I talked in my essay at the beginning of this volume about my own efforts at self-improvement, a form of human enhancement which is not often discussed in the vast current literature on enhancement. In this essay I to turn to the efforts of others to effect my improvement either by friendly criticism or commentary or by sending in my direction thoughts from which I have undoubtedly benefitted and which I hope will interest and engage all readers of this book. All the chapters in this book deserve very detailed study and discussion and all are more than just commentaries or discussion pieces. I also note that each chapter is a self-contained and elegant contribution to the literature which would be worth reading in its own right quite independently of any engagement with my own approaches to the issues discussed. In this essay I say some, necessarily very brief, things, if not always in response, then at least about the very stimulating essays which comprise this book. It is part a response to my critics and part a further clarification of my philosophy.

Suppose a state proposes a vaccination against Smoking, Alcohol and Drugs, the SAD programme. Children could be vaccinated not only against mumps and measles but also against enjoying dangerous substances such as nicotine and alcohol. Some might argue that such a vaccination is ethically justified indeed a wonderful solution to individual and social problems related to addiction; others might consider this to be unacceptable. The following arguments are discussed - the future autonomy - would it be different if one could ‘undo’ the vaccination - the moral importance of the liberty to decide about (trivial) lifestyle choices - the idea that some unhealthy habits are part of one’s personality and identity - ‘healthism’ sometimes people, e.g. mountaineers, take risks with their health because life is not only about health and longevity. Some slippery sloping is done to imagine vaccination against gambling, gluttony and obesity. A danger is that in the name of health a particular moral view is imposed on persons, e.g. a teetotaller’s view on alcohol. Immunisation may seem ideal from a public health perspective but there are serious ethical problems to be considered.

This chapter explores John Harris’s ‘safety of the people’ argument, which contends that there is a moral obligation on the modern state to protect its citizens against serious threats to security, safety and welfare. The potentially wide-ranging implications of this argument are examined in the context of current policy trends towards regulating and restricting individual health behaviour relating to, for example, smoking and unhealthy diet. It is concluded that although there may be a general obligation on the state to protect, this obligation can only apply to immediate threats. It is further argued that threats from within, such as lacking will power or risk seeking behaviour are not easily equated with threats from without, such as violent attack. The safety of the people argument therefore will not serve as an appropriate moral foundation for state interference in individual lifestyle choices.

This chapter will explore how it was that patient choice came to occupy a central position within health policy from the late 1990s onwards. Beginning with an exploration of the notion of choice in health prior to this period, the chapter will then go on to chart the rise of choice as a central objective of health policy under the New Labour government. The chapter suggests that although the notion of choice was present in earlier formulations of patient consumerism, the meaning and relative importance ascribed to choice changed in the late 1990s and early 2000s. A crucial shift took place that involved a move away from choice as something that was of importance to patients collectively and towards a focus on choice as an individual matter. Such a focus on the patient rather than patients undermined the position of patient-consumer organisations that aimed to represent patients as a group. Speaking for patients was more difficult when the individual was thought to be best at determining his or her own needs.

John Harris has made a lot of use of "consistency arguments" in developing his positions in applied ethics. In this chapter I look at the role of consistency in moral theory and practical argument, and consider some of the ways we might reject consistency as a requirement in moral argument, borrowing some inspiration from Frank Jackson. My argument is somewhat playful, in the spirit of John's well known good humour in public debate.

This chapter reflects on the role of reason in law and bioethics. The aspiring lawyer makes the acquaintance of the ‘reasonable man’ early in her or his student days. The chapter then addresses the work in bioethics of that most ‘reasonable person ’, Professor John Harris. It contends that in terms of law and policy, the reasonable Professor Harris is not always right but argues that Harris’s uncompromising and consistent ethical arguments make an invaluable contribution to debate on policy and legal regulation. Laws in most modern multi-cultural and democratic societies are of necessity based on compromise. Harris would classify some of those compromises as ‘fudge’. Lawmakers need to be acutely aware when they are ‘fudging’ the issue, even when ‘fudge’ is inevitable.

This chapter looks anew at John Harris’s critical discussions of the Quality Adjusted Life Year (QALY) and its use determining the just allocation of health care resources. It is argued that Harris presupposes that the QALY is grounded in subjective evaluations of the experience of health and illness, and that the justice of its application may be assessed by examining how individual subjects would be differentiated through QALY calculations. It is argued that this misconstrues the intended use of QALYs, and fails to reflect recent developments in QALY research. If a subjective interpretation is replaced by an intersubjective interpretation, such that the values and meanings expressed by a QALY matrix are understood to be the results of communication and negotiation between human subjects, then the QALY may be defended as an important resource for facilitating reflection on the moral challenges of health care allocation.

This chapter critically evaluates John Harris's arguments for the rocurement of organs and tissues from the living and the dead. Harris regards objections to the use of material from dead bodies for life-saving purposes as "implausible to the point of wickedness", sharing the view of Emson that cadavers should be regarded as a national resource to be put at the disposal of the state. In the case of tissue and organs from the living he is in favour of an "ethical market" to ensure an adequate supply for transplantation and other medical purposes. Against these views it is argued that we need to escape from a Cartesian dualistic view of mind and body, which commits us to an overly restrictive account of rationality, a neglect of morally relevant human emotions, and a failure to see the centrality of our embodiment in our understanding of ourselves and others as persons of worth.

John Harris famously rejects basing views in bioethics on what Orwell called "moral nose": detecting wrongness by how something "smells". This chapter supports his view that moral intuitions without critical evaluation can reflect mere prejudice. But it gives reasons for giving some of them more respect than he allows. When moral nose merely reflects disturbance at the unfamiliar, or at the disruption of categories based only on tradition, it has no credentials at all. But sometimes, as in Orwell's reaction to Stalinism ("there is something wrong with a regime that needs a pyramid of corpses every few years... the Russian regime stinks") or in the reactions of many of us to Guantanamo, they are based on our human responses to killing and cruelty. Moral intuitions coming from these human responses can be an early warning system it is dangerous to ignore. They should be over-ridden after a strong case has been made that the alternative will be, in human terms, even worse.

In this chapter I will analyze one characteristic of John Harris’s thinking: its controversial nature. Some of Harris’s formulations and arguments can be read as strong criticisms of the status quo. Is this a fruitful position or is it useless and possibly "detrimental"? Even if the status quo can be viewed positively as condensing common knowledge, it can sometimes be the product of prejudice. Status quo frequently prolongs inherited authoritarian patterns and the "traditional values" that oppress certain members of society, for example, women or minorities, precisely those groups that lack the power to make decisions. Their voices are ignored and are imperceptible to already established and accepted structures. In this chapter I try to examine the role of criticism in the development of thinking and culture in general, as well as the function of intellectuals in society. I consider the role of philosophy and bioethics in these matters. And finally, I outline the implications of Harris’s work in relation to the criticism he proposes.

This chapter explains the rise of patient ‘voice’ in the late 1990s, explores its multiple meanings and the implications that these had for organisations claiming to speak for the patient-consumer. The abolition of the CHCs in 2003 was indicative of a change in ideas not only about who was best placed to speak for patient-consumers, but also in the kinds of things that they were expected to say. More attention was to be paid to the voice of the individual patient rather than patients’ voices as a whole. Such a view fitted with the broader reform of the NHS that was directed towards a more marketised model with a tendency to see patients as individuals rather than as a group. Examining the ‘alphabet soup’ of organisations that replaced the CHCs suggests that despite growing attention, collective mechanisms for representing the patient-consumer were weakened. Individual voice began to be equated with greater individual choice, leaving less space for collective patient representation.

This chapter discusses Harris’s principle of justice in health care. Harris contends that his view is an equal opportunity principle of justice representing "the patient’s conception of benefit," and is superior to the provider’s or funder’s conception of benefit." He argues that the latter position is "essentially a ‘public health’ conception," as it "sees the business of health care as maintaining and improving public health or the health of the community." This is a rather narrow construal of a public health conception; a more nuanced view can incorporate considerations of justice in a scheme for allocating scarce medical resources. The chapter discusses several competing principles of justice in addressing a situation of compelling need for policy makers in developing countries: setting priorities for choosing among HIV-infected individuals who are potential recipients of antiretroviral drugs (ARVs) at a regional or national level in resource-poor countries ravaged by AIDS.

The Introduction sets the making of the patient-consumer in historical and theoretical context, delineates the key themes of the book and the issues covered. It begins by considering historical approaches to the separate figures of the patient and the consumer, and then examines how these two distinct entities were brought together in the early 1960s. The application of consumerism to health was (and to a great extent remains) contested. Key debates about the meaning of consumerism within health care, such as whether or not it was appropriate to talk about consumerism in the context of health, and the extent to which the patient-consumer can even be said to exist, will be examined. Finally, the content and key arguments of the book are surveyed.