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Abstract

Retrieving the etymological meaning of the word “tolerance,” accompanying the evolution of the concept along its history, and exploring some of its major current uses and their impact in common morality and within bioethics, this research paper proposes to make clear and accurately deﬁne the legitimate usage of the term “tolerance.”

“Tolerance” started to be advocated in the wake of the rejection of moral absolutism and gained importance in an increasingly pluralistic world. But its growing hegemony in the moral debate leads dangerously to a moral indifferentism, which subsequently leads to the suppression of morality itself. The issue of the limits of tolerance becomes unavoidable.

In this context, the moral status of tolerance is also examined, being challenged as an ideal, and as a value, and being redeﬁned as a virtue.

This reﬂection will unfold at the level of philosophical clariﬁcation of “tolerance,” the common morality perception of it, and its impact on bioethical theory and practice.

Introduction

The word “tolerance” was introduced quite recently in daily vocabulary, but quickly became very common, and always evoked with a positive connotation. It originated in the religious debate in the early modernity, soon became important at the political level, afterwards extended to morality, and lately appeared in all spheres of human activity, bioethics included, being a major issue for some contemporary philosophers. Broadly understood as acceptance of what is different – faith and convictions, practices and behaviors, ideals and values, options and actions – today, public opinion perceives “tolerance” as a major and absolute value and therefore as a goal to be reached by all and that can be required to all from all.

The etymology of the word and also the historical background of the concept, however, do not endorse this common perception. Indeed, it is well known that the more a concept is used, and in more different contexts, the less its deﬁnition remains accurate, as if its meaning were eroded by the plurality and frequency of uses.

In the case of “tolerance”, this fact is particularly severe because a different conceptualization entails different evaluations of right and wrong. And that is why the reﬂection on tolerance has to start by the rigorous and objective deﬁnition of the concept, in order to establish the boundaries of its legitimate use, and before deepening into the contemporary ethical discussions, from which it matters to draw its implications in the bioethical debate and in the rules of action.

The Need Of A Triple Definition: Etymological, Conceptual, And Operational

Bioethics uses many concepts of philosophical origin which, sometimes, develop in a particular way or call to play a speciﬁc role. “Tolerance” is one of them.

These philosophical concepts used by bioethics deserve special attention, and it could even be said that they need a triple deﬁnition (or a deﬁnition under three different perspectives). The ﬁrst is an etymological deﬁnition that recovers the roots of the word and its original meaning. This is also the only objective basis for a sound understanding of the word and for its further conceptualization. The second is a conceptual deﬁnition that clariﬁes the different meanings the term can express, taking into consideration its use along history, in different geo-cultural realms and also in different academic and professional contexts. The third is what can be called an operational or practical deﬁnition, which is particularly important in bioethics, because it shows the way the concept can be applied to different concrete contexts and/or situations and how it works on the establishment of a framework for reasoning and of guidelines for practice. This procedure will be followed accordingly in what concerns “tolerance.”

The Etymological Roots

“Tolerance” is a word of Latin root. The Latin verb “tolero” means to bear, to endure, and to suffer, and the noun “toleratio, onis” means the capacity to endure. Therefore, from the etymological perspective, “to tolerate” means to endure, to bear, and to admit something that is not really appreciated, that is not actually approved. One can only “tolerate” what one does not approve (in a strict sense) or what does not please him/her (in a broad sense). What one approves or what pleases him/her, one supports it or shares it. One does not “tolerate” what one considers to be good or right; one agrees with it and follows it. One only “tolerates” what one admits in spite of disapproving it. Therefore, “tolerance” refers to an attitude of condescendence toward something that is, for oneself, objectionable or disagreeable. Nevertheless, the decision to admit it and tolerate it is a result of balancing conﬂicting principles, different circumstances, or various interests, maximizing beneﬁts and minimizing risks and costs.

Following the etymological perspective, there are two conclusions that have to be drawn. The ﬁrst one is that “tolerance” only applies if three essential features are met: criticism toward what will ﬁnally be tolerated, power to act against what it is criticized, and voluntary refraining from action. Disapproval and criticism are not enough to identify “tolerance.” If one disapproves of something but does not have the power to contradict it or to act against it, imposing one’s views and forcing others to follow one’s way, then one has no other option than to just suffer the consequences; one did not, in fact, admit it. But if one disagrees, and one decides, voluntarily, to refrain to oppose for the sake of a higher value, then one tolerates.

Examples might help to understand the true meaning of “tolerance” in these three required features. Parents can disapprove some options of their teenage children, and despite having the authority to forbid or to stop them, nevertheless, they let them go through with it anyway because they believe their children can beneﬁt from the experience (even if it is a bad experience) and also learn to be autonomous and responsible for their choices and actions. Another example could be when a person or the local people disapprove of traditions and customs followed by immigrants, but refrain from forbidding these practices out of respect for that community. In both cases, the three features are present: there is disapproval, power to oppose, and will to, nevertheless, admit it.

The second conclusion that needs to be drawn from the etymological perspective that has been followed is that tolerance is paradoxical: it always involves two opposite attitudes, one considered negative and another positive, which are not reconcilable and are both kept; but, furthermore, “tolerance” deﬁnes an attitude of going along with something that one believes to be bad or wrong.

The etymology of words is the solid ground from which concepts are built up and evolve.

The History Of The Concept

The meaning of a concept is built not only, objectively, by its etymology but also subjectively by the history of its use and the philosophical reﬂection upon it. The concept of “tolerance” emerged with a speciﬁc meaning in a very restricted realm, the religious one. It was mainly along the seventeenth century, within the religious disputes between Catholics and Protestants, in Europe, that tolerance was advocated as a way for peaceful coexistence.

The most paradigmatic text of this time and also the one that truly established the concept of religious tolerance and the ground for further developments of the concept is A letter concerning Toleration (1689) by John Locke. “Tolerance” is then presented, with a very positive meaning, at two different levels: a theoretical one, as a rational requirement to guarantee individual freedom, and a practical one as being quite useful, rather than convenient, to the internal peace of the states.

Locke begins his letter by distinguishing “the business of civil government from that of religion,” the ﬁrst having to do with the “care of the commonwealth” and the second one with “men’s souls” (Locke 1689, p. 6): “Church itself is a thing absolutely separate and distinct from the commonwealth” (Locke 1689, p. 15). For the church, toleration should “be the chief characteristic mark” (Locke 1689, p. 5), and all churches should be “obliged to lay down toleration as the foundation of their own liberty, and teach that liberty of conscience is every man’s natural right, equally belonging to dissenters as to themselves; and that nobody ought to be compelled in matters of religion either by law or force” (Locke 1689, p. 36). At the civil level, “no private person has any right in any manner to prejudice another person in his civil enjoyments because he is of another church or religion. All the rights and franchises that belong to him as a man, or as a denizen, are inviolably to be preserved to him. These are not the business of religion” (Locke 1689, p. 12).

Tolerance is then said to be a duty, which entails not only negative but also positive obligations:

It is not enough that ecclesiastical men abstain from violence and rapine and all manner of persecution. [.. .] He [.. .] is obliged also to admonish his hearers of the duties of peace and goodwill towards all men, as well towards the erroneous as the orthodox; towards those that differ from them in faith and worship as well as towards those that agree with them therein. And he ought industriously to exhort all men, whether private persons or magistrates (if any such there be in his church), to charity, meekness, and toleration, and diligently endeavour to ally and temper all that heat and unreasonable averseness of mind which either any man’s ﬁery zeal for his own sect or the craft of others has kindled against dissenters. I will not undertake to represent how happy and how great would be the fruit, both in Church and State, if the pulpits everywhere sounded with this doctrine of peace and toleration (Locke 1689, pp. 15–16).

Nevertheless, tolerance is not without limits to Locke: those who deny the existence of God, the atheists, cannot be tolerated.

During the eighteenth century, the concept of “tolerance” kept itself restricted to the religious realm, and it was only later, on the nineteenth century, that it spread to the political and moral domains. Tolerance is then especially advocated by the utilitarians, such as Jeremy Bentham and John Stuart Mill.

Mill develops the concept of “tolerance,” within the liberal doctrine of politics, in his work On Liberty (1859) where he presents it at two different levels. At the sociopolitical level, tolerance is a natural consequence of the diversity among men, and it turns out to be good for the society:

——-If all mankind minus one, were of one opinion, and only one person were of the contrary opinion, mankind would be no more justiﬁed in silencing that one person, than he, if he had the power, would be justiﬁed in silencing mankind. [.. .] But the peculiar evil of silencing the expression of an opinion is that it is robbing the human race; posterity as well as the existing generation; those who dissent from the opinion, still more than those who hold it. If the opinion is right, they are deprived of the opportunity of exchanging error for truth: if wrong, they lose, what is almost as great a beneﬁt, the clearer perception and livelier impression of truth, produced by its collision with error (Stuart Mill 1859, p. 20).

At the personal level or at the interrelation level, tolerance is a moral requirement dictated by the individual autonomy, being also essential for the happiness of individuals:

——-No society in which these liberties are not, on the whole, respected, is free, whatever may be its form of government; and none is completely free in which they do not exist absolute and unqualiﬁed. The only freedom which deserves the name is that of pursuing our own good in our own way, so long as we do not attempt to deprive others of theirs, or impede their efforts to obtain it. Each is the proper guardian of his own health, whether bodily, or mental or spiritual. Mankind are greater gainers by suffering each other to live as seems good to themselves, than by compelling each to live as seems good to the rest (Stuart Mill 1859, p. 16).

The philosophical reﬂection on “tolerance” in the contemporary age, mainly shaped by Locke and Mill, unfolds in three major lines of reasoning. The ﬁrst one, a sociopolitical argument, claims that tolerance is required because the state, in order to be fair and to treat all citizens equally, has to stay neutral in what concerns religious and moral values, speciﬁcally, moral conscience’s issues. Therefore, the state should not take part for or against citizens’ convictions or opinions which are indeed plural. The second line of reasoning is characterized by a moral skepticism which underlines the impossibility to reach a universal and absolute moral truth that could legitimately prevail over other perspectives. All points of view ought then to be likewise respected – and this statement constitutes also a deﬁnition of “tolerance.” The third argument is a moral and legal one which stresses the value of individual autonomy for personal fulﬁllment and for social accomplishment together with the lack of legitimacy for anyone to impose his views to any other. These can only be guaranteed if “tolerance” is respected.

The history of the concept has led us from the effort of acceptance of tolerance to its broader meaning as acceptance of what is different, regardless of any other considerations beyond preservation of individual freedom and promotion of personal happiness – in line with utilitarianism. The pendular movement will pursue its course toward equilibrium.

The Role Tolerance Plays

The evolution of the concept “tolerance” is characterized by the progressive widening of its meaning and the extension of its scope. This is, at the same time, the cause and effect of the relevant role it has been playing in democratic societies respectful of human rights.

Within these communities that reject moral absolutism, after the fall of ethical universals, and that recognize moral pluralism, enhanced in a globalized world, tolerance has been expandingly working like a tool to promote individual freedom. By individual freedom, it means the possibility of each person to express himself/ herself differently from others in their own individuality and social peace, which is a harmonious coexistence of all different persons in the same community.

Notwithstanding the remarkable beneﬁts of tolerance to build up democratic and peaceful societies as well as happier citizens, its understanding as an absolute value, that is, as a value to be accomplished regardless of circumstances, raises serious problems that only started to be addressed in the late twentieth century.

In what concerns the large domain of common morality, tolerance is plainly and equivocally understood as allowing whatever whoever wants, as long as it does not negatively affect the individual self. This would be the single limit to tolerance. The slippery slope, however, is that if no one cares about anything that does not affect him/her directly, no one really cares about anyone else but himself/herself. This is the loneliest individualism, the most unvoiced society, and a dreadful moral indifferentism: no one cares about anyone. There is an emptiness of guidance or even counseling; norms do not apply anymore and tend to vanish; morality itself tends to dissipate.

The risks of tolerance as a hegemonic value also lead to the question of its limits: Are there any? If so, which? And under which criteria and who’s authority can they be imposed on others? After all, if tolerance were an absolute value, there would be nothing intolerable, not even female genital mutilation, pedophilia, slavery, torture, genocide, just to mention a few human behaviors, that repeat themselves throughout history and are today consensually condemned; and society would also have to tolerate what threatens tolerance itself, such as radical political regimes or religious extremism.

The urgency to prevent moral indifferentism, by establishing limits to tolerance, as the contemporary new absolutism, is the main issue in today’s philosophical and ethical reﬂection on tolerance.

Tolerance also plays a signiﬁcant role in the speciﬁc and narrower domain of bioethics, being inseparable from the principle of respect for autonomy, although only seldom having been explicitly associated to it. Acknowledgment of different religious practices and other differences at the level of values and customs in the clinical setting testiﬁes respect for one’s autonomy but also tolerance toward the other’s choice. Indeed, tolerance is implicated when reference is made to respect autonomy in cases where there is disagreement upon the decision to be taken, power or authority to impose one’s decision against the others opposing, and, nevertheless, acceptance of the option of the weakest part of the relationship, that is, the patient, vulnerable, instead of the healthcare professional, authoritative.

Again, examples can help to understand the beneﬁts of the exercise of tolerance within bioethics. A good example would be the refusal of blood transfusion by Jehovah’s Witnesses, even at the risk of their own death. Today, it is already widely consensual that this refusal, on religious grounds, from a competent adult Jehovah’s Witness, is to be respected even if it entails the patient’s death. In this case, the ﬁrst point to stress is that respect for religious beliefs prevails, regardless of the comprehension or of the agreement of the healthcare team or of their acceptance of the patient’s decision. The healthcare professionals can step away from this kind of cases or others, by invoking conscientious objection, but they cannot impose their personal convictions or beliefs, nor appeal to the authority of their professional knowledge or skills to make their will prevail. Respect for individual autonomous decision requires tolerance.

This example can be extended a little bit further in order to stress a second equally important point. When Jehovah’s Witnesses inform the physicians that, on religious grounds, they will not accept the blood transfusion, which is vital for their survival and health recovery, the healthcare professionals have at least two options. One would be to proceed according to the best medical interest of the patient, force the blood transfusion, and save their (biological) life (condemning the spiritual life). This is no longer acceptable in Western countries and in many other countries around the world. A second way to go would be immediately and fully respect the decision transmitted by the patients and let them die (biological death, allowing the spiritual life to be saved). This is the consensual approach recommended in Western countries and even more worldwide.

Nevertheless, objections can be easily raised to both decisions: the forceful blood transfusion goes against the patient’s autonomy and, by reducing people to their physical or biological dimension, also denies their dignity (what makes each person singular, unique), the protection of which is the core of bioethics; the straightforward obedience to the patient’s will goes against several moral virtues such as compassion, care, and solidarity and diminishes the essence of healthcare professionals to a delivery of services upon request. In the ﬁrst situation, the patient is violated; in the second, the patient is abandoned.

This second situation should be also viewed as an example of how tolerance, considered as an absolute value, leads to indifference: a decision considered wrong is accepted without any effort to turn it into a decision considered right in the name of full compliance with tolerance, leaving the other to his own fate.

It could be argued that there is also a third and intermediate way to go, respecting all the apparent contradictory values. Confronted with the Jehovah’s Witness’ refusal of a blood transfusion and awareness of the imminent death that he would like to prevent for the patient’s good, the physician can try to create an adequate situation to promote a truthful and transparent dialogue between both, free of any coercion (family and ministers included), from which different decisions might emerge, namely, the patient’s request for a blood transfusion if absolute conﬁdentiality is guaranteed. In this situation, and regardless of the outcome, the physician would be respecting the autonomous decision of the patient, whatever it might be, thus keeping his commitment to tolerance, but without abandoning the patient. He would not be indifferent to the patient’s decision, to the patient’s fate.

The triple approach to which “tolerance” was submitted contributed to draw a broad but also rigorous meaning of the term. From the etymological perspective, it has been shown that “tolerance” can never have an absolute positive meaning. “Tolerance” is paradoxical at its roots, always involving negative and reprehensible attitudes. From its conceptualization throughout history, it is now clear that the common perception of “tolerance” as total acceptance of what is different was built up by the progressive stretching of the concept, following the successive realms in which it has been applied. However, and regardless of the relevant advantages of tolerance for individuals and societies, it also became obvious that the absolutism of tolerance leads to an intolerable indifferentism. The so called operational approach decisively discloses the paradoxical dimension of “tolerance” also at the practical level and the urgency of ﬁnding an intermediate way that answers to the different values at stake, allowing its legitimate use.

“Tolerance requires us to accept people and permit their practices even when we strongly disapprove of them. Tolerance thus involves an attitude that is intermediate between wholehearted acceptance and unrestrained opposition” (Scanlon 1996, p. 226). And it is this intermediate way that practice pushes for, that contemporary reﬂection focuses on today, thus contributing to a pendular equilibrium.

The Contemporary (Bio)ethical Debate

In contemporaneity, especially in the late twentieth century, the debate on tolerance developed substantially with the contribution of many of the most remarkable philosophers of the era, namely, John Rawls (1971), Claude Lévi-Strauss (1987), Paul Ricoeur (1991), Thomas Nagel (1994), Bernard Williams (1996), and Michael Walzer (1988). Generally, the main focus of this debate was not on the claim of tolerance, deriving from the growing moral pluralism, which was already acknowledged, but on the prevention of indifferentism and the subsequent dissolution of morality which the hegemony of tolerance compelled.

Therefore, at the theoretical level, the reﬂection on tolerance focused on its limits and on its moral nature, which are interrelated; at the practical level, in applied ethics and particularly in bioethics, it was on the impact of tolerance in the decision-making process in the realm of biomedicine.

The Limits Of Tolerance

The rigorous deﬁnition of tolerance leads necessarily to its paradoxes: how can the admission of what one considers morally wrong be morally justiﬁable? How can one tolerate the intolerable? And these paradoxes necessarily lead to the deﬁnition of limits to tolerance – the admission of what one considers morally wrong must contribute to a greater good; the intolerable cannot be tolerated – and this has to be pursued and justiﬁed at the theoretical level.

However, there is no consensual doctrine to draw these limits. Tolerance itself is grounded on common morality, regarding either what already gathers a wide consensus or what falls outside that consensus but slipping not too far apart. Most frequently, tolerance regards issues that strongly divide society and exclude what is consensually rejected. Indeed, common morality is already partially shaped by the exercise of tolerance when it includes acceptance of pluralism. Tolerance expresses the range of pluralism accepted by that society. And it is within common morality that a balance between the costs of what is considered morally wrong and the beneﬁt of admitting it is done that the intolerable is deﬁned as such and not tolerable.

Therefore, the defense of tolerance is quite weak at the theoretical level, but deﬁnitely strong at the practical level where it is demanded by common morality.

The Nature Of Tolerance

“Tolerance” was historically presented as an attitude, a way of being worthy of appreciation, that was cherished and valued. This attribution of value to tolerance is of a subjective nature, that is, it depends on the subject or agent and on the various circumstances that surround and inﬂuence his/her evaluation. Subjective values change throughout space and time.

This widely spread subjective perception of the value of tolerance was more recently misled with an objective value, that is, the one that relies on the object which is good in itself, not depending on anyone’s evaluation. Tolerance cannot be an objective value because it always regards what is considered bad or wrong. Only values of an objective nature are worth in themselves, regardless of circumstances. Objective values are permanent. This is certainly the case of human beings when considered not in their features but on their essence: one can subjectively value one person more than another due to a biological or affective relation, his looks, his character, etc., but all human beings, on their own uniqueness, on their own singularity, have an objective value, valued unconditionally.

Some would also like to perceive tolerance as a principle or a rule, that is, a formal statement that grounds and guides human action and which entails different levels of obligation. But tolerance cannot always be followed and might sometimes be overcome, as was shown already. Therefore, it does not perform as a principle or a rule.

Tolerance is not a value in itself, neither a principle nor a rule. Nevertheless, the moral nature and status of tolerance are recognized, by all philosophers, to be of paramount importance to determine its moral strength.

More recently, philosophers, inspired by Aristotle, started to designate tolerance as a virtue, that is, a predisposition to act (habit) in a certain way, an intermediate way (virtue) between two extremes (vices), one of excess and the other of deﬁciency. In the current case, the virtue of tolerance would be the tendency to admit different ways of thinking and acting, although not shared and even criticized, instead of opposing and ﬁghting them. Virtues cannot be required, they are not obligations, but should be encouraged, as marks of character.

At the same time, tolerance as a virtue does perform the intermediate way, between “wholehearted acceptance and unrestrained opposition,” the only way that can overcome the theoretical paradox and actively shape practice and daily life.

Tolerance Within Bioethics

“Tolerance” is not a common term in the realm of bioethics. As it was pointed out before, “autonomy” is the preferable word in bioethics under which “tolerance” is always implicitly assumed, being only seldom explicitly mentioned and even more rarely elected as an issue in itself, as it is the case of Tristram Engelhardt, Jr. Engelhardt is, indeed, the philosopher bioethicist who dedicates more attention to “tolerance.” The theme is still absent in 1986, on his ﬁrst edition of The Foundations of Bioethics. However, Bioethics and Secular Humanism: The Search for a Common Morality, 1991, and the second edition of The Foundations of Bioethics, 1996, do point out the importance of tolerance in bioethics. It comes along with the deepening of differences and distance between a content-full morality and contentless morality or a secular morality, between moral friends and moral strangers, and also with the radicalization of the principle of autonomy into the principle of permission.

In Bioethics and Secular Humanism: The Search for a Common Morality, Engelhardt’s main idea in what concerns tolerance is that “secularity requires tolerance” (Engelhardt 1991, p. 11). In a postmodern world, in the most common secular pluralist states, there is no shared vision of the good, no substantial or content-full deﬁnition of good. Therefore, all particular visions are equally worthy and have to be likewise accepted. Nevertheless, in this pluralist world, a “canonical hierarchy of values” is needed, to avoid moral fragmentation, apathy, relativism, and nihilism. Moral strangers, “persons who do not share sufﬁcient moral premises or rules of evidence and inference to resolve moral controversies by sound rational argument, or who do not have a common commitment to individuals or institutions in authority to resolve moral controversies” (Engelhardt 1996, p. 7), have to be able to identify and avoid, in the present and in the future, for example, the carnage of lives that the twentieth century witnessed with Fascism, National Socialism, and Communism, this “slaughtering of millions on the altar of history or the use of unwilling human experimental subjects” (Engelhardt 1991, p. 100). There must be a morality by common agreement. “Secular humanism is the attempt to justify and elaborate a common moral framework grounded in what we share as persons” (Engelhardt 1991, p. 138), and its elaboration requires tolerance (which is not deﬁned in 1991).

Engelhardt then proceeds to establish a common bioethics, built out of what humans share, “without special appeal to religious or other particular moral or metaphysical assumptions” (Engelhardt 1991, p. XI), and focuses on the foundation of a secular healthcare policy, in a pluralist world, and for moral strangers. Indeed, in the postmodern world, healthcare policies have to be structured from a secular vision so they can equally satisfy all citizens as well as healthcare professionals, both advocating a plurality of competing moral viewpoints. But a healthcare policy grounded on the agreement of moral strangers is procedural and minimalist, not even recognizing the authority of the state to impose whatever goes against individual civil rights. Therefore, Engelhardt illustrates a free and informed consent that is at the basis of all programs of treatment to be decided together, by health professionals and patients, regardless of all substantial views on health or goals of medicine; much of the “morality and value judgments involved in healthcare” are privatized (Engelhardt 1991, p. 130); a mixed healthcare system, both public and private, is unavoidable. Also, at the individual level, and always from a secular, axiologically neutral, healthcare policy, “there is nothing one can say a priori about the meaning of well-being, the content of the good life, of the meaning of sickness, illness, and death” (Engelhardt 1991, p. 137), or sexuality, or the purposes of procreation, etc. Therefore, there are no arguments to forbid practices like abortion or euthanasia which are only refused from a content-full understanding of values (Engelhardt 1991, p. 37).

In The Foundations of Bioethics, Engelhardt goes beyond the description of the requirement of tolerance and its justiﬁcation, developed in secular humanism, and stresses the “need to learn to be tolerant” (Engelhardt 1996, p. 15), also classifying it as a virtue, as “the primary cardinal virtue in the morality of mutual respect” (Engelhardt 1996, p. 419). Engelhardt refers to virtues not as a mark of character, according to Aristotle’s deﬁnition, which would be impossible in a content-less morality, but as strength of moral will, on the wake of Kant. Tolerance is a “disposition to let other persons develop peaceably their own views of a good life” (Engelhardt 1996, p. 419).

In the healthcare setting, the virtue of tolerance implies enduring and avoiding “all unconsented to force against others” (Engelhardt 1996, p. 419), that is, in a secular moral framework, the healthcare professional will only act with the permission of the patient. Therefore, for Tristram Engelhardt, tolerance is not only underneath or implicit in the principle of autonomy, to respect the will of an autonomous person, but also ahead or explicitly acknowledged in the principle of permission, which stresses that “secular moral authority is derived from the permission of those involved in a common undertaking” (Engelhardt 1996, p. XI).

Beyond bioethical issues already mentioned before – such as free and informed consent and healthcare policy, abortion, and euthanasia – and others that came along the profound development that these themes underwent in The Foundations of Bioethics, there are some others that raise strong controversies, such as the moral status of some humans who are not self-conscious and infanticide.

Those who are not self-conscious, such as “fetuses, infants, the profoundly mentally retarded, and the hopelessly comatose” (Engelhardt 1996, p. 139), as well as senile, are recognized as members of the human species, but lacking a moral status because they do not have the characteristics – self-consciousness, rationality, moral sense, and freedom – that would allow them to give permission or to engage in the procedure of an agreement for a common morality. These human nonpersons do not have moral claims either, and the members of the moral community do not have any obligations toward them.

Infanticide is said to be unavoidable due to the inexistence of a secular moral authority of the state that would override parental autonomy and forbid it (Engelhardt 1996, pp. 269–271). Both perspectives derive from Engelhardt’s presupposition of the need for a secular morality in the pluralist postmodern world and his description of the limits of such morality for strangers. This is a libertarian view of morality, of bioethics, of healthcare, and also of tolerance that is not shared by the West and much less in the rest of the world.

Engelhardt’s perspective on tolerance, although presented it as a virtue, does not preview any limits. One important answer to the absolutism of tolerance, as it is proposed in secular morality, an important answer to this minority libertarian perspective, is conscientious objection. This one testiﬁes the daily practice of tolerance within the clinical setting, disagreeing but admitting what is considered wrong, without participating but providing the necessary means for someone to pursue it. Conscientious objection is already, in itself, the implicit acknowledge of the other’s right to difference and of the one’s own claim to difference, as well as an intermediate solution for both.

Opposing the libertarian perspective on tolerance that presents it as absolute in the narrow context of a secular morality, respect for difference in the clinical setting, in this twenty-ﬁrst century, has centered on the critical assessment of its limits, also accompanying the evolution of the theory of tolerance also in the healthcare setting.

The main problem for healthcare professionals is the right assessment of the personal preferences and choices that, in the context of cultural diversity and moral pluralism, ought to be respected because they promote speciﬁc goals or values in the community, without violating human rights. This is the major challenge for healthcare professionals in today’s cross-cultural clinical settings.

Conclusion

Tolerance has been subjected to different interpretations along its still short history. Nevertheless, since the time it became a speciﬁc issue of reﬂection and was said to be highly convenient for individual fulﬁllment and societal accomplishment, it kept being largely recognized as needed.

The main problem it raises today is the one of its limits which, in a dynamic and unstable equilibrium, has to be critically re-appreciated everyday for each new concrete situation.

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