Katrien Devolder's The Ethics of Embryonic Stem Cells Research represents a very interesting contribution to the ongoing debate on the ethical issues of human embryonic stem cells research. Devolder's reflection is beautifully written, avoids jargon without losing precision and clarity and adds valuable material to the debate. The book can be aligned with an important tradition of philosophical reflections within medical ethics, which relies on the formal tools of logic and analytic philosophy to challenge, clarify and refine the consistency and strength of commonly used arguments. This approach to problematic issues in medical ethics includes attempts to reflect on assumptions underlying euthanasia, reproductive technologies and enhancement. In accordance to this tradition, Devolder aims to show the ‘serious shortcomings' of the ethical and legal attempts to address the ethical issues of human embryonic stem cells (ESC) research.

According to Devolder, the debate surrounding ESC research stems from a ‘fundamental disagreement on how we should treat early human embryos' (1). Reasons of beneficence (i.e. the great potential of ESC research for the prevention and treatment of ‘devastating diseases, death and suffering’) clash with reasons against harming early human embryos (1). In the first chapter, the author describes this clash of opposing ethical beliefs as The Problem: ‘either one supports embryonic stem cell research and accepts resulting embryo destruction, or one opposes embryonic stem cells research and accepts that the potential benefits of this research will be foregone’ (2).

Throughout the book she reflects on the two main types of responses that have been adopted to solve The Problem: developing middle-ground positions and/or technical solutions. Middle-ground positions are very common in bioethics and represent an attempt to reconcile opposing views on moral issues. In the context of this book, these positions try to reconcile two opposing views on the permissibility of ESC research: one holds that all ESC research is morally unacceptable, whereas the opposing view holds that ESC research is not at all problematic. Instead, technical solutions developed to address The Problem aim to allow researchers to obtain ESC or their functional equivalent without harming the embryo.

In chapters Two and Three, Devolder analyses the two main middle-ground positions that have informed stem cells debates and policies of many Western countries: the discarded-created distinction (It is presumptively permissible to derive and use stem cells from embryos discarded following IVF. However, it is impermissible to derive and use stem cells from embryos created solely for the purpose of stem cell research or therapy’ (26)) and the use-derivation distinction. (‘It is presumptively permissible to use embryonic stem cells in research, even though it is always impermissible to derive embryonic stem cells’ (77).) The discarded–created distinction draws an ethical line between deriving ESC from embryos discarded following in vitro fertilization (IVF) – which is considered morally acceptable, and embryos created ad hoc for ESC research – which is considered morally dubious. Devolder presents the most common arguments used in support to this distinction: the least controversial approach, the nothing-is-lost principle, the doctrine of double effect and the notion of respect. After an exhaustive analysis of them, she concludes that even if they support a moral difference between creating and destroying research embryos and discarded embryos, they do not satisfactorily support the case for the discarded-created distinction. According to the author, the distinction represents an ‘untenable ethical position’ and that it is either permissible to derive ESC from either source of from none (77).

In Chapter Three, Devolder challenges the use-derivation distinction on the basis of the underlying problematic assumption namely that ESC are neither embryos nor their moral equivalent. Devolder maintains that if the moral status of the embryo derives from their capacity to develop into a person, tetraploid complementation experiments show that also ESC have the same potential as embryos and the assumption is thus ill-founded. The author then carefully presents the main argument adduced in support of this position, namely that using ESC in research does not directly encourage embryo destruction. She challenges this argument maintaining that researchers using ESC always directly or indirectly encourage embryo destruction and concludes that ‘as long as no stronger arguments are presented, we should reject the use-derivation distinction as a correct ethical position’ (104).

In Chapter Four, Devolder focuses on the second order of responses that have been put forward to address The Problem: the use of technical solutions. These solutions would allow bypassing The Problem, namely they would allow obtaining ESC or their functional equivalent without harming the embryos – either because they already died spontaneously (i.e. using organismically dead embryos), or because there is a good chance that they will survive the procedure (i.e. using embryo biopsy to extract a blastomere from the embryo to produce an ESC line). A last cluster of technical solutions involves either the creation of entities that may be used instead of embryos to conduct ESC research (i.e. parthenogenesis and altered nuclear transfer), or finding alternative ways to achieve similar research goals to ESC research without using ESC (i.e. creating induced pluripotent stem cells, iPSC). Devolder presents different shortcomings of these technical solutions: either they would need to rely on more ESC research to be developed further or they cause harm to the embryo in some way.

Referring to the green/white papers distinction of documents issued by the UK Parliament, philosopher John Harris has famously argued that in ethics there is a clear line between green and white papers too. Green papers are ‘discussion documents putting forward ideas seriously but not necessarily for implementation in legislation’,Footnote ¹ whereas white papers are proposal for legislation.

In the last section of the book (Chapter Five), Devolder seems to refer implicitly to the white/green paper distinction, and argues that there is a value in defending compromises over epistemically justified positions when writing white papers. Following an accurate analysis of different reasons in favour of defending compromises over epistemically justified positions, Devolder allows that even if the costs of compromises might be high there could still be good reasons to defend them. However, the rest of her book is clearly positioned within a green paper tradition as mentioned above, i.e. the tradition of analytical philosophy applied to questions of medical ethics. Devolder's point about the value of compromising in stem cell ethics would have possibly been better suited at the beginning of her book, to clearly lay out some methodological considerations.

One of the unquestionable merits of the green paper choice is that it allows Devolder to show the importance of consistency and philosophical medical ethics. In this sense, her book is not only interesting for its content, but also represents an important methodological tool for further reflections in this field. Moreover, Devolder's ideas could be used for reopening the debate on ESC research in the countries with policies that rely on analytically inconsistent arguments. For these reasons, the book represents a very good example of green literature in bioethics and an interesting read for scholars involved in the debate on ESC research.

Despite these merits, writing a green paper on ESC research can be problematic: the middle-ground positions discussed in the book are arguably not formulated in order to win the philosophical argumentation prize, but to design policies that respect at best the different moral values that inevitably coexist in multicultural and multi-moral societies. Many arguments that support medical ethics policies would fail Devolder's scrutiny, not due to the failure to devote to consistency of their authors, but more likely due to an overarching duty to respect coexisting moral diversities. ESC research is not a purely philosophical dilemma, but a practical problem that arises in the context of public policy. Criticizing policies for the inconsistency of their underlying arguments seems a relatively easy task for a skilled philosopher like Devolder.

Building on philosopher Jonathan Wolff we could say that ‘it is tempting to think that the way to approach a moral problem that arises in the context of public policy is to formulate the correct moral theory and then argue for it’.Footnote ² Devolder's approach risks to undermine the importance of respecting different views and the commitment to inclusion of democratic societies. Perhaps, all papers in medical ethics should tend towards whiteness and towards the idea that the correctness of a moral view is often less important than whether or not it is widely shared. After all, as Churchill has famously argued democracy itself is ‘the worst form of government, except for all the others'.