走向中國生命倫理學——重審後基礎之醫學道德

Towards a Chinese Bioethics: Reconsidering Medical Morality after Foundations

Abstract

LANGUAGE NOTE | Document text in Chinese; abstract also in English.

當代西方面臨多重挑戰，有些是理論層面的，有些是實踐層面的。目前佔主導地位的西方世俗文化的普世主義的道德和生命倫理學工程認為道德基礎可以從道德哲學系統中的有效論證來獲得。這種思維方式源於西元前5 世紀希臘的世俗化，並在13 世紀的西方獲得新生。其後的體系基於對理性的信仰，喪失了維繫西方基督教信仰的承諾，導致康德的理性主義道德工程。

1970 和80 年代出現的西方生命倫理學對個體自主性的強調試圖得到這一道德工程的印證，但這種努力已經擱淺：期望依賴普世主義的術語，通過有效理性論證來確保具體內容的所有嘗試，到頭來都不過是乞題論證、循壞論證、或無窮後退，因為人們沒有可能通過對基本前提和證據規則的理性反思來必然地達成共識。人們總是需要進一步的背景前提和規則。從歷史的脈絡來看，一旦西方世俗道德反思拋棄其上帝之眼的視角，標杆化的世俗道德體系就會陷入麻煩。一切強調無名氏的道德視角，無論是以沒有境遇的道德主體身份出現，還是以大多數人的最大利益原則出現，都無法提出標杆化的規範內容。

文章認為，西方現代社會-民主制福利國家醫療資源的配置方式所引發的財政上的不可持續的危機帶來三個基本難題：(1) 醫療權利一旦確立，它們所帶來的道德風險；(2) 依靠後人為今人交付醫療服務的做法所帶來的人口風險；(3) 社會保險計劃誘發政治家玩弄空頭支票所帶來的政治風險。西方社會所面臨的危機，無論是經濟上的，還是文化上的，都為我們提供了很好的理由說明我們需要重新考量構建在中國文化視域下的、更有能力迎接21 世紀倫理學挑戰的生命倫理學。

Unnoticed by many bioethicists, the very foundations of the dominant Western secular morality, and by extension the foundations of the dominant secular bioethics of the West, have been brought into question. After Immanuel Kant (1724-1804) and in the light of arguments by philosophers from G.W.F. Hegel (1770-1831) to Richard Rorty (1931-2007) and Gianni Vattimo (1936-), it has become ever clearer that neither the content of the dominant Western secular morality nor the content of the dominant Western bioethics can be secured as canonical through sound rational argument. Western secular morality and Western secular bioethics have become foundationless. They are not secured by a canonical moral rationality or by being anchored in being as it is in itself. Theimplications are wide-ranging. This paper sketches both what it means to do bioethics after foundations, and what opportunities exist for rethinking the possibilities for a Chinese bioethics.

Among the difficulties of the Enlightenment moral project is that it attempted to understand individuals in anonymously universalist terms. To do this, individuals had to be considered outside of their social and historical contexts. They were as a consequence portrayed as bare moral agents. This is most saliently the case with Immanuel Kant, who understands his morality in terms of the kingdom of ends, within which all members, save God, are fully interchangeable. The members of the kingdom of ends are persons without sex, sexual orientation, species-membership, history, or family. This state of affairs is tied to a universalist, egalitarian vision of persons and society, which in the West has been understood in terms of a social-democratic morality and political agenda. The difficulty is that it is now clear that there is a challenge to the financial sustainability of healthcare allocation within social-democratic welfare states. The difficulties stem from at least three challenges to its sustainability: (1) the moral hazard due to the inclination to overuse entitlements once they are established, (2) the demographic hazard due to relying on future generations to pay for the health care of current recipients (i.e., when there are fewer children, financing becomes difficult), and (3) the political hazard due to social insurance schemes that reward politicians for promising benefits even when sufficient funds may not be available.

For scholars doing bioethics in China, this state of affairs means that Chinese bioethicists are freed from having to meet secular Western bioethicists on the terms established by secular Western bioethicists. Instead, they can fashion an authentically Chinese bioethics, which nests its own moral commitments within the traditional Confucian moral narrative of China. A Chinese bioethics need not, and should not, in content or form be like the bioethics of the dominant secular morality and bioethics of the West. Given the character of secular morality and bioethics, given its inability to establish a universal, canonical morality through sound rational argument, as well as given the particularity of all morality and bioethics that possesses content, and given the promising moral content salient in Chinese culture, a move by Chinese to establish a Chinese bioethics becomes quite plausible.

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