Sources and References

• Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. 8th ed. Oxford University Press, 2019.
• Wicclair, Mark R. “Conscientious Objection in Medicine.” Bioethics 14, no. 3 (2000): 205–227.
• Schuklenk, Udo. “Conscientious Objection in Medicine: Accommodation versus Professionalism and the Public Good.” British Medical Bulletin 126, no. 1 (2018): 47–56.
• Dea, Shannon. “A Harm-Reduction Approach to Abortion.” In Without Apology: Writings on Abortion in Canada, edited by Shannon Stettner. AU Press, 2016.
• Schuklenk, Udo, Johannes J. M. van Delden, Jocelyn Downie, et al. “The Royal Society of Canada Expert Panel: End-of-Life Decision Making.” In Bioethics in Canada, edited by Charles Weijer, Anthony Skelton, and Samantha Brennan. Oxford University Press, 2013.
• Shahvisi, Arianne. “Engendering Harm: A Critique of Sex Selection for ‘Family Balancing’.” Journal of Bioethical Inquiry 15, no. 1 (2018): 123–137.
• Saulnier, Katie M., Hortense Gallois, and Yann Joly. “Prenatal Genetic Testing for Intersex Conditions in Canada.” Journal of Obstetrics and Gynaecology Canada 43, no. 3 (2021): 369–371.
• Asch, Adrienne. “Disability Equality and Prenatal Testing: Contradictory or Compatible?” Florida State University Law Review 30, no. 2 (2003): 315–342.
• Evans, John H. “Setting Ethical Limits on Human Gene Editing after the Fall of the Somatic/Germline Barrier.” Proceedings of the National Academy of Sciences 118, no. 22 (2021): e2004837117.
• Alessandri, Angela J. “Parents Know Best: Or Do They? Treatment Refusals in Paediatric Oncology.” Journal of Paediatrics and Child Health 47, no. 9 (2011): 628–631.
• DeMichelis, Carey. “The Best Interests Standard as a Logic of Empire: Unpacking the Political Dimensions of Parental Refusal.” The American Journal of Bioethics 18, no. 8 (2018): 83–85.
• Richmond, Chantelle A. M., and Catherine Cook. “Creating Conditions for Canadian Aboriginal Health Equity: The Promise of Healthy Public Policy.” Public Health Reviews 37 (2016): 2.
• Manuel, Arthur. “From Dispossession to Dependency.” In Whose Land Is It Anyway? A Manual for Decolonization, edited by Peter McFarlane and Nicole Schabus. Federation of Post-Secondary Educators of BC, 2017.
• Nath, Rekha. “The Injustice of Fat Stigma.” Bioethics 33, no. 5 (2019): 577–590.
• Farrelly, Colin. “Aging, Equality and the Human Healthspan.” HEC Forum 36, no. 2 (2024): 187–205.
• Goering, Sara, Eran Klein, Laura Specker Sullivan, et al. “Recommendations for Responsible Development and Application of Neurotechnologies.” Neuroethics 14, no. 3 (2021): 365–386.
• Dresser, Rebecca. “Dworkin on Dementia: Elegant Theory, Questionable Policy.” The Hastings Center Report 25, no. 6 (1995): 32–38.
• Spital, Aaron, and James Stacey Taylor. “Routine Recovery of Cadaveric Organs for Transplantation: Consistent, Fair, and Life-Saving.” Clinical Journal of the American Society of Nephrology 2, no. 2 (2007): 300–303.
• Stanford Encyclopedia of Philosophy entries on bioethics, informed consent, disability ethics, euthanasia, and reproductive ethics.

Chapter 1: Foundations of Biomedical Ethics

1.1 What Is Biomedical Ethics?

Biomedical ethics (生命医学伦理学) is the systematic study of moral questions arising in the health sciences, clinical medicine, and biomedical research. It draws on moral philosophy, law, social science, and medicine to evaluate issues such as the patient-physician relationship, reproductive technologies, genetic testing, resource allocation, and end-of-life care. As a subdiscipline of applied ethics (应用伦理学), biomedical ethics does not merely describe what people believe; it asks what people ought to do and seeks to justify those prescriptions through rigorous argumentation.

The field emerged in its modern form during the mid-twentieth century, catalyzed by revelations of research abuses (the Nuremberg Trials, the Tuskegee Syphilis Study), rapid technological change (organ transplantation, life-sustaining treatment, in vitro fertilization), and broader social movements demanding civil rights and patient autonomy. In Canada, bioethical debate has been shaped by constitutional principles of equality and liberty under the Canadian Charter of Rights and Freedoms, the publicly funded health care system, and the country’s multicultural and Indigenous contexts.

1.2 The Principlist Framework: Beauchamp and Childress

The most influential framework in contemporary biomedical ethics is principlism (原则主义), developed by Tom L. Beauchamp and James F. Childress in their landmark textbook Principles of Biomedical Ethics, first published in 1979 and now in its eighth edition. Rather than deriving ethics from a single overarching theory (utilitarianism, Kantianism, or virtue ethics alone), Beauchamp and Childress identify four mid-level prima facie principles (初始义务原则) that capture widely shared moral convictions across diverse ethical traditions. These principles function as starting points for moral reasoning; none automatically overrides the others, and conflicts among them must be resolved through careful contextual judgment, a process the authors call specification (具体化) and balancing (权衡).

1.2.1 Respect for Autonomy

Autonomy (自主权) literally means “self-rule.” In the biomedical context, respect for autonomy requires that health care professionals acknowledge and support a competent patient’s right to make informed, voluntary decisions about their own care. This principle grounds the practice of informed consent (知情同意), the duty to protect confidentiality, and the legal recognition of advance directives.

Respect for autonomy is not unlimited. If a patient’s autonomous choice would gravely endanger others (for example, refusing quarantine during a virulent epidemic), other principles or public-interest considerations may justifiably constrain individual liberty. Furthermore, certain populations – young children, persons with severe cognitive impairment – lack the capacity for autonomous decision-making, which gives rise to questions about surrogate decision-making (代理决策) and the best interests standard (最佳利益标准).

1.2.2 Non-Maleficence

Non-maleficence (不伤害原则) is often summarized by the Latin maxim primum non nocere (“first, do no harm”). This principle imposes an obligation not to inflict harm on others. In clinical medicine, it requires that physicians avoid treatments or interventions whose risks of harm outweigh their potential benefits. It also encompasses negligence: a health care provider who fails to meet the standard of due care and thereby causes preventable injury violates non-maleficence.

1.2.3 Beneficence

Beneficence (行善原则) requires that health care professionals act in the best interest of the patient by relieving, lessening, or preventing harm and by providing benefits. Two sub-principles fall under this heading: positive beneficence (the duty to confer benefits) and utility (the duty to balance benefits against risks and costs in order to produce the best overall outcome).

Beneficence can come into tension with autonomy when a physician judges that a patient’s choice is medically detrimental. Paternalism (家长式作风) – overriding a patient’s autonomous decision for their own good – may be justified in rare circumstances (so-called “strong paternalism”), but contemporary bioethics strongly favors patient self-determination.

1.2.4 Justice

Justice (正义 / 公正) concerns the fair distribution of benefits, risks, and costs. In health care, questions of justice arise at many levels: who receives scarce organs for transplantation? how should public health budgets be allocated? does a universal health care system owe the same services to every resident?

Beauchamp and Childress identify several material principles of justice that different theories emphasize:

• To each person an equal share
• To each person according to need
• To each person according to effort
• To each person according to contribution
• To each person according to merit
• To each person according to free-market exchanges

No single material principle captures everything we mean by justice, and different contexts call for different weightings. Distributive justice (分配正义) in health care typically gives considerable weight to need, which is why triage systems prioritize the most urgently ill, and why publicly funded systems aim to guarantee a minimum standard of care for all.

1.3 Criticisms of Principlism

Although the four-principles approach is dominant, it has attracted significant criticism. Some philosophers charge that the principles are too abstract to resolve real disputes without the kind of contextual narrative judgment that casuistry (决疑法) or feminist ethics (女性主义伦理学) provide. Others argue that principlism is culturally parochial, reflecting a Western liberal emphasis on individual autonomy that may not translate to collectivist cultures. Still others maintain that the framework offers no principled method for adjudicating conflicts among the four principles, leaving it open to ad hoc rationalization. Despite these objections, principlism remains the most widely taught and applied framework in biomedical ethics because of its practical flexibility and its capacity to structure complex moral deliberation across diverse cases.

1.4 Constructive Disagreement in Bioethics

A distinctive feature of philosophical bioethics, as emphasized in this course, is the practice of constructive disagreement. Unlike adversarial debate, constructive disagreement proceeds from the assumption that each person’s experience, imagination, and knowledge are limited. Others can help you think more carefully by sincerely trying to understand your view and then asking honest, challenging questions about the parts they do not understand or with which they disagree. The goal is not victory but clarity: you may end up with a deeper understanding of the view you already held, or you may change your view – either outcome represents philosophical progress.

Chapter 2: Conscientious Objection in Medicine

2.1 The Problem

Modern medicine increasingly offers legal services that some health care professionals find morally objectionable. Physicians have refused to participate in abortions, prescribe contraception, provide assisted dying, or treat transgender patients, claiming that doing so would violate their conscience (良知). When such refusals affect patients’ access to lawful health care, a conflict arises between the professional’s claim to moral integrity (道德完整性) and the patient’s right to receive timely, competent care.

2.2 Wicclair’s Defence of Accommodation

In his influential 2000 article, Mark R. Wicclair argues that conscientious objection in medicine can carry significant moral weight, but only under certain conditions. His central claim is that the most promising justification for honouring appeals to conscience is respect for moral integrity – the coherence between a person’s actions and their core moral commitments.

Wicclair proposes several guidelines for evaluating appeals to conscience:

1. An appeal to conscience has genuine moral weight only when it is grounded in core ethical values that correspond to recognized moral values within medicine (not mere personal preference or prejudice).
2. The objecting professional must provide timely notice and referral, so that the patient’s access to care is not obstructed.
3. The strength of a conscience claim is inversely related to the burden it imposes on the patient – the greater the obstacle to patient access, the weaker the claim.
4. Conscience claims regarding genuinely controversial procedures (such as assisted dying in jurisdictions where it is newly legalized) carry more weight than objections to well-established, ethically settled practices.

Wicclair thus occupies a moderate position: he neither endorses unlimited conscientious objection nor denies it any role. Instead, he seeks criteria that balance respect for the physician’s moral integrity against the patient’s legitimate interest in receiving care.

2.3 Schuklenk’s Case Against Accommodation

Udo Schuklenk (2018) takes a considerably harder line. He argues that health care professionals who refuse to provide lawful services on conscience grounds are acting unprofessionally and should not be accommodated. His reasoning rests on several key premises:

1. Monopoly power. In most jurisdictions, licensed physicians are the sole authorized providers of medical services. Patients cannot obtain prescriptions, perform surgery, or access certain treatments without the cooperation of a physician. This monopoly imposes a corresponding obligation to serve all eligible patients.

2. Voluntary entry. No one is compelled to become a physician. By entering the profession, individuals voluntarily accept its duties, including the duty to provide all lawful services within their competence. To claim a right of refusal after assuming the role is akin to accepting a job and then refusing to do core parts of it.

3. Patient harm. In practice, accommodating conscientious objectors frequently harms patients, particularly those in rural or underserved areas who have no alternative provider. The burden of objection falls disproportionately on vulnerable populations.

4. The public good. Health care systems exist to serve patients, not to protect the moral sensibilities of professionals. When these interests conflict, the patient’s right to care should prevail.

2.4 Comparing the Two Views

Both authors agree that patient access to lawful care is morally important. They disagree about whether the physician’s conscience can ever justifiably limit that access. This tension has become practically urgent in Canada, where medical assistance in dying (MAiD) has been legal since 2016 and where physicians and institutions in some provinces have invoked conscience to decline participation.

Chapter 3: Abortion Ethics

3.1 The Traditional Framing

Philosophical debate about abortion (人工流产 / 堕胎) has traditionally been dominated by the question of the moral status of the fetus. Is the fetus a person from conception? Does personhood arise at viability, at sentience, or at birth? Depending on how one answers, standard arguments apply: if the fetus is a full moral person, abortion is presumptively wrong (the conservative position); if the fetus has no significant moral status, abortion is morally permissible (the liberal position); and various moderate positions seek a developmental threshold.

3.2 Dea’s Harm-Reduction Approach

Shannon Dea (2016) offers a deliberately different framing. Rather than attempting to resolve the metaphysical question of fetal moral status – a question on which centuries of philosophical and theological argument have produced no consensus – Dea proposes a harm-reduction (减害) approach to abortion.

Dea’s central observation is empirical: jurisdictions with liberal abortion laws consistently have lower abortion rates than jurisdictions with restrictive laws. This counterintuitive finding arises because the social and economic supports that accompany liberalized abortion policies – comprehensive sex education, accessible contraception, parental leave, and poverty reduction – are the same policies that reduce the demand for abortion in the first place. By contrast, criminalizing abortion does not eliminate it; it merely drives it underground, increasing maternal injury and death.

From this evidence, Dea draws a provocative conclusion: those who sincerely wish to see fewer abortions should support liberalized access combined with robust social supports, rather than prohibition. The harm-reduction framework has three strategic advantages:

1. It sidesteps the unresolvable status debate. Whether or not the fetus is a person, everyone can agree that fewer abortions and fewer harms to pregnant persons are desirable outcomes.
2. It is evidence-based. The correlation between liberal laws and low abortion rates is well documented across multiple countries.
3. It finds common ground. By reframing the issue around practical outcomes rather than metaphysical commitments, harm reduction can unite people across the ideological spectrum.

3.3 Philosophical Implications

Dea’s argument illustrates the difference between ideal-theory ethics and non-ideal-theory ethics. Ideal theory asks what the morally correct answer is in principle; non-ideal theory asks what policies will produce the best outcomes given the world as it actually is. Even someone who believes abortion is morally wrong might, on non-ideal-theory grounds, endorse legal access as the most effective means of reducing total abortions. This pragmatic orientation is characteristic of the harm-reduction tradition and represents a departure from the standard philosophical debate.

Chapter 4: End-of-Life Decision Making

4.1 Background: Assisted Dying in Canada

Canada’s legal landscape around end-of-life care underwent a transformation beginning with the 2015 Supreme Court of Canada decision in Carter v Canada, which struck down the criminal prohibition on physician-assisted dying. Parliament responded with the 2016 Medical Assistance in Dying (MAiD) Act (Bill C-14), later expanded by Bill C-7 in 2021 to include persons whose natural death is not reasonably foreseeable. This legal evolution was anticipated and partly catalyzed by the 2011 report of the Royal Society of Canada Expert Panel on End-of-Life Decision Making.

4.2 The RSC Expert Panel Report (Schuklenk et al., 2011)

The RSC Expert Panel, chaired by Udo Schuklenk and including Jocelyn Downie, Johannes J. M. van Delden, Sheila McLean, Ross Upshur, and Daniel Weinstock, produced a comprehensive review of the ethics, law, and empirical evidence surrounding end-of-life decisions.

4.2.1 Key Distinctions

The report begins by clarifying several distinctions that are essential to the debate:

• Voluntary euthanasia (自愿安乐死): A physician administers a lethal substance at the competent patient’s explicit, informed request.
• Assisted suicide (协助自杀): A physician provides the means (e.g., a prescription) for the patient to end their own life.
• Withdrawal or withholding of treatment (撤回或不施予治疗): A decision to discontinue or not initiate life-sustaining treatment (e.g., mechanical ventilation, artificial nutrition), which is already legal in Canada and widely practiced.
• Palliative sedation (姑息镇静): Administering sedatives to relieve intractable suffering, sometimes to the point of unconsciousness, in a terminally ill patient, which may hasten death as a foreseen but unintended side effect.

4.2.2 The Panel’s Arguments

The panel’s central philosophical argument is that there is no morally relevant distinction between, on the one hand, withdrawing life-sustaining treatment (which is legal) and, on the other, voluntary euthanasia or assisted suicide (which were then illegal). In both cases, the patient makes an autonomous decision to end a life they judge no longer worth living; in both cases, the physician acts (or refrains from acting) knowing that death will result. If we accept the moral permissibility of the former, consistency requires us to accept the latter.

The panel deployed arguments grounded in:

1. Autonomy. Competent adults have the right to make decisions about their own bodies, including the decision to end their lives when confronted with intolerable suffering. The state’s interest in preserving life must yield to the individual’s autonomous choice.
2. Beneficence and non-maleficence. When a patient experiences irremediable suffering, the compassionate response may be to help them die rather than to prolong their agony. Refusing assisted dying in such cases may itself constitute a harm.
3. Justice. The existing legal framework was inconsistent: wealthy, mobile patients could travel to jurisdictions where assisted dying was legal (e.g., Switzerland), while poor and disabled patients could not. Legalizing assisted dying within Canada would remove this inequity.

4.2.3 Safeguards and Slippery-Slope Concerns

The report also addressed the slippery slope (滑坡论证) objection – the worry that legalizing assisted dying for competent adults would inevitably lead to abuses against vulnerable populations. The panel reviewed evidence from jurisdictions that had already legalized some form of assisted dying (the Netherlands, Belgium, Oregon) and found no empirical support for a slide toward involuntary euthanasia. Nonetheless, the panel recommended robust safeguards: multiple requests, waiting periods, independent medical assessments, and reporting requirements.

Chapter 5: Reproductive Ethics – Sex Selection and Prenatal Testing

5.1 Sex Selection and “Family Balancing”

The development of reproductive technologies such as preimplantation genetic testing (PGT) and sperm-sorting has made it possible for prospective parents to choose the sex of their child. While sex selection motivated by son-preference in patriarchal societies is widely condemned, a more nuanced debate surrounds so-called family balancing (家庭性别平衡) – the use of sex selection to ensure that a family with children of one sex has a child of the other.

5.1.1 Shahvisi’s Critique

Arianne Shahvisi (2018) argues that even family balancing cannot be ethically justified. She presents four novel objections:

1. Medicalization of the family. Treating the sex composition of a family as a condition requiring technological intervention pathologizes normal family structures. There is no medical indication for “unbalanced” sex ratios among siblings; the concept itself presupposes that families are deficient if they lack children of both sexes.

2. Entrenchment of heteronormativity. The desire for “one of each” reflects and reinforces the assumption that boys and girls are fundamentally different kinds of beings who serve fundamentally different roles in family life. This assumption is heteronormative (异性恋规范的) because it maps gendered expectations onto biological sex and ignores the diversity of gender identities and expressions.

3. Misappropriation of affirmative-action logic. Proponents of family balancing sometimes argue that selecting for the underrepresented sex in a family is analogous to affirmative action. Shahvisi rejects this analogy: affirmative action addresses systemic social disadvantage, while family balancing addresses a perceived personal preference. The structural conditions that justify affirmative action are absent in the private family context.

4. Misuse of reproductive autonomy. While reproductive autonomy (生殖自主权) is an important moral value, it does not extend to choosing the characteristics of one’s children at will. Reproductive autonomy protects the right to decide whether to reproduce and under what circumstances, not the right to design children to specification.

5.2 Prenatal Testing for Intersex Conditions

Saulnier, Gallois, and Joly (2021) raise concerns about the expansion of non-invasive prenatal screening (NIPS) to identify intersex (间性) conditions at the fetal stage. Their commentary highlights several ethical challenges:

1. Lack of clinical benefit. Intersex conditions are not diseases requiring prenatal intervention. Early detection may prompt unnecessary anxiety, pressure to terminate, or plans for postnatal surgical “normalization” that intersex advocacy groups have long opposed.

2. Absence of Canadian-specific guidance. There are currently no explicit Canadian legal protections or clinical guidelines addressing prenatal testing for intersex conditions, leaving health care providers without a framework for counselling.

3. Voices of the intersex community. The authors argue that any policy on prenatal intersex testing must incorporate the perspectives of intersex individuals themselves, who have historically been subjected to non-consensual surgeries and medicalization.

5.3 Asch’s Disability Rights Critique of Prenatal Testing

Adrienne Asch (2003) provides a foundational critique of prenatal genetic testing from the perspective of disability rights (残障权利). Her core claim is that the practice of testing for and selectively aborting fetuses with disabilities sends a harmful message about the value of disabled lives.

5.3.1 The Expressivist Objection

Asch’s argument is built on what is known as the expressivist objection (表达性反对): the claim that selecting against disability “expresses” a negative judgment about people who currently live with those disabilities. When a prospective parent terminates a pregnancy solely because the fetus has Down syndrome or spina bifida, the implicit message is that a life with that condition is not worth living – a message that disabled people experience as a denial of their equal moral worth.

5.3.2 Disability versus Illness

Asch draws a sharp distinction between disability and illness. Disabilities such as blindness, deafness, or mobility impairment are stable traits around which people construct meaningful identities and communities. They are not diseases to be cured. The medical model of disability, which treats disability as a deficiency located in the individual, stands in contrast to the social model (社会模型), which holds that people are disabled not by their bodily traits but by social barriers (inaccessible buildings, stigma, exclusion). If disability is primarily a social problem, then the appropriate response is to change society, not to eliminate disabled people through prenatal selection.

5.3.3 Autonomy and Disability

Asch does not claim that prenatal testing should be banned. Rather, she argues that the information provided to prospective parents is often biased, emphasizing medical complications and ignoring the quality of life that people with disabilities actually report. She advocates for balanced counselling that includes the perspectives of disabled individuals and their families, accurate information about living with a disability, and awareness of the social supports available.

Chapter 6: Gene Editing – Ethics of Enhancement

6.1 The Somatic/Germline Distinction

For over fifty years, the ethical debate about human gene editing has rested on a fundamental distinction:

• Somatic gene editing (体细胞基因编辑): Modifying the DNA of non-reproductive cells in a living person. Changes affect only that individual and are not heritable.
• Germline gene editing (生殖细胞基因编辑): Modifying the DNA of reproductive cells (sperm, eggs) or embryos. Changes are heritable and will be passed to all future descendants.

The consensus position, enshrined in guidelines from bodies such as the US National Academies, has been that somatic editing for therapeutic purposes is permissible (analogous to any medical treatment), while germline editing should be prohibited or subject to a moratorium because of its irreversible, multigenerational consequences.

6.2 Evans on the Fall of the Barrier

John H. Evans (2021) argues that this long-standing consensus has collapsed. The somatic/germline barrier functioned as a bright-line ethical boundary – a clear, easily enforced rule that prevented a “slippery slope” from therapeutic gene editing down to eugenic enhancement. Evans shows that this barrier has been eroded by three developments:

1. Technological blurring. Advances in CRISPR-Cas9 technology have made germline editing technically feasible and increasingly precise, weakening the pragmatic argument that germline editing is too risky.
2. Moral blurring. The argument that germline editing for severe genetic diseases (e.g., Huntington’s, sickle cell disease) is qualitatively different from somatic editing has become harder to sustain. If it is permissible to cure a disease in a living person, why is it impermissible to prevent that disease from ever arising by editing the germline?
3. The He Jiankui case. In 2018, Chinese scientist He Jiankui edited the genomes of twin embryos in an attempt to confer resistance to HIV. The experiment was widely condemned, but it demonstrated that the barrier was no longer holding in practice.

6.2.1 The Slippery Slope Below

Evans’s most troubling finding is that there are no strong replacement barriers below the somatic/germline divide. He examines several candidates:

• Treatment vs. enhancement (治疗 vs. 增强): Distinguishing between editing to cure disease and editing to enhance traits (e.g., intelligence, athletic ability). Evans finds this boundary conceptually unstable because the distinction between treatment and enhancement is context-dependent and contested.
• Serious vs. trivial conditions: Editing to prevent fatal diseases might be permitted while editing for cosmetic traits is not. But who decides what counts as “serious”?
• Individual choice vs. societal mandate: Permitting individual parents to choose gene edits for their children but prohibiting state-mandated programs. This may prevent the worst forms of eugenics but does nothing to address the cumulative social effects of widespread individual choices.

Chapter 7: Pediatric Ethics and Parental Authority

7.1 The Default Position: Parental Decision-Making

In most legal and ethical frameworks, parents are presumed to be the appropriate decision-makers for their minor children. This presumption rests on several grounds: parents typically know their children best, have their children’s interests at heart, and bear the long-term consequences of decisions made on behalf of their children. The principle of parental authority (父母权威) is also grounded in the wider liberal commitment to family privacy and pluralism.

However, parental authority is not absolute. When parental decisions endanger a child’s life or health, the state may intervene. The standard mechanism is the best interests standard (最佳利益标准): decision-makers (parents, courts, physicians) should choose the option that best promotes the child’s welfare.

7.2 Alessandri on Treatment Refusals in Paediatric Oncology

Angela Alessandri (2011) examines the specific problem of parents who refuse conventional cancer treatment for their children, often in favour of alternative or complementary therapies. Although such refusals are infrequent, they pose serious ethical challenges because paediatric cancers often have high cure rates with standard treatment, and the consequences of refusal can be fatal.

Alessandri’s key points include:

1. Parental rights have limits. While there are good reasons to respect parental decision-making, the child’s right to life and health imposes a ceiling on parental authority. When parents refuse treatment for a condition with a high probability of cure, the child’s interests should prevail.

2. The therapeutic relationship matters. Most disagreements between clinicians and families can be resolved through empathic communication, cultural sensitivity, and the involvement of clinical ethics services. Resorting to legal coercion (e.g., court-ordered treatment) should be a last resort because it damages trust and may discourage the family from engaging with the health care system.

3. The rise of alternative therapies. The increasing popularity of unproven “natural” treatments, combined with vaccine hesitancy and distrust of conventional medicine, may lead to more frequent refusals in the future.

7.3 DeMichelis and the “Logic of Empire”

Carey DeMichelis (2018) offers a critical counterpoint by interrogating the political dimensions of the best interests standard itself. Her central argument is that the best interests standard, as applied in cases of parental refusal, can function as a logic of empire – a mechanism through which the liberal state imposes its own values on communities (particularly Indigenous communities and other marginalized groups) under the guise of protecting children.

DeMichelis’s critique raises several important questions:

1. Whose “best interests”? The best interests standard presupposes a shared understanding of what constitutes a child’s welfare. But this understanding is culturally embedded. Western biomedicine defines health in terms of biological survival and functioning; Indigenous and other non-Western frameworks may incorporate spiritual, relational, and communal dimensions that the standard fails to recognize.

2. Historical context. In Canada, the state has a long history of removing Indigenous children from their families (the residential school system, the Sixties Scoop) under the justification of promoting the children’s welfare. Against this backdrop, invoking the best interests standard to override Indigenous parents’ medical decisions carries a freight of colonial power that cannot be ignored.

3. Structural determinants. When families refuse treatment, the reasons may include poverty, transportation barriers, distrust of institutions, or culturally grounded healing practices. Addressing these structural conditions is more just than overriding parental decisions through the courts.

Chapter 8: Indigenous Health and Structural Inequity

8.1 Health Inequities in Indigenous Canada

Indigenous peoples in Canada – First Nations, Inuit, and Metis – experience dramatically worse health outcomes than the non-Indigenous population on virtually every measure: life expectancy, infant mortality, rates of diabetes, tuberculosis, suicide, and mental illness. These disparities are not the result of individual lifestyle choices; they are the product of structural determinants of health (健康的结构性决定因素) – the political, economic, and legal systems that shape the conditions in which people live.

8.2 Richmond and Cook: Healthy Public Policy

Chantelle Richmond and Catherine Cook (2016) examine the roots of Indigenous health inequity in Canada through a structural lens. Their core argument is that current health policy fails Indigenous peoples because it does not address the historical and ongoing processes of colonization that produce health disparities.

8.2.1 The Indian Act and Its Legacy

Richmond and Cook trace the scope of Indigenous health inequity to the Indian Act (《印第安人法》) of 1876, a piece of federal legislation that has governed virtually every aspect of First Nations life for over a century. The Indian Act created the reserve system, imposed the band-council governance structure, restricted economic activity, and enabled the residential school system. Its cumulative effect has been to dispossess Indigenous peoples of their lands, disrupt their social and cultural systems, and create conditions of chronic poverty and dependency.

8.2.2 Healthy Public Policy

The authors argue that achieving health equity for Indigenous peoples requires a paradigm shift from individually focused health interventions (disease treatment, lifestyle counselling) to healthy public policy (健康公共政策) that addresses the structural roots of inequity. This means:

1. Recognizing Indigenous rights. Health policy must be grounded in recognition of Indigenous peoples’ inherent rights to self-determination, land, and culture, as articulated in the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP).
2. Addressing the social determinants. Housing, education, employment, clean water, food security, and connection to land and culture are all determinants of health that policy must address.
3. Indigenous-led solutions. Effective health policy must be designed and implemented by Indigenous communities themselves, not imposed from above.

8.3 Manuel: From Dispossession to Dependency

Arthur Manuel (2017), a Secwepemc political leader, provides a powerful first-person account of how colonial dispossession created the conditions of dependency that continue to undermine Indigenous health and well-being. Manuel documents that Indigenous reserves constitute only 0.2 percent of Canada’s total land mass – a staggering disproportion given that Indigenous peoples are the original inhabitants of the entire country.

Manuel argues that this land dispossession is the foundational cause of Indigenous poverty, and that poverty is the foundational cause of poor health. The solution is not more government programs but decolonization (去殖民化) – the restoration of Indigenous land rights and self-governance.

8.4 Implications for Biomedical Ethics

The readings in this chapter challenge biomedical ethics to move beyond the individual patient-physician encounter and to grapple with the structural and historical forces that shape health. The four principles – autonomy, beneficence, non-maleficence, and justice – are necessary but not sufficient. Justice, in particular, must be understood not merely as fair distribution of health care resources but as the rectification of historical injustice and the dismantling of ongoing colonial structures.

Chapter 9: Fat Stigma and Health Justice

9.1 The Pervasiveness of Fat Stigma

Fat stigma (肥胖污名) refers to the pervasive social devaluation of people perceived as overweight or obese. Fat persons face discrimination in employment, education, health care, and interpersonal relationships. They are assumed to be lazy, undisciplined, and morally deficient. In the health care setting, fat stigma manifests as dismissive treatment, failure to take complaints seriously, and the attribution of all health problems to weight.

9.2 Nath’s Argument

Rekha Nath (2019) argues that fat stigma is not merely unfortunate but unjust (不正义的). She examines and refutes two common justifications for stigmatizing fatness:

9.2.1 The Consequentialist Argument

The first justification holds that stigmatizing fatness promotes public health by motivating people to lose weight. Nath responds with both empirical and normative objections:

• Empirically, the evidence does not support this claim. Fat stigma is associated with increased stress, depression, binge eating, and avoidance of physical activity and medical care – all of which worsen health outcomes. Decades of intense anti-fat social messaging have not reduced obesity rates.
• Normatively, even if stigma did produce health benefits, it would be unjust to achieve those benefits by degrading a subset of the population. We do not stigmatize people who engage in other risky behaviours (e.g., extreme sports, excessive sun exposure) with anything like the same intensity.

9.2.2 The Moral Blame Argument

The second justification holds that fat people deserve stigma because they are morally responsible for their weight – they have freely chosen to eat too much and exercise too little, and stigma is an appropriate response to this moral failure. Nath responds:

• The science of weight is complex. Body weight is influenced by genetics, epigenetics, gut microbiota, socioeconomic conditions, food environments, medication side effects, and numerous other factors beyond individual control. The assumption that weight is simply a matter of willpower is scientifically indefensible.
• Even if weight were fully within individual control, singling out fat people for blame while ignoring comparable choices by thin people (who may eat poorly and not exercise but happen to remain thin due to metabolic factors) is inconsistent and discriminatory.
• Stigma is not proportionate. Even if some degree of responsibility for weight could be established, the severity and pervasiveness of fat stigma far exceeds any plausible moral blame.

Chapter 10: Aging, Healthspan, and Equality

10.1 The Aging Population

Global population aging is one of the defining demographic phenomena of the twenty-first century. By 2050, an estimated two billion people will be over 60. Aging is the single most prevalent risk factor for chronic disease, frailty, disability, and death. Senescence (衰老) – the biological process of molecular and cellular decline – affects virtually every organ system and is the background condition for diseases from cancer to dementia.

10.2 Farrelly’s Argument for a Duty to Retard Aging

Colin Farrelly (2024) argues that an intervention capable of slowing the rate of biological aging would be one of the most important public health advances in human history, and that there is a moral duty to pursue and fairly distribute such an intervention.

10.2.1 Critique of the Egalitarian Objection

Some egalitarians have argued that life-extension technologies would exacerbate inequality: only the wealthy would benefit, creating a world of long-lived elites and short-lived poor. Farrelly challenges this framing on several grounds:

1. The aging status quo is already profoundly unequal. Health inequalities in aging are enormous – the poor and socially marginalized age faster, get sicker sooner, and die younger. An intervention that slows aging could reduce inequality if fairly distributed.

2. Historical precedent. Many medical innovations (antibiotics, vaccines, sanitation) were initially available only to the privileged but eventually diffused broadly. There is no reason in principle why an aging intervention could not follow the same trajectory, especially with proactive public policy.

3. The duty of beneficence. Given the sheer scale of suffering caused by age-related disease, and the feasibility of interventions emerging from the science of geroscience (老年科学) – which seeks to target the fundamental mechanisms of aging – the moral case for pursuing these interventions is overwhelming.

10.2.2 Healthspan vs. Lifespan

Farrelly draws an important distinction between lifespan (寿命) and healthspan (健康寿命期). The goal of geroscience is not merely to extend lifespan (adding years to life) but to extend healthspan (adding healthy years to life). Compressing the period of morbidity at the end of life – rather than prolonging it – would reduce suffering, lower health care costs, and allow older adults to continue contributing to their communities.

Chapter 11: Neurotechnology Ethics

11.1 Emerging Neurotechnologies

Rapid advances in neurotechnology (神经技术) – including brain-computer interfaces (BCIs), deep brain stimulation (DBS), transcranial magnetic stimulation (TMS), and neural recording devices – are transforming the diagnosis and treatment of neurological and psychiatric conditions. BCIs can restore communication to patients with locked-in syndrome; DBS can alleviate symptoms of Parkinson’s disease and severe depression. At the same time, these technologies raise profound ethical questions about identity, privacy, autonomy, and justice.

11.2 Goering et al.: Recommendations for Responsible Development

Sara Goering, Eran Klein, Laura Specker Sullivan, and colleagues (2021) offer a set of ethical recommendations organized around four key areas of concern:

11.2.1 Identity and Agency

Neurotechnological devices can alter mood, personality, impulse control, and decision-making. Patients with DBS for depression sometimes report feeling “not themselves” when the device is active. This raises the question: if a technology changes how a person thinks and feels, does it change who they are?

The authors recommend that developers and clinicians take seriously the phenomenological reports of users – how the technology feels from the inside – and design devices that preserve and enhance, rather than diminish, the user’s sense of self and agency.

11.2.2 Privacy

Neural data – information about a person’s brain states, thoughts, and emotions – is among the most intimate information imaginable. As neurotechnologies generate increasing volumes of neural data, questions arise about who owns this data, who can access it, and how it can be used. The authors call for robust protections for neuroprivacy (神经隐私), including new legal frameworks that treat neural data as a special category deserving heightened protection.

11.2.3 Bias

Like all technologies, neurotechnologies can encode and amplify existing social biases. If clinical trials disproportionately include certain demographic groups, the resulting devices may not work as well for others. Algorithmic bias in brain-computer interfaces could systematically disadvantage marginalized populations. The authors recommend inclusive research practices and ongoing audits for bias.

11.2.4 Enhancement

As neurotechnologies become more capable, the prospect of cognitive enhancement (认知增强) – using devices not to treat disease but to boost normal cognitive functioning – becomes increasingly real. This raises concerns about fairness (will enhancement be available only to the wealthy?), coercion (will employers or militaries pressure individuals to use enhancement technologies?), and the meaning of human achievement.

11.2.5 Neurorights

The authors propose the recognition of neurorights (神经权利) – a new category of human rights designed to protect individuals in the age of neurotechnology. These include the right to cognitive liberty, the right to mental privacy, the right to mental integrity, and the right to psychological continuity.

Chapter 12: Dementia and Prior Autonomy

12.1 The Philosophical Problem

Dementia (痴呆 / 失智症) presents a unique challenge to the principle of autonomy. As dementia progresses, the patient gradually loses the cognitive capacity to make informed decisions. Yet many people, while still competent, execute advance directives (预先指令) specifying the treatment they wish to receive (or refuse) if they become incapacitated. What happens when the demented person appears content and engaged with life, but their advance directive instructs that treatment be withheld or that life-ending measures be taken?

12.2 Dworkin’s View: Precedent Autonomy

The philosopher Ronald Dworkin, in his book Life’s Dominion (1993), argues for the primacy of what he calls precedent autonomy (先前自主权). Dworkin distinguishes between two kinds of interests:

• Experiential interests (体验性利益): interests in having pleasant experiences and avoiding unpleasant ones – the kind of interests that even persons with severe dementia retain.
• Critical interests (批判性利益): interests in living a life that is coherent, meaningful, and consistent with one’s deepest values – interests that require the capacity for reflection and narrative self-understanding.

Dworkin argues that critical interests are more important than experiential interests because they reflect the person’s autonomous conception of a good life. When a competent person writes an advance directive refusing life-sustaining treatment in the event of severe dementia, that directive expresses their critical interests – their judgment about what kind of ending is consistent with the life they have lived. Honouring the directive respects their autonomy, even if the demented person appears happy.

12.3 Dresser’s Critique: The “New Person” Problem

Rebecca Dresser (1995) offers a powerful challenge to Dworkin’s position. She argues that the person with dementia is, in a morally relevant sense, a different person from the one who wrote the advance directive. The demented Margo (a real case that Dresser uses as illustration) enjoys painting, listening to music, and being read to. She appears content. To enforce her earlier directive to withhold treatment or hasten death would be to privilege the wishes of a person who no longer exists over the evident well-being of the person who does.

Dresser’s objections include:

1. Psychological discontinuity. The narrative identity that grounded the original directive has been dissolved by the disease. The competent person who feared dementia and the demented person who enjoys daily life do not share enough psychological continuity to justify treating the former’s wishes as binding on the latter.

2. Current welfare matters. The principle of beneficence requires us to attend to the patient’s current state. If Margo is not suffering – if she derives genuine pleasure from her daily activities – then withholding treatment or hastening death cannot serve her present interests.

3. Epistemic limitations. When competent people write advance directives, they cannot truly know what it will be like to live with dementia. They may imagine the worst, not realizing that many people with dementia retain the capacity for enjoyment. Decisions based on this kind of predictive error deserve less moral weight.

12.4 Implications for Policy

Neither position offers a simple rule. A strict Dworkinian approach risks inflicting harm on contented patients; a strict Dresserian approach risks rendering advance directives meaningless and stripping competent persons of the power to plan for their own futures. Many bioethicists advocate a middle ground: advance directives should carry significant weight but may be overridden when the demented person demonstrates clear evidence of current well-being and when enforcing the directive would cause manifest harm.

Chapter 13: Organ Transplantation Ethics

13.1 The Organ Shortage

Organ transplantation saves thousands of lives each year, but demand for transplantable organs far exceeds supply. In Canada, as in most countries, hundreds of people die each year while waiting for a kidney, liver, heart, or lung. The gap between supply and demand has prompted a search for ethical strategies to increase organ availability.

13.2 Current Systems

Most countries operate under one of two frameworks:

• Opt-in (explicit consent) (明确同意制): Organs are recovered only if the deceased person (or their family) has affirmatively consented, usually by signing a donor card or registering in a database. This is the system in Canada and the United States.
• Opt-out (presumed consent) (推定同意制): All persons are presumed to consent to organ donation unless they have explicitly registered an objection. This system operates in Spain, Austria, and several other European countries, and has been associated with higher donation rates.

13.3 Spital and Taylor: Routine Recovery

Aaron Spital and James Stacey Taylor (2007) propose a more radical solution: routine recovery (常规回收) of all transplantable cadaveric organs without any consent requirement. Under this proposal, organs would be recovered from every eligible deceased person automatically, regardless of the wishes of the deceased or their family.

13.3.1 Arguments in Favour

Spital and Taylor advance several arguments for routine recovery:

1. Consistency. Society already mandates autopsies in cases of suspicious death, requires vaccinations for school attendance, and taxes citizens to fund public goods. Routine organ recovery is analogous: a modest imposition on bodily sovereignty that produces enormous social benefit.

2. Fairness. Under the current opt-in system, some families consent and others do not, creating an unequal distribution of the “burden” of donation. Routine recovery eliminates this inequality by making donation universal.

3. Life-saving potential. The authors argue that routine recovery has the greatest potential among all proposed reforms to close the gap between organ supply and demand. Every year that the status quo persists, people die who could have been saved.

4. Minimal harm. The deceased person, by definition, can no longer be harmed by the removal of their organs. While family members may experience distress, the authors contend that this distress is outweighed by the lives saved.

13.3.2 Objections

Routine recovery faces several serious objections:

1. Bodily autonomy. Even after death, many people believe they retain a right to determine what happens to their bodies. Routine recovery overrides this right entirely, in contrast to opt-out systems that at least provide an opportunity to register an objection.

2. Religious and cultural values. Many religious traditions hold that the body must be buried intact (e.g., Orthodox Judaism, some Islamic traditions). Routine recovery would override these deeply held convictions.

3. Family grief. Removing organs from a deceased loved one against the family’s wishes may compound grief and undermine trust in the health care system.

4. Public trust. If people believe that hospitals are eager to harvest their organs, they may avoid seeking medical care or refuse to register as donors under the current system, potentially decreasing donation rates in the short term.

13.4 Allocating Scarce Organs

Even if the supply of organs were increased, questions of allocation (分配) would remain. On what basis should scarce organs be distributed among patients on the waiting list? Common criteria include medical urgency, time on the waiting list, likelihood of successful transplantation, and geographical proximity to the donor. Each criterion embodies a different conception of justice:

• Urgency prioritizes the sickest patients (a need-based criterion).
• Likelihood of success prioritizes patients most likely to benefit (a utilitarian criterion).
• Time on the waiting list treats waiting as a proxy for fairness (an egalitarian criterion).

No single criterion captures all dimensions of justice, and allocation policies must balance competing considerations. The ethical complexity of organ allocation mirrors the broader challenge of the principlist framework: multiple valid moral considerations must be weighed against one another in specific cases, with no algorithm to produce the “correct” answer.

Conclusion: Themes Across Biomedical Ethics

Several themes recur across the chapters of this course:

1. The centrality and limits of autonomy. Autonomy is a foundational value, but it is not the only value. It must be balanced against beneficence (Chapters 7, 12), justice (Chapters 8, 9, 10, 13), and non-maleficence (Chapter 6). Moreover, autonomy is not merely an individual attribute but is shaped by social structures – poverty, colonialism, stigma, and disability all affect the conditions under which autonomous choices are made.

2. The interplay of individual and structural ethics. Biomedical ethics began with a focus on the individual clinical encounter (patient-physician relationship, informed consent). But many of the most pressing ethical problems are structural: Indigenous health inequity, fat stigma, the organ shortage, the distribution of genetic technologies. Addressing these problems requires moving beyond principlism’s traditional focus on individual cases to engage with questions of social justice, power, and institutional design.

3. The role of empirical evidence. Bioethical arguments are not purely a priori. Dea’s harm-reduction approach relies on epidemiological data; Nath’s critique of fat stigma draws on public-health research; the RSC panel’s argument for assisted dying cites evidence from other jurisdictions; Farrelly’s case for aging interventions depends on geroscience. Good bioethics requires both philosophical rigour and empirical literacy.

4. The importance of diverse perspectives. The voices of disabled people (Asch), Indigenous peoples (Richmond, Cook, Manuel), intersex individuals (Saulnier et al.), and fat persons (Nath) are essential to bioethical deliberation, not as tokens of diversity but as sources of knowledge and moral insight that the dominant perspective systematically overlooks.

5. The Canadian context. Many of the issues in this course have a distinctly Canadian dimension: MAiD legislation, Indigenous health policy, the Indian Act, publicly funded health care, and the balance between individual rights and collective welfare under the Charter. Biomedical ethics in Canada is not merely the application of universal principles to local circumstances; it is shaped by a specific legal, political, and cultural context that must be understood on its own terms.