Absolutely Essential: Bioethics and the Rules‐Based International Order By Jonathan D.Moreno, Cambridge, MA, USA: MIT Press, 2025. 198. USA $45.00/CAN $60.00, ISBN: 978‐0‐262‐55337‐7.

Moreno sets out to provide “an historical and sociological assessment of bioethics,” examining the extent to which the field's conceptual content and institutional manifestations have been influenced over the last 80 years by post-WWII international politics (p. xviii). In terms of audience, Moreno hopes to persuade political scientists and intellectual historians to be interested in bioethics, and bioethicists to be interested in international politics. His main aim is to show that “bioethics is a creature of the rules-based international order” (p. 167). That order, designed by the Allies in the wake of WWII, is characterized by a push for open markets, liberal democracy, and multilateral organizations, its aim being to promote peaceful economic cooperation, including with Germany and Japan, as well as (perhaps unofficially) to facilitate American leadership (read, hegemony) after the collapse of the previous imperial order of colonial powers. Moreno explains the (often international) political context leading up to and shaping major events in the history of bioethics. The book's wide-ranging discussion is helpful not only for enriching our understanding of how we got here, but also for alerting us that bioethics may be affected by neo-imperial efforts (including American ones) to weaken the rules-based international order—a concern that has only become more relevant since the book's publication. Moreno covers a lot a ground, so I will pick out a few examples to illustrate the book's value. Although he briefly touches on clinical ethics and public health ethics, the focus is on the ethics of medical research. A first example is Moreno's comparison of the trial of Nazi doctors, which led to the Nuremburg Code and its statement that voluntary consent is absolutely essential (hence the book's title), with the equivalent trial of Japanese doctors, where the American military hid from its own prosecutors evidence of horrific medical experiments, having deemed the biological warfare data too valuable for American security interests (p. 45). Through his discussion of the first trial, Moreno argues that respect for patient autonomy became the cornerstone of modern bioethics in large part because it was a good match for the push for multilateral organizations with their emphasis on national sovereignty and individual rights—part of the order shaped by Americans to facilitate their dominance. That explanation of the nonetheless laudable and groundbreaking Nuremburg Code suggests that the cover-up in Japan was more continuous (in terms of the political forces at work) with Nuremburg than one might otherwise have thought. A second example is Moreno's discussion of the move from the 1947 Nuremburg Code, written by judges, to the World Medical Association's 1964 Declaration of Helsinki. He shows how important the medical researchers' desire to self-regulate was in the development of the Declaration. This is a recurring theme in the book: a key part of bioethics' raison d’être is to assure legislators that they do not need to (and should not) step in to write ethical regulations. Moreno shows this with Asilomar in 1975, the 2005 National Academy of Sciences committee on stem cells, and the response to He Jiankui's gene editing in 2018, to name a few examples. A third example is Moreno's discussion of the American move away from the Declaration of Helsinki in the early 2000s. The original version had been significantly influenced by the AMA (and, in turn, by the American pharmaceutical industry), resulting in it being more permissive than the Nuremburg Code, such as dropping the prohibition on prisoner research—popular in the United States at the time. But a few decades later, when the sixth edition of the Declaration included what the FDA considered to be excessive restrictions on placebo controls, the FDA broke away from it, since “a reference in any regulations to a document [they] had no control over (such as the Declaration) was not prudent” (p. 67). Through this and other examples in bioethics, Moreno shows the United States, faced with waning hegemony, making choices that weaken the rules-based international order it helped create. Moreno suggests, I think, a two-way relationship between bioethics and the rules-based international order. The ability of bioethics to support that order is a key part of why it is a thriving field, and conversely, bioethics relies on that order and its (always imperfect) global norm favouring consensus-building for ethical guidelines. Since the book's primary aim is sociological and historical, Moreno does not provide an in-depth ethical analysis of the threat of the current international order giving way to neo-imperialism. The reader is left with a keen but vague sense that such a change could be very bad, not only in general for peace and quality of life, but also specifically for medical research. This raises questions like: What kinds of bioethical problems are likely to arise? Is fighting to preserve the rules-based international order the ethical response, or should we, accepting the inexorability of neo-imperialism, instead work to adjust bioethics accordingly? If the latter, what bioethical concepts are vulnerable, and (in search of a silver lining) could there be opportunities for desirable additions? Early in the book, I hoped to see such normative questions taken up in the later parts. This did not happen, but to be fair, by the end, I appreciated that Moreno's sociological and historical project was more than enough of a task. He ends with normative ambiguity, noting, on the one hand, that “there can be no turning back” to a time before “trends undermining the post-World War II rules-based order,” and, on the other hand, that “an ordered international system of liberal nation-states under recognized norms and conventions remains absolutely essential” (pp. 141, 167). This could be read as a rallying cry or a dire warning to brace for what comes next; perhaps it is meant to be both. Although the book, understandably, did not include the extended normative analysis I was hoping for, it did emphatically succeed at making the case that it is needed. I will offer, then, some very brief thoughts about one of the normative questions: What kinds of ethical problems in medical research might neo-imperialism pose? The book's wealth of examples of unethical medical research suggests a division into three types. First, medical research can be unethical due to bad science, where a protocol lacking scientific rigour exposes research participants to risks (or harms) without generating useful data. A virtue of the rules-based international order is that it (imperfectly) supports a global culture of science that sustains a reasonably high level of compliance with consensus-based norms about the needed rigour. Neo-imperialism—especially when it combines isolationist tendencies with a populist disdain for science and expertise—has the potential to weaken those norms, making them more vulnerable to being overpowered by commercial or military interests. Second, scientifically rigorous medical research can be unethical if it uses unethical methods. For some, US-sponsored clinical trials that satisfy the FDA but violate the Declaration of Helsinki are instances of this. Other examples are explained by military interests, such as Project SHAD of the 1960s, in which navy personnel were exposed to chemical and biological agents without consent (pp. 86–87). The risk of ethical requirements being disregarded appears to be greatest when an otherwise unapprovable medical research project is deemed both time-sensitive and necessary for national security. To the extent that neo-imperialism makes nations less cooperative and more likely to go to war (or at least more aggressively compete for superior military capacity), the risk is increased. Third, scientifically rigorous medical research can be unethical if its research questions are antithetical to medicine, such as improving torture techniques (as seen in Guantanamo) or developing biological weapons (as seen in the CIA's Clear Vision project of the early 2000s) (pp. 89–94). The risk of such research occurring may increase if neo-imperialism results in government and military officials offering national security justifications more frequently and more boldly, even if only internally. Finally, let us consider the relationship between these three ethical violations. One virtue of the rules-based international order is its (imperfect) ability to make the prohibition of the second and third (i.e., unethical methods and aims) part of the price of admission to participation in global science, without which it is difficult to preserve scientific rigour. A nation that does not want to fall behind scientifically (which could be bad for national interest and security) will be strongly motivated to enable its scientists and research institutions to be seen as globally reputable; and this currently requires avoiding not only research that is unethical due to bad science, but also scientifically rigorous research that is unethical in methods or aim. In other words, scientific rigour is not sufficient for reputability. Let us hope that this remains the case, even amid threats to multilateralism and consensus-building of the rules-based international order.

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