1. Introduction

During recent years an ongoing attempt has been to challenge bioethical mainstream thinking, often by way of offering novel overall perspectives on the field that seek to incorporate new topics in bioethical canon. This attempt has materialized through the introduction of new branches of bioethics, such as “feminist bioethics,” [1] “pragmatic bioethics,” [2] or “worst case bioethics.” [3] In this article, we will tap into this trend by introducing a similar kind of branch, that of “organic bioethics.”

Our work relies on Dr. Heikki Saxén’s extensive historical research on the origins and development of bioethics, in practice, on his recent Ph.D. dissertation on the intellectual and cultural history of bioethics. [4] Based on this inquiry, we argue that the two core aspirations of the field are to be intellectually open-ended and socially inclusive. In other words, we see these two ideals as central coordinates that motivated the birth of the field and continue to guide, or at least should continue to guide bioethics. Explicating and defending this argument, in itself, leads to a lengthy discussion, [5] which we will not cover here. Rather, in this article, we will take this argument for granted and focus on potential implications that this underlying historical interpretation has for understanding and applying bioethics.

As noted, to make our understanding and its implications more accessible, we have developed a conception of “organic bioethics,” which is an overall way to conceive and apply bioethical thinking. Essentially, the organic bioethics perspective shifts the attention from classical bioethical thought into ongoing—"organic”—interaction between bioethics and its social and cultural surroundings. Organic bioethics seeks to better grasp and foster this interaction for the benefit of supporting intellectual open-endedness and social inclusivity. Put differently, organic bioethics aims to treat bioethics not so much as an entity in itself as a kind of rich and democratizing mirror for the surroundings of bioethics: traditionally, life sciences and health care. In this pursuit, organic bioethics seeks to reconceive bioethics theoretically as well as practically.

In this article, we will illustrate organic bioethics by utilizing an empirical study on the bioethical views of stakeholders who have participated in personalized medicine research. Thus, rather than laying out deeply theoretical conception of organic bioethics in the beginning, we will proceed by discussing the empirical study, conducted in Finland, and aim to introduce organic bioethics to the reader through connecting it with the findings of the study.

Eventually, our core message will be that paying attention to the organic interaction between bioethics and its surroundings will not only be in tune with the essence of bioethics as a field but also clearly help to enrich its contributions in practice.

2. The case of personalized medicine

Typically, personalized or precision medicine, PM for short, raises a pressing ethical and social challenge of bringing together different relevant actors and their perspectives into common dialogue and decision-making regarding the implementation of this new type of care. This endeavor particularly connects with the underlying expectation, created by personalized medicine, that it would mean that patients could be treated more individually in every respect. In practice, this is usually thought to centrally require that patients would enter common dialogue and decision-making with professionals more integrally and actively than before. [6]

Simply put, fostering joint deliberation is a central challenge and one that is not often addressed adequately. However, even outside this call for joint deliberation, the situation is demanding: As complex medicine and technology at the heart of personalized medicine are currently advancing with such a rapid speed, even for the most well-informed experts, already for themselves, the challenge of grasping the theme is immense, not to mention the equal intellectual barrier facing patients, citizens, and regular medical staff. Beyond grasping the relevant aspects of the theme, then, lies the challenge of fostering joint deliberation between different parties, which oftentimes only seems to amplify the underlying confusion. Too often the outcome is that due to these unresolved obstacles, personalized medicine remains distant from meaningful adaptation in everyday health care, its potential being left utilized as well as its perils unrecognized. [7]

To tap into this theme, we conducted a qualitative social scientific and bioethical study on the ethical and social challenges presented by the gradual implementation of personalized prostate cancer care in Finnish health care. The study focused on interviewing relevant stakeholders: patients, who were also enrolled in prostate cancer research, medical staff, cancer researchers, and IRB members. Clinical bioethicists were not interviewed as such a profession is currently not found in Finnish health care. [8]

The study confirmed the basic suspicion that well-rounded knowledge regarding the relevant aspects of the theme is usually lacking as each group perceives only its own share, if even this, of the gradual implementation of PM in prostate cancer care. Moreover, joint deliberation, which could break this trend and inform action, is practically missing, following the traditionally siloed structure of health care, that of a university hospital in this case. All in all, the situation presented us with a clear task of improving social interaction in this context to support the implementation of PM in an ethically and socially sustainable way.

Then, as outlined in the beginning, we will continue to analyze the situation from the organic bioethics perspective next. Furthermore, we will investigate how organic bioethics could help to improve this setting.

3. The first insight of organic bioethics: Common language is at the heart of organic bioethics

As the organic bioethics perspective is based on the thesis that at the heart of bioethics lie its aspirations to be intellectually open-ended as well as socially inclusive, it is natural to focus on the very elementary building blocks of social interaction. What, then, could be a more natural place to start in this respect than to concentrate on language?

This brings us to the first insight that is elementary to organic bioethics—that language matters greatly, especially as a way to either allow or deny open-ended thinking and social inclusion. In other words, reaching these ideals centrally depends on whether common language can be established or not—if it is denied by resorting to exclusive expert knowledge and discussion. Then, if we think of the case of personalized medicine from this perspective, it becomes clear that a huge obstacle in allowing for intellectual open-endedness and social inclusion to take place is the lack of common language around personalized medicine. In our study, we could clearly see that different stakeholders were speaking well past one another, if they were speaking to one another at all. This is detrimental to the aims of organic bioethics. Furthermore, as fostering social interaction is at the heart of the aspirations to implement personalized medicine, lacking intellectual open-endedness and social inclusion are understandably likely hindrances for the overall instigation of PM. All in all, in the end, the lack of common language between the stakeholders of PM, stands at the center.

Then, as organic bioethics helps to identify the problem, it can also help to address it. It is understandable that the demanding medical terms of PM create a huge challenge for establishing common language; however, the ethics of PM could at least offer a more natural starting place. Success in this regard could also spill over to the other domains of PM in time and help to broaden the scope of common language between the stakeholders. Here, then, organic bioethics highlights the virtues of what has already been developed in bioethics and what could be drawn on.

In existing bioethics literature and practice, especially principlism [9] is an excellent case in point of this aspiration already materializing in many cases—bioethics working as a kind of mediator between different actors and their perspectives, helping to establish common language. Often accused of being shallow, arbitrary, or even conflicting in content, principlism has nevertheless arguably succeeded in offering an easily accessible platform for various actors to voice their views and concerns in the same, bioethical terms. From the perspective of organic bioethics, this is exactly what matters. In fact, as to the criticism, a degree of shallowness and other such perceived shortcomings of principlism even seem to be prerequisites for being successful in this regard. [10]

Thus, the argument arising from organic bioethics is that introducing principlism to address the challenge of establishing common language for the stakeholders of PM could be a great way to proceed. This would foster intellectual open-endedness as well as social inclusion, and overall, it would enhance the social interaction that is fundamentally important to the sustainable implementation of PM. Furthermore, it needs to be added that principlism is only one possible avenue for proceeding. In fact, we argue that principlism should rather be taken as a beacon for quality of bioethics that should be significantly developed further, namely, the way how bioethics can function as a mediator between actors and perspectives, offering them the same terms, or, common language, be this in personalized medicine or in something else.

4. The second insight of organic bioethics: Social capital can either foster diversity or stifle it

As language seems a natural building block of social interaction, the focus of organic bioethics, so, too, appears to be the case with social capital. Put simply, social capital is the invisible glue that ties different people together and ensures that they co-operate with and trust one another, as well as seek mutual benefits out of this interaction. Equally the lack of social capital can break down social interaction in all these different ways. Directing attention to social capital is especially important as it is often overlooked in discussions revolving around the implementation of personalized medicine, as well as in standard bioethics literature and practice.

In our study of the stakeholders of PM, we could clearly register a problem with social capital. Simply put, the challenge was that different stakeholders of PM primarily associated with their own groups, such as medical staff with other medical staff, a cancer researcher with other cancer researchers, and so forth, rather than with the members of the other stakeholder groups involved with the implementation of PM. Understandably, as with missing common language previously, this poses a two-fold problem: first, it is a challenge for organic bioethics, which seeks to advance intellectual open-endedness and social inclusivity, and second, it is an overall problem for the implementation of PM, which relies heavily on extensive social interaction.

Then, organic bioethics can also shed light on analyzing the situation in a more nuanced manner and for moving toward potential remedies. Following the work of political scientist Robert D. Putnam, we argue that it is important to distinguish between different types of social capital, particularly two types: bonding and bridging. [11]

The first type, bonding social capital, is the social glue that brings together similar kinds of people, helping them to support each other and achieve common goals—however, this comes at the price of excluding outsiders who are different. The latter type, bridging social capital, in turn, is almost the opposite of the first, as it is based on exactly the differences between people. This kind of social capital grows out of mutual recognition and appreciation of people’s differences and concomitant reciprocal need to allow room for these differences, even to utilize them for the common good. In this case, differences are exactly what unite people.

For organic bioethics, Putnam’s division between the two types of social capital offers a central framework for ethics. As intellectual open-endedness and social inclusion are seen as essential aspirations of bioethics, the argument favors eroding the first type of social capital—despite its merits—as it tends to create inward-looking groups that exclude others. Accordingly, this understanding points toward fostering the latter type of social capital that creates room for differences between people as well as utilizes these differences for the common good. Again, as with the common language thesis, we see that this pursuit has already characterized bioethics to a large degree. However, equally often this has not been fully recognized and it could be so to a greater degree.

This observation sends a strong signal for designing social systems as well as for valuing and supporting different kinds of social interaction in both organizations and society. As social capital sets an important backdrop for bioethics as well as for implementing PM, it is important to recognize and seek to influence this kind of invisible air that surrounds social action.

As noted, it seemed clear in our study, which is probably very indicative of other similar kinds of settings, that different parties, from patients to medical staff to researchers and IRB members do not simply feel that they belong to the same table. They primarily associate, or “bond,” with their own group, not as participants sitting, “bridging,” around the table of personalized medicine, as people who would centrally draw meaning from this shared purpose to their work.

For instance, in the interviews we conducted for the study, the desire to reduce bonding with the traditional group roles and associated siloes of health care for the benefit of this new kind of bonding was evidently lacking. In such a situation it is hard to see how common deliberation, the one called for by organic bioethics or any meaningful deliberation at all, could genuinely take place. Nevertheless, we do not think that the challenge is insurmountable. Supporting social bonding by which different stakeholders come together, not anymore primarily as representatives of their groups but rather as true stakeholders of the current context, can surely be achieved if the social challenge is acknowledged and addressed in a determined fashion—mirroring, for instance, the shift in regular health care toward multi-professional teams.

All in all, whether in the context of implementing PM or something else, paying attention to social capital and especially seeking to foster bridging social capital through designing appropriate social systems is what centrally characterizes organic bioethics.

5. The third insight of organic bioethics: The theory of political order and decay helps to uncover institutional realities

As with language and social capital, the explicit institutional structure, such as the administrative structure of a university hospital, is understandably a key ingredient of social interaction and thus interesting for both the implementation of PM and the particular perspective of organic bioethics. The institutional structure centrally governs social action, and perhaps more interestingly, appears to have dynamics of its own, which need to be acknowledged.

In our study of the implementation of personalized medicine and how the stakeholders view this endeavor, a central institutional element was emphasized repeatedly: the procedure of acquiring informed consent from the research participants. The idea of acquiring such consent is not a novel idea, and moreover, it is a commonplace practice; however, the nuances and the extent to which this consent should reach is another and pressing issue. In fact, this topic is already heavily debated in current PM as well as in bioethics literature; nevertheless, its connection with institutional dynamics is rarely addressed and this is where we turn our attention.

This brings us tothe theory of political order and decay, [12] which centrally informs organic bioethics. Following the theory formulated by political scientists Samuel Huntington and Francis Fukuyama, we focus on the dynamic by which institutional representation works.

As it has become clear, the implementors of PM and particularly the organic bioethics perspective seek to find and support ways to include, or empower, new participants to join common dialogue and decision-making. However, it is essential to recognize how such endeavor, when materialized, creates new expectations among these groups of having a genuine say, of having the power to influence. The challenge is new expectations to participate are not usually adequately matched by institutions as they are, almost by definition, rigid, particularly slow to change. Put simply, newly empowered groups demand greater institutional representation, which again, is not usually adequately matched at first, if ever. This, in turn, can set these institutions on a perilous path as they gradually lose their touch with underlying social reality and support. Ironically, having more say oftentimes leads to greater expectations and this, in turn, can easily lead to greater disappointments.

Thus, to have successful reforms and avoid the disruption, or decay, of institutions, it is of paramount importance to secure a good fit between institutional realities and the underlying social participation. In its simplest form, the argument is that it is vital to recognize that these two parts of the equation, institutional incorporation and social participation, are not necessarily the same; however, ideally, they should be.

As with the previous observations, we see that bioethics’ pursuit of finding new institutional avenues for potentially newly empowered groups has already been in many ways in tune with this understanding. However, as before, we equally see there is still a way to go in fully acknowledging the importance of this task.

In practice, and coming to our study on personalized medicine, this especially seems to mean that it is not enough to simply acquire consent from research participants, not necessarily because this would be ethically inadequate but rather because it sets of, in all likelihood, a social dynamic that soon calls for even greater participation—provided of course that acquiring the consent carries any real weight and is not simply an empty social routine. Then, not answering these demands, in turn, creates unstable and dysfunctional institutions.

To put simply, our message is that acquiring consent needs to be accompanied by even greater representation by research participants. This could mean, for example, deliberative bodies that could be part of designing research settings from the very early on, or, this could mean more dynamic participation by research participants to affect central decisions regarding the study along the way. Alternatively, the second-best option from the perspective of institutional dynamics would be to abandon the practice of acquiring consent altogether, which is not a likely route to be taken and which would be, plainly put, unwise given the broader social and cultural milieu.

Then, the broadest message of organic bioethics here is that institutional dynamics appear to have a life of their own and it is vital to understand such dynamics as well as to design institutions appropriately.

6. The fourth insight of organic bioethics: Political philosophy helps to connect high ideals with practice

To better grasp and motivate the goals of organic bioethics, we also emphasize the role of political philosophy in discussing and setting commonly shared ideals. In other words, the two core aspirations of organic bioethics, i.e. to be intellectually open-ended and socially inclusive, are high ideals and they need to be explicated and clearly connected with practical insights. Political philosophy as a field appears to be particularly well suited to cross between such different levels of thought and action, finding and creating a harmonizing balance between them. Perhaps the most well-known positive example of this has been the “reflective equilibrium” proposed by political philosopher John Rawls. [13] Put short, as institutions, high ideals, too, can lose their connection with reality all too easily.

Beyond Rawls, a good example of how to create such balance and tie different aspects of thought and action together in a crystalized way can be seen in the work of political theorist Philip Pettit, which revolves around the conception of freedom as a non-domination. [14] With his concept, Pettit highlights the fact that oftentimes freedom is not sufficiently guaranteed by granting freedoms in themselves. Rather, it seems that a central element of securing meaningful freedom is in avoiding overt dependence on the continued goodwill of others, which eventually leads to and connects with the arbitrariness of social systems.

To counter this pitfall, Pettit sketches an ideal to design systems that would constantly stay vigilant and guard against the dangers of placing people under such domination—which typically operates in very subtle and covert forms and thus needs to be clearly acknowledged. Paying attention to this ideal, then, goes well hand in hand with the central aspirations of organic bioethics. It helps to keep the question of domination on the agenda as a clear and resonating motivation for the central ideas of organic bioethics and it also offers an accessible tool to check whether they have been achieved in practice.

Overall, as noted, we see that Pettit’s thought is only a good example of how political philosophy can support the goals of organic bioethics and that broadly speaking political philosophy in this vein should be utilized more. Nevertheless, the ideal set by Pettit in itself already offers a good starting point for introducing political philosophy into organic bioethics.

To connect with our study on the implementation of personalized medicine, then, for example, Philip Pettit’s idea of freedom as non-domination aids in communicating why indeed all the different stakeholders, especially patients and research participants, need to have a real say and to be part of the process. In other words, it is not enough to just inform them or invite them to participate when others see this fit, as then the risk of merely creating an illusion of freedom, or rights—supporting domination—is evident. Rather, patients and research participants need to be genuinely part of the process from the very beginning and this needs to be a clear idea from the outset.

7. The fifth insight of organic bioethics: The need to make bioethics even more tangible and accessible

Finally, the last insight arising from organic bioethics that we want to introduce in this article is that the previous efforts need to be tangible and accessible so that everyone can grasp them—otherwise, socially and culturally speaking, they are doomed to extinction. The challenge is that of popularizing thought. Bioethics truly needs to bring, on a full scale, ethics out of the ivory towers of academic philosophy if it aims to democratize thought.

Previously we mentioned that principlism has arguably been a success story in this regard as it has managed to offer an easily accessible forum, a language, for different participants to voice their thoughts in bioethical terms. However, we hope that bioethics could do even more to make its ruminations tangible and accessible so that it would encourage new participants and perspectives to join the discussion and related decision-making. This comes to the style of discussing philosophy, even conceiving its overall role. Perhaps organic bioethics could be best described in this regard as leaning toward pragmatism.

For example, we see that philosopher Michael Sandel has mastered the art of popularizing his thinking so that it connects well with, and refines, the everyday experiences of the public. [15] Beyond Sandel, bioethicist Robert Veatch in his thought-provoking book “Patient, Heal Thyself: How the ‘New Medicine’ Puts the Patient in Charge” [16] offers a good example of how to connect, somewhat boldly and radically, philosophical thinking with everyday experiences. Veatch seeks to alter the traditional medical concepts and language, for instance, to avoid “discharging patients” from hospitals as if they were prisoners.

Put simply, we argue that too often bioethics falls short of finding enough tangible and broadly accessible ways to address ethics in everyday settings and this is what organic bioethics, with its pragmatist undertones, seeks to avoid to support social interaction. According to our view, bioethics resembles traditional academic philosophy too much in its style, and this it should seek to avoid more adamantly. A central yardstick of its success for bioethics should be whether its ruminations are accessible to a person who is not at all familiar with philosophy or academic thought in general.

Then, coming again to our study on the implementation of personalized medicine, the central challenge in instigating the new ideas presented here to support social interaction, or, organic bioethics’ ideals of open-ended knowledge and social inclusion, is to make these efforts tangible and accessible so that everyone can grasp them. For instance, Veatch’s new language could be perhaps now more than ever needed. If the aim is that personalized medicine would truly be personalized, it is essential to abandon any illusions that what is at stake is merely new medicine or technology, the restricted domains of experts. Rather, professionals need patients and research participants as equal discussants and decision-makers, not fundamentally as subjects—to be utilized by and “discharged” from medical facilities.

8. The overall picture: Connecting the dots of organic bioethics

Now, the reader might wonder how exactly the previous five insights connect with one another to form central content for organic bioethics. What is organic bioethics as a whole and what it has to offer eventually? First of all, why is it “organic”?

As noted in the beginning, in using the term organic bioethics we want to direct attention to the ongoing intellectual and social interaction between bioethics and its surroundings, particularly life sciences and health care. This very interaction should be the main focus of bioethics, rather than ethical content in itself, as the central ideals of the field are to be intellectually open-ended and socially inclusive. To push the envelope, from our perspective, this interaction between bioethics and its social and cultural surroundings is bioethics.

In practice, this means that bioethics should seek to be highly reflective of its intellectual and social context, aspiring, most of all, to create room for and support intellectual open-endedness and social inclusion. This is the factor that was manifest in all the previous five insights and what connects them.

However, this reflection is only part of the practical aims of organic bioethics. Besides it, organic bioethics highlights the potential for even broader reflection. Organic bioethics also seeks to turn the attention away from bioethics altogether—from typical bioethical topics—arguing that because of its interactive nature, it can offer an excellent vantage point from which to view the surroundings of the field even beyond the domain of ethics. Put differently, with this we mean that organic bioethics offers a tremendous avenue, through its open-endedness and social inclusion, to grasp the surroundings of bioethics, for example, to develop novel ideas for working hospitals or well-rounded medicine.

All in all, we think that organic bioethics has a clear potential for offering new perspectives for bioethical thought, and even beyond. To summarize, our key argument is that organic bioethics shifts the place of bioethical thought, placing it at the center of the interaction between bioethics and its social and cultural surroundings, which is a somewhat departure from the traditional understanding of ethics, which typically revolves around ethics itself. However, at the same time we argue that this is what forms the essence, the reason for being, of bioethics.

9. Conclusion

As the discussion illustrates, there is evidently much to do if personalized medicine is to be well incorporated into everyday health care and medicine. At least this is what our social scientific and bioethical study suggests, especially when viewed from the perspective of organic bioethics. To us, it is hard to see any other way of introducing personalized medicine in a meaningful and sustainable way, particularly ethically and socially speaking. The good news is that at the same time organic bioethics offers an intellectual toolkit for navigating ways forward.

Naturally, organic bioethics that we have now sketched cannot overcome the challenges of implementing personalized medicine by itself. First of all, the previous insights are indeed only brief examples of what should be acknowledged and tentative suggestions as to how these issues could be addressed. Moreover, our broader argument is that organic bioethics is a lot more than what has been manifest in these insights, they merely help to set key coordinates. 

Rather, organic bioethics is an overall way to refocus bioethics for the benefit of reflecting, ethically and otherwise, on themes such as the one now discussed in a manner that creates room for its two core ideals to materialize: for the intellectually open-ended and socially inclusive deliberation to take place. Our belief is that instigating and supporting such deliberation is the essential beginning of finding meaningful and sustainable solutions for implementing personalized medicine, or, for any other themes arising in the domain of bioethics and its social and cultural surroundings.

 The authors would like to thank colleagues Petri Koikkalainen and Stowe Locke Teti for their constructive criticisms of the manuscript.
 

[1] Donchin, Anne and Jackie Scully. “Feminist Bioethics,” in the Stanford Encyclopedia of Philosophy (Stanford, CA) December 16, 2015. https://plato.stanford.edu/entries/feminist-bioethics.

[2] McGee, Glenn. Pragmatic Bioethics, 2nd ed. (Cambridge, MA: MIT Press, 2003).

[3] Annas, George J. Worst Case Bioethics: Death, Disaster, and Public Health (Oxford: Oxford University Press, 2010).

[4] Saxén, Heikki. A Cultural Giant: An interpretation of bioethics in light of its intellectual and cultural history. PhD. diss. (Tampere: University of Tampere, 2017). http://urn.fi/URN:ISBN:978-952-03-0523-9.

 [5] Ibid.

[6] For example, see Dresser, Rebecca. Silent Partners: Human Subjects and Research Ethics (Oxford: Oxford University Press, 2017): 123–154. 
Reardon, Jenny. The Postgenomic Condition: Ethics, Justice, and Knowledge after the Genome (Chicago: University of Chicago Press, 2017).
Prainsack,Barbara. Personalized Medicine: Empowered Patients in the 21st Century? (New York: New York University Press, 2017).

[7] For example, see Nina R. Sperber, Janet S. Carpenter, Larisa H. Cavallari, Laura J. Damschroder, Rhonda M. Cooper-DeHoff, Joshua C. Denny, Geoffrey S. Ginsburg, et al. “Challenges and Strategies for Implementing Genomic Services in Diverse Settings: Experiences from the Implementing GeNomics In PracTicE (IGNITE) Network,” BMC Medical Genomics 10, no. 35 (2017). https://doi.org/10.1186/s12920-017-0273-2.

[8] In total, we conducted 18 thematic in-depth interviews of key stakeholders. Publications relating to this study are still forthcoming.

[9] Beauchamp, Tom L. and James F. Childress. Principles of Biomedical Ethics. 7th ed.(Oxford: OxfordUniversity Press, 2013).

[10] Saxén, Heikki. A Cultural Giant. Academic diss. (Tampere: University of Tampere, 2017): 171–200.

[11] Putnam, Robert D.. Bowling Alone: The Collapse and Revival of American Community (New York: Simon & Schuster, 2000).

[12] Huntington, Samuel P. Political Order in Changing Societies. Repr. ed. Foreword by Francis Fukuyama (New Haven: Yale University Press, 2006).
Fukuyama, Francis. The Origins of Political Order: From Prehuman Times to the French Revolution (London: Profile Books, 2011).
Fukuyama, Francis. Political Order and Political Decay: From the Industrial Revolution to the Globalization of Democracy (New York: Farrar, Straus and Giroux, 2014).

[13] For example, see Daniels, Norman. Justice and Justification: Reflective Equilibrium in Theory and Practice (Cambridge: Cambridge University Press, 1996).

[14] Pettit, Philip. Republicanism: A Theory of Freedom and Government (Oxford: Oxford University Press, 1999).
Pettit, Philip. A Theory of Freedom: From the Psychology to the Politics of Agency (Oxford: Oxford University Press, 2001). 
Pettit, Philip. On the People’s Terms: A Republican Theory and Model of Democracy (Cambridge: Cambridge University Press, 2012) 
Pettit, Philip. Just Freedom: A Moral Compass for a Complex World (New York: W.W. Norton & Company, 2014).

[15] For example, see Sandel, Michael J. What Money Can’t Buy: The Moral Limits of Markets (New York: Farrar, Straus and Giroux, 2012).

[16] Veatch, Robert M. Patient, Heal Thyself: How the New Medicine Puts the Patient in Charge (Oxford: Oxford University Press, 2009).