Philosophy and Medicine Rosamond Rhodes & Mark Sheldon, Co-Editors Spring 2005 Volume 04, Number 2

FROM THE EDITORS We offer you our profound regrets and apologies for not having provided advance notice of the change from print to online-only format for the Newsletter on Philosophy and Medicine. Copy for the Fall 2004 issue had been accepted under the presumption of business as usual, that is, paper copy mailed to members some time during the fall. We only learned of the Executive Director’s decision to make the change to online-only format starting with the Fall 2004 issue after the copy for that issue had been submitted to the APA in mid-July. The Fall 2004 issue, which was not posted until mid-January 2005, is only available to APA members who visit the APA website. Originally, the print version of the Newsletters had been mailed to all APA members free of charge. Then, a few years ago, the APA began to charge an additional fee for the Newsletters. Those who wanted to receive a copy had to check a small box that appeared on the annual dues notice and to add the fee to their payment. The most recent dues notice omitted that box. Some of us failed to notice the change. Others presumed that the omission signaled reverting to having the Newsletters mailed as a membership benefit. The change from a print format to an electronic format was not adequately communicated. Neither Newsletter contributors nor readers were notified in advance of the change to an online-only format. Approximately 4,000 of approximately 11,000 APA members have not provided the APA with an email address, and many of the email addresses that the APA has are obsolete. Nevertheless, the only notification of the change that members received consisted of an email note after the fact. APA members would have been better served by a general mailing that included an invitation for APA members to provide the National Office with an (updated) email address so that they would be able to receive notice of Newsletter postings in the future. Notification about the appearance of the online-only Newsletters was also inadequate. It would be very useful for readers who receive notice of Newsletter posting to be able to see the Table of Contents. Members could easily be provided with a list of articles along with a mechanism to open articles directly from the posting (e.g., hyperlinks or URLs). Since the APA has the electronic capability to electronically circulate surveys, the office should have the wherewithal to properly circulate the Newsletters’ full Table of Contents with hyperlinks or URLs. Newsletter availability is another important concern. We have repeatedly urged that the Newsletters posted on the APA website be made available without a membership restriction. This change would not involve any cost to the APA. It would also make the Newsletter contents available to students and to anyone who finds an article through a web or literature search. Open availability would promote greater readership and allow philosophy to play more of a role in ongoing public discussions. This issue is particularly significant for the Newsletter on Philosophy and Medicine because its contents are listed on Medline and PUBMED. Unrestricted availability would allow physicians and students, who are not likely to be APA members, to access Newsletter articles electronically. Whereas the APA Executive Director argued for discontinuing the paper version of the Newsletter because of low interest, he also argued for restricting access to the Newsletters because it is a crucial membership bonus and that making the Newsletters available to nonmembers would lead to a loss of APA members. These claims are contradictory and cannot justify both eliminating the paper edition of the Newsletters and also restricting access to the Newsletters. Furthermore, we question the authority for making a change of this magnitude without notification of the membership. It is not clear to us that the APA Board actually decided to eliminate the paper version of the Newsletters or that the Board considered or acted on the any of the issues mentioned above. Since these are matters that concern all APA members, they are issues that the Board needs to evaluate. They should also review questions such as: Who will lose access to the Newsletters by the change to an online-only format? What can be done to minimize the loss of access? Why have no Newsletters since the Spring 2001 been posted on the APA website? Because these issues concern all of us, all of our contributors, and all of our readers, we urge you to communicate your views to the APA Board as well. Regardless of these drastic changes, we have carried on. This edition of the Newsletter on Philosophy and Medicine is filled with the kind of work that readers are accustomed to find in these pages. It includes papers from two Committee-sponsored sessions along with two interesting submitted papers. One group of papers comes from panelists at the 2004 Eastern Division Meetings session on "The President’s Council on Bioethics: Political Legitimacy and the Report on Stem Cell Research," which was organized by David DeGrazia. The first paper, "On the Monitoring Stem Cell Research Report: Report of the President’s Council on Bioethics," was written by Alfonso Gómez-Lobo, who is actually a member of the Council. Separate papers by Leslie Francis, Timothy F. Murphy, and Hilary Bok present their own critical analyses of the importance of consensus, the membership of the Council, and the content of the report. Together this group of papers provides detailed and informative discussion of the Council’s role and some of the work that it has produced. The session sponsored by the Committee on Philosophy and Medicine at the spring 2004 Central Division Meeting was devoted to the ethical issues raised by "Home Health Care." This session was organized by Mark Sheldon and included presentations by Rosalind Eckman Ladd, Sheri Smith, and Martha Holstein. Ladd’s paper, "Ethical Issues in Home Health Care: The Ambivalent Client," examines the significance of a client who changes her mind and what significance this has in relation to the issue of competence. Sheri Smith, in "Context Matters: Ethical Issues in Home Health Care," lays out, in detail, the way the fact that the patient is at home creates unique ethical challenges. Finally, we were unable to obtain permission to publish Martha Holstein’s paper, since a more extended version of it will appear as a chapter in a book that will be published next spring by Johns Hopkins University Press. Also in this issue are two provocative articles that address enduring issues in medical ethics. "What Price Hope?" by Jeffrey P. Whitman is an interesting reflective discussion of the place of complementary and alternative medicine in the treatment of patients with serious chronic illness. It explores claims of efficacy and evidence and provides an account of the needs that medicine fails to address. "Desires and Values in Medicine" by Chad Bumgardner continues the discussion of the limits of paternalism. He challenges the neat categories that define autonomy in the contemporary literature with interesting examples and questions about desires and personal values. In sum, this is another exciting issue jam-packed with timely philosophical discussions. We want to continue to offer our readers similarly rich issues in the future. So, we remind you to think of this Newsletter as a place for your announcements, letters, papers, case analyses, poetry, and stories. Please feel free to volunteer a book review. Your contributions and queries should be sent to Rosamond or Mark at the addresses below. Please include your phone and fax numbers and email address. Rosamond Rhodes and Mark Sheldon Co-Editors, Newsletter on Philosophy and Medicine Rosamond Rhodes Box 1108 Mount Sinai School of Medicine One Gustave Levy Place New York, NY 10029 Phone: 212-241-3757; Fax: 212-241-5028 Email: rosamond.rhodes@mssm.edu Mark Sheldon Department of Philosophy and Medical Ethics and Humanities Program Northwestern University Evanston, IL 60208 Phone: 847-328-2739 Email: sheldon@northwestern.edu

FROM THE CHAIR

A Committee Energized by Great Topics for Critical Reflection

David DeGrazia George Washington University A half year into my tenure as chair of the APA Committee on Philosophy and Medicine, I would like to take this opportunity to introduce us to our readers and say something about our direction and immediate plans. I joined the group, as chair, in July 2004. The other committee members are Ben Rich (UC– Davis), Gary Seay (CUNY), Hilde Lindemann (Michigan State), Lee Brown (Howard), Mary Rorty (Stanford)—as well as Mark Sheldon (Northwestern) and Rosamond Rhodes (Mt. Sinai School of Medicine), who, as editors of our Newsletter, serve as ex officio members. Next July, Robert Baker (Union University) will join us as Hilde completes her term. My thanks to the outgoing chair, Ken Kipnis (University of Hawaii), for doing such a fine job in his tenure and for including me in committee deliberations for several months before my term began in order to give me a running start. Before joining the Committee on Philosophy and Medicine, my perception was that its most important functions were to sponsor high-quality panels for each APA divisional meeting and to maintain its excellent Newsletter on Philosophy and Medicine. One half year after joining the committee, my perception remains the same. While leaving the business of producing the Newsletter in the hands of its dedicated editors, I have so far focused more on the business of setting up panels. Over the years, as an outsider to the committee, I sometimes felt that panels featured too many familiar faces and were, at times, a bit "chummy." To be sure, the committee’s panels consistently addressed important issues and were of consistently high quality. And, admittedly, my experience was mostly limited to panels of Eastern Division meetings, which I attended. Still, I was a little uncomfortable. With so much talent spread around the field, I thought, maybe we could mix things up a bit more and bring to the table more people who were not among the familiar faces. After I suggested this to the committee, it quickly became apparent that it could be difficult to achieve the desired diversity while also ensuring expertise, or at least excellence, in the specific area represented by a given panel and finding individuals who planned to attend the meeting and were willing to serve! Nevertheless, we have agreed to try harder to mix things up and not to appoint ourselves to serve as presenters on panels— though it makes sense, we agree, to offer the service of moderating a panel we have organized (inasmuch as the service/prestige ratio of moderating is fairly high). At the recent 2004 Eastern Division meeting, we sponsored a panel entitled The President’s Council on Bioethics: Political Legitimacy and the Report on Stem Cell Research. I believe it is fair to rate the event as a success. Certainly, we had an enthusiastic audience, which filled the medium-sized room and spilled into the hallway—and, more importantly, remained for the four presentations and asked enough questions to stretch the event, easily, to two and a half hours. After introducing the panel on the President’s Council on Bioethics (PCB), I, serving as moderator, turned it over to them. Alfonso Gómez-Lobo (Georgetown University), who is a member of the President’s Council, addressed the ethics of stem cell research. Carefully noting that he spoke only for himself, he outlined his moral reasoning about this issue while also illuminating much of the PCB’s report, Monitoring Stem Cell Research. Hilary Bok (Johns Hopkins) challenged the PCB on several of its policy suggestions with special attention to the recommendation of a moratorium—as opposed to a ban—on cloning-for-biomedical research (a recommendation made in the earlier report, Human Cloning and Human Dignity). Addressing the charge that the PCB’s membership reflects the president’s conservative agenda, Tim Murphy (University of Illinois in Chicago) explained that the federal law permits a great deal of latitude in making appointments to advisory committees. Nevertheless, various appointment strategies could enhance public confidence in these committees, he argued, and the bioethics community would do well to devise means of communication that do not depend on prevailing political winds. Finally, Leslie Francis (University of Utah Law School) presented demographic data regarding the PCB’s membership and argued that the report on stem cell research could, at best, represent a modus vivendi rather than an overlapping consensus in the Rawlsian sense. For my part, I tried to keep each speaker to twenty minutes and directed the question-and-answer segment of the program. On the whole, the discussion was vigorous, illuminating, and civil. For the benefit of those unable to attend, and those attendees who would like to revisit the arguments, several (possibly all) of the presentations will appear in this issue of the Newletter on Philosophy and Medicine. This spring, our committee will sponsor one panel each at the Pacific Division meeting in San Francisco (March 25) and the Central Division meeting in Chicago (April 29). Both panels should be of great interest to those working in bioethics, the medical humanities, and related fields. The Pacific panel, to be moderated by Rosamond Rhodes, is entitled The Belmont Report: The 25^th Anniversary. The panelists will be Tom Beauchamp (Georgetown University), one of the authors of the Report, Ruth Macklin (Albert Einstein College of Medicine), Alex John London (Carnegie Mellon), Jodi Halpern (Berkeley), and Franklin Miller (National Institutes of Health). The title of the Central panel, which Hilde Lindemann will moderate, is The Limits of and Challenges to Liberalism in Bioethics. The speakers will be Howard Brody (Michigan State University), Agnieszka Jaworska (Stanford), Rebecca Kukla (Georgetown), and Margaret Battin (University of Utah). Speakers for both panels have been invited to submit their presentations, which we expect to be provocative and memorable, for publication in the Newsletter. Happy New Year!

ARTICLES

On the Monitoring Stem Cell Research Report of the President’s Council on Bioethics

Alfonso Gómez-Lobo Georgetown University I would like to start with some explanations and clarifications. Although I am a member of the President’s Council on Bioethics, I do not in any way speak for the Council, and, even less so, for the Bush administration. I speak for myself. would also like to make clear that I do not receive remuneration for my service on the Council (except for a modest per diem when the Council is in session) and am totally free to dissent from the administration. I should complement that remark by disclosing (something to be expected, or course, if you know what academic salaries in the humanities are like) that I am not invested in the biotechnology industry. The Council itself, as many of you know, holds its sessions at different public places in Washington, D.C., and the meetings are open to anyone who wants to attend. There is also time set aside for comments from interested citizens, as required by law. The meetings themselves consist, for the most part, of testimony from experts (as can be seen in the Appendices of the Monitoring Report) and open discussion among the members of the Council. These discussions are sometimes quite lively because, contrary to a widely disseminated view, this is a highly pluralistic body. There are deep differences of opinion on some of the most important issues, and the report we are examining clearly confirms this.

The Report¹The Report has five basic aims: (1) to explain what stem cells are, to describe their basic types, and to offer some indications with regard to the terminology employed in this domain of science; (2) "to clarify and explain the current federal policy regarding stem cell research and to make clear the legal, ethical, and prudential foundations on which the policy rests" (x); (3) "to provide an overview of the ethical and policy debates surrounding stem cell research in the two preceding years" (2002-2003) (ibid.); (4) to offer the non-scientific public an overview of "recent scientific developments in human stem cell research, embryonic and adult, basic and applied"(xi); and (5) "to convey the moral and social importance of the issue at hand and to demonstrate how people of different backgrounds, ethical beliefs, and policy preferences can reason together about it" (ibid.). At this point in time, I do not need to explain that stem cells have two basic properties: they can differentiate into the cell types of the developed organism, but they can also multiply without differentiation. This second property explains why stem cells have been found (and continue to be found) in organisms that are well beyond the embryonic stage. These are the so-called "adult stem cells." A better label would be "non-embryonic stem cells" to indicate that, for example, they are found in the cord blood of newborns. When stem cells were first isolated in 1998, it became immediately clear that they held great promise for the cure of diseases that are caused by the degeneration of cells of a certain type. If stem cells could be induced to differentiate into cells of the destroyed type and transplanted into the body of the patient, cures could be obtained. This is the source of the hope and the hype. The source of the public controversy, on the other hand, is that, in order to obtain embryonic stem cells, human embryos have to be intentionally destroyed. This, in my view, is the heart of the matter, and I will return to it presently. The Federal Funding Controversy The Report devotes considerable attention to the funding of stem cell research in order to explain and justify the policy of the Bush administration. That policy consists basically in allowing practically unlimited funding for research on stem cell lines derived from IVF embryos prior to August 9, 2001. The justification is developed at two different levels, the legal level and the moral level. From a legal point of view, the decisive fact is that, in 1996, Congress passed the Dickey Amendment that prohibits "the use of any federal funds for research that destroys or seriously endangers human embryos, or creates them for research purposes" (25). This is the background assumption that governs the withholding of funds. Although the law could be interpreted as allowing the use of funds for research on embryos that were previously destroyed using private funds, this probably goes against the spirit of the law because the law itself surely is to be understood as grounded on the moral principle that it is wrong to destroy human embryos. Why then allow the use of federal funds but only after a certain date? This is where the moral justification kicks in. It is a classical argument concerning complicity with (or appropriation of) evil. It is generally agreed that it is wrong to profit from or make use of the results of a morally wrong action, such as using medical data obtained through coercive or brutal means, as the Nazi doctors did. But it is also generally acknowledged that if the wrong action is distant in time, and no aiding and abetting of that type of action is now possible, then it could be morally permissible to use the proceeds of the action. Using Nazi medical records now (if they are of any use) would not encourage further Nazi research. A cut-off date then seems to make sense. By setting a cut-off date for the derivation of the stem cell lines, the use of federal funds to encourage renewed embryo destruction is blocked. There would be no financial incentive coming from taxpayers’ money to induce researchers to destroy more human embryos than the ones already destroyed in the past. Embryo destruction, of course, can be engaged in (and is being engaged in at present) using private funds because there is no federal ban on this activity. All of the above makes sense, of course, only if the principle that it is morally wrong intentionally to destroy human embryos is accepted, and on this the Council has been and is deeply divided. The Moral Standing of Human Embryos The Report devotes a section to this topic (3.IV A and B), sometimes using the expression "moral status," an expression that, in the minds of those of us who are foreign born, conjures up the idea of "immigration status," a status that an official confers upon one and may be withdrawn. I prefer to frame the question in terms of the inviolability of a human organism at the embryonic stage because this formula avoids both the suggestion of an external (and perhaps, arbitrary) conferral and the obscure notion of degrees of status. But in this I have been in the minority. The Council did not engage in a focused discussion of the moral status or the inviolability of human embryos. It was considered by some to be a divisive issue on which, in principle, there could be no agreement. Nevertheless, the report includes a summary of arguments for and against the claim that it is morally right to destroy human embryos for biomedical research. There are also some paragraphs devoted to the idea of "special respect" or "intermediate moral status" of human embryos, a thesis that was upheld during the sessions leading to the drafting of the cloning report by several members of the Council, notably by Michael Sandel and Francis Fukuyama.²This position leads to the acceptance of "the use of early embr yos in medically valuable research in some circumstances" (82). The view that a human embryo is just a clump of cells that deserves no respect whatsoever and may be destroyed without qualms has also been put forth in the Council, especially by Michael Gazzaniga, but, if I recall correctly, it did not find its way into this report. Another omission worth recording is the absence of religious views on early human life (except for a passing reference in a footnote on p. 78). I have been personally adamant in requesting that we not include religious traditions in our deliberations. I reached this position after reading Volume III of the NBAC 2000 report on stem cell research.³ The conviction I arrived at is this. Religious traditions certainly have much to tell us about compassion and the caring for the sick, but we should realize that the sources of divine revelation in the three major traditions in our midst (Jewish, Christian, and Muslim) all antedate by centuries the discovery of the female ovum in 1827 by Von Baer and the subsequent realization that there is a 50/50 genetic contribution by the mother and the father to their offspring. Without access to these basic biological facts, those traditions have nothing reliable to tell us about the beginning of a human life. The recurring reference to 40 days (or multiples of 40) after conception as marking the beginning of hominization seems to be either a standard application in the Talmud of a canonical number that appears often in the Torah (40 days of deluge, 40 years in the desert, etc.) or is derived from Aristotle’s date for quickening of the male embryo, as is clear in Aquinas and in Muslim scholarship. None of this is helpful today. No religious reasons appear in the report, nor should they. In my view, public discussion of early human life should be based exclusively on the biological evidence understood within a philosophical framework. Lógos, after all, is what we have in common. The report makes an effort to present, in a simplified form, the dissoi lógoi, "the double (or opposing) arguments," to use a late fifth century label, on whether human embryos deserve respect or not. The main arguments are well known to professional philosophers and touch upon the metaphysical problem of identity through time. The possibility of twinning (which allegedly ends with the appearance of the primitive streak) plays its standard role in the rejection of trans-temporal identity between an adult and the embryo from which she developed. The common moral background assumption is that a human individual deserves respect at any stage of her life, but on the basis of the twinning argument, some deny that the embryonic stage counts as a stage in the life of a human individual. With this move, the door is open for the standard consequentialist justification of embryo destruction, a form of justification embraced by many members of the Council. In reading this section of the report, one should not forget that this is not a philosophical treatise from which one could demand rigor and exhaustive argumentation. It is a government document that aims to present to the American public and its leaders the basic moral issues as the members of the Council see them. The report includes an appendix by Paul Lauritzen offering an overview of the ethics of stem cell research that can be read as tilted, in my opinion, towards the permissibility of embryo destruction. I am personally persuaded by the opposite view and would be happy to address the twinning objection in light of recent research that shows that there is differentiation from day one, and hence very early loss of totipotency on the part of the blastomeres. Although this might seem to be extraneous to the stem cell report, I actually found my way to this interpretation thanks to a key notion explained in the appendix authored by Rudolf Jaenisch. The reference to his contribution takes us from the highly disputed ethical issue discussed by the Council members to the actual monitoring of stem cell research contributed by the experts in the field and summarized by the Council staff. Two Years of Stem Cell Research For the general public, this may be the most important part of the report, for it contains a reliable and understandable overview of what has hitherto been achieved in the field and what the prospects are for the immediate future. It is quite useful, I think, to temper the hype, especially with regard to therapeutic applications. I should add that there is an update, prepared by the Council staff, covering the developments between January and November of 2004 that, as of this writing, has not yet been posted on the Council website. The actual overview of stem cell research is based upon expositions presented by leading figures in the field: John Gearhart on embryonic germ cells, Jamie Thomson (and Tenneille Ludwig) on embryonic stem cells, and Catherine Verfaille on multipotent adult progenitor cells. David Prentice, a biologist who follows the development of adult stem cell research, was asked to provide a comprehensive overview of his area of expertise. Their papers were printed without staff editing, and all the science in the report was carefully reviewed before publication by John Gearhart (Johns Hopkins), Ira Black (Princeton), and Diane Krause (Yale), all of them distinguished scientists who oppose the Bush policy on funding for stem cell research. I mention this revision simply to emphasize that if any non-scientist wants to obtain a reliable picture of what was going on in stem cell research by the end of 2003, the Monitoring Report would be a good place to look for it. In this connection, let me mention the greatest hype of all, and perhaps the most cruel one: that a cure for Alzheimer’s disease was just around the corner, if only more money had been thrown at embryonic stem cell research. After the publication of the Monitoring Report, the Council invited Professor Dennis Selkoe from Harvard, a leading figure in Alzheimer’s research, to inform the Council, and hence the public, on progress in his field. From the presentation and subsequent discussion, it emerged that the most promising leads have to do with protein inhibitors. At present, it seems, there are no viable research projects to cure Alzheimer’s involving embryonic stem cells. The silence of the Report on this matter was therefore justified. The Monitoring Report ends with two papers by Silviu Itescu and one by Rudolf Jaenisch from MIT. The latter deals with the process of cloning and has been for me ver y illuminating, especially because of the clarity with which it presents the almost irresolvable obstacles human reproductive cloning would have to face as well as the key notions of reprogramming, imprinted genes, epigenetic changes, and DNA methylation. This article is, in my opinion, an invaluable resource for the non-scientist. One Person’s View Let me finish, for whatever it is worth, with my own position after having been the lucky recipient of a free education in stem cell research. Most of what follows requires detailed argumentation that I cannot provide here. I am prepared to argue that whatever else we may be, we are essentially organisms; that, in spite of the apparent cogency of the twinning argument, it can be shown that those of us who are not twins (the vast majority of people) are trans-temporally identical with the zygote we once were, and that inviolability has to be co-extensive with one’s existence. Late onset of inviolability is morally inadequate. Later inviolability is of no use to me if it would have been morally permissible to destroy me at an earlier stage of my life. On this basis, it should come as no surprise that I see as a tragic step for humanity the project of intentionally dismantling humans who find themselves at the embryonic stage, a stage through which I also went, in order to harvest the core components of their organism. I would add that even those who have doubts about their having been an embryo should have reason to pause and rethink the meaning of this drastic and profoundly disrespectful instrumentalization of organisms that are at least biologically continuous with them now. Those young organisms, after all, contain the same genetic program they now possess in all of their cells. Is this an anti-science stand? I do not think so. It is, in fact, based on the best evidence science conveys to us today about our origins. In this connection, it is rewarding to read the article "Your Destiny, from Day One" by Helen Pearson (Nature, July 10, 2002). Moreover, if embryonic stem cells could be obtained without destroying human embryos, I would strongly support it. In fact, two proposals along these lines were submitted to the December 2004 meetings of the President’s Council, and I would be happy to discuss them with you. But if therapies are the ultimate goal, we should not underestimate the progress in clinical trials and clinical applications involving non-embryonic (i.e., adult) stem cells. For example, the December issue of the Journal of Cranio-Maxillofacial Surgery reported that a team from Giessen, Germany, repaired the skull of a seven-year-old girl using stem cells from her own fat. The fact that the cells were taken from the patient herself bypasses the problem of rejection and thus the standard rationale for individualized therapeutic cloning. And, of course, there are absolutely no moral problems related to the extraction of adult stem cells if informed consent has been provided. I hope I have given a fair account of what the Report is about and what my own position on the key moral issue is.

Endnotes Monitoring Stem Cell Research: A Report of The President’s Council on Bioethics, Washington, D.C. Januar y 2004. I quote from the pre-publication version. It is available at www.bioethics.gov Human Cloning and Human Dignity. An Ethical Inquir y. The President’s Council on Bioethics. Washington, D.C., July 2002, pp. 138 and 294-296. Ethical Issues in Human Stem Cell Research, Vol. III. Religious Perspectives. Rockville, MD. June 2000.

Stem Cell Research and the President’s Council on Bioethics: Of What Value is Consensus?

Leslie Pickering Francis University of Utah In my talk as part of this symposium, I took up these interrelated questions: (1) What should be the function or functions of the President’s Council, as it deals with issues such as stem cell research that apparently feature moral disagreement at the deepest level? Should it act as an "expert" scientific body providing peer-reviewed advice, such as the National Academy of Sciences? Should it provide ethical advice, and on what basis? Or, should it function to generate consensus on controversial issues, and in what sense? (2) How has the Council conceptualized its own functions, and what metaethical view(s) might lie behind these conceptualizations? (3) What are some of the crucial demographic similarities and differences among members of the Council that might be relevant to claims about the status of any consensus it might generate? (4) IF the Council sees itself as functioning to generate consensus, what sense of "consensus" is it using? Is this "consensus" in any interesting moral or political sense? My argument, in brief, is this. The Council sees itself as trying to provide the president with consensus reports on difficult ethical issues. But its makeup is too remarkably uniform on several important dimensions for the consensus it generates to be interesting as a representative political matter. Moreover, its approach to the analysis of stem cell research suggests that any consensus it has generated with respect to that issue can at best be regarded as a modus vivendi rather than an "overlapping consensus," to put the point in Rawlsian terminology. Its "consensus" report, therefore, is of limited interest as a moral justification.

Tasks for the Council Bodies such as the President’s Council might perform many different tasks. Perhaps the simplest would be to hand to the president "updates" about the issues under its purview, letting the president know what has been happening scientifically, legally, or in public debates. More to the point for an expert body, the Council might assess for the president the quality and significance of these developments. Like the National Academies of Science, it might give the president "expert" scientific advice—advice that is typically peer reviewed. As an "ethics" council, presumably it could generate expert advice about moral reasoning with respect to the issues it takes up— although it could see itself as engaged in creating scientific reports as well. Following out the model of science, however, any "expert" ethical advice would presumably require professional peer review. Still another task for the Council would be to present the president with legal or policy recommendations about what steps to take on these controversial issues. If it were to undertake this last task, the Council would function more like a political body but in an advisory role. As it approaches each of these tasks, the Council might— or might not—believe consensus is important. If so, it would need to confront questions about consensus. What must the consensus be about? The identification of issues? The conclusions? Or the reasoning structures used to reach these conclusions? (Multi-judge courts, after all, can reach consensus on the result in a case without agreeing on the reasoning used to reach it.) Who are the necessary parties to the consensus? For example, if the Council were presenting the president with expert scientific advice, perhaps the relevant consensus would be drawn from the scientific community—and not from the political community more broadly, which includes evolutionists and creationists alike. But if the Council were presenting the president with policy recommendations, something more like a democratic consensus might be most relevant. And why does consensus matter in the first place? Is it because consensus reveals that shared views are widespread across society? Because disagreement or backlash is less likely if a recommendation can be viewed as a consensus? Because consensus demonstrates that a decision resulted from a careful democratic procedure? Or because consensus suggests that the recommendations are true?

How the Council Viewed Its Task—Part One In drafting Monitoring Stem Cell Research, the Council deliberately and specifically avoided making policy recommendations. It took itself instead to be attempting to reach consensus about the current state of the issues regarding such research. In my judgment, however, the Council’s deliberations and report reveal deep complexities—and perhaps as deep confusion—about the Council’s understanding of its function. These conflicts about the Council’s task also surfaced in the session devoted to the Council’s work at the recent (fall 2004) meeting of the American Society for Bioethics and Humanities (ASBH), a session that generated rather more heat and perhaps less light in my judgment. The Council’s letter of transmittal to the president reported that it had consulted experts on "all aspects" of the research. Based on this consultation, the Council averred that it had tried to "present the arguments and counter-arguments, faithfully and accurately." The Council expressed the hope that it had demonstrated how "people of different backgrounds, ethical beliefs, and policy preferences can reason together" about stem cell research. In Monitoring Stem Cell Research, the report itself, the Council describes its members as trying to set personal moral views aside. It emphasized that it was eschewing policy recommendations—although it did make recommendations about federal policy at the present time. In Monitoring, the Council addressed several issues about stem cell research, outlining the arguments from the background papers and from other discussions. The Council saw itself as principally addressing this question: "How can stem cell research be maximally supported without encouraging the destruction of nascent human life for research purposes?" It achieved consensus on two points, that research involving embryos over fourteen days old should be prohibited and that federal funding should continue to be limited to research on lines from already-harvested stem cells without the further destruction of embryos to provide new cell lines. Finally, at the conclusion of the report, Council members express the importance to them of achieving consensus on all aspects of the report— although not necessarily on the justifications for it. There is yet further evidence that the Council believes that achieving consensus is an important task for it. In its posted mission statement, the Council rejects naïve moral relativism. For a body interested in ethical justification, consensus might be regarded as an alternative stance. Metaethical moral realists, to be sure, may reject consensus in favor of a "right" answer, such as that found in natural law— and there may be as many as five members of the Council who are natural law theorists (George, Gómez-Lobo, and perhaps Glendon, Kass, and Meilaender). Nonetheless, consensus might appear as a metaethical alternative. In their meeting in 2004 devoted to selecting topics for the president’s next term—to take a further example of the Council’s commitment to consensus—members of the Council sought topics on which there was likely to be agreement, and shied away from topics on which disagreement was likely, such as abortion, or topics on which they lacked expertise, such as justice in health policy more generally. At the ASBH session devoted to the Monitoring report, the Council chair, Leon Kass, pointed out that the report reflected a consensus—and that the Council was more representative than President Clinton’s NBAC had been, in terms of political affiliation. The Representativeness of the Council If the Council believes that consensus among its members is important, we might want to know something about levels of diversity on the Council. After all, the fact that consensus exists is only interesting insofar as it results from drawing together what might otherwise have been difference. Consensus that is merely agreement among those who already agree is uninteresting as consensus—if indeed it can be called an "achieved" consensus—although it might be useful to know that people already agreed on the matter in question. At the ASBH session on Monitoring, the Council’s chair, Leon Kass, defended its representativeness with respect to partisan political affiliation. It does not take long, however, to observe that the Council is not very representative in many other respects that might be equally important to the significance of the consensus it achieved. The following data are drawn from the Council’s website, from the respective websites of current Council members, and from the websites of professional organizations. Currently, there are eighteen members of the Council. All but one (Charles Krauthammer, a journalist trained as a psychiatrist) hold academic appointments—a fact that might lead others to question the Council’s representativeness. Of these, exactly one (Gómez-Lobo) is trained in philosophy (in Germany, at Tubingen), a member of a philosophy department and of the APA. Two members (Dresser and Glendon) are law professors. Six (Fukuyama, George, Lawlor, Sandel, Schaub, and Wilson) have training in political science or political theory/ philosophy, a particularly interesting finding in light of what we will see was the paucity of discussion of political philosophy in the Council’s deliberations or in the Monitoring report. One (Meilaender) is trained in Christian ethics. The remaining seven Council members are scientists or physicians, presumably to ensure adequate scientific understanding among Council members; counting Krauthammer, eight of the Council members have scientific or medical training. If bioethics is of special relevance to the Council, no members have specific training in that discipline. Only one member of the Council (Dresser) is a member of the American Society for Bioethics and Humanities. Two other Council members (Kass and Meilaender) have had longstanding associations with the field of bioethics. The academic institutions represented on the Council are an unusual mix. Only two Council members (Foster and Wilson) teach at a public university (Texas Southwestern and UCLA). The other Council members teach at private or religious institutions. The private institutions represented are Chicago (Kass and Rowley), Dartmouth (Gazzaniga), Harvard (Glendon and Sandel), Johns Hopkins (Carson, Fukuyama, and McHugh), Princeton (George), Stanford (Hurlbut), and Washington University (Dresser)—all institutions that might be regarded as "elite." The religiously-affiliated institutions represented are Berry College (interdenominational Christian) (Lawlor), Georgetown University (Catholic) (Gómez-Lobo), Loyola Maryland (Catholic) (Schaub), and Valparaiso (Lutheran) (Meilaender). States represented on the Council are California (2), Georgia (1), Indiana (1), Illinois (1), Maryland (4), Massachusetts (2), Missouri (1), New Hampshire (1), New Jersey (1), Texas (1), and Washington, D.C. (3, counting Kass and Krauthammer’s current affiliations as D.C.). Outside of Chicago, St. Louis, Stanford, and UCLA, only one member of the Council hails from beyond the eastern seaboard (Foster, at Texas Southwestern). One member of the Council (Carson) is African American and four (22%) are women. I could not ascertain political affiliations of Council members from information publicly available on the web; thus, I cannot verify Kass’s contention that they are politically diverse. I would note that several have associations with organizations recognized as conservative, such as Kass with the American Enterprise Institute and George with the Federalist Society. Quite a number—five, by my count—have interests in natural law theory, an approach to political theory associated with Leon Strauss. By contrast, one (Sandel) is a critic of Rawls, but none would appear roughly Rawlsian in persuasion. Thus, at least five (the Straussians) would appear to have conservative allegiances in political theory, and none would appear to have sympathies with one of the best known liberal political theorists (Rawls) of recent times. Thus the Council would appear not to be ver y representative on grounds of race, sex, class, or geographic distribution. It is highly skewed towards elite private and religious institutions. And it has limited expertise in its core fields of bioethics, ethics, philosophy, or health law; and no expertise at all in health policy. Does this matter? IF the role of the Council is to achieve consensus amid divergence, it might, depending on the type of consensus sought. IF, however, the Council is to be viewed on the model of other expert bodies, perhaps diversity doesn’t matter, but expertise does; there is no effort, for example, to have the Institute of Medicine be "representative" in the political sense in contrast to the sense of calling on the relevant expertise in developing reports. Unfortunately, the Council is limited in the variety of its expertise as well. Types of Consensus What kind of consensus were members of the Council seeking in the Monitoring report, and what kind matters? One account of the Council’s consensus is that the consensus in the report gave the president a description of where agreement in fact exists in society. This descriptive task might be particularly important for decisions about federal funding, if we think that federal funding should track public agreement—a view we do not hold for scientific research but might for issues such as funding of abortion where there is deep disagreement. The Council, however, does not contain the kind of expertise such as political scientists who do empirical work that might equip them to develop such reports. Nor did it see itself as representing a kind of popular consensus—if indeed a group with the Council’s makeup could be regarded as any sort of cross-section of viewpoints in the United States. A different account of the Council’s role is that it attempted to achieve consensus through difference. This seems to be what both Leon Kass and the Council itself thought. On this view, the Council might provide the president with a justification for certain policies—those policies on which consensus has been achieved. The Rawlsian distinction between a modus vivendi and an "overlapping consensus" is helpful in exploring whether the consensus the Council might try to achieve can be regarded as a justification for the views on which it achieves consensus. A modus vivendi is a mere agreement that allows people with different comprehensive ethical views to continue to function together politically. It provides no deeper justification than the fact of agreement. As I have already indicated, the Council does not have (and does not pretend to have) the kind of expertise that would allow it to report the presence of a modus vivendi across the larger society. And there are certainly questions about whether it contains the kind of representativeness that would enable it to put forth consensus among Council members as a modus vivendi of any broad scope. An "overlapping consensus" in the Rawlsian sense is a justification that all reasonable citizens in a democratic society can accept, whatever their comprehensive theories of the good. Understanding whether or not there is an overlapping consensus in any respect is a philosophical enterprise. It requires examining the kinds of justifications that can be offered for positions and whether they are shared among reasonable comprehensive views. It also requires examining where justifications are not shared as a matter of public reason— but instead derive only from the comprehensive views in which they are embedded. The consensus of the stem cell report, by its own characterization, is a modus vivendi; Council members indicate in their discussion at the conclusion of the report that their most important goal was achieving consensus rather than exploring the justifications that might support consensus and how they might do so.

How the Council Viewed Its Task, Part Two—What the Council Did Not But Should Have Done As an expert body, the Council could have attempted to provide expertise about moral argument. On this view, the Council might have at least analyzed for the president where there is the basis for an overlapping consensus, and where moral disagreements result from different comprehensive views. The Council might have attempted to unearth the assumptions made by and the arguments made for different positions in areas of moral controversy, such as stem cell research. The Council’s role would have been to present the most careful and balanced accounts of the moral arguments in the debate, including where the arguments can be made as a matter of public reason. This admittedly was not the model followed by the current Council, as is apparent in both the background papers and the Monitoring report itself. The Background Papers In developing Monitoring, the Council commissioned background papers in both science and ethical theory. There were eight background reports in all, five on aspects of the science of stem cell research, one on state law governing the research, one on the meaning of federal funding, and one on ethical issues. The legal background paper was by Lori Andrews (at Chicago–Kent), perhaps the best known legal expert in the area, and presented a comprehensive survey of state law governing stem cell research, proposed state statutes, and likely constitutional challenges. The paper on the meaning of federal funding, by Peter Berkowitz (from George Mason Law School and Stanford’s Hoover Institution), argues that there is no right to federal funding, that those who would like to see changes in federal policy should seek them through the political process, and that stem cell research is no exception in these regards. It does not, however, present a careful or rigorous analysis of the significance of moral disagreement to political justification, other than advancing the author’s own position that changes should be sought through the political process. The ethics paper was by Paul Lauritzen (professor of religious studies at John Carroll University). In the paper, Lauritzen contends that the stem cell debate has been too narrowly focused on the moral status of the embryo (to which, by the way, he does not object). Instead, he suggests, the debate should focus on the issues raised by the technology of stem cell research generally: commodification of human tissue, justice in access to the results of research, and reunderstanding what it means to be human. Lauritzen’s view is that both proponents and opponents of stem cell research must take seriously the trajector y of human life and the potential problems involved in extending the human life span. The paper is a summary of the arguments about what it means to be human and is not particularly philosophically deep. As a part of its proceedings, the Council also discussed a paper by Gene Outka, professor of religious studies and philosophy at Yale, exploring whether the "nothing more is lost" principle permits the killing of innocents who would otherwise be sacrificed in any event and can justify the use of embryos for stem cell research. The "nothing more is lost" principle, as Outka understands it, allows use of the fruits of immoral activity if nothing more is to be lost. The Council’s discussion was highly critical of the paper’s analysis of the principle’s breadth. These papers, and discussions of them, represent the entire background in moral philosophy presented to the Council, at least as a matter open to public observation and discussion. How the Questions Were Framed in Monitoring In Monitoring, the Council started with the assumption that embryos ought not to be destroyed for research purposes. It then asked when it is permissible to use the fruits of what will not be brought into existence. Three conditions of permissibility are identified: there must not have been cooperation in the destruction, destruction must not be abetted, and the act of using what has been destroyed must affirm the principle previously violated. In the judgment of the report, government funding expresses support for a policy and thus is problematic if it can be regarded as in violation of one of these conditions. Hence the Council concludes that the Bush administration boundar y of permitting federal funding for research with already-created stem cell lines finds ethical support. In reaching this conclusion, the Council analogized this limit to other restrictions on research with human subjects, contending that we set many moral limits on human subject research, and this one is no more problematic than the others. The report stopped short, however, of exploring the nature of support for the analogy. In framing the discussion in this way, the Council accepted as a given that there is no middle ground between those who find the destruction of embryos abhorrent and those who do not (39). But it fails to explore the nature of the arguments for these views, and, hence, either the extent to which they can be part of an overlapping consensus or the significance of making public policy in the face of contending comprehensive views. In fairness, Monitoring does observe that this may be a problem, writing that some have criticized contemporary discussions for failing to pay attention to the appropriate process of policy development. But the report goes no further in considering different accounts of or justifications for this process. The report took this structure as a given. Most troubling, in my judgment, is that it failed to scrutinize the arguments that have been given for framing the problem in this way. Although the Council canvassed various views about the biological features of the embryo that some have found to make a moral difference, it did so in the descriptive manner of an introduction to a (bad) applied ethics text book. It simply lists the points people have made on one side or the other, without doing the work to explore the arguments underlying them. Readers of the report, therefore, are left without any sense of the ethical foundations of different positions in the debate or any tools that might be used to assess them. Thus the reader cannot, based on the report, judge whether a position about stem cell research is—or is not—part of an overlapping consensus based in public reason. Far from contributing to an assessment of the kinds of arguments that should inform public reason, the Council simply assumed that existing arguments must remain entrenched. In so doing, it deepened rather than enlightened the character of our public discussion. Enlightening the character of public debate, by contrast, was the model for the first President’s Commission, the one from the years of the Carter Presidency. That first Commission provided genuine contributions to bioethics—many still classics today—from people trained in philosophy, economics, law, and other related fields. Unfortunately, the current Council apparently does not see its role in this way.

Representation and Balance on Presidential Commissions

Timothy F. Murphy, Ph.D. University of Illinois College of Medicine at Chicago It was President Ronald Reagan’s 1987 Presidential Commission on AIDS that first drew my attention to the staffing of federal bodies. I objected to several appointees, especially one member who objected to homosexuality as one of the great moral evils of the age,¹ and some of the scientist and physician members had no experience with AIDS research or patient care.² How was a commission with members like this going to be sensitive to the needs of people with AIDS in the United States? After a period of unproductive wrangling, the original chair left, and the Commission eventually managed to put together a 1988 document that made a number of decent—if overdue—recommendations. I still wonder where the United States might be in the effort against AIDS if that Commission had had other members from the beginning. The membership of federal advisory commissions is always a sensitive topic, and the current president’s choices are no exception to this rule. Both the procedure for making appointments and the members themselves have drawn fire in George W. Bush’s administration. For example, the Los Angeles Times has reported that the White House asked potential nominees to federal scientific advisory committees about their political views.³ Some nominees were asked if they favored the death penalty, abortion, and the like. In some cases, the nominees were directly asked if they voted for the current president. Depending on what answers these candidates gave, their names did or did not go forward for further consideration. The Union of Concerned Scientists has called attention to what it described as a pattern of suppression and distortion of scientific findings across the Bush administration.⁴ To be sure, scientific expertise in drug addiction, gene therapy, and bioterrorism cannot be measured through political commitments: scientific expertise does not belong to one political party, Republican, Democrat, Libertarian, or the rest. On the contrary, this kind of political profiling suggests that the administration was looking not for disinterested evaluation but for advice compatible with its political agenda. A few advisor y commissions on ethics have done significant and credible work for the government, and we owe their membership thanks for their efforts. These groups include the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research and, more recently, the Advisory Committee on Human Radiation Experiments. For the record, though, it should be noted that even these advisory bodies drew some criticism over their membership. Even so, the current criticism of the president’s bioethics choices has been considerably sharper. Many leading bioethicists have expressed doubts about the credibility of the current president’s Council on Bioethics. For example, Robert Cook-Deegan, Director of the Center for Genome Ethics, Law, and Policy at Duke University, has said: "the credibility of this Council is now deeply damaged, probably irreparably, except in the ‘already converted’ neocon circles. …It’s too bad. The nation needs a bioethics council that works. I don’t think this one can."⁵In part, some of the difficulties of the current Council may be traced to early political missteps. For example, in July 2001, the president was formulating policy in regard to federal funding of human embryonic stem cell research, and he asked Professor Leon Kass of the University of Chicago to make a presentation on the matter, and he also asked Kass to identify someone who held a different viewpoint. Kass invited Daniel Callahan, with the result that the discussion yielded more agreement than disagreement.⁶ When it came to representing a broad spectrum, these two eminent scholars were not opposing interlocutors for one another. Later that year, the president went on to create the Presidential Council on Bioethics, and he appointed Kass as its chair. As the White House went about the business of appointing other council members, its staff did indeed ask at least one potential member about her political views. Given this history, the seeds of doubt about fairness in balance and representation were already planted when the Council met for the first time in January 2002.⁷It was not long before other concerns surfaced. Eric Meslin of Indiana University wondered aloud about the nature of the executive order establishing the Council. In particular, he wondered about the directive that the Council be "guided by the need to articulate fully the complex and often competing moral positions on any given issue, rather than by overriding concern to find consensus." While this might look like circumspect moral counsel to pay attention to everyone involved in the argument, Meslin wondered whether this very approach would undercut the Council’s actual advisory role.⁸In other words, was the president setting the Council up to be irrelevant, to lose it in academic busy work and inviting it to speak in the kind of academic language lost on legislators and policymakers? Meslin also criticized the executive order for failing to include specific reference to "public members."⁹In any case, if the White House was hoping for unanimous judgments from its bioethics advisory body, it was surely disappointed. In its first report, the Council did agree in calling for a ban against the use of somatic nuclear transfer (SNT) for producing children, but the Council divided when it came to human somatic nuclear transfer for research. One camp recommended a moratorium on somatic nuclear transfer for research. The reasons for this moratorium varied; some members of the majority wanted more time for study and for putting regulatory oversight mechanisms into place. Others wanted to use the time to press the case with the public that SNT should never be done. By contrast, the other camp recommended using SNT for research, provided appropriate regulatory mechanisms were put in place.¹⁰In February 2004, as terms came round for renewal, the president let two members of the Council go, and—not surprisingly—accusations flew that the White House wanted a more compliant Council. The two let go—William May and Elizabeth Blackburn—were among the members who supported human somatic nuclear transfer for research. Why were they—and not others—singled out? Leon Kass took to the op-ed pages of the Washington Post to explain.¹¹ He said William May did not want to stay longer, and Professor May agreed with that account. Kass applauded Blackburn’s expertise and insight even as he took a swipe at her by noting that "her important work kept her from attending many council meetings," saying this despite the fact that she did not have the worst attendance record.¹²Ultimately, though, Kass remained silent about any rationale for removing Blackburn from the Council. It probably did not help that Professor Blackburn and another councilor had criticized specific council recommendations and said, further, that the Council had ignored analysis they wanted represented in those reports.¹³ For her part, Blackburn did not go quietly: she indicated that many choices about and by the Council opened it to perception of bias.¹⁴ Even so, Kass called the council "easily the most intellectually and diverse of the bioethics commissions to date."¹⁵In other remarks, Kass said that he didn’t know anything in particular about the views of the new members of the Council, but their public remarks suggest that their views are more compatible with the administration’s views than those of the two members they replace.¹⁶ For example, new member Diana J. Schaub has said that the use of somatic nuclear transfer for research purposes "is slavery plus abortion."¹⁷ Another new member, Peter A. Lawler, has publically stated his opposition to abortion. To protest the decision to let Professor Blackburn’s appointment expire, more than 100 U.S. bioethicists asked the president for a better explanation of what happened, saying the changes compromise the credibility of the Council. The White House offered no reply. In one sense, it might seem like partisan carping to complain about the personnel presidents turn to for advice, but the membership of federal advisory bodies is not—in a strict sense—entirely discretionary. As a matter of law, the President’s Council on Bioethics is subject to the 1972 federal Advisory Committee Act.¹⁸ This Act requires membership to be "fairly balanced in terms of the points of view represented and the functions to be per formed by the advisor y committee." The Act also requires that committees make "appropriate provisions to ensure that advisor y and recommendations...will not be inappropriately influenced by the appointing authority or by any special interest, but will instead be the result of the advisory committee’s independent judgment."¹⁹From a philosophical point of view, a key issue to be noted is that the terms of balance and function are not specified exactly. As it stands, this language is open to var ying interpretation and could accommodate any membership that is not, strictly speaking, completely one-sided or completely unequipped to carry out its duties. In practice, then, there is a lot of discretionary authority when it comes to appointing bioethics advisory groups. Moreover, the language of the Act is such that it is not clear exactly how one could argue that its terms have been violated. Except for egregious instances in which relevant parties had been intentionally excluded, there are ways to appoint an advisory body that is—on paper— balanced, but which, in fact, leans one way or the other. To make this point more plainly, it is not clear that there has ever been a successful challenge to an advisory body on the grounds that its membership violated the requirements of this Act. In addition to federal requirements, the nature of the advisory body’s tasks can also suggest standards to guide the selection of members. The charge to the Presidential Council on Bioethics is broad, to say the least, and its mandate is flexible enough to justify the appointment of almost any single member or group of members without worrying that—through that appointment—the body ’s goals cannot be met. Specifically, the president has charged the Council to advise him on bioethical issues and—in the course of doing so—to undertake fundamental moral inquiry into the human and moral significance of developments in biomedical and behavioral science and to explore ethical and policy questions related to these developments.²⁰ The Council is also expected to provide a forum for a national discussion of bioethics, to facilitate a greater understanding of bioethical issues, and to explore possibilities for useful international collaboration on bioethical issues. As there are many ways to meet these goals— especially the charges that do not ask for legislative or policy recommendations on specific matters—the membership of the Council can be composed in many different ways that do not impede its stated functions. Despite legislative and procedural cautions about observing balance in advisory bodies, it is almost impossible to underestimate the way in which political concerns guide the choice of membership. From a political point of view, presidents are cautious creatures and frequently unwilling to move to the vanguard of new social ventures or research. For example, in 1986, the U.S. Surgeon General produced an AIDS report that recommended, among other things, AIDS education starting in grade school. The report also cautioned against excessive testing programs with the sole purpose of identifying people with HIV infection. These recommendations and others like them caused considerable consternation in President Reagan’s political base. Enter the political need for another set of recommendations from the administration. While one might assume that a presidential advisory body on AIDS would be a natural development within an administration faced with a novel epidemic of communicable disease, it is not clear that the Reagan administration wanted the very Commission it eventually put in place. In fact, one commentator observed skeptically that "the Commission was created to deflect attention from the administration’s own inept policy response to AIDS."²¹ It is no wonder, therefore, that the Reagan White House went on to appoint members who could be expected to pay attention to the moral and social concerns of the president’s constituency. Whether it is Congress or the president appointing advisory bodies, their creators will certainly pay attention to the political risks of doing so, asking themselves whether there is more political gain or risk from these bodies, bioethics advisory groups included. One way to contain what risks there are is to appoint members who—while meeting the stated purposes of the advisory group—will not rock the political boat more than necessary. It would be odd for a president to seek counsel from people whom he expects to put him at political risk with the voters who put him in office. It is true that advisory bodies can offer the president a certain amount of political cover. Since their recommendations are not binding, advisory bodies can float ideas in order to gauge their political reception. If the ideas are not well received, the president can always distance himself from the group’s views—but, in general, one should not expect recommendations to differ radically from the political soil in which they have grown. One way to minimize substantial political risk is, of course, to sideline advisory committees into public education or other less controversial areas.²² It can be wondered if the Presidential Council on Bioethics is not drifting more and more this way. The second Council report offered an overview of the science and ethics of human embr yonic stem cell research, an overview of the scientific and ethical issues involved. In 2003, the Council issued Beyond Therapy: Biotechnology and the Pursuit of Happiness, which plunked down a number of concerns associated with technological tools used to enhance human life and to extend the lifespan.²³ In 2003, the Council also issued Being Human, an anthology of texts from short stories, poetry, memoirs, and novels, because these readings "can contribute to a richer understanding and deeper appreciation of our humanity, necessar y for facing the challenges confronting us in a biotechnological age."²⁴Whatever its next projects, most of the Council’s efforts to date have not involved specific advice to the president in regard to legal and policy matters. To be sure, each major bioethics advisory body has embraced some degree of responsibility for public education, but as George Annas has put it, the Council now seems to be in the business of conducting a national seminar.²⁵ There is, of course, a lot of expertise that could be represented on federal advisory bodies in the name of public education, but balance and representation in membership really does matter here, too, especially when it comes to framing particular issues, or even in making judgments about which samples of literature best represent the ethical issues at stake in bioethics.²⁶So far, most commentators looking at governmental advisory bodies have asked whether bioethics is good for government,²⁷ and in this regard there is—appropriately—lots of concern that advisor y bodies be constituted in a representative and balanced way. But another question is at stake, too: Is the government good for bioethics? As a matter of drawing public attention to the goals and methods of the field, the answer appears to be an unequivocal and legitimizing yes. But it should also be asked whether governmental advisory bodies are the best way for bioethics as a field to conduct research and communicate with public and policymakers alike. I ask this question, of course, in full knowledge that the main professional association of bioethics in the United States does not adopt positions on burning political issues of the day. That is, it cannot adopt a position that says, in effect, it is opposed to federal sponsorship of human embryonic stem cell research, the use of somatic nuclear transfer to produce babies, or any other matter. When it comes to offering deliberated judgments from professionals active in the field, this bioethics association stands mutely on the sidelines, confined by its by-laws mostly to educational exchange. I mention this professional silence because governmental advisory bodies, while useful, should not be the only sources of deliberated and considered advice from bioethics, especially when it comes to public education. As matters stand, there is a communication gap between bioethics as a field and the public it hopes to serve. Looking to presidential advisory bodies as the most important or primary mechanism through which to help conduct public education and determine public policy strikes me as a case of asking too very little from the profession. I believe that bioethics ought to find its own mechanisms for communicating fully deliberated views to the public, legislatures, and policymakers in order to make it less susceptible to the political winds of the moment. Presidents surely have need for real advice from advisory bodies from time to time, but they will ask for this advice only when there is enough political gain in doing so. A more mature bioethics is one in which its leaders offer their collective and deliberated counsel when it is ready and not simply in response to requests that are sometimes only a part of a larger political strategy. I want to offer one note of caution, too, in regard to bioethics theory and its sense of ethical problems. Key texts of bioethics typically treat the "state" and "government" as an idealized Platonic form, as if there were no ethical questions to be asked about how legislatures, agencies, departments, and institutions do their work. A great deal of bioethics theory treats the state as a morally neutral system of levers, which may be pushed or not, depending on the appropriate uses of government. For example, one looks in vain in most texts for counsel about the moral ambiguities of working through institutional and political organizations in all their complexity, about the ethics of compromise, or standards of institutional integrity. I mean no disrespect to the pioneers of bioethics, but it really is time that we start asking more fine-grained questions about how government works to avoid complicity with dubious compromises, to avoid partisan erosions of public goods, to examine what it means to accept help from parties with dirty hands, and so on. And—as I have been suggesting all along here—I think we also need to ask what it means to have