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Medicina y ética

versão On-line ISSN 2594-2166versão impressa ISSN 0188-5022

Med. ética vol.33 no.1 Ciudad de México Jan./Mar. 2022  Epub 31-Jul-2023

https://doi.org/10.36105/mye.2022v33n1.03 

Articles

Global Bioethics: new arguments on animals’ rights?

José Enrique Gómez Álvarez* 
http://orcid.org/0000-0002-8964-2207

* Centro de Investigación Social Avanzada (CISAV). Querétaro, México. Correo electrónico: jegomezalvarez@yahoo.com


Abstract

The article addresses some recent variants of the arguments in favor of possible animal rights. To achieve this objective, a convenience sample was made from 2017 to the present of articles using the Google Scholar that will address both concepts. From the sample (first 40 search results) we selected those that summarized or presented some novel argument around the topic. After the analysis, basically two arguments were found that can be presented as novel, but when analyzing their assumptions, it was concluded that they present the same ontological assumptions as traditional arguments such as those of Peter Singer.

Keywords: Ontology; global bioethics; debunking argument; mother Earth

Resumen

El artículo aborda algunas variantes recientes de los argumentos a favor de un posible derecho de los animales. Para lograr este objetivo se hizo una muestra por conveniencia de artículos en los que apareciesen ambos conceptos desde el año 2017 hasta el presente, usando el buscador Google Académico (Google Scholar). De la muestra (primeros 40 resultados de búsqueda) se seleccionaron los que resumiesen o presentasen algún argumento novedoso en torno al tema. Después del análisis se encontraron básicamente dos argumentos que pueden presentarse como novedosos pero que, al analizar los presupuestos de los mismos, se concluye que presentan los mismos supuestos ontológicos que los argumentos tradicionales, como los de Peter Singer.

Palabras clave: ontología; bioética global; argumento desacreditador; madre Tierra

1. Global bioethics and animals

The term «global bioethics» is a disputed term. To some authors the term suggests that, from a practical point of view, it means that those who use the same «bioethics» should engage in «similar» academic behavior in terms of topics, sources used and communication with other researchers. Thus Holm and Williams-Jones in «Global bioethics-myth or reality?» (1), point out that even researchers and bioethicists from countries «related» by language and culture, such as Canada, USA and England, in practice do not follow (almost) the same authors, consume different bibliography on Bioethics topics and consult different web sites. They, from a social approach thus argue that:

Our three exploratory studies of behavioral patterns in the field of bioethics support the position that there is, in fact, no unified global field of bioethics. It appears that even in English-speaking countries, bioethicists do not link to each other’s websites as much as one would expect, do not cite each other as much as one would expect, and do not converge on the same books as much as they would if bioethics were truly a «global» field (1).

Thus at least in a sense of «global bioethics» there is evidence that the expectation of common ethics is not met: the interrelationship between thinkers is not as strong as it would seem. In addition to the situation described above with Anglo-Saxon authors, the interrelationship with authors of different languages is scarce. Of course, the language barrier is one explanation (2) although it seems that also, in the opinion of these same authors cited, there is a certain localism: they quote and study those they know or are accessible (1). In this sense, the use of the term «global bioethics» does not seem to be entirely correct.

Other authors argue that «global bioethics» may refer to a unity of common principles (3). In this sense, the bioethics of principles, being dominant in the Western world, would at least show that there is a certain methodological and doctrinal unity around the (4) principles of Beauchamp and Childress. Another sense of global bioethics is that expressed by Potter, as pointed out by Vargas:

...emphasizes the need to build a bridge to the future that will allow the long-term survival of the human species. For Potter, the separation between science and the humanities is a problem that could endanger life on the planet. This idea, which seeks to unite scientific knowledge and the humanities, is the one that best expresses the bridge metaphor. However, this metaphor contains an additional meaning... the double meaning of the word «bridge» has on the one hand a component of unity (between the sciences and the humanities) and on the other hand, a call to overcome the problems that put the future of the human species at risk (4).

Other authors (5) point out that there are 4 senses of the notion of bridge: a connection between the present and the past where human survival (and that of the planet) is guaranteed; a bridge between science and values; a bridge between nature and culture; and a bridge between human beings and nature (ecology).

What is of interest here is that this consideration of human survival implies the question of how we humans should behave towards animals. It has been argued for decades that (non-human) animals have rights just as we do. The question one can ask oneself is: Have the arguments in this regard changed at all? What are the most recent arguments in this regard? To answer this question, a documentary sample was conducted by convenience in Google academic from 2017 to date where «global ethics» and «animals» were related. From the result, articles were selected that expose arguments for and against the alleged animal rights. Here we outline the arguments found and comment on two of them that add or attempt to add something new to the debate.

2. An antecedent: Paul Max Fritz Jahr (5, 6, 7)

The central idea of this theologian, apart from conceiving and using the term «bioethics», is to include animals in the chain of living beings similar to humans. Jahr, in short, opposes Descartes and his mechanicism with respect to animals. Jahr thus comments that Eastern culture recognizes a spiritual nature to animals that requires respect and care (6). Jahr nevertheless points out the differences with the West by commenting on the utilitarian character of the use of plants and animals and their limited protection in terms of our benefit. Nevertheless he argues for a reformulation of Kant’s categorical imperative in which animals and plants are somehow included. Jahr points out at the end of his essay:

But we are making progress and the protection of animals is gaining ground, having an ever wider space at its disposal. In the same way, a decent man no longer tolerates flowers being destroyed or a naughty child plucking them from a garden and then carelessly throwing them away.

Our self-education has made many advances, but we must continue to develop it so that we adopt the following principle as a guideline of bioethical demands for our conduct: Consider every living being as an end in itself and treat it as such if possible! (6).

Of course, the final indication points out a certain limitation: «as far as possible» which leaves open the question of how much the utilitarian criterion should persist in the care of animals. It is clear that in a collision of priority interests, what should we choose? Jahr in another paper (7). «Three Studies on the Fifth Commandment» points out that «thou shalt not kill» does not allude only to human life, but to all living things. If physiologically and psychologically animals are similar to us, then shouldn’t we respect them equally? Of course, as Jahr points out, animal rights may not be the same, but in proportion to the being to which they apply. In this sense animals should not be tortured for no reason. Here, of course, in one sense, there is not much difference from the traditional defense that in man there is a qualitative leap over other living things, but it does not imply unrestricted dominion over them. Man must treat animals and plants with a character of guardianship although without ceasing to be a lordship or dominion over them. In this sense there is no apparent conflict. Thus, for example, the Catholic Church, in the words of Pope Francis, can affirm: In this line, it must be recognized that our own body places us in a direct relationship with the environment and with other living beings. The acceptance of one’s own body as a gift from God is necessary to welcome and accept the whole world as a gift from the Father and a common home, while a logic of dominion over one’s own body is transformed into a sometimes subtle logic of dominion over creation(10). One way to interpret the above passage is to understand that human dominion is not despotic: By recognizing that there is a nature in us that must be respected helps to understand that non-human nature also points out limits to our freedom. Another sense of Jahr’s theology would bring closer to positions that argue that nonhuman animals deserve equal consideration of care even when there are radical differences in capacities (4).

Jahr’s thought contrasts with the position of Thomas Aquinas who poses a similar question. Thus Thomas writes that Murder is sin because it deprives man of life. But life is common to animals and plants. Therefore, by the same token, it seems to be sinful to kill brute animals and plants(11). But Thomas’ answer to the objection shows the distance between classical thought and Jahr’s: animals are not rational and there is a certain order between animals and plants that allows us to use them to our advantage. It should be noted that Thomas does not deny that animals have something in common with humans: the sentient character, but man’s own radicality, of being personal, allows the use of animals and plants, just as animals «use» plants. In short, non-human animals and plants are not ends in themselves as human beings are.

The defenders of the rights of nonhuman animals would insist that it is not enough to treat them with care, but to recognize their intrinsic rights and not derived from human behavior and nature. In other words, to recognize animal rights as we recognize human rights. Jahr’s bioethics:

...starts from a biologicist conception that postulates a fundamental continuity between plants, animals and man. This continuity does not deny a certain differentiation, also admitted by Darwin on account of the moral sense or conscience in man. But such differentiation is ultimately reduced to that of movement with respect to its own term. The human being would be different only because he is the highest point of an evolutionary process that includes all living beings (5).

Thus it is presented that the difference between humans and animals is only one of degree. This conception is the central presupposition that appears in recent arguments about animals and that in essence does not make a special difference with traditional «animal rights» arguments (4, 12).

3. Animal rights: A common argument

When reviewing the literature in Spanish, we find references to the arguments of Anglo-Saxon authors in favor and against the supposed duties (rights) of animals (13, 4). There are basically two ideas that are repeated in the arguments: speciesism is the same as racism, sexism or ageism, i.e., they are undue discriminations. The other argument is that of species overlap: it is possible to show that in reality, in terms of capabilities, humans and animals are sometimes on the same level. In fact, both arguments have a common element: there is no qualitative leap between humans and animals.1 Both arguments can be summarized as follows:

  1. Any discrimination based on characteristics irrelevant to the distinction between a personal and a non-personal entity is a morally improper act.

  2. Holding superiority because of belonging to another species is discrimination based on irrelevant characteristics...

  3. Therefore, holding superiority for belonging to another species is a morally improper act.

Premise 1 seems reasonable and in fact as Singer points out was eventually recognized to be wrong in situations such as skin color (racism) or sexuality (sexism). But it is clear that the key to the argument is the notion of personhood which is an assumption of premise 2. Singer will insist that the notion of personhood is an empirical characteristic attributable in the course of life and is not present only in the human species. In that sense it is when, for example, the attributes of «self-consciousness» and «vision of the future» «appear» that persons can be said to exist. Singer sees personhood not from an ontological point of view, but merely phenomenal: the ability is available only when it becomes manifest in a way similar to riding a bicycle. We can only have that ability when it is given, when it becomes manifest. Consequently, only when a person expresses in an articulate language that his life is worthwhile and can visualize or express desires in the future time is he a person in «that moment». To be a person is therefore a manifestation of abilities that we attribute to the word «person», that is to say, a nominalist, actualist and functionalist position of the person. Therefore embryos and perhaps very young children are not persons.

It has been objected that this view of capacities is erroneous. Human capacities are radical, or in other words there is a radical capacity, which has classically been pointed out as intelligence and will, which are given from the beginning of existence. Intelligence and will are capacities to learn skills. Without that radical capacity one could not have human intelligence with its capacity to know universally and immaterially. In animals thus «intelligence» is not said in the same sense (11), since it could be explained rather as instinct, however similar their acts may seem to humans.

In other words, human beings have a radical capacity to acquire abilities: «capable of» must be understood as the possession of a nature whose full manifestation allows us to make such a valuation (to value one’s own existence), independently of whether or not the individual is in a position to exercise this capacity(14). To value existence is not only a question of having more or less conscious states of pleasure or pain, but the capacity to visualize, for example, possible future states and a capacity of abstraction and of knowing the universal that imply a radically different nature.

In section V, I comment a little more on this human peculiarity that Singer and others consider non-existent.

4. A new argument?

France Jacquet in «A debunking argument against speciesism» (15), published in 2021 proposes a new way of refuting speciesists: ...I propose a novel perspective on this subject by developing a debunking argument against speciesism(15).

Prof. Jacquet starts from the idea that our moral reasoning is shaped and reconfigured by comparing our moral intuitions with each other and with our own experience. In other words, for example, we have an intuited principle «as long as no physical harm is done to someone an action is (morally) lawful» and then when we compare our intuition with reality we discover incest as a practice «that does not do physical harm» and if we intuitively consider incest to be wrong, it collides with the original intuition since a clear contradiction is produced: we have a particular affirmative case that is considered true (Some practice that does not do physical harm is bad) that conflicts with the universal negative principle (Every practice that does not do physical harm is not bad). This contradiction leads us to reformulate our moral intuitions.

In the case of animals the author believes that it is the same case and gives as an example the already cited argument of Singer. One has a fundamental moral intuition: racism, sexism and other differences are irrelevant to how people should be treated. On the other hand, with (non-human) animals we make a distinction in treatment only on the basis of their belonging to the species:

A number of humans are psychologically on a par with some non human animals or even inferior to them in those capacities, compare, for example, severely mentally handicapped people with adult apes, for example. Consequently these psychological differences do not separate all humans from all non-humans... the species difference is merely biological (15).

Again the argument assumes that radical human capacities do not exist as such, but only appear and disappear abilities that in themselves are no different from animals or as we said before, the emergent human is considered only a matter of degree. Biological evolution disproves the idea of a «fixed» human essence, which objectors believe nullifies ethical naturalism of the Aristotelian type (16). Evolution debunks the theory of a fixed human nature.

The previously exposed example of incest, which seems morally repugnant, illustrates the non-moral origin of certain «moral» beliefs: incest being in fact a mechanism product of evolution, that is, the evolutionary process generated in people a certain rejection of parents to avoid the generation of defective human beings and thus allowed the dissemination of human genes, then, the origin of the moral belief is a non-moral element but a factual fact of evolution.

A discrediting argument because it is an argument whose purpose is to «dismantle» a moral belief based not on other moral beliefs, but on causal history that shows its unjustification by showing that it is not really an ethical principle. The moral belief is produced by an off-track process with respect to morality. Thus the example of incest, according to this author, by showing the «non-moral» origin of the belief, product of an evolutionary mechanism, discredits it. It is an idea that seems strange to me. The author does not point it out, but it seems to be one that assumes that the naturalistic fallacy occurs: morality is deduced from a purely factual element that has nothing to do with duty. It is rejected that human tendencies are indicators of a certain normative order (17).

The author thus finds irreconcilable a metaphysical vision of finality and evolution. As the former is «evident», it is discredited by the latter and it is taken for granted that there are no final causes (18).

Now, starting from the idea of cognitive dissonance or, in other words, the incongruence between our actions and our beliefs, something must be done to eliminate or neutralize the dissonance. Thus, for example, smoking and knowing that cigarettes are harmful is an example of dissonance: I do not want to harm myself, but I smoke and the only way to solve the incongruence is either to stop smoking, that is, to change the action, or to modify my belief, for example, to consider that the benefit of smoking tobacco is greater than the harm it causes me.

What paradox do we find with respect to animals? Some people who eat meat think that eating the meat of animals does harm to the animals (it is understood unnecessary harm such as being without freedom in production farms). Also it is not necessary to eat meat to survive and harming animals is therefore morally wrong and nevertheless people continue the habit of eating meat thus generating cognitive dissonance.

The meat paradox, according to Prof. France Jacquet leads to theoretical inconsistencies or adjustments to avoid cognitive dissonance either:

  1. Saying that animals do not feel, so no harm is done to them. It may not be necessary to eat meat, but no harm is done to them (15).

  2. Pointing out that it is necessary to eat animal meat (15).

These inconsistencies increase in situations where the opportunity to eat animal meat is presented; i.e., people tend to be more speciesist when confronted with the situation of being carnivores. Speciesists hold their beliefs not by a process of acceptance of the truth, but by an adjustment to their prejudices. In other words, when the interests of the subjects are involved, they tend to be speciesists. Thus, opponents of dog or cock fights oppose them when they do not participate in them. When they do participate they tend to adjust their cognitive dissonance, but not by a rational process but by an offtrack process. The author points out that:

  1. Speciesist belief is explained by the attempt to reduce cognitive dissonance.

  2. The attempt to reduce cognitive dissonance is an offtrack process. Consequently, the species ist belief is unjustified.

The first premise is shown by several empirical data pointed out in the article that show how the species ist attitude increases in feeding situations (15). In the case of the second premise: The reduction of cognitive dissonance is not a process that tracks the truth of how we should treat animals... it is due to a distorting influence, a factor unrelated to its truth(15).

Dissonance is not the rational product of a search for truth, but the result of a process that we could say is «apocryphal». The consumption of meat is produced in spite of the belief that it is illicit to unnecessarily harm animals, so the belief is maintained for psychological reasons such as avoiding the conflict of interests. It is in a few words, inconsistent in being emotional (voluntarist). If it is not rational and the other option is the non-species ist one, it seems reasonable to select the second option that does have rational justification. Why is the vegetarian right? Well, because there is no difference between animals and humans except in degree, as pointed out in the common argument. That is to say, despite its apparent strength, the argument is based on or takes for granted the traditional argument already pointed out in section II.

5. Another recent argument: the new Latin American constitutionalism (18, 19)

The Constitutions of Ecuador and Bolivia have proposed to introduce concepts of «deep ecology» (18, 20) that have implications for animals. The argument could be schematized as follows:

  1. If Nature is recognized as mother earth (as indeed the native cultures of Ecuador and Bolivia do) then all organisms are interdependent.

  2. If they are interdependent then there is no hierarchy among living things.

  3. Therefore, if Nature is recognized as mother Earth then there is no hierarchy among living things.

  4. Animals (including man) are part of Nature recognized as mother Earth.

  5. Animals (including man) have no hierarchy among themselves.

The second premise is undoubtedly the most problematic. The fact of interdependence is undoubtedly real, but does that imply that humans are not on the upper scale? Sometimes ecology, in its eagerness to protect nature, rather than elevating it, reduces man.

The defended question is that ecologically man cannot or should not dominate other beings (20, 21). Non-human nature thus possesses a value independent of human appreciation itself. Man dwells in his common home, nature, but this dwelling must be adjusted to recognize the intrinsic value of nature. The original cultures had, according to this position, this clear concept:

And this is how in certain regions mainly indigenous from their worldview have come to subjectively recognize nature as a subject that deserves care and protection, this in order to get to build a relationship of reciprocal stability human-nature to which we can call a relationship with a Biocentric touch... Being a way to resume a holistic and historical awareness of the natural value of non-human life that breaks with the conventional anthropocentrism of Eurocentric modernity (21).

The defense of premise 2 implies that the complexity of the natural world precludes putting man at the top: the interrelationships of survival mean that if one being is «above» the others, it produces dissonant effects on the whole of Nature. These dissonant effects would thus be proof that something is wrong in the argument in favor of the primacy of the human.

From premise 4 it follows that there must be a genuine respect for animals. Of course, this has ontological presuppositions (20). These ontological presuppositions are: The capacity to suffer and to feel pleasure is vital, as well as a prerequisite for a being to become an object of interest, and, therefore, equality of consideration must exist independent of species(19).

Prerequisite is equivalent to ontological presupposition in this context. Already accepted, it can be applied to concrete cases. Again the idea of the superposition of species arises: non-human animals only have a difference of degree and the capacity to feel and suffer is the ethical criterion, instead of the rationality and self-control proper to the human. Of course, one can go further and insist that the non-sentient and abiotic elements also possess rights: the Rights of Mother Earth or of Nature (Pachamama) (19).

It is a separate issue to analyze the care of non-human nature as part of human responsibility. Thus, the Universal Declaration on Bioethics and Human Rights states:

Due account must be taken of the interconnection between human beings and other forms of life, the importance of appropriate access to and use of biological and genetic resources, respect for traditional knowledge and the role of human beings in the protection of the environment, the biosphere and biodiversity (21).

The basic ontological question is thus the concept of «ontological leveling» between man and nature as proposed by the theories of utopian ecology. There would be no ontological difference between plants, animals and man. Thus seen, it would justify stopping the exploitation of natural resources by man insofar as it would affect the «dignity» of other living beings. However, the truth of the ecological movement is that man’s relationship with other living beings cannot be seen as a despotic domination of the latter, but there must be a certain harmonization of the aims of nature and man (22). Man can and must administer nature so as not to generate its unjustified destruction. However, there is a problem when one tries to eliminate the difference between humans and other species: If all species are equal, there is no basis on which they should be respected by one another, because in the face of such equality they should all be subject to the becoming whose strength allows some to triumph over the others(22).

Thus the man who is more capable of intervening could, in this logic, do so without worrying or arguing that other living beings are affected in their dignity. Curiously, human dignity is given by the capacity for self-mastery and rationality that allows this: to deal rationally with the natural world without abusing it, but this supposes recognizing human dignity itself. The question that arises, in another sense, is whether «animal rights» arise from the capacity of animals to have responsibilities or only from the fact of coexisting among them (22). The idea of a non-despotic government recognizes at the same time that the human being is with nature and at the same time is more than «mere» nature: man is not finite in the species. Man is the only one who makes personal history and is shaped by free and rational action. It is not a matter of super naturalizing, so to speak, man, but of co-responsibilizing: only rational beings with a will are, strictly speaking, responsible for something, that is to say, moral subjects.

6. Some concluding remarks on the uniqueness of the human

The presupposition of the theoretical inconsistency about the only gradual nature of human beings and animals is exactly the topic that emerges in all the arguments presented. Not to produce unnecessary suffering to nonhuman animals is out of an indirect duty to them insofar as it dehumanizes people (22).

It may be insisted that it remains an ad hoc argument just to maintain the prejudice: the argument of difference in treatment because of species membership is just that, only a counterintuitive prejudice.

Nevertheless, to my mind, the «species overlap» is the touchstone of animal rights arguments: if we judge empirical features of rational capacities as just upgrades without a radical background capacity then there is no difference but one of degree. Thus, that man makes, for example, tools would not make a difference between non-human animals since it could be explained as a difference of degree: it is just more complex. However, opponents have pointed out with respect to the example of tools that animals use tools without doubt, but they do not possess an abstractive capacity to conceive of tools as tools or to use tools to create others. That implies a capacity to possess universal concepts, of abstraction (23, 24, 25). If we understand man’s capacity to know and make tools as such and in the very conception of «tool» the difference does not seem to be one of degree.

Another argument against ontological equalization is that the person is incommunicable, that is, unique. If incommunicability is understood only as more or less sharable spatial location it is quite clear that a cat, for example, is a cat and not another and in that sense is a unique cat (23). But, personal incommunicability means ontologically irreplaceable, that is, being fully autonomous insofar as it can propose ends. It implies a radical capacity, as mentioned above, where intelligence and will emerge as immaterial capacities and not only as a manifestation of problem-solving (22). The characteristic rational nature of persons is their capacity for self-direction outside of instinct, as it were: Unlike common and proper names, the term «person» directly names the act of being that is what makes the person subsist. That formal constitutive makes the person exist by itself and in itself and makes the person a subsistent reality of a rational nature(23).

It can be insisted that there is confusion between the way of knowing and the way of being: discovering voluntariness, the capacity to laugh, the capacity to think of oneself as a self, are what allow us to know that we are before a person, but they are not its constitution since it derives from a radical capacity: because we are persons we can do that and not the other way around (24).

There has also been discussion about human and animal language, with some insisting that animal language is only a difference of degree with human language and the opponents that it is a level of complexity that cannot be explained in this way (24, 25).

In any case, the bottom line of the discussion ends up being the ontology that arises in all arguments even in non-utilitarian arguments such as Nussbaum’s (26). How José Justo Megías sums it up:

Those who insist on placing the animal and the human being on the same plane of being on the grounds that they possess some of these capacities, overlook the fact that the former have them in a partial way and that none of them reaches the degree in which they are present in the human being. The key lies in their way of being, in the complex rationality and freedom... qualities that manifest themselves in concrete capacities that allow him to take charge of his life in the environment in which he lives together with others, something beyond the reach of any other known animal. When and how these qualities and capacities that differentiate us from animals appeared and developed are questions that are difficult to answer... But what is certain is that only we have them, or only we have them to such a qualified degree as to make us distinct from animals in the way we are (25).

In short again it is the ontological level that is made manifest in various qualities such as self-consciousness, ethical capacity, mastery of language, culture, and a sense of death and transcendence. A summary of all these characteristics with some recent discussions can be found in the cited text by José Justo Megías (25), in the text by Renée Mirkes (24) and from the perspective of the Magisterium of the Catholic Church in Rodrigo Frías (27).

7. Conclusions

The relatively recent arguments about alleged animal rights have not been substantially modified from the traditional arguments against speciesism. They start from assumptions that the distinction between human and nonhuman is merely a matter of aggregation and material complexity. It is considered that there is no radical difference between intelligence and will, these being a matter of degree. Prof. Jacquet’s argument attempts to be an adjustment of the classical argument from the superposition of species. The moral argument that is not correctly grounded is deviant reasoning that is weaker than the opposite, so the egalitarian principle must be accepted. Nevertheless, I have tried to show that at bottom the metaphysical presuppositions are the same as always: if man possesses spiritual faculties and is a subject of himself he will be radically different from non-human animals.

Recent arguments concerning animal rights continue to assume the superposition of species and the principle that the difference between humans and animals is only a matter of degree. Likewise the defense of speciesist difference and justification remains the same: there is indeed a radical difference between humans and animals. The emergence of the human is a qualitative leap that can justify the use of nonhuman animals for human needs, though not in a despotic sense. The argument of mother earth does not prove that nonhuman animals and man are equal, but it does show that man’s uncontrolled dominion over nature harms, in the first place man himself, and secondly animals. However, another issue to be discussed is the limits and criteria with which man should treat the rest of living beings.

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Received: August 15, 2021; Accepted: September 12, 2021

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