Bioethics: Ancient Themes in Contemporary Issues (Basic Bioethics)

Theory and Bioethics

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As an analogical method of thinking, casuistry attempts to extend the judgments reached in so-called paradigm cases to new cases that present somewhat different fact patterns.

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Our confidence in this analogical process stems from our confidence that the moral principle s embedded in Y extend to the present case, notwithstanding a certain number of factual differences. As the factual differences mount, we might conclude that the principle still holds, but does so only weakly, with less confidence. And at a certain point, the differences may become so great that the original principle animating our judgment in Y loses its justifying force entirely, at which point we begin reaching for another paradigm.

The crucial point here is that analogical reasoning is not self-directed.

It requires principles or maxims, a sense of what's ethically relevant, or a background moral vision of some sort in order to give it direction. If we think of casuistry as an engine of moral justification, it is natural to ask about the steering wheel that provides a sense of direction to our analogical reasoning.

In the most influential version of casuistry practiced today, as articulated by Albert Jonsen , moral principles or generalizations provide this sense of direction. Paradigm cases are defined here as those cases in which a given principle applies most clearly, straightforwardly, and powerfully. To the extent that we are at all able to approximate certainty in moral matters, it will be in the context of a strong match between a principle and a paradigmatic set of facts.

Generalizations or principles also provide us with the crucially important understanding of what's morally relevant and why, which drives analogical reasoning forward. In conceding these pivotal roles to moral principles, Jonsen both distanced himself from Toulmin's more radically particularistic brand of casuistry and softened the differences between casuistry and its principal methodological rival, the principlism of Beauchamp and Childress.

What then to make of Dancy's particularistic, anti-principled, and anti-theoretical moral epistemology that appears to pose such a threat to business as usual in bioethics? Although this isn't the place for a full-blown examination of Dancy's subtle and philosophically sophisticated position, [ 8 ] we can sound a couple of cautionary observations.

First, we can all agree with Dancy that sound moral judgment depends upon the particularities of moral situations in all their individuality and complexity.

Blundering into a situation armed with inflexible and invariant moral principles that must hold everywhere and always in the same way, no matter what the facts on the ground, is, we can concede to Dancy, a big mistake, although identifying actual theorists who are guilty of such ham-handed blundering might prove to be a challenge. Second, however, it is unclear that Dancy's reliance upon nuanced moral perception and narrative epistemology can really provide us with a plausible, let alone serviceable, notion of moral justification. Third, the distance between Dancy's anti-principlist position and the standard approach to moral principles taken by, e.

Ross and Beauchamp-Childress, is in practice not that great, and the remaining differences tend to tell in favor of the latter position rather than the former. Let us recall that the standard view of principles in bioethics, following Ross, is that various elements of action e. So it is quite possible to imagine cases where the wrong-making element of telling a lie might be vastly outweighed by other good-making considerations. Think of the case of the Nazis banging on your door, asking about Jews you've been harboring.

In cases of this sort, Dancy's strong particularist epistemology will reach the same result, and only for a slightly different reason. Pragmatically, then, so long as the defenders of principles remain sensitive to context, it seems there is little, if anything, to be gained by embracing strong particularism, but perhaps something of value may be lost.

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Again, according to the strong particularist, the valence of any contextual element is not fixed in any way outside of particular contexts. Considerations that have told in favor of past actions might tell against other actions in the future. Although Dancy concedes that some properties of actions e. For this rival particularist camp, principles and moral generalizations give us real knowledge about certain types of action and what makes them right or wrong Lance and Little , Little While conceding to Dancy that the standard conditions that make them right or wrong may not hold in aberrant or idiosyncratic cases e.

His brand of strong particularism would threaten not only the methodology of standard issue principlists like Beauchamp and Childress, but it would also trouble moderate casuists like Albert Jonsen, whose method commits them to the value of consistency in analogically passing from one case to another G. Dworkin If a certain general feature e.

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Jonsen's moderate casuistry requires consistency in such cases, and appeals to consistency constitute a reasoned argument offered to those who might initially disagree with our judgment in the instant case. In sum, then, the anti-theory position in both its strong casuist and strong particularist incarnations is problematic. Although we can and should learn from the anti-theorist critique, and pay special heed to its insistence upon the importance of particular circumstances for moral judgment, the most uncompromising versions of casuistry and particularism threaten to replace reasoned argument by the delicate and nuanced perceptions of sensitive moral judges.

Many will find this to be a deficient or at least incomplete mode of moral justification. Having duly noted the appeal and shortcomings both of high moral theory and of particularist anti-theory, it is time to move toward a more plausible middle ground marking the intersection of bioethics and philosophical theory. Is there then a role for theory in bioethics, and, if so, what kinds of theory?

In addition to ideal political theory, which provides us with an objective to aim at, we also need nonideal theory, which takes account of messy realities on the ground in charting a practical course towards that objective. Unlike the ideal theorist, the nonideal theorist must consider whether a proposed policy is:. Notwithstanding its manifest importance for practical ethics, there has been relatively little self-conscious scholarly work on nonideal justice theory in either political philosophy or bioethics.

The need for such theorizing is perhaps most obvious and compelling in the area of global bioethics, where biomedical research is conducted against a backdrop of appalling disparities between rich and poor nations. What norms should govern the conduct of international research and post-trial access to benefits flowing therefrom when the subjects of such research often lack access to even the most rudimentary forms of health care and public health?

Should a single ethical standard representing perfect justice be applied within rich and poor nations alike Macklin ? Or will the attempt to impose rules required by perfect justice backfire, making the worst off even worse off than they might have been under policies that acknowledged the need to recognize and compensate for past and present injustices Wertheimer forthcoming? One important exception to the neglect of nonideal theory within bioethics is provided by the work of Madison Powers and Ruth Faden In developing a theory of social justice for deployment in the areas of health care and public health, these authors begin with an account of human well being, similar to the capabilities approach of Sen and Nussbaum, but then insist that unjust inequalities provide the real world context in which questions of justice arise for us.

Determining priorities for health care and public health requires both normative and empirical studies bearing on the cumulative effects of various structural inequalities on prospects for human flourishing, and thus cannot be accomplished within the ambit of standard-brand ideal theories of justice.

Bioethics should also be nonideal in terms of its assumptions about those who are engaged in the public bioethical discussion. As we saw above in Sec. The reasons we offer in favor of our basic social arrangements must not be so esoteric and technical that citizens of average intelligence and normal capacities cannot comprehend them. Democracy requires comprehensible rationales for its basic norms as a matter of respect for each person.

Patients, families, potential research subjects, health care providers, public health officials, and the public itself generally lack both the specialized intellectual skills of philosophical theoreticians and the time and inclination to develop such skills; yet, as members of a democratic polity, all those engaged in the activities of medicine, nursing, biomedical research, and public health deserve a set of policies whose respective rationales can be explained to them in language that they can understand London This is yet another reason why clinical and policy-oriented bioethics should not be grounded in some versions of high philosophical theory.

Just as theorists must take account of various nonideal factors, such as the existence of deeply entrenched social inequalities within society as we know it, so too must we take account of the fact that most people in society lack the time, inclination, and perhaps the intellectual aptitude to engage in rigorous philosophical theorizing.

The intellectual moorings of public bioethics should, then, be sought primarily in modes of thought and policy analysis that are more down to earth and publicly accessible. Beauchamp , Arras The convergence of all these initially rival methodologies into a widely shared mid-level approach to bioethical problems has been facilitated by two developments in the literature. First, each faction has made a convincing case for its particular methodological emphasis.

This has required each approach to acknowledge or incorporate elements drawn from other methodologies and, accordingly, to soften its claims to methodological supremacy. For example, the casuistry of Jonsen and Toulmin arose as a robust particularist challenge to the principlism of Beauchamp and Childress.

This challenge led Beauchamp and Childress to concede the important role of particularized case judgments in the identification and specification of moral principles. Following this critical exchange, the avatars of an allegedly deductive principlism acknowledged a two-way relationship between moral principles and case judgments.

Conversely, the exchange with principlism led the proponents of casuistry to soften their initial claims that bioethics should be theory free and that principles only played a heuristic but not justificatory role in moral judgment. Both sides emerged from this confrontation agreeing upon a critical role for ethical principles and maxims, and upon a constructive role for case judgments in the development and refinement of principles. The differences between these rival methodologies now appeared to be more a matter of emphasis than of principle or the lack thereof Kuczewski The second major development leading to a convergence on a theory-modest method within bioethics was the widespread adoption of reflective equilibrium as a widely shared method of moral justification Arras In contrast to earlier methodological formulations within bioethics that gave foundational status to, say, moral principles or intuitions about paradigm cases, reflective equilibrium finds justification through the coherence of all these elements, each of which impinges on all the others in a multi-directional dialectic.

To simplify just a bit, principles and moral theories function within this method to organize, explain, criticize, and extend our intuitive responses to cases, but those very responses can, in turn, help us to amend and sharpen our principles and theories when they prove inadequate to the complexities of emerging cases.

One important implication of adopting the method of reflective equilibrium is a blurring of the allegedly sharp boundary between practical ethics and ethical theory. Indeed, one common rationale for inquiring into the relationship between bioethics and ethical theory is the widespread presumption that these two activities must operate within entirely different spheres: ethical theory addresses fundamental questions at a high level, divorced from the messy reality of everyday practice, while bioethics is thought merely to apply the ready-made findings of ethical theory to practical problems.

If we are guided by a holistic method like reflective equilibrium, however, we should expect theory to shed critical light on our responses to cases, but we should also expect reflection on cases to shape the sort of principles and theory we eventually develop. Ethical reflection is a two-way street Beauchamp , Brock Reflective equilibrium can, however, be interpreted in two different ways, each of which yields a different gloss on the relationship between bioethics and moral theory Arras On a narrow reading, reflective equilibrium encompasses our intuitions about cases and the moral principles we use to explain, organize, critique, and extend such intuitions.

Brody Subsequent commentary debated the appropriateness of applying a principle governing discrimination against racial minorities and women in education, jobs, and housing to decisions to terminate medical care for some extremely ill or malformed newborns.

Many physicians and bioethicists contended that the nondiscrimination principle was far too blunt an instrument to do justice to such enormously delicate and complex cases, and sought to amend the moral principles governing such cases in a way that would capture such complexity Rhoden and Arras On a much broader and ambitious reading, reflective equilibrium encompasses not just sets of intuitive responses to cases and matching moral principles, but also a reasoned choice among the full panoply of live options in moral and political theory, as well as background theories of human agency, personhood, and the workings of social systems Daniels The rationale for buttressing NRE with these additional moral, political and social theories is that a relatively narrow focus upon our most confident intuitions and the principles that organize and explain them could engender an uncritical provincialism in our moral outlook.

Hence the need to supplement our intuitions and organizing principles with the best moral, political, and social theories we can muster. Since both narrow and wide reflective equilibrium posit a relationship characterized by mutual dependency and critical tension among our intuitions, principles, and theories, both methods would effectively blur the alleged dichotomy between moral theory and practical ethics. By engaging in practical ethics via reflective equilibrium of any sort, we are already thereby engaging in a form of ethical theorizing, albeit perhaps at a lower level of abstraction than traditional high theory.

But because WRE would have us choose among various live options in moral and social theory, it would yield a different kind of relationship between bioethics and theory. By incorporating a reasoned choice among various moral and social theories as part of its method of justification, WRE might provide independent theoretical discipline to our intuitions and moral principles, [ 11 ] but it does so at the cost of vastly enlarging our methodological ambitions and the complexity of the task at hand.

Although WRE might well be the optimal method for the ultimate justification of our moral judgments—i. First, if WRE requires reasoned choices among various live options in moral, political and social theory, this will no doubt reintroduce many of the problems we have already canvassed with regard to using high moral theory in bioethics. Were the constraints of WRE taken seriously by practitioners of bioethics, we would have to postpone judgment on the particular case or policy question before us until we had reached closure on the best theories governing ethics, politics, and social organization.

Needless to say, this could result in a very long delay. It would also be a contentious delay, since the likelihood of achieving widespread agreement on any version of high theory would be low.

WRE would most likely reintroduce the same social fissures at the level of theory that we have already witnessed at the level of intuitions and moral principles Arras Second, the most credible and philosophically sophisticated glosses on WRE have literally nothing to say about exactly how we should go about making choices from among the various live options in political, moral, and social theory.

They don't give us criteria for judging what an optimal theory would look like, and they therefore make no effort to rank the various theories against one another. In other words, the criteria for choosing among various theories would have to be drawn from sources outside the ambit of WRE, which, in turn, casts doubt upon its potential as a stand-alone method of moral and political thought, at least at the level of practice.

The field of bioethics has been fertile ground for the development of relatively modest, mid-level theories on a vast range of topics.

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In contrast to the vaulting structures so disfavored by Annette Baier—i. Like the handyman surrounded by a garage full of tools accumulated for past purposes, the moral philosopher takes stock of the problem at hand, surveys her shelves for available conceptual resources, and then attempts to solve the problem by taking things apart, reordering, culling out, weighing, specifying, splicing in, and putting them all back together. Stout , p. In response to a good deal of sloppy criticism of new reproductive technologies and research in developing countries, usually claiming that various practices should be morally condemned for allegedly being harmful, coercive or exploitative, words that seem to have become all-purpose terms of abuse for disfavored practices, philosophers have engaged in fruitful mid-level theorizing about the meaning and moral import of such concepts.

Most often, this kind of theorizing gets done without any appeals to ultimate high-level moral theory. It begins by taking stock of a problem at hand; the theorist then looks around for available conceptual resources for shedding light on it.

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