A large tranche of contemporary bioethical inquiry is self-consciously focused on purpose and methodology. Bioethics is a field of disparate disciplines, and it is not always clear what role the philosopher plays in the wider scheme. Even when philosophical reflections can, in principle, find application in the real world (and often, in bioethics, there is too heady a degree of abstraction for this), there can be difficulty in finding sound resolution between the competing perspectives. Where fundamentals differ, we face apparent deadlock, with theorists seemingly able only to talk across each other. Perspectives on this vary. For example, some will argue that the philosopher’s role is purely reflective and need have no practical resonance whatsoever. Others may say that philosophers are not equipped to engage with empirical questions or, when they do, they do so on flawed understandings of “the real world”; bad science or science fiction replaces brute fact and emotional, social, and empirical reality. Some may seek to strike a balance by trying to engage the questions within a political framing, allowing both for normative and real-world concerns.

Bioethics is, as is moral philosophy in general, a field spanning a range of different philosophical approaches, normative standpoints, methods and styles of analysis, metaphysics, and ontologies. In discussing bioethics, it is often seen as useful to introduce some kind of order on the field by categorizing individual philosophers or specific arguments into a relatively small number of categories. Such categorization or classification has several functions. It may help to show the relationship between basic assumptions and specific arguments or it may be used argumentatively by arguing not against a single philosopher or her arguments but against the category to which she or they belong or are claimed to belong. In this way, whole lines of argument can be disposed of in one fell swoop and whole groups of philosophers dismissed by showing that they belong to some category that can, in some way, be discounted because it is fallacious. Or, conversely, lines of arguments and groups of philosophers can be celebrated and appropriated as support for yet new arguments.

Bioethics as a distinctive field is undergoing a critical turn. It may be a quiet revolution, but a growing body of scholarship illustrates a perceived need for a rethink of the scope of the field and the approaches and priorities that have carried bioethicists through many heady years of success. Few areas of bioethical practice have been left unexamined, ranging from questions as to the sustainability of the discipline in its current form to the “expertise” of its practitioners; the legitimacy of bioethics in the realms of policymaking; its relationship to philosophy; the purchase of empirical and interdisciplinary method; the relationship of bioethics to the real world; bioethical understandings of the concept of “health” (and methods of attainment); its agenda, priorities, and inclusiveness right up to what might be the overarching question: “What is bioethics all about?” Unsurprisingly, these questions elicit varied responses. Scholars from various disciplines have critiqued fundamental tenets of the “ethics” business, albeit as claims of its “conservatism,” “corruption,” and its questionable “usefulness” suggest, not always with a charitable or constructive eye. But quite crucially and often overlooked, bioethics itself has not shied away from the question as to what bioethics is and what it should become; increasingly apparent is that this kind of self-conscious and reflexive theorizing is regarded as a key priority for taking contemporary ethics forward.

From my flat on the eighth floor, I enjoy the panoramic view of the bay and beaches of Montevideo. Except for days of rain and stormy weather—which happen often in these months of winter—the beach is frequented by dogs and their masters and mistresses. I have a passion for dogs, and every morning and afternoon I take short breaks to watch from my window the playfulness of my four-feeted soulmates. They differ in race, color, and size, but from a bird’s-eye view, these differences are negligible, as are the differences in their behavior: they all stop to sniff and deposit their “biological fingerprints” at exactly the same places, they leap and jump around, they move back and forward in different directions, always close to water—a few of them even risk brief visits into the water—and always ahead of their guardians, though not too far away from them. Only occasionally do I observe barking confrontations. Often, however, I see them joined in ceremonial acts aimed at repeatedly outshining each other with regard to “depositional” pace and outreach.

Dashiell Hammett’s reaction was “sharp and angry, snarling” when he read, at her request, a work in progress by his friend and lover, Lillian Hellman. “He spoke as if I had betrayed him.” His judgment was absolute and his advice unsparing: “Tear this up and throw it away. It’s worse than bad—it’s half good.” That is exactly what I thought of Matti Häyry’s Rationality and the Genetic Challenge as, for the third time in the evening, I penned a note in its margins and sent it sailing across the room in disgust. Cambridge University Press knows its book binding, however, and the spine of the text was undamaged.

Matti Häyry’s new book is deliberately challenging; it tells six contemporary bioethicists, and all who share their methodologies or even their general approach, that they have got it badly wrong. From the striking photograph of Häyry himself on the front cover to the very last line, the genetic challenge is issued and elaborated. Häyry has divided his protagonists into three pairs, of which I find myself a member, and this makes responding a duty as well as a pleasure. Although I cannot speak for my partner in crime, Jonathan Glover, I am at least in the very best of all possible company.

From the first initiatives in preimplantation genetic diagnosis (PGD) and gene therapy through the advent of stem cell research to the development of mammalian cloning, the past two decades have witnessed remarkable advances in “reprogenetic” medicine: the union of assisted reproductive technologies (ARTs) with genetic control. This period has also been marked by intense debates within the bioethical literature and in national policy forums about the appropriate uses of these emerging human capabilities. We can now, in a limited way, select for genetic traits, and the power to modify the genome or introduce new gene sequences is not far off. How should these new powers be used?

Rationality and the Genetic Challenge by Matti Häyry is a well-written and thoughtful book about important issues in the contemporary ethical discussion of genetics. The book is well structured around seven practical themes that the author takes to exemplify “the genetic challenge.” He also refers to them as “seven ways of making people better,” which the subtitle of the book already puts into question form: Making People Better? In the first chapter of the book, Häyry introduces these seven themes and he discusses each of them in Chapters 3–9. In the remaining two chapters, 2 and 10, he describes the main normative positions analyzed in the book and clarifies his own methodology and position. He chooses six authors, or three pairs of authors, whom he takes to “represent the three normative doctrines of Western Moral philosophy” (p. 27) in order to demonstrate six “divergent rationalities” or “methods of genethics.” In this way, Häyry both summarizes the main prescriptive positions in contemporary bioethical debate and contrasts them with his own “nonconfrontational notion of rationality,” which aims to show that there is a variety of divergent, not mutually exclusive normative views, the justification of which “depends ultimately on the choice of worldviews, attitudes, and ideas about the foundation of moral worth” (p. 47).

Matti Häyry’s new book Rationality and the Genetic Challenge discusses the ethics of human genetic modification and the bioethical rationalities that inform the different ethical conclusions authors have advanced. It is aimed at correcting the belief that “only one rationality exists or one morality exists; that those that disagree [with them] are unreasonable or evil.” Häyry argues that there are multiple rationalities, and that even though ethical issues may have solutions within individual rationalities, disagreements that have their root in separate rational approaches cannot be universally solved by intellectual arguments. In debates about the ethics of using new biotechnologies to genetically modify human beings, the normal state is one of fundamental disagreement over almost all of the anticipated uses to which the technology could be put. Häyry’s point is that such a state of affairs is not necessarily due to a lack of reason because there are many, equally valid, ways of being reasonable.

Reviews of philosophical books run the risk of being either excessively and unconstructively critical or superficially praiseworthy. To avoid both these risks, we test the approach outlined by Häyry in his book Rationality and the Genetic Challenge: Making People Better? by applying it to an eighth genetic challenge, namely, a variation of the genetic enhancement challenge discussed by Häyry as it applies to sports. We assess whether genetic enhancement in sports should be conceived as an eighth wonder or an eighth cardinal sin that stems from the interaction between genetics and society, question whether Häyry’s nonconfrontational approach is really useful for dealing with these issues, and discuss how his method can be improved.

The claim that the answers we give to many of the central questions in genethics will depend crucially upon the particular rationality we adopt in addressing them is central to Matti Häyry’s thorough and admirably fair-minded book, Rationality and the Genetic Challenge. That claim implies, of course, that there exists a plurality of rationalities, or discrete styles of reasoning, that can be deployed when considering concrete moral problems. This, indeed, is Häyry’s position. Although he believes that there are certain features definitive of any type of thinking that can accurately be labeled rational, he maintains that nothing about that set of features compels us to conclude that there is a single rationality. What is more, and significantly for the way in which Häyry’s book develops, there is no Archimedean point from which we are licensed to pronounce one flavor of rational deliberation to be intrinsically superior to any other or to be justified to the exclusion of all others. To this belief that “there are many divergent rationalities, all of which can be simultaneously valid,” we can perhaps give the name “the Doctrine of the Plurality of Rationalities” or, for short, “DPR.”

In Rationality and the Genetic Challenge: Making People Better? Matti Häyry provides a clear and informed discussion and analysis of a number of competing answers to the above questions. Häyry describes three main perspectives on the morality of prenatal genetic diagnosis (PGD), the “restrictive,” “moderate,” and “permissive” views, and his analysis illuminates that these views can be distinguished in terms of their different “rationalities”—their respective understanding of what counts as a reasonable choice for parents to make in light of PGD.

As the authors of the Millennium Development Goals (MDG) Gap Task Force have noted, access to medicines is a vital component of realizing the human right to health. Without reliable access to drugs, the highest attainable standard of health cannot be achieved.

Dying before one’s time has been a prominent theme in classic literature and poetry. Catherine Linton’s youthful death in Wuthering Heights leaves behind a bereft Heathcliff and generations of mourning readers. The author herself, Emily Brontë, died young from tuberculosis. John Keats’ Ode on Melancholy captures the transitory beauty of 19th century human lives too often ravished by early death. Keats also died of tuberculosis, aged 25. “The bloom, whose petals nipped before they blew, died on the promise of the fruit” is how Percy Bysshe Shelley expressed his grief over Keats’ death. Emily Dickinson wrote So Has a Daisy Vanished, being driven into depression by the early loss of loved ones from typhoid and tuberculosis.

“I want my leadership to be judged by the impact of our work on the health of two populations: women and the people of Africa.” This is how Dr. Margaret Chan, the current Director-General of the World Health Organization (WHO), described her leadership mission. The reason behind this mission is evident. Women and girls constitute 70% of the world’s poor and 80% of the world’s refugees. Gender violence against women aged 15–44 is responsible for more deaths and disability than cancer, malaria, traffic accidents, and war. An estimated 350,000 to 500,000 women still die in childbirth every year. The negative health implications of absolute poverty are worst in Sub-Saharan Africa and South Asia. Hence, Chan aims to have the biggest impact on the world’s poorest people.

The highest attainable standard of health is a fundamental human right, which has been part of international law since 1948. States and their institutions are the primary duty bearers responsible for ensuring that human rights are respected, protected, and fulfilled. However, more recently it has been argued that pharmaceutical companies have a coresponsibility to fulfill the human right to health. Most prominently, this coresponsibility has been expressed in the United Nations (UN) Millennium Goal 8 Target 4. “In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries.”

Health is higher on the international agenda than ever before, and improving the health of poor people is a central issue in development. Poor people suffer from far higher levels of ill health, mortality, and malnutrition than do those better off, and their inadequate health is one of the factors keeping them poor or for their being poor in the first place. Health is a crucially important economic asset, particularly for poor people. Their livelihoods depend on it. When poor people become ill or injured, their entire household can become trapped in a downward spiral of lost income and high healthcare costs—a vicious circle of poverty and ill health.

Firstly I would like to acknowledge the Traditional Owners whose land we are meeting on today. I acknowledge that I stand before you on the shoulders of Indigenous Peoples globally, past and present that have been marginalised, had their knowledge exploited, and generally had their inherent native title rights ripped off for the financial and health benefit of others.

In a widely cited 2003 article, DiMasi, Hansen, and Grabowski estimated the cost of pharmaceutical research and development to be $1.1 billion (year 2000 U.S. dollars) per new medicine coming onto the market in 2001. They also estimate that this cost is going up at a real (inflation-adjusted) rate of 7.4% annually. According to these estimates, the innovation cost per new medicine today is about $2.1 billion (year 2000 U.S. dollars) or $2.65 billion (year 2010 U.S. dollars).