treat patients. And with this shift has come increasing attention to the processes of moral inquiry that enable inquirers to gather all of this moral information and find their way from complex cases to context-sensitive responses.

The debate regarding physician-assisted suicide continues in our society. Despite the recent opinions of the United States Supreme Court, this issue is unlikely to go away anytime soon. For a variety of reasons, this debate is now conducted in the legalistic terms of individual rights and liberties. As a result, perhaps we philosophers have been left behind. This is now a matter for the legal arena and philosophy is likely to be irrelevant. I would like to suggest otherwise for two reasons.

Examining health policy and its recent reform misadventures in the United States from a moral viewpoint is painful. That the nation devotes 14% of its Gross Domestic Product to health services—sometimes of doubtful clinical efficacy and value for money—and yet lets more than 40 million citizens go without health coverage strikes critics, both foreign and domestic, as a disgrace explicable only by ethical deficiencies distinctive to the American value system. There is certainly merit in this critique, which understandably incites fire and brimstone about the urgent moral imperative of getting the nation on the path of righteousness at last.

In writing this paper I am reminded of a conference that I once attended. On that panel, the Jewish scholar spoke first. “Let me tell you what the Talmud says,” he began, and he gave a wonderful talk full of references to the legal rulings and stories of the Jewish tradition. Then the Catholic priest spoke. “Let me tell you what the Magisterium says,” he began, and he gave a wonderful talk carefully attentive to the moral tradition of the Catholic Church. Finally, a Protestant spoke. “You have heard what the Talmud says and what the Magisterium says,” he began, “Now let me tell you what I think.” I didn't know whether to laugh or cry, but now I find myself in a similar situation.

Modern feminism has been preoccupied with difference. An early and continuing struggle has been to acknowledge differences between men and women without having those differences used against women. That struggle has been extended to recognizing differences among women. By the end of the 1980s, women were calling for a “politics of difference” in which “redefining our differences, learning from them, becomes the central task.” Although cautioning words were raised by some, feminists in general moved to trying not only to recognize but to celebrate difference.

The possibility of human cloning first surfaced in the 1960s, stimulated by the report that a salamander had been cloned. James D. Watson and Joshua Lederberg, distinguished Nobel laureates, speculated that the cloning of human beings might one day be within reach; it was only a matter of time. Bioethics was still at that point in its infancy—indeed, the term “bioethics” was not even widely used then—and cloning immediately caught the eye of a number of those beginning to write in the field. They included Paul Ramsey, Hans Jonas, and Leon Kass. Cloning became one of the symbolic issues of what was, at that time, called “the new biology,” a biology that would be dominated by molecular genetics. Over a period of five years or so in the early 1970s a number of articles and book chapters on the ethical issues appeared, discussing cloning in its own right and cloning as a token of the radical genetic possibilities.

This paper examines the following line of argument against allowing euthanasia in Canada: “[Sue] Rodriguez... argued that she be given the able bodied person's freedom of choice. But true choice requires equal support for a decision to live. ... Were freedom of choice in fact a primary concern, liberalized euthanasia legislation would require full levels of mandated social support. ...”

In “Euthanasia and Health Reform in Canada,” Michael Stingl argues that the legalization of euthanasia can be made reasonable social policy only in the context of healthcare reform to deliver primary- and community-based care. Stingl accepts that euthanasia “is in effect a treatment for unbearable suffering caused by a patient's health condition” and that includes not only pain, but “a personal response to a medical situation that the individual finds unbearable given his or her beliefs and values about the meaningfulness of human life.” He is not worried “about the reasonableness or validity of their request, but about the validity of the situation which leads to their request.” The failure of the healthcare system to adequately respond to the needs of people who are suffering with chronic or terminal conditions may lead competent people to elect euthanasia. Stingl argues that it is the institutionalization of care for dying people that reduces their ability to find meaning in prolonged life, and thereby makes it more attractive to consider ending one's life sooner. Options such as palliative care at home that significantly improve quality of life and make euthanasia less attractive are currently only available to those who can privately subsidize healthcare services. If an emphasis is placed on community-based initiatives and well-supported self-help, then there would be less inequality of healthcare and the voluntariness of choices, including euthanasia, would be more equal for all people under the healthcare system.

My discussion is presented in three steps: The present position of the Catholic Church; why it is a relatively recent tradition; and the roots of the tradition.

Cultural difference has been largely ignored within bioethics, particularly within the end-of-life discourses and practices that have developed over the past two decades in the U.S. healthcare system. Yet how should culture—specifically cultural differences as reflected among groups defined as ethnically or racially different—be taken into account?

Dolly is a lamb that was cloned by Dr. Ian Wilmut, a Scottish embryologist. But she is also a Rorschach test. The public response to the production of a lamb by cloning a cultured cell line reflects the futuristic fantasies and Frankenstein fears that have more broadly surrounded research in genetics and especially genetic engineering. Cloning was a term originally applied to a botanical technique of asexual reproduction. But following early experiments in the manipulation of the hereditary and reproductive process during the mid-1960s, the term became associated with human biological engineering. It also became a pervasive theme in horror films and science fiction fantasies. Appearing to promise both amazing new control over nature and terrifying dehumanization, cloning has gripped the popular imagination.