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UBC Theses and Dissertations

Ethics by the people Pawliuk, George Kevin 1991

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ETHICS BY THE PEOPLE by GEORGE KEVIN PAWLIUK B . S c , The U n i v e r s i t y o f A l b e r t a , 1982 THESIS SUBMITTED IN PARTIAL FULFILLMENT THE REQUIREMENTS FOR THE DEGREE OF MASTER'S OF ARTS i n THE FACULTY OF GRADUATE STUDIES DEPARTMENT OF PHILOSOPHY We a c c e p t t h i s t h e s i s a s c o n f o r m i n g t o t h e r e q u i r e d s t a n d a r d THE UNIVERSITY OF B R I T I S H COLUMBIA A p r i l 1991 @ G e o r g e K e v i n P a w l i u k , 1991 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. DepartmgilftI bPSOPHY  The University of British Columbia Vancouver, Canada DE-6 (2/88) ABSTRACT The Problem I w i l l be a d d r e s s i n g i s , q u i t e simply, "What r o l e , i f any, can p h i l o s o p h e r s l e g i t i m a t e l y p l a y i n b i o m e d i c a l e t h i c s ? " When one c o n s i d e r s the r e c e n t backlash a g a i n s t e t h i c a l theory; p h i l o s o p h e r s ' own d i s s a t i s f a c t i o n with t h e i r r e l a t i o n s h i p with biomedicine; and the depth and urgency of the p e r t i n e n t moral i s s u e s , i t i s n e a r l y i m p o s s i b l e to be unmoved by the enormity of the c h a l l e n g e . But w i l l p h i l -osophy meet the c h a l l e n g e ? Many of those who are f a m i l i a r with the c u r r e n t s t a t e of b i o m e d i c a l e t h i c s are i n c l i n e d t o be d o u b t f u l . The t h e s i s I s h a l l advance and defend i s t h a t t h i s doubt i s well-founded i f we suppose t h a t p h i l o s o p h e r s continue to apply t h e i r t h e o r e t i c a l resources i n biomedicine i n the same manner as has u s u a l l y been done. Unless p h i l o s o p h e r s dram-a t i c a l l y change the nature of t h e i r approach i n biomedical e t h i c s , they w i l l continue to face f r u s t r a t i o n and to be r e -garded as i n e f f e c t u a l . The r o l e they must adopt r e q u i r e s them to work with many others (nurses, p a t i e n t s , d o c t o r s , lawyers, etc.) as equals, b r i n g i n g t h e i r s k i l l s and t a l e n t s to bear along with the s k i l l s and t a l e n t s of non-philosophers. Without a strong inter-dependence between p h i l o s o p h e r s and non-philoso-phers, b i o m e d i c a l e t h i c s w i l l not prosper, nor evolve i n t o the kind of t o o l t h a t i s d i r e l y needed i n the h e a l t h s c i e n c e s . i i In order to defend the t h e s i s I am advancing, I w i l l survey some of the l i t e r a t u r e t h a t has d e a l t with the problems f a c i n g p h i l o s o p h e r s i n the c l i n i c i n re c e n t years. The case a g a i n s t b i o m e d i c a l e t h i c s (and, i n p a r t i c u l a r , normative e t h i c a l theory) w i l l be expl o r e d to r e v e a l the content of the c r i t i c i s m s and t h e i r f o r c e . F o l l o w i n g some d i s c u s s i o n of these c r i t i c i s m s , pursued i n order t o d i s c o v e r elements of a new approach t o the r o l e p h i l o s o p h e r s can l e g i t i m a t e l y p l a y i n biom e d i c a l e t h i c s , I w i l l attempt t o b u i l d a c o n s t r -u c t i v e a l t e r n a t i v e from these p o s i t i v e fragments. My c o n c l u s i o n , very g e n e r a l l y , i s t h a t p h i l o s o p h e r s ' s k i l l s and resources permit them t o f u n c t i o n best i n c l o s e c o o p e r a t i o n with o t h e r s . I w i l l r e l y on an account of a p u b l i c forum (comprised of d o c t o r s , p a t i e n t s , t h e o l o g i a n s , nurses, e t c .) to i l l u s t r a t e the k i n d of r o l e p h i l o s o p h e r s c o u l d most e f f e c t i v e l y and l e g i t i m a t e l y pursue. Because of the nature of t h e i r a c t i v i t i e s , p h i l o s o p h e r s would, f o r example, o f t e n p l a y an important r o l e i n i s o l a t i n g and defend-ing s i g n i f i c a n t value q u e s t i o n s . A strong sense of i n t e r - d e p -endence would develop as p h y s i c i a n s and the forum i n t e r a c t e d . P h y s i c i a n s , who must be a c t i v e i n t h e i r r o l e s as moral agents, would p r i m a r i l y be concerned with developing r u l e s , g u i d e l i n e s , e t c . f o r p r a c t i c a l cases. Physicans would be a s s i s t e d by a small group of non-physicians to ensure t h a t important s o c i a l goals are taken i n t o account. The forum would a c t as an e x t e r -n a l c r i t i c of these r u l e s , both p r o s p e c t i v e l y and r e t r o - a c t i v e -l y . The success of the forum would p r o v i d e biomedical e t h i c s i i i with important p r a c t i c a l input that should be used for i t s growth and development. i v TABLE OF CONTENTS ABSTRACT i i INTRODUCTION 1 Chapter 1. MEDICINE AND MORALITY 5 2. TECHNOLOGY AND MORALITY 18 3. MEDICINE AND ETHICS 31 4. BIG CHALLENGES AND BIG LIMITATIONS . . . . 42 5. ANTI-THEORY 59 6. THE CONVALESCENCE OF CASUISTRY 70 7. LIMITATIONS OF CASUISTRY 80 8. PHILOSOPHERS AND BIOMEDICINE 89 CONCLUSION 99 BIBLIOGRAPHY 101 V INTRODUCTION For t h e p a s t few decades, moral p h i l o s o p h e r s have i n -v o l v e d themselves more and more i n the h e a l t h s c i e n c e s . O f t e n , t h i s i n v o l v e m e n t has not been v e r y d i f f e r e n t from the u s u a l a c t i v i t i e s pursued by p h i l o s o p h e r s i n academic s e t t i n g s . P h i l o s o p h e r s have m a i n l y worked w i t h t h e o r i e s t h a t have p r i -m a r i l y been d e v e l o p e d i n a h i g h l y a b s t r a c t manner. S i n c e t h e s e t h e o r i e s were seldom a p p l i e d w i t h i n a p r a c t i c a l c o n t e x t , most o f t h e c r i t i c i s m s r a i s e d a g a i n s t them have been o f a l o g i c a l o r c o n c e p t u a l n a t u r e . R e c e n t l y , however, moral p h i l o s o p h e r s have begun t o encounter p r a c t i c a l c r i t i c i s m s of t h e i r t h e o r i e s . I t i s not j u s t a b s t r a c t s h o r t c o m i n g s t h a t c o n f r o n t n o r m a t i v e e t h i c a l t h e o r i e s , but a l s o problems o f a p p l i c a t i o n and r e l e v a n c e . In t h e p a s t , a few moral p h i l o s o p h e r s have deve l o p e d c e r t a i n approaches t o moral r e a s o n i n g t h a t have had a v e r y p o s i t i v e response from the h e a l t h s c i e n c e s . In p a r t i c u l a r , the a p p l i e d e t h i c s paradigm ( c h a p t e r s 3 and 4) deve l o p e d by Beauchamp and C h i l d r e s s has been w i d e l y r e g a r d e d as an a c c e p t a b l e method of moral r e a s o n i n g f o r h e a l t h c a r e w o r k e r s . A l t h o u g h i n a b s t r a c t d i s c u s s i o n s t h i s method seems p r o m i s i n g and i s s i m p l e t o l e a r n , i t i s next t o u s e l e s s when one at t e m p t s t o a p p l y i t i n c o n c r e t e c a s e s . Given t h e problems and f a i l u r e s o f n o r m a t i v e e t h i c a l 1 theory i n the h e a l t h s c i e n c e s , p h i l o s o p h e r s and others have begun to r e c o n s i d e r the nature of the r o l e p h i l o s o p h e r s ought to p l a y i n biomedicine. I f normative e t h i c a l t h e o r i e s are r e a l l y u s e l e s s i n r e s o l v i n g concrete d i f f i c u l t i e s , then, perhaps, such t h e o r i e s have no p l a c e i n the h e a l t h s c i e n c e s (or anywhere). Of course, a l t e r n a t e approaches to the a p p l i e d e t h i c s paradigm (and other uses of normative e t h i c a l theory) have emerged i n r e c e n t y e a r s . Most noteworthy of these i s c a s u i s t r y . Even though there are c e r t a i n promising f a c t s about t h i s method of moral reasoning, the mere f a c t t h a t i t i s h i g h l y dependent on s e v e r a l elements of the a p p l i e d e t h i c s paradigm speaks s t r o n g l y a g a i n s t i t . In t h e i r attempt to avoid the approaches they c r i t i c i z e , the new c a s u i s t s have, i n f a c t , been unable to do without the very t h i n g s they r e j e c t . T h i s convergence on methods and resources employed by others suggests t h a t t h i s approach i s not as unique as they c l a i m . Another development i n moral philosophy i s the a n t i -theory movement. T h i s l i n e of c r i t i c i s m h olds, q u i t e sim-p l y , t h a t normative e t h i c a l theory has no r o l e to play any-where. For a n t i - t h e o r i s t s , such t h e o r i e s are not p o s s i b l e and w i l l never s a t i s f a c t o r i l y do what those i n the h e a l t h s c i e n c e s r e q u i r e of them. To date, however, the a n t i - t h e o r i s t s ' have only made s c a t t e r e d a t t a c k s on normative e t h i c a l theory and i t i s probably too e a r l y to f u l l y e v a l u a t e the success of t h e i r e f f o r t s . In a d d i t i o n , they have not yet provided those i n biomedicine with a more s u c c e s s f u l a l t e r n a t i v e . To m e r e l y d e s t r o y w i t h o u t r e p l a c i n g w i t h u s e f u l t o o l s seems s e n s e l e s s l y r a d i c a l and n o t p a r t i c u l a r l y h e l p f u l f o r t h o s e w o r k i n g i n t h e p r a c t i c a l r e a l m . I n o p p o s i t i o n t o t h o s e who w o u l d c o m p l e t e l y r e j e c t n o r m a t i v e e t h i c a l t h e o r y as a u s e f u l t o o l i n b i o m e d i c i n e , I a r g u e , i n s t e a d , t h a t i t has an i m p o r t a n t r o l e t o p l a y . I c l a i m t h a t p h i l o s o p h e r s and t h e i r t h e o r i e s a r e a n e c e s s a r y p a r t o f t h e f o r m a t i o n o f p o l i c y and t h e r e s o l u t i o n o f d i f f i c u m o r a l i s s u e s . However, due t o t h e t h e o r e t i c a l and p r a c t i c a l l i m i t a t i o n s o f b i o m e d i c a l e t h i c s , p h i l o s o p h e r s must work c o o p e r a t i v e l y w i t h t h e c a r i n g p r o f e s s i o n s i n o r d e r t o be s u c c e s s f u l . S p e c i f i c a l l y , t h o s e i n t h e c a r i n g p r o f e s s i o n s ( e . g . p s y c h i a t r i s t s , s o c i a l w o r k e r s , c h a p l a i n s , e t c . ) w i l l e n s u r e t h a t t h e m o r a l i n t e r p r e t a t i o n s o f p e r p l e x i n g c a s e s a r e n ' t o v e r l y s i m p l i s t i c . The p u b l i c f o r u m t h a t I d e s c r i b e ( c h a p t e r e i g h t ) w i l l a l l o w t h e t a l e n t s and s k i l l s o f p h i l o s o p h e r s and n o n - p h i l o s o -p h e r s ( n u r s e s , d o c t o r s , l a w y e r s , e t c . ) t o be c o m b i n e d i n an a t t e m p t t o r e s o l v e p r a c t i c a l m o r a l p r o b l e m s . A f t e r some c o n -s i d e r a t i o n o f t h e n o t i o n o f m o r a l e x p e r t i s e and i t s r e l a t i o n -s h i p t o m o r a l p h i l o s o p h e r s , I c o n c l u d e t h a t i t i s o n l y by w o r k i n g i n c l o s e c o o p e r a t i o n w i t h o t h e r s i n t h e f o r u m t h a t p h i l o s o p h e r s w i l l s u c c e e d i n b i o m e d i c a l e t h i c s . I a l s o a r g u e t h a t t h e e x t e n t t o w h i c h p h i l o s o p h e r s a r e s u c c e s s f u l a t r e s o l v i n g m o r a l i s s u e s and f o r m i n g p o l i c i e s w i l d e p e n d on w h e t h e r t h e r e a r e r a t i o n a l l y c o m p e l l i n g m o r a l t h e o r i e s and c o n c e p t s . I f t h e r e a r e , p h i l o s o p h e r s have a g r e a t de to o f f e r . If there are no r a t i o n a l l y compelling moral theor-ie s , philosophers may s t i l l contribute a great deal, for the i r a b i l i t y to provide r a t i o n a l l y compelling concepts w i l l make the resolution of pa r t i c u l a r moral issues (e.g. abortion) a p o s s i b i l i t y . It i s important to r e a l i z e that i f there are better theories and better concepts, then there i s the l i k e -lihood of a r r i v i n g at better answers to moral problems. The s k i l l s that philosophers work hard at acquiring make these better answers attainable. However, as one moves from the abstract to the concrete i n biomedicine, more and more input from non-philosophers w i l l be required. CHAPTER 1 MEDICINE AND MORALITY One t h i n g seems c l e a r about t h e v e r y complex p r a c t i c e of m e d i c i n e : i t has been the sour c e o f s e v e r a l p r o f o u n d moral d i f f i c u l t i e s i n r e c e n t decades. Why i s i t then t h a t t h e c l a i m t h a t m e d i c i n e i s an i n h e r e n t l y moral e n t e r p r i s e has not been s i m p l y r e j e c t e d out of hand as b e i n g p a t e n t nonsense ( C a s s e l l 1973)? A p p a r e n t l y , t h i s c l a i m i s not w i t h o u t i t s p l a u s i b i l i t y . An e x a m i n a t i o n o f the s u p p o r t f o r t h i s c l a i m (and o t h e r s much l i k e i t ) w i l l be t h e t a s k o f t h i s c h a p t e r . Of p a r t i c u l a r i n t e r e s t w i l l be t h e n o t i o n t h a t m e d i c i n e , as an i n h e r e n t l y moral endeavor, m a i n l y i n v o l v e s d o i n g what s h o u l d be done. E a r l y H i p p o c r a t i c Roots The b e l i e f t h a t m e d i c i n e i s f u n d a m e n t a l l y a m o r a l , i n d e e d s a c r e d e n t e r p r i s e can be t r a c e d back t o t h e f o u r t h c e n t u r y B.C., when t h e H i p p o c r a t i c Oath i s b e l i e v e d t o have been w r i t t e n (Zaner 1988, 206, 218). At t h i s time i t was b e l i e v e d t h a t any-t h i n g g i v e n t o a p a t i e n t produced a c e r t a i n d i s p o s i t i o n o f h i s s o u l . S i n c e p h y s i c i a n s knew t h i s b e t t e r than most p e o p l e , t h e y were no doubt aware of t h e p o t e n t i a l f o r c o n t r o l they had over t h e i r p a t i e n t s . What s t o o d i n t h e way o f t h e i r t a k i n g advan-tage o f tho s e i n t h e i r c a r e ? The . . . [ H i p p o c r a t i c ] Oath s e t s out "the c l o s e s t and most s a c r e d r e l a t i o n s h i p t h a t can be imagined between 5 6 men...." The p r a c t i c e o f t h e a r t , t h e r e f o r e , seems t o t h e s e p h y s i c i a n s a most unique and demanding en-t e r p r i s e . W h i l e t h e v i r t u e s o f j u s t i c e and f o r b e a r -ance are i n h e r e n t t o e v e r y s o c i a l r e l a t i o n s h i p , t h a t s p e c i f i c s o c i a l r e l a t i o n s h i p between p h y s i c i a n and p a t i e n t , and between p h y s i c i a n and p u p i l , i s s a c r e d , such t h a t t h e p r a c t i t i o n e r must be bound by moral covenant. W i t h i n t h e s e r e l a t i o n s h i p s , j u s t i c e and f o r b e a r a n c e a r e t r a n s f o r m e d i n t o something more e l e -v a t e d and more demanding th a n i s found i n t h e common s o r t s of s o c i a l r e l a t i o n s h i p s ( I b i d . 211). Because of i t s prominence i n H i p p o c r a t i c m o r a l i t y , i t i s n e c e s s a r y t o c o n s i d e r i n more depth the n o t i o n t h a t e v e r y -t h i n g g i v e n t o t h e body produces a c e r t a i n d i s p o s i t i o n of t h e s o u l . Around th e time the H i p p o c r a t i c Oath was w r i t t e n , b o d i l y a p p e t i t e s were r e g a r d e d as c r a v i n g s f o r t h e presence or absen-ce of v a r i o u s t h i n g s . R e g a r d l e s s o f whether u n h e a l t h y appet-i t e s a r e i n n a t e o r a c q u i r e d , they i n t e n s i f y u n t i l t h ey b r i n g about d i s c o m f o r t and sometimes m i s e r y . P u r s u i n g an u n h e a l t h y l i f e s t y l e - - i n p a r t i c u l a r , e a t i n g an u n h e a l t h y d i e t - - r e s u l t s e v e n t u a l l y i n i l l n e s s and even d e a t h . I t was t h e H i p p o c r a t i c p h y s i c i a n ' s p r i m a r y duty t o d i s t i n g u i s h h e a l t h y d e s i r e s from u n h e a l t h y and t o p r e s c r i b e a h e a l t h y regimen f o r h i s p a t i e n t s . S i n c e t h e s e p h y s i c i a n s b e l i e v e d t h a t u n h e a l t h y d e s i r e i s un-c o n t r o l l e d d e s i r e , they were v e r y much concerned t o a l t e r the d i s p o s i t i o n s of t h e s o u l . In o r d e r t o do so, they had t o make i m p o r t a n t v a l u e judgments about what the p a t i e n t s h o u l d and s h o u l d n ' t do. Thus, t h e s e p h y s i c i a n s were e s s e n t i a l l y p r e o c c u p p i e d w i t h f i n d i n g the r i g h t a c t i o n s f o r a g i v e n p a t i e n t . In o t h e r words, they d e s i r e d both t h a t t h e i r c a r e f o r t h e p a t i e n t and h i s c o r r e c t e d b e h a v i o u r were a c l e a r e n a c t -7 ment of what s h o u l d be done ( I b i d . 208). The Long, Unbroken T r a d i t i o n Even though n e a r l y 2400 y e a r s have passed s i n c e t h e H i p p o c r a t i c Oath was w r i t t e n , i t has c o n t i n u e d t o have a s i g -n i f i c a n t a f f e c t on t h e modern p r a c t i c e o f m e d i c i n e . T h i s remains so d e s p i t e t h e r e c e n t emphasis on t h e autonomy of p a t i e n t s and t h e i r r i g h t s . Edmund P e l l e g r i n o ' s p o s i t i o n i s , i n many r e s p e c t s , a modern statement o f many o f t h e b e l i e f s and v a l u e s found i n the a n c i e n t H i p p o c r a t i c t r a d i t i o n . He c l a i m s t h a t c l i n i c a l judgment on b e h a l f of each s p e c i f i c p a t i e n t . . . i s i n f u s e d w i t h both s c i e n t i f i c and v a l u e components, i n i t s b e i n g u n i q u e l y governed by a f u n d a m e n t a l l y p r a c t i c a l m oral end--the r i g h t a c t i o n f o r a s p e c i f i c p a t i e n t (Zaner 1988, 155). S p e c i f i c a l l y drawing a t t e n t i o n t o the n o t i o n of the r i g h t a c t i o n f o r a g i v e n p a t i e n t , P e l l e g r i n o argues t h a t m e d i c i n e i s o n l y j u s t i f i e d when i t i s t r u l y f o c u s e d on the p a t i e n t ' s needs ( P e l l e g r i n o 1979, 171). In h i s view, a " v a l u e s c r e e n " i s c a s t over the e n t i r e p r o c e s s l e a d i n g t o t h e r i g h t a c t i o n f o r the p a t i e n t , s i n c e what i s m e d i c a l l y i n d i c a t e d may n o t , i n f a c t , be i n a c c o r d w i t h the p a t i e n t ' s v a l u e s ( I b i d . 170). Someone's r e l i g i o u s b e l i e f s may e x c l u d e modern b i r t h c o n t r o l methods as an o p t i o n even though m e d i c a l e v i d e n c e has amply e s t a b l i s h e d t h e i r s a f e t y and e f f e c t i v e n e s s . Some peopl e might r e g a r d t h i s as an i n s t a n c e of moral r e l a t i v i s m a t the i n d i v i d u a l l e v e l : " Although b i r t h c o n t r o l i s r i g h t f o r you, i t i s out o f t h e q u e s t i o n f o r me." Be t h a t as i t may, 8 P e l l e g r i n o i s on to something i m p o r t a n t , f o r he f r e q u e n t l y draws a t t e n t i o n to the need to unpack "the r i g h t a c t i o n f o r t h i s p a t i e n t " i n a way t h a t s t r e s s e s the p a t i e n t ' s v a l u e s . H . T r i s t r a m E n g e l h a r d t J r . has uncovered a deep ly i n s i g h t f u l way of l o o k i n g a t medic ine as the e n t e r p r i s e t h a t does what shou l d be done. He b e l i e v e s t h a t "medicine i s the most r e v o l u t i o n a r y o f human t e c h n o l o g i e s . I t does not s c u l p t s t a t u e s or p a i n t p a i n t i n g s : i t r e s t r u c t u r e s man and man's l i f e " ( E n g e l h a r d t 1973, 445) . But medic ine i s not j u s t a s c i e n c e or a t e c h n o l o g y , i t i s "the a r t of remaking man, not i n the image of n a t u r e , but i n h i s own image; medic ine opera te s w i t h an i m p l i c i t i d e a o f what man sh ou ld be" ( I b i d . ) . Of c o u r s e , p h y s i c i a n s must possess c e r t a i n impor tant v a l u e s i f they are to s u c c e s s f u l l y remake humans i n d e s i r a b l e ways. M e d i c i n e i s , t h u s , e s s e n t i a l l y m o r a l , because i t opera te s w i t h a dense nexus of va lues and e x p e c t a t i o n s . A l i s d a i r M a c l n t y r e ' s a n a l y s i s o f " s o c i a l p r a c t i c e s " a l s o o f f e r s r e a s o n a b l e support f o r the c l a i m t h a t medic ine i s an i n h e r e n t l y moral e n t e r p r i s e . M e d i c i n e i s a s o c i a l p r a c -t i c e because i t i s a coherent and complex form of s o c i a l l y e s t a b l i s h e d c o o p e r a t i v e a c t i v i t y through which goods i n t e r n a l to t h a t form of a c t i v i t y are r e a l i z e d i n the course of t r y i n g to a c h i e v e those s tandards o f e x c e l l e n c e t h a t are a p p r o p r i a t e t o , and p a r t i a l l y d e f i n i t i v e o f t h a t form of a c t i v i t y , w i t h the r e s u l t t h a t human powers to a c h i e v e e x c e l l e n c e , and human c o n c e p t i o n s o f the ends and goods i n v o l v e d , are s y s t e m a t i c a l l y extended (Zaner 1988, 51) . As a s o c i a l p r a c t i c e , med ic ine has both i n t e r n a l and e x t e r n a l goods. E x t e r n a l goods are o n l y c o n t i n g e n t l y 9 attached to the p r a c t i c e and do not define i t (Maclntyre 1978, 28). Relevant e x t e r n a l goods f o r medicine might be wealth, s t a t u s , r e c o g n i t i o n , s e c u r i t y , e t c . I n t e r n a l goods on the other hand are d e f i n i t i v e of the p r a c t i c e , since they can be s p e c i f i e d only i n terms of the p r a c t i c e i n question; and they may only be i d e n t i f i e d and recognized by those who have experienced the given p r a c t i c e (Zaner 1988, 51). Those who lack the experiences provided by the p r a c t i c e aren't able to judge the goods i n t e r n a l to i t . I t i s important to have a c l e a r conception of an i n -t e r n a l good. When a doctor accepts someone as a p a t i e n t , he serves the p a t i e n t ' s best i n t e r e s t s and works, i d e a l l y , w i t h i n a "covenantal r e s o l v e " to do the most good f o r the p a t i e n t ( I b i d . ) . For t h i s s p e c i f i c reason medicine i s an i n h e r e n t l y moral e n t e r p r i s e . This th e r a p e u t i c r e s o l v e i s c l e a r l y an i n -t e r n a l good of medicine as a s o c i a l p r a c t i c e . The achieve-ment of the i n t e r n a l goods of the p r a c t i c e b e n e f i t s both p r a c t i t i o n e r s and those who b e n e f i t from t h e i r a c t i v i t i e s ( i n t h i s case, p a t i e n t s ) . Zaner extends Maclntyre's a n a l y s i s by c l a i m i n g that medicine's i n t e r n a l goods are "expressed by i t s t h e r a p e u t i c theme and underlying moral r e s o l v e , and t h e i r s i t u a t i o n a l s p e c i f i c a t i o n s " ( I b i d . ) . He argues that i f these goods are a t t a i n e d , i t i s only during the attempt to meet the standards of excellence w i t h i n the p r a c t i c e of medicine (e.g. obser-v a t i o n a l a c u i t y and d i a g n o s t i c accuracy). The goods i n t e r n a l to medicine can only be achieved by those who p a r t i c i p a t e i n 10 t h e p r a c t i c e . Zaner goes on t o g i v e an account of m o r a l i t y t h a t " r e l a t e s d i r e c t l y and d e e p l y t o t h e moral f o u n d a t i o n s o f m e d i c i n e and t h e e x p e r i e n c e of i l l n e s s " ( I b i d . 300). He bases h i s p o s i t i o n on t h e w r i t i n g s o f H e r b e r t S p i e g e l b e r g and A l b e r t S c h w e i t z e r , both of whom have much t o say about t h e c o n n e c t i o n between human w e l f a r e and t h e o b l i g a t i o n s o f m o r a l i t y . S p i e g e l b e r g argues t h a t the f o u n d a t i o n f o r t h e moral l i f e i s not freedom, but t h e compromise, o r im b a l a n c e , of an i n d i v i d u a l ' s o p p o r t u n i t i e s as a r e s u l t o f the a c c i d e n t o f b i r t h (1974, 202). Because of the a c c i d e n t o f b i r t h , many people s u f f e r undeserved d i s a d v a n t a g e s , w h i l e s t i l l o t h e r s e n j o y e q u a l l y undeserved advantages. But j u s t i c e r e q u i r e s , he c l a i m s , t h a t we r e g a r d a l l persons as e q u a l s (1944, 113). S p i e g e l b e r g c o n c l u d e s t h a t we must t r y t o r e d r e s s a l l un-de s e r v e d i n e q u a l i t i e s of b i r t h . In o p p o s i t i o n t o c e r t a i n w i d e l y h e l d views o f modern p h i l o s o p h y , S p i e g e l b e r g c l a i m s t h a t ...the c o n n e c t i o n between d e s e r t and r e s p o n s i b i l i t y i s not freedom o r autonomy, a t l e a s t not i n the most b a s i c sense. That c o n n e c t i o n i s grounded i n our e s s e n t i a l human c o n d i t i o n , and t h i s i s f u n d a m e n t a l l y shaped by t h e a c c i d e n t o f b i r t h - - t h a t i s , by t h a t over which we had no c h o i c e , our r u d i m e n t a r y and i n i t i a l " l o t , " b i o l o g i c a l endowment, and s o c i a l s t a t i o n i n l i f e (whether as p r i v i l e g e o r handicap) (Zaner 1988, 300). S i n c e what we have and who we are c o n s t i t u t e s an e s s e n t i a l m oral i m b a l a n c e , whether p o s i t i v e o r n e g a t i v e , and s i n c e t h i s k i n d of i n e q u a l i t y i s wrong, something s h o u l d be done about i t . Thus i n j u s t i c e i s b a s i c to the moral l i f e , the " i n j u s t i c e i n h e r e n t to our unchosen i n i t i a l l o t s i n l i f e " ( I b i d . 303). Because these i n i t i a l l o t s are v o i d of moral j u s t i f i c a t i o n , they should be red r e s s e d , a view t h a t suggests a u n i v e r s a l e q u a l i t y of moral s t a t u s . Zaner then draws important a t t e n t i o n t o the f a c t t h a t not only are people s u b j e c t to the i n j u s t i c e s imposed on them by the a c c i d e n t of b i r t h ; they are a l s o , u n f o r t u n a t e l y , s u b j e c t t o d i s c r i m i n a t i o n by others who have f a r e d b e t t e r i n l i f e ' s l o t t e r y ( I b i d . ) . These two f a c t s - - i n j u s t i c e and d i s c r i m i n a t i o n - - h e claims are the found-a t i o n of the moral l i f e . In what way are Spieg e l b e r g ' s c o n c l u s i o n s r e l a t e d to the moral foundations of medicine and the experience of i l l -ness? Modern medicine can improve the q u a l i t y of the l i v e s of many of those who've been disadvantaged by the a c c i d e n t of b i r t h . Modern r e s e a r c h w i l l soon make d i a b e t e s nothing more than a minor inconvenience. Medical technology o f f e r s the freedom of m o b i l i t y f o r many d i s a b l e d people. C e r t a i n l y , improving the q u a l i t y of these l i v e s i s an important form of r e d r e s s . Although the i n j u s t i c e of human l i f e i s o f t e n a source of d e s p a i r , we must do a l l we can to minimize the e f f e c t s of misery and s u f f e r i n g . Since medicine's s t a r t i n g p o s i t i o n i s i t s t h e r a p e u t i c r e s o l v e , i t i s best s i t u a t e d to improve the l i v e s of those i n need.''' C l e a r l y , i f the r i g h t "*"One doesn't have to pursue t h i s l i n e of reasoning very f a r before i t becomes obvious t h a t no p r e s e n t l y e x i s t i n g h e a l t h care system would be a c c e p t a b l e from t h i s p e r s p e c t i v e . 12 t h i n g to do i s to combat the i n j u s t i c e s of e x i s t e n c e , then medicine would appear to be a fundamentally moral endeavor. In the course of i t s d a i l y business medicine c o r r e c t s c e r t a i n moral imbalances. I t i s important to s p e l l out i n more d e t a i l the con-nection between desert and r e s p o n s i b i l i t y . To begin w i t h , no one i s r e s p o n s i b l e f o r h i s genetic make-up; where he was born; h i s f a m i l y ' s economic s t a t u s ; e t c . People aren't born i n t o c e r t a i n places and s t a t i o n s because they choose to be. In a s i m i l a r manner, people aren't born i n t o hardships be-cause t h i s i s a f a t e they deserve. This i s c l e a r l y the point of emphasizing the accident of b i r t h . A l l people, however, are equal i n t h e i r c a p a c i t y to s u f f e r and be miserable. Since a l l people are of equal moral s t a t u s , each should r e c e i v e whatever redress i s j u s t i f i e d to improve h i s i n i t i a l l o t . Thus, those who have been more fortunate have a r e s p o n s i b i l i t y to a i d those who have fared badly i n l i f e ' s l o t t e r y . This i s the case, because the advantages of the f o r t u n a t e are as undeserved as the disadvantages of t h e i r f e l l o w humans. To the extent that I heed my r e s p o n s i b i l i t i e s and a i d other l e s s f ortunate i n d i v i d u a l s , I behave morally. To the extent that phy s i c i a n s do the same, medicine i s a moral endeavor. For those who have fared w e l l as a r e s u l t of the accident of b i r t h or who e v e n t u a l l y enjoy happy circumstances i n t h e i r l i v e s d espite e a r l y d i f f i c u l t i e s , a sense of g r a t i t u d e or contentment may o f t e n be experienced. A sense of having en-joyed good fortune can sometimes be a humbling experience; but i t can a l s o be a s o u r c e o f o b l i g a t i o n . A l b e r t S c h w e i t z e r s t r e s s e d our need t o pay back some o f t h e good t h i n g s we may e n j o y , s i n c e t h e s e p l a c e on us a " s p e c i a l r e s p o n s i b i l i t y " f o r t h o s e worse o f f than we a r e ( i n S p i e g e l b e r g 1975, 228). S p i e g e l b e r g c l a i m s t h a t S c h w e i t z e r was, i n f a c t , m a i n l y a r g u i n g t h a t we s h o u l d s t r i v e t o deepen and c u l t i v a t e our moral sense, a c a p a c i t y t h a t i s m o s t l y dormant but t h a t i s awakened i n s p e c i a l cases ( I b i d . 232). What i s t h e n a t u r e o f t h e s e s p e c i a l c a s e s ? S c h w e i t z e r c l a i m s t h a t a n x i e t y and p h y s i c a l s u f f e r i n g b r i n g p e o p l e c l o s e r t o g e t h e r , t h a t t h e r e i s a " f r a t e r n i t y of t h o s e marked by p a i n " ( I b i d . ) . For t h o s e who p u l l t h r o u g h t h e i r d i f f i c u l t i e s , t h e r e i s o f t e n a sense o f o b l i g a t i o n as a r e s u l t o f t h e i r good f o r t u n e . T h i s i s an awakening t o the f a c t t h a t o t h e r s a r e i n need of h e l p , t h a t one i s surrounded by examples of the moral imbalances of l i f e . I t i s a f a c t t h a t most p h y s i c i a n s i n N o r t h America have come from f a i r l y a f f l u e n t f a m i l i e s ; have e n j o y e d good e d u c a t i o n s , h e a l t h , and r e c r e a t i o n ; and many w i l l l e a d r e a s o n a b l y p r o d u c t i v e and r e w a r d i n g l i v e s . I t i s a l s o a f a c t t h a t s o c i e t y expends c o n s i d e r a b l e r e s o u r c e s t o p r o v i d e m e d i c a l e d u c a t i o n . P h y s i c i a n s a r e no doubt among t h e most f o r t u n a t e members of our s o c i e t y . S i n c e most p h y s i c i a n s have e n j o y e d c o n s i d e r a b l e good f o r t u n e , i t seems r e a s o n a b l e t o assume t h a t they have s i g n i f i c a n t o b l i g a t i o n s t o s o c i e t y , and, i n p a r t i c u l a r , t o t h o s e l e s s f o r t u n a t e than they a r e . I t i s , n a t u r a l l y , a happy outcome t h a t t h o s e who bear the burden of 14 t h i s o b l i g a t i o n are a l s o those who can do a g r e a t d e a l to r e d r e s s the i n j u s t i c e s imposed by b i r t h . Since p h y s i c i a n s spend most of t h e i r time around the s i c k and dying, they ought to be a c u t e l y aware of the f r a t e r n i t y of those b a t t l i n g d i s e a s e and death. Spending year a f t e r year watching people can, at l e a s t i n some cases, only make one g r a t e f u l f o r whatever good h e a l t h one has l e f t . T h i s i s , of course, another i n s t a n c e of an o b l i g -a t i o n imposed by one's r e l a t i v e l y good f o r t u n e . Of course, s i n c e the duty to help those i n need i s o f t e n s t a t e d as a simple requirement of the p r o f e s s i o n , i t may be p o s s i b l e f o r some p h y s i c i a n s to a v o i d f e e l i n g o b l i g a t e d as a r e s u l t of being f o r t u n a t e . However, i t i s d i f f i c u l t to t rade simple concern f o r others f o r the s t e r i l e d i c t a t e s of an a b s t r a c t duty. Concern f o r others n a t u r a l l y presupposes empathy and sympathy. Exposure to the s i c k and dying can be the source of a moral awakening, of a sense of the s t r e n g t h of the human s p i r i t and the power of hope. The sense of f r a t e r n i t y t h a t i s present may, i n some cases, be nothing more than a w i l l i n g -ness to a s s i s t the vunerable so t h a t one might expect s i m i l a r a s s i s t a n c e when i t becomes necessary. But i n other cases i t may become something more profound. Departures from the H i p p o c r a t i c T r a d i t i o n I t i s time to c o n s i d e r where the d i s c u s s i o n of t h i s chapter has brought us. We have examined a number of very d i f f e r e n t arguments f o r the c l a i m t h a t medicine i s an i n h e r -e n t l y moral e n t e r p r i s e . Each of these views lends some support t o t h i s c l a i m . C e r t a i n l y , the f a c t t h a t they each support C a s s e l l ' s c l a i m to a l e s s e r or g r e a t e r extent speaks i n favour of i t s p l a u s i b i l i t y . I t appears t h a t the best support f o r the c l a i m comes from Zaner 1s argument based on S p i e g e l b e r g 1 s view ( i n c l u d i n g my extension of i t ) , s i n c e Zaner deepens the d i s c u s s i o n s i g n i f i c a n t l y . I t i s important to r e -a l i z e , n e v e r t h e l e s s , t h a t i f Spi e g e l b e r g ' s n o t i o n of " n a t u r a l i n j u s t i c e " has the o b l i g a t o r y e f f e c t s he c l a i m s , then med-i c i n e i s n ' t unique i n being o b l i g e d to overcome these i n j u s -t i c e s . In f a c t , a l l human a c t i v i t i e s ought to serve the end of r e d r e s s i n g those disadvantaged by the a c c i d e n t of b i r t h . Despite the p l a u s i b i l i t y they o f f e r C a s s e l l ' s c l a i m , some of the views examined i n t h i s chapter are c l e a r l y d e f i c i e n t . The H i p p o c r a t i c understanding of medicine i s becoming ever more remote from r e a l i t y as medicine responds to the c u r r e n t emphasis on p a t i e n t s ' autonomy and r i g h t s . The e a r l y Hippocrat-i c t r a d i t i o n ' s preoccupation with d i e t and i t s avoidance of surgery and a b o r t i o n (because of i t s d e r i v a t i o n from the Pytha-gorean C u l t ) a l s o f a i l to capture the p l e t h o r a of h e a l t h care o p t i o n s a v a i l a b l e to us and t h e i r accompanying problems (Zaner 1988, 207). Nonetheless, we owe our b a s i c conception of medicine as the a r t of "doing what should be done" to the H i p p o c r a t i c t r a d i t i o n . Maclntyre's a n a l y s i s f a i l s to c o n s i d e r c e r t a i n problems t h a t may a r i s e concerning "doing what should be done." For example, many p h y s i c i a n s i n the United S t a t e s r e c e i v e a b r i e f i n t r o d u c t i o n to l i p o s u c t i o n and then perform t h i s technique without being adequately t r a i n e d . In some cases, p a t i e n t s have d i e d as a r e s u l t . Why t h i s tragedy? C e r t a i n e x t e r n a l goods (money i n p a r t i c u l a r ) have caused these p h y s i c i a n s to compromise the standards of e x c e l l e n c e t h a t are c r u c i a l t o the moral p r a c t i c e of medicine. Maclntyre claims t h a t the e x t e r n a l goods are only c o n t i n g e n t l y attached to the p r a c t i c e and don't d e f i n e i t . T h i s seems mistaken. The l i p o s u c t i o n case suggests t h a t , at l e a s t i n the American h e a l t h care sys-tem, a l u c r a t i v e technique and greed are having a s u b s t a n t i a l impact on the p r o f e s s i o n ' s standards of e x c e l l e n c e , which are sometimes low indeed as w e l l as being i n c o n f l i c t with an i n t e r n a l good ( v i z . the t h e r a p e u t i c r e s o l v e ) . I f a p a t i e n t comes to a p h y s i c i a n f o r l i p o s u c t i o n , she expects to have the procedure done p r o p e r l y or to be r e f e r r e d elsewhere. The i d e a l of t h e r a p e u t i c r e s o l v e becomes secondary, or worse, when a p h y s i c i a n wants to t r y out a technique mainly because i t i s h i g h l y p r o f i t a b l e . Thus, the i n t e r n a l goods of medicine are j e o p a r d i z e d when the q u e s t i o n , "What should be done?", s h i f t s from a primary focus on the p a t i e n t ' s i n t e r e s t s . To what ex-t e n t the p r a c t i c e can r e t a i n the proper i d e n t i t y under these c o n f l i c t s i s worth pondering. Even i f we admit--as seems r e a s o n a b l e - - t h a t medicine i s an i n h e r e n t l y moral endeavor, i t i s necessary, of course, to admit t h a t not every a c t i o n performed by a d o c t o r i s moral. T h i s was the H i p p o c r a t i c b e l i e f . However, given the p e r p l e x i n g c h o i c e s c o n f r o n t i n g today's p a t i e n t s and d o c t o r s , and the 17 tremendous v a r i a t i o n of values present, i t i s d i f f i c u l t t o be comfortable with such a n c i e n t c o n c l u s i o n s . That d o c t o r s do what should be done i s no longer a matter of gr e a t con-f i d e n c e i n many cases. Why t h i s i s so i s the s u b j e c t of the next chapter. CHAPTER 2 TECHNOLOGY AND MORALITY In the Garden of Eden, we are t o l d , Adam and Eve co u l d l i v e h a p p i l y — p r o v i d e d they d i d not eat the f r u i t of the Tree of Knowledge. As long as they l i s t e n e d t o God and avoided t h a t t r e e , they c o u l d be c o n f i d e n t they were doing the r i g h t t h i n g . But, as we a l l know, the f r u i t was imp o s s i b l e to a v o i d . T h e i r b i t e s of the apple brought them i n t o the throes of the knowledge of good and e v i l and ended t h e i r days i n P a r a d i s e . The t e r r o r they f e l t upon t h e i r e x i l e from Eden has worked i t s way i n t o modern consciousness i n numerous ways. The most eloquent e x p r e s s i o n of t h i s h o r r o r can be found i n the Brothers Karamazov, i n the words of Ivan: "Without God, e v e r y t h i n g i s pe r m i t t e d . " Leaving most t h i n g s up to God o f f e r e d a comforting degree of c e r t a i n t y i n the face of d i f f i c u l t c h o i c e s . Modern medicine, too, has found i t s e l f banished from P a r a d i s e . In the past, p r i o r to the i n c r e d i b l e successes of re s e a r c h and technology, there was o f t e n very l i t t l e t h a t c o u l d be done f o r the very i l l and dying. Most people d i e d be-cause of problems with t h e i r h e a l t h , a f a c t t h a t was t r a g i c perhaps, but expected and b e t t e r accepted than i t i s today. What should be done f o r these people was a l l t h a t could be done: very l i t t l e or even nothing. With l i m i t e d o p t i o n s , the t r a d -18 19 i t i o n a l p r i n c i p l e s and values of medicine seemed to be adequate to handle the choices available. However, after the technological revolution i n medicine ( i . e . after the apple was b i t t e n ) , things became wonderfully and enormously d i f f e r e n t . New technology brought more options but i t also escalated uncertainty. Although, on the surface, technology appeared to be the means to desired outcomes, i t was often extremely d i f f i c u l t to decide which of the possible out-comes should be chosen. In fact, technology created choices that t r a d i t i o n a l values were not only inadequate to handle but also even seemed to give the wrong answers for (e.g. the Quinlan case and the early cases of organ r e t r i e v a l ) . Because of these d i f f i c u l t i e s , i t soon became apparent to those working in the health sciences that the t r a d i t i o n a l p r i n c i p l e s and values of medicine couldn't simply be extended to cover the new choices. Dostoevsky's insight i s especially pertinent to modern medicine: with options, everything i s permitted, including the p o s s i b i l i t y that the wrong options s h a l l be chosen. In this chapter, the roots of this uncertainty s h a l l be considered in greater d e t a i l . Why i s i t that medicine, as an inherently moral enterprise, experiences such profound d i f f i c u l t i e s with knowing what should be done? Moving Outside of Philosophy for a Clue On 17 October 1990, Richard Taylor, who received his MSc. i n 1952 from the University of Alberta, won the Nobel 20 P r i z e i n P h y s i c s ( P i l g e r 1990, 16) . He r e c e i v e d the award as a r e s u l t o f e x p e r i m e n t a l work done between 1968 and 1973 a t the S t a n f o r d L i n e a r A c c e l e r a t o r Centre ( S L A C ) , where he i s a f a c u l t y member and former a s s o c i a t e d i r e c t o r o f r e s e a r c h . H i s work l e d to the f i r s t p h y s i c a l ev idence f o r q u a r k s , which was no s m a l l achievement , s i n c e quarks are now b e l i e v e d to be the most fundamental b u i l d i n g b l o c k s o f mat ter ( I b i d . 17) . Oddly enough, a l t h o u g h quarks comprise n i n e t y - n i n e p e r c e n t o f a l l matter on e a r t h , p h y s i c a l ev idence f o r t h e i r e x i s t e n c e had to wa i t u n t i l T a y l o r ' s work. In o r d e r to o b t a i n p h y s i c a l ev idence f o r something as fundamental as q u a r k s , T a y l o r had to work w i t h e x t r a o r d i n a r i l y complex and expens ive t echno logy (the a c c e l e r a t o r c o s t 114 m i l l i o n d o l l a r s i n the mid-1960s) ( I b i d . 19 ) . SLAC, near S t a n f o r d , i s over t h r e e k i l o m e t e r s i n l e n g t h and i s used to a c c e l e r a t e e l e c t r o n s u n t i l they o b t a i n s t u n n i n g amounts of energy (twenty b i l l i o n v o l t s ) . These h i g h energy e l e c t r o n s are then used to p e n e t r a t e the protons and neutrons at the atom 1 s c o r e . What i s the na ture of T a y l o r ' s i n t e r a c t i o n w i t h the t echno logy he employs? He d e s c r i b e d h i s r e l a t i o n s h i p wi th SLAC i n an i n t e r e s t i n g way when he d i s t i n g u i s h e d between the two k i n d s of p a r t i c l e p h y s i c i s t s : t h e o r e t i c i a n s and e x p e r -i m e n t a l i s t s . T a y l o r , s u r p r i s i n g l y enough, groups h i m s e l f e x c l u s i v e l y w i th the l a t t e r k i n d o f p h y s i c i s t . In response to a q u e s t i o n about whether p r i o r to the p h y s i c a l ev idence f o r quarks he had b e l i e v e d them to be o n l y a mathemat ica l a b s t r a c t i o n he r e p l i e d : " E x p e r i m e n t a l i s t s don't have t o d e c i d e - - t h e y j u s t have t o work." He then added: "We were out on a voyage.... The new a c c e l e r a t o r gave us new room t o l o o k f o r t h i n g s and we were d o i n g j u s t t h a t " ( I b i d . 1 7 ) . Is T a y l o r ' s c a s u a l , s e e m i n g l y u n r e f l e c t i v e a t t i t u d e t o -ward t e c h n o l o g y s i m p l y t h e p r o d u c t o f a b r a s h form of A l b e r t a n modesty or i s t h e r e something deeper and more ominous beh i n d t h i s p o s t u r e ? I s t h i s p o s t u r e c o n f i n e d t o t h e modest men and women of SLAC o r i s i t more widesp r e a d t h r o u g h modern, i n -d u s t r i a l i z e d s o c i e t i e s ? In a r e c e n t C.B.C. Radio i n t e r v i e w [20 January 1991], th e New York p s y c h i a t r i s t Robert Jay L i f t o n was asked t o comment on t h e d i s t o r t e d r e p o r t s about t h e t e c h n o l o g y b e i n g used i n the P e r s i a n G u l f War."*" The r e p o r t s a r e d i s t o r t e d because the v i e w e r s a r e n ' t b e i n g shown who i s b e i n g k i l l e d and wounded, o n l y how. He e x p l a i n e d t h a t t h e most d e v a s t a t i n g e f f e c t of t h e s e r e p o r t s i s a form of d i s s o c i a t i o n between knowledge and f e e l i n g i n the v i e w e r s , such t h a t they know the t e c h n o l o g y i s b r u t a l but they do not f u l l y a p p r e c i a t e i t s consequences. Indeed, f o r t o o many peopl e w a t c h i n g the media coverage of t h e war, t h e s u f f e r i n g the t e c h n o l o g y produces has been f o r g o t t e n , o r a t l e a s t t e m p o r a r i l y r e p r e s s e d . T h i s l e a d s t o what L i f t o n c a l l s " p s y c h i c numbing," a s t a t e i n which l e g i t i m a t e e m o t i o n a l r e s p o n s e s t o t h e h o r r o r s of war a r e d e n i e ^"This i n t e r v i e w was a l s o shown on C.B.C. T e l e v i s i o n on 23 January 1991. L i f t o n has l o n g been a v o c a l opponent of n u c l e a r weapons and has r e c e n t l y w r i t t e n a book t i t l e d N a z i D o c t o r s . I n s t e a d o f c o n s i d e r i n g who's on t h e r e c e i v i n g end o f t h e c r u i s e m i s s i e s and the B52s' p a y l o a d s , t h e h i g h l y a n x i o u s T.V. v i e w e r s a r e b e i n g l u l l e d i n t o a t r a n c e by the s t e a l t h bomber and t h e p a t r i o t m i s s l e . Because of t h e i r deep a n x i e t y , the T.V. v i e w e r s a r e v e r y r e c e p t i v e t o t h e wishes of s t r o n g a u t h o r i t y f i g u r e s (e.g. George Bush and h i s g e n e r a l s ) . H i g h l y a n x i o u s p e o p l e p e r m i t themselves t o be m a n i p u l a t e d by t h o s e who promise t o remove t h a t which t h r e a t e n s them. However, when the p u b l i c snaps out of i t s t r a n c e and r e a l i z e s t h e h i g h c o s t of h a v i n g a l l o w e d i t s e l f t o be m a n i p u l a t e d , i t w i l l e x p e r i e n c e a deep sense of anger. The h i g h c o s t s , of c o u r s e , a r e the e n v i r o n -mental t r a g e d i e s , the c i v i l i a n c a s u a l t i e s , t h e a r c h e o l o g i c a l d e s t r u c t i o n , the i n s t a b i l i t y i n the G u l f , e t c . The anger t h a t w i l l be e x p e r i e n c e d i s n e c e s s a r y , s i n c e i t a l l o w s one t o escape from a s t a t e o f p s y c h i c numbness. To a s s i s t us i n our escape from our p s y c h i c numbness, L i f t o n encourages us t o use our "moral i m a g i n a t i o n s . " T h i s i n v o l v e s i m a g i n i n g , say, a c r u i s e m i s s l e heading towards an I r a q i n u r s e r y s c h o o l . In o r d e r t o a v o i d b e i n g pawns i n our l e a d e r s ' hands and t o be c a p a b l e o f anger, we must d e v e l o p our moral i m a g i n a t i o n s . Of c o u r s e , a number of o b j e c t i o n s can be r a i s e d a g a i n s t t h i s view. I t can be o b j e c t e d t h a t we s h o u l d a l s o d i r e c t our moral i m a g i n a t i o n s towards th e p e o p l e of K u w a i t , the Kurds, and a l l of t h e o t h e r v i c t i m s of Saddam H u s s e i n . I f we do so, we w i l l , no doubt, agree t h a t t h e G u l f War had t o be f o u g h t . While me may concede t h a t Saddam Hussein had to be defeated ( i . e . we support the g o a l ) , we can be s e l e c t i v e about which means of d e f e a t i n g him we w i l l support. Though we may approve c a r e f u l bombing of m i l i t a r y t a r g e t s , we can c o n s i s t e n t l y r e f u s e t o endorse the use of chemical, b i o l o g i c a l , and nu c l e a r weapons. In a d d i t i o n , c a r p e t bombing of c i v i l i a n t a r g e t s (e.g. Hanoi) i s d i f f i c u l t to approve of i f one a p p l i e s one's moral imagi n a t i o n to the I r a q i c i v i l i a n s . Another o b j e c t i o n i s as f o l l o w s . Imagine t h a t i n 1936 Da l a d i e r and Chamberlain decided to go to war with H i t l e r to prevent him from a c h i e v i n g h i s s o r d i d g o a l s . I f the war had been fought a t t h a t time, 100,000 people would have been k i l l e d , a t i n y number i n comparison to the many m i l l i o n s who a c t u a l l y p e r i s h e d i n World War Two. Imagine, however, t h a t the j o u r n a l i s t s of the day began to send p i c t u r e s and s t o r i e s back to the p a c i f i s t i c people on the home f r o n t s . The e f f e c t of such r e p o r t i n g probably would have turned the p u b l i c a g a i n s t the war, thereby p e r m i t t i n g H i t l e r t o commit c o u n t l e s s a t r o c i t i e s . In t h i s case, wouldn't the p a c i f i s t i c moral imaginations undermine a cause t h a t ought, i n s t e a d , to be given f u l l support? ' While i t i s e s s e n t i a l to defeat such e v i l regimes, there are a number of ways to do so, not a l l of which are mora l l y a c c e p t a b l e . C e r t a i n l y , as a r e s u l t of the t e r r i b l e bombings of Dresden, Hiroshims, Nagasaki, Hanoi, e t c . many people r e f u s e to support i n d i s c r i m i n a t e a t t a c k s on c i v i l i a n t a r g e t s . Instead, they expect t h e i r l e a d e r s to be moral and humane i n the p u r s u i t of j u s t i f i e d g o a l s . In the Gulf War, we are t o l d , the c o a l i t i o n f o r c e s went to great lengths to av o i d c i v i l i a n c a s u a l t i e s . I f t h i s i s t r u e , then we have j u s t goals pursued i n a moral and humane f a s h i o n , a s t a t e of a f f a i r s t h a t i s very d i f f e r e n t from dropping napalm on Vietnamese c i v i l i a n s or fire-bombing p e a c e f u l Dresden. The p u b l i c ' s r e f u s a l t o support the wholesale s l a u g h t e r of c i v i l i a n s i s a n a t u r a l consequence of the a c q u i -s i t i o n of a healthy moral i m a g i n a t i o n . Given the h o r r o r s of the tw e n t i e t h century, i t i s no s u r p r i s e , perhaps, t h a t many people are s e l e c t i v e about what causes t h e y ' l l support. I f we couple a healthy moral i m a g i n a t i o n with the courage to stand-up to despots, we produce a group of i n d i v i d u a l s who can be c o n f i d e n t of t h e i r values and g o a l s . Thus, L i f t o n i s r i g h t t o i n s i s t t h a t people know and f e e l the h o r r o r s of war. N a t u r a l l y , a c o n s i d e r a b l e amount of c o o r d i n a t i o n would have to e x i s t i n a s o c i e t y t h a t d e s i r e d both t o f i g h t despots and to not become i n v o l v e d i n mo r a l l y unacceptable wars. The n a t i o n ' s f o r e i g n p o l i c y and arms r e g u l a t i o n s would have to be such t h a t despots aren't allowed to f l o u r i s h (e.g. Hussein as the l e a d e r of the f o u r t h l a r g e s t army i n the wor l d ) . The media would have to be c o n t r o l l e d to al l o w the d e s i r e d p u b l i c o p i n i o n f o r the p a r t i c u l a r c o n f l i c t . Whole-hearted support f o r j u s t causes would be necessary, while widespread p r o t e s t would be best i n cases where involvement appears unwise. The m i l i t a r y would have to be t r a i n e d to value winning major wars a t the l e a s t c o s t . Instead of t r y i n g t o carpet bomb 25 every square metre of a c o u n t r y (e.g. Vietnam and N a z i Germany), they might p r i d e themselves on how l i t t l e " c o l l a t e r a l damage" they i n f l i c t . W h i l e we must resound-i n g l y d e f e a t t h o s e who t o r t u r e , r a p e , and use b a r b a r i c weapons, we must not employ th e same means and share t h e same v a l u e s t o do so. To t h e e x t e n t t h a t we compromise our m o r a l s t a n d a r d s , we a l s o make a f a r c e out of t h e n o t i o n of a " j u s t war." A p p l y i n g These C l u e s t o the H e a l t h S c i e n c e s I t i s time t o r e l a t e the i n s i g h t s d e r i v e d from T a y l o r and L i f t o n t o t h e p r a c t i c e of modern m e d i c i n e . F i r s t we w i l l con-s i d e r t h e r o l e o f t h o s e who o p e r a t e t h e " s t a t e o f t h e a r t " t e c h n o l o g y t h a t i s becoming ever more r o u t i n e i n t h e h e a l t h s c i e n c e s . U n d e r s t a n d a b l y , t h o s e who a r e f i r s t i n t r o d u c e d t o the machines t h e y w i l l o p e r a t e f e e l h i g h l y a n x i o u s . T h e i r f e a r s c e n t r e around t h e i r "greenness." They a r e concerned about b r e a k i n g t h e machine; e m b a r r a s s i n g t h e m s e l v e s ; o b t a i n -i n g i n a c c u r a t e d a t a ; e t c . Of c o u r s e , b e f o r e l o n g t h e sense o f b e i n g a greenhorn passes and t h e machine o p e r a t o r s can calm down and enjoy t h e i r work. However, because of the l a r g e volume of p a t i e n t s handled i n many h o s p i t a l s and c l i n i c s , what may have once been e n j o y a b l e soon proves p r e d i c t a b l e and even u n p l e a s a n t . A f t e r the i n s t a l l a t i o n o f h i g h l y automated a n a l y t i c machinery, t h e l a b t e c h n i c i a n s who once had t o examine every t e s t tube t h a t a r r i v e d i n t h e l a b e x p e r i e n c e a sense of l i b e r a t i o n . But even t h i s sense o f l i b e r a t i o n i s soon masked by a new r o u t i n e . More e f f e c i e n t labs can accept more t e s t tubes and so the use of the new equipment i t s e l f becomes drab. The i m p e r s o n a l i t y of the modern h e a l t h care s e t t i n g i s found most everywhere, but nowhere more c l e a r l y than among those who handle l a r g e numbers of "cases." Cases don't be-come persons f o r these people, s i n c e a l l t h a t matters i s g e t t i n g the data r i g h t f o r the given case. In much the same way t h a t T a y l o r d i d n ' t have to worry about the bigger questions concerning quarks, machine opera t o r s i n the h e a l t h care s e t t i n g simply concern themselves with accuracy and don't o f t e n t h i n k about the p a t i e n t ' s h i s t o r y , needs, f e a r s , e t c . L i k e the p i l o t s who are amputating legs and dropping napalm, the t h i n g t h a t matters most i s t h a t the machinery i s operated competent-l y , not the broader i m p l i c a t i o n s . We take the x-rays because the doctor ordered them and we drop the bombs because i t ' s our duty. L i f t o n ' s remarks can be r e l a t e d to the p a t i e n t ' s exper-ience of the a s t o n i s h i n g technology present i n even the most humble h e a l t h care f a c i l i t y . Most p a t i e n t s know very l i t t l e about medicine and next to nothing about i t s t o o l s . At best, a p a t i e n t w i l l know t h a t a CAT scan i s only ordered i f some t r o u b l e i s suspected. Because of t h e i r l a c k of i n f o r m a t i o n about t h e i r c o n d i t i o n s and t h e i r ignorance about medical technology, most p a t i e n t s are extremely p a s s i v e . They put themselves completely i n t h e i r p h y s i c i a n s ' hands and submit themselves to the b a t t e r y of t e s t s and procedures deemed necessary. As p a t i e n t s venture deeper and deeper i n t o the l a b y r i n t h of medical technology, t h e i r sense of powerlessness and v u n e r a b i l i t y i n c r e a s e s c o r r e s p o n d i n g l y . The l e a r n e d h e l p l e s s n e s s t h a t many experience as a p a t i e n t i s not u n l i k e the t r a n c e experienced by the anxious T.V. viewers. T h i s s t a t e of p a s s i v i t y and powerlessness i s a s i g n i f i c a n t blow to the autonomy of p a t i e n t s and a c t s to cut them o f f from themselves. The r e s u l t i s a form of d i s s o c i a t i o n because the p a t i e n t knows he i s being dehumanized, but he doesn't acknow-ledge h i s f e e l i n g s ( i . e . he f a i l s to express them). Despite the deep a n x i e t y and f e a r the p a t i e n t f e e l s , he goes along with e v e r y t h i n g , because he wants to be a good p a t i e n t , and he hopes e v e r y t h i n g w i l l t u r n out O.K. N a t u r a l l y , from the p a t i e n t ' s p e r s p e c t i v e , knowing what should be done becomes n e a r l y impossible i f he hasn't got a c l u e what's going on. His experience of the technology and i t s o p e r a t o r s i s but an u n i n t e l l i g i b l e smear without any comprehension of "what i t ' s a l l about." When T a y l o r was asked whether he thought b u i l d i n g blocks even more fundamental than quarks w i l l be d i s c o v e r e d , he r e p l i e d t h a t a f a r more important q u e s t i o n i s : "Do you want to keep on l o o k i n g ? " He s a i d t h a t the obvious answer to t h i s q u e s t i o n i s , "Yes" ( P i l g e r 1990, 1 7 ) . For p h y s i c i a n s , the q u e s t i o n of what should be done i s o f t e n decided by our c u r r e n t a t t i t u d e towards and e x p e c t a t i o n s of technology. Our a t t i t u d e , c e r t a i n l y w i t h i n the h e a l t h s c i e n c e s , i s very much l i k e T a y l o r ' s . Even i n cases where we don't f e e l completely c o n f i d -28 ent about th e m o r a l i t y o f what we're d o i n g , we c o n t i n u e t o use t e c h n o l o g y t o " h e l p " p a t i e n t s . Why i s t h i s so? We keep peopl e connected t o machines because t h e s e a r e t h e o n l y machines we have and because we a r e a l l c o n f i d e n t t h a t w e ' l l have much b e t t e r ones tomorrow. L i k e . T a y l o r , h e a l t h c a r e work-e r s answer the q u e s t i o n , "Do you want t o keep on l o o k i n g ? " a f f i r m a t i v e l y . Thus, the i n t e r e s t i n g q u e s t i o n f o r most h e a l t h c a r e workers i s n o t , "Are we a b u s i n g t h i s t e c h n o l o g y ? " b u t , r a t h e r , "How can we overcome th e l i m i t a t i o n s of t h i s machine?" O f t e n , t h e n , what s h o u l d be done i s answered i n terms of the b e s t use o f the a v a i l a b l e machinery. The moral u n c e r t a i n t i e s can be and o f t e n a r e d i s p l a c e d by the r e l a t i v e c o n f i d e n c e p r e s e n t e d by t h e b e l i e f t h a t e v e r y t h i n g p o s s i b l e i s b e i n g done f o r t h e p a t i e n t . The " p i e i n t h e sky" e x p e c t a t i o n s p o s s e s s e d by many peo p l e who become i l l a l s o c r e a t e problems f o r d e t e r m i n i n g what s h o u l d be done. Peo p l e want t o keep out of t h e c l u t c h e s of death i n d e f i n i t e l y ; we want t o escape p a i n , t o have " p e r f e c t " b o d i e s , t o shake o f f t h e b l u e s , t o s t a y young f o r -e v e r . Given e x p e c t a t i o n s l i k e t h e s e , t h e demands p l a c e d on t h e m e d i c a l p r o f e s s i o n a r e d a u n t i n g i n d e e d . Of c o u r s e , t e c h n o l o g y i s o f t e n c a l l e d upon t o s a t i s f y t h e wants of an outrageous p u b l i c , so much so t h a t , a g a i n , what s h o u l d be done g e t s d i s p l a c e d by what can be done. R e g a r d l e s s of what v a l u e s someone might have, he or she i s c o n f r o n t e d w i t h the f a c t t h a t m e d i c a l t e c h n o l o g y i s a p p l i e d i n c e r t a i n n a r r o w l y p r e s c r i b e d ways. Thus, an i n d i v i d u a l who does not share the f o l l i e s of the " d e n i a l s o c i e t y , " or the enthusiasm of the philosophy of progress, may f i n d h i s or her own values very much at odds with how t h i n g s are r o u t i n e l y done i n h o s p i t a l s . Although many people view the present h e t e r o g e n e i t y of values as somehow endemic to modern s o c i e t y ( c f . Maclntyre's A f t e r V i r t u e ) , t h i s fragmentation can a l s o be viewed i n an e n t i r e l y p o s i t i v e l i g h t . I f every-one shared the same v a l u e s , a t t i t u d e s , and e x p e c t a t i o n s with r e s p e c t to technology, then very l i t t l e time would be spent worrying about what should be done. Instead, because some doctors and nurses are d i s t u r b e d by t h e i r work, and because some p a t i e n t s don't l i k e what modern medicine sometimes has to o f f e r , an atmosphere of disagreement becomes i n e v i t a b l e . T h i s disagreement i s e x a c t l y what i s r e q u i r e d to make people ask important questions l i k e , "How can we overcome the l i m i -t a t i o n s of t h i s machine i n a way t h a t i s m o r a l l y a c c e p t a b l e ? " In the end, we must, l i k e Ivan Karamazov, accept the h o r r o r of freedom: even though we b e l i e v e t h a t some of the o p t i o n s a v a i l a b l e to us shouldn't be chosen, we are f o r c e d to accept t h a t no matter how c a u t i o u s we are we remain f a l l i b l e . F o r t u n a t e l y , many of the unexpected problems caused by medical technology have served to snap s i g n i f i c a n t numbers of people out of t h e i r t r a n c e s , making them more c r i t i c a l of the r o l e technology p l a y s i n the h e a l t h s c i e n c e s . While there some-times i s no agreement about what should be done, there i s at l e a s t more r e f l e c t i o n on the q u e s t i o n . In the next chapter, we s h a l l examine the r o l e e t h i c s i s asked to play i n the d e t e r m i n a t i o n o f what s h o u l d be done and t h e r e s o u r c e s has t o o f f e r . CHAPTER 3 MEDICINE AND ETHICS The a b i l i t y t o shoot down SCUD m i s s i e s i s the r e s u l t of a lengthy i n t e r a c t i o n between theory and p r a c t i c e ( i n a couple of senses of " p r a c t i c e " ) . I t i s easy t o assess the success of such t h e o r e t i c a l r e s o u r c e s : they're adequate i f they produce the d e s i r e d r e s u l t . In e x a c t l y the same manner, medical engineers who are attempting to design a b e t t e r form of medical technology w i l l have a d i r e c t , q u a n t i t a t i v e way to measure t h e i r p r o g r e s s . As we saw i n the l a s t chapter, these i n d i v i d u a l s a ren't p r i m a r i l y concerned with questions l i k e , "What i s the p o t e n t i a l f o r abuse of t h i s technology?", or "How w i l l t h i s technology change the nature of human ex-i s t e n c e ? " Questions l i k e these, however, are i n e s c a p a b l e , s i n c e technology has a strong tendency to l e a d us i n t o problems of enormous magnitudes. When nation s h o s t i l e to us and our values possess n u c l e a r , b i o l o g i c a l , and chemical weapons, we may have o c c a s i o n to r e g r e t the impact technology has had on our d a i l y l i v e s . When loved ones are impaled upon s t e r i l e and menacing l i f e support systems, with no l i k e l y p rospects of r e g a i n i n g a l i f e of s e l f - p o s s e s s i o n and d i g n i t y , we have to c o n f r o n t the dehumanization and chaos t h a t await us when our luck runs out. Are we doomed to an e x i s t e n c e of s l a v e r y t o technology or 31 can we shape the k i n d of people we w i l l become and the r o l e technology w i l l p l a y i n our l i v e s ? Although the s i t u a t i o n may seem much more t h r e a t e n i n g i n the case of m i l i t a r y technology, the problems posed f o r us by medical technology are a l s o d i s t u r b i n g . Awareness of these problems i s n ' t c o n f i n e d to those who have been i l l and have had unpleasant experiences with the h e a l t h care system. Even f o r many h e a l t h care workers technology i s no longer an unmixed b l e s s i n g . As Zaner observes: "Beleaguered by the emergence of profound moral i s s u e s i n the very midst of i t s own r e s e a r c h and p r a c t i c e , medicine appealed to philosophy and others of the humanities f o r help" (1988, 20). Strange Bedfellows Why medicine turned to philosophy, e s s e n t i a l l y a t h e o r e t i c a l f i e l d , i s an i n t e r e s t i n g q u e s t i o n . Perhaps some of the reasons are as Arthur Caplan sees them. Because of new t e c h n o l o g i e s and procedures, the s c i e n t i f i c community faced s e r i o u s p o l i c y c h o i c e s . "Some s c i e n t i s t s were u n w i l l i n g qua s c i e n t i s t s to make d e c i s i o n s concerning the r e g u l a t i o n and a p p l i c a t i o n of these new d e v i c e s and techniques" (Caplan 1980, 24). Caplan claims t h a t others w i t h i n the medical and s c i e n -t i f i c communities were eager to i n v o l v e p h i l o s o p h e r s and others i n s o c i a l p o l i c y debates i n order to l e g i t i m a t e these p o l i c i e s " i n the eyes of a s k e p t i c a l and even h o s t i l e pub-l i c " ( I b i d . ) . He adds t h a t d octors welcomed medical e t h i c s i n the l a t e 1960s and e a r l y 1970s as a way of d e a l i n g with 33 p u b l i c and governmental d i s c o n t e n t with the way medicine was being p r a c t i c e d ( I b i d . ) • Of course, some p h y s i c i a n s were no doubt prepared to acknowledge t h a t advances i n medicine and biomedical technology r a i s e d new s u b s t a n t i v e i s s u e s of genuine p h i l o s o p h i c a l and e t h i c a l importance. As the c a p a c i t y of medicine to in t e r v e n e at a l l p o i n t s i n the human l i f e s p a n has i n -creased, i s s u e s concerning c o n f i d e n t i a l i t y , autonomy, r i g h t s , p a t e r n a l i s m , the d e f i n i t i o n of d i s e a s e , and the d e t e r m i n a t i o n of l i f e and death have come to the f o r e . I t was only n a t u r a l t h a t some e x i s t i n g e f f o r t be made to extend t r a d i t i o n a l p h i l o s o p h i c a l a n a l y s i s of e t h i c s to the world of medicine ( I b i d . 2 4 - 2 5 ) . What, then, could philosophy o f f e r medicine? For the moment, l e t us c o n f i n e our a t t e n t i o n to the resources p h i l -osophy has made a v a i l a b l e to d e a l with the moral i s s u e s emerging from the p r a c t i c e of medicine. Whether these resources have been what those i n the medical p r o f e s s i o n have d e s i r e d or expected w i l l be b r i e f l y c o n s i d e r e d below and explored i n g r e a t e r depth i n the next chapter. A p p l i e d E t h i c s : A Resource-Based Industry Many undergraduate biomedical e t h i c s courses are now o f f e r e d i n c o l l e g e s and u n i v e r s i t i e s throughout North America. These are u s u a l l y taught by p h i l o s o p h e r s who have at l e a s t some background i n e t h i c s . The courses s t a n d a r d l y d i s c u s s v a r i o u s types of e t h i c a l theory (e.g. d e o n t o l o g i c a l and t e l e o -l o g i c a l t h e o r i e s ) ; d e f i n e a number of terms (e.g. "pa t e r n a l i s m " , "autonomy", "informed consent", e t c . ) ; and i n v o l v e exposure to an assortment of a r t i c l e s o f f e r i n g arguments f o r one s i d e or the other i n v a r i o u s moral i s s u e s r e l a t e d t o medicine (e.g. a b o r t i o n , euthanasia, and c o n f i d e n t i a l i t y ) . The courses are taught very much from the vantage p o i n t of those i n v o l v e d i n academic philosophy and are o f t e n a standard e t h i c s course i n a new package. Students leave the courses knowing a l i t t l e more about philosophy, and, i f a l l has gone w e l l , with a d e s i r e to pursue the s u b j e c t f u r t h e r . Whether they have been t r a i n e d t o make moral d e c i s i o n s i n d i f f i c u l t cases i s d o u b t f u l . Although most nurses and doctors r e c e i v e some t r a i n i n g i n matters of e t h i c s and v a l u e s , few of t h e i r courses are much l i k e the standard biomedical e t h i c s courses j u s t c o n s i d -ered. In a survey conducted by the I n s t i t u t e on Human Values i n Medicine, i n which 122 medical schools were asked whether they o f f e r courses i n e t h i c s and v alues, i t was learned t h a t these schools had 1,064 f a c u l t y members t e a c h i n g i n the area of 'human v a l u e s , ' and t h a t n e a r l y h a l f of these were p h y s i c i ans ( P e l l e g r i n o 1981, 2). Only about ten percent of the t o t -a l number of f a c u l t y were bona f i d e humanists ( I b i d . ) . Of these only one out of f i v e a c t u a l l y devotes more than 25 per cent time to such t e a c h i n g . I n s t i t u t i o n s which have h i r e d p h i l o s o p h e r s as r e g u l a r f a c u l t y have been commended f o r ' p r a c t i c i n g what they preach' (Mahowald 1986, 144). Although t h i s survey suggests humanists have only had a minor impact on medical education i n the past, they have, n e v e r t h e l e s s , produced an impressive a r r a y of resources f o r bi o m e d i c a l e t h i c s . Humanists were a c t i v e l y i n v o l v e d i n the founding of both the Hastings and Kennedy Centres (both i n -volve people of d i v e r s e backgrounds). A v e r i t a b l e f l o o d of books have appeared on the market and there i s no end i n 35 s i g h t . The l a s t twenty years have seen the r i s e of a number of j o u r n a l s i n the f i e l d and a v a r i e t y of p h i l o s o p h i c a l a n t h o l -ogies f o r biome d i c a l e t h i c s . While acknowledging these advan-ces, one must be c a r e f u l not to overestimate t h e i r i n f l u e n c e . I t would be very i n t e r e s t i n g t o see the r e s u l t s of a survey conducted of h e a l t h p r o f e s s i o n a l s t h a t determined t h e i r l e v e l of awareness of these many r e s o u r c e s . U n f o r t u n a t e l y , i t seems l i k e l y t h a t most of them would make very l i t t l e , i f any, use of them. Even while a d m i t t i n g t h a t p a r t i c i p a t i o n i n biomedical e t h i c s i s r a t h e r skewed towards philosophy, i t i s nonetheless t r u e t h a t i t f u n c t i o n s best as a m u l t i - d i s c i p l i n a r y endeavor. As Mary Mahowald notes, i t i s not only the c o n t r i b u t i o n s made by medicine and philosophy t h a t are v a l u a b l e ; so, too, are those from theology, law, and the s o c i a l s c i e n c e s (1986, 146). The e x t e r n a l c r i t i c i s m medicine has undergone f o r many years has had a s i g n i f i c a n t impact on the way i t i s c u r r e n t l y prac-t i c e d . Not s u r p r i s i n g l y , the backlash a g a i n s t biomedical e t h i c s ' e a r l y r o l e i n the h e a l t h s c i e n c e s i s a l s o having an i n f l u e n c e on how the f i e l d i s e v o l v i n g . At t h i s p o i n t , per-haps, medicine i s becoming more concerned with the moral j u s t i f i a b i l i t y of the r e s u l t s i t produces and biome d i c a l e t h i c s i s being f o r c e d to pay c l o s e r a t t e n t i o n t o the e s s e n t i a l l y p r a c t i c a l s i d e of the h e a l t h s c i e n c e s . T h i s i n t e r p l a y between d i s i p l i n e s i s he a l t h y and c e r t a i n l y both medicine and p h i l -osophy are dynamic enough to withstand the t h r e a t s of i n t e l l -e c t u a l r u t s and moral u n c e r t a i n t i e s . 3 6 Philosophy and What Should Be Done It i s time to consider the role philosophers were expected to play i n dealing with questions about what should be done within the health sciences. Philosophers are often regarded as possessing some form of moral expertise. Philosophy... retains the d i s t i n c t i o n of being the only d i s c i p l i n e e x p l i c i t l y engaged in the study of et h i c a l theory as one of i t s special subject matters. Unlike practitioners or theoreticians i n other disc-i p l i n e s , who assume the truth of one e t h i c a l theory or another without c r i t i c a l investigation, philos-ophers t r a d i t i o n a l l y attempt to j u s t i f y the theories they propose (Fox 1986, 4). What follows from th i s i s perhaps not surprising: ...when one seeks answers, not only to what i s right or wrong in pa r t i c u l a r cases, but also to questions of correct p r i n c i p l e s , i t seems only natural to turn to philosophy for answers (Ibid.). Thus, the claim that philosophers possess some expertise on p r a c t i c a l problems i s plausible. We w i l l explore the extent of t h i s expertise in a l a t e r section (chapter eight) and discover that there are some profound limitations associated with the kind of role philosophers ought to play in the health sciences. For some philosophers, engagement in biomedical ethics has simply involved a s l i g h t adjustment i n the way they pur-sue t h e i r d a i l y a c t i v i t i e s . Medical ethics i s a special kind of ethics only inso-far as i t relates to a pa r t i c u l a r realm of facts and concerns and not because i t embodies or appeals to some special moral p r i n c i p l e s or methodology.... It consists of the same moral pri n c i p l e s and rules we would appeal to and argue for i n ordinary circumstan-ces. It i s just that i n medical ethics these familiar moral rules are being applied to situations peculiar to the medical world. We have only to scratch the 37 s u r f a c e o f m e d i c a l e t h i c s and we b r e a k t h r o u g h t o t h e i s s u e s o f " s t a n d a r d " e t h i c s as we h a v e a l w a y s known them ( C l o u s e r 1978, 1 1 5 ) . I n much t h e same manner as C l o u s e r , H a r e a t t e m p t s t o make m e d i c i n e f i t i n t o t h e P r o c r u s t e a n bed o f p h i l o s o p h y . H a r e s e e s p h i l o s o p h y ' s p r i m a r y t a s k as b e i n g c o n c e p t u a l a n a l y s i s and c l a r i f i c a t i o n , s i n c e p h i l o s o p h y i n v o l v e s . . . t r a i n i n g i n t h e s t u d y o f t r i c k y w o r d s and t h e i r l o g i c a l p r o p e r t i e s i n o r d e r t o e s t a b l i s h c a n o n s o f v a l i d a r g u m e n t o r r e a s o n i n g , and s o e n a b l e p e o p l e who h a v e m a s t e r e d i t t o a v o i d e r r o r s i n r e a s o n i n g . . . and s o a n s w e r t h e i r m o r a l q u e s t i o n s w i t h t h e i r e y e s o p e n . ...once t h e i s s u e s a r e t h o r o u g h l y c l a r i f i e d i n t h i s way, t h e p r o b l e m s w i l l n o t seem so p e r p l e x i n g as t h e y d i d a t f i r s t a n d , t h e p h i l o s o p h i c a l d i f f i c u l t i e s h a v i n g b een r e m o v e d , we c a n g e t on w i t h t h e p r a c t i c a l d i f f i c u l t i e s ( H a r e 1977, 5 2 ) . An i n t e r e s t i n g q u e s t i o n f o r H a r e , o f c o u r s e , i s w h e t h e r one s h o u l d g r o u p v a l u e c o n f l i c t s among t h e p h i l o s o p h i c a l d i f f i c u l t i e s o r w i t h t h e p r a c t i c a l d i f f i c u l t i e s ? N o t s u r p r i s i n g l y , p e r h a p s , C a p l a n f i n d s a s s e s s m e n t s o f a p p l i e d e t h i c s t h a t r e s e m b l e H a r e ' s c o m i c a l : O f t e n t i m e s i n t h e c o u r s e o f t r y i n g t o e x p l a i n t o t h e u n i n i t i a t e d o f h e a l t h c a r e what i t i s t h a t p h i l o s o p h e r s d o , t h o s e i n p h i l o s o p h y a n d , i n p a r t i c u l a r , a p p l i e d e t h i c s w i l l m e n t i o n s u c h t a l e n t s a s b e i n g a b l e t o a n a l y z e t h e m e a n i n g s o f w o r d s , d e t e c t l o g i c a l c o n f u s i o n s and f a l l a c i e s , and t h e a b i l i t y t o e s t a b l i s h c a n o n s o f s o u n d and v a l i d a r g u m e n t a t i o n . T h u s , one s k i l l t h a t someone e x p e r t i n a p p l i e d e t h i c s c a n p r o v i d e t o t h o s e w o r k i n g i n a m e d i c a l s e t t i n g i s f e l t t o be t h a t o f p a t r o l l i n g and p o l i c i n g l o g i c a l m a l e f a c t o r s ( 1 9 8 3 , 3 1 3 ) . B e c a u s e o f t h e r e m o t e n e s s f r o m c l i n i c a l r e a l i t y o f v i e w s l i k e H a r e ' s and C l o u s e r ' s , t h e y h a v e begun t o f a l l i n t o e v e r more d i s f a v o u r . A f t e r a c o u p l e o f d e c a d e s o f t r y i n g t o a p p r o a c h t h e p r o b l e m s o f b i o m e d i c i n e i n i t s s t a n d a r d way, m o r a l p h i l o s o p h y has begun t o l o s e , s t e a m . Some p h i l o s o p h e r s , 38 l i k e E r i c C a s s e l l , s e e t h i s f l o u n d e r i n g as a s i g n o f c o m p l e t e f a i l u r e ( Z a n e r 1988, p r e f a c e ) . Z a n e r ' s own c r i t i c i s m s , w h i l e n o t as h a r s h as C a s s e l l ' s , a r e no l e s s t e l l i n g : A t f i r s t g e n e r a l l y t h o u g h t t o be an e x e r c i s e i n p h i l -o s o p h i c a l a n a l y s i s o f c o n c e p t s , r u l e s , and a p p l i c a t i o n s , b i o m e d i c a l e t h i c s has g r a d u a l l y , and o n l y w i t h much r e s i s t a n c e , b een f o r c e d t o r e a l i z e t h a t t h i s a p p r o a c h s i m p l y has n o t had much b i t e o r r e l e v a n c e f o r t h e a c t u a l c o n t e x t s o f d o c t o r ' s c l i n i c a l p r a c t i c e s and i n t e r v e n t i o n s i n t h e l i v e s o f r e a l p a t i e n t s s t r u g g l i n g t o r e s t o r e o r m a i n t a i n t h e m s e l v e s i n t h e f a c e o f p a i n f u l , h i g h l y e m o t i o n a l , and w h o l l y i n d i v i d u a l d e -c i s i o n s w i t h i n t h e i r own r e s p e c t i v e m o r a l and s o c i a l f r a m e w o r k s ( I b i d . x i i ) . We w i l l r e t u r n t o t h e p r o b l e m o f t h e l a c k o f " b i t e " and t h e i r r e l e v a n c e o f t h e s t a n d a r d a p p r o a c h t o b i o m e d i c a l e t h i c s i n t h e f i n a l c h a p t e r . I r o n i c a l l y , i n o r d e r f o r us t o s e e why Z a n e r ' s c r i t i c i s m s a r e s o f o r c e f u l , i t i s n e c e s s a r y t o c o n s i d e r b r i e f l y one o f b i o m e d i c a l e t h i c s ' g r e a t e s t s u c c e s s e s , Tom Beauchamp's and James C h i l d r e s s ' P r i n c i p l e s o f B i o m e d i c a l E t h i c s , a work t h a t f i r s t a p p e a r e d i n 1979. I w i l l q u i c k l y o u t l i n e t h i s m e t h o d o l o g y i n t h e r e m a i n d e r o f t h i s c h a p t e r and e x a m i n e i t s d e f i c i e n c i e s i n t h e n e x t . A N e a t and T i d y P a r a d i g m P r i o r t o t h e a p p e a r a n c e o f Beauchamp's and C h i l d r e s s ' w o r k , t h e l i t e r a t u r e o f b i o m e d i c a l e t h i c s m a i n l y c o n s i s t e d o f e s s a y s and a r t i c l e s , some o f w h i c h were g a t h e r e d i n t o a n t h o l -o g i e s t h a t b e gan by o f f e r i n g b r i e f r e m a r k s a b o u t them. "These e s s a y s u s u a l l y d i s c u s s e d t h e c u r r e n t p e r p l e x i n g c a s e s a nd i s -s u e s . . . b u t o n l y r a r e l y o f f e r e d much i n t h e way o f m e t h o d o l o g y " (Jonsen 1990, 32). For many p h i l o s o p h e r s , the most p o s i t i v e f e a t u r e of P r i n c i p l e s of Biomedical E t h i c s was the l i n k i t made between the c u r r e n t l y i n t e r e s t i n g e t h i c a l questions of biomedicine and the c u r r e n t l y accepted approaches of moral philosophy ( I b i d . ) . In a d d i t i o n , the paradigm maintained a strong connection with the dominant t r a d i t i o n s i n moral p h i l -osophy and the important values of the day ( a n t i - p a t e r n a l i s m , i n d i v i d u a l r i g h t s , e t c . ) , and d i d so i n a way th a t seemed comprehensive and coherent. The r e s u l t was a methodology that was both e a s i l y taught and lear n e d , a v i r t u e t h a t no doubt guaranteed i t s p o p u l a r i t y . Beauchamp and C h i l d r e s s r e l y on an approach to d e l i b -e r a t i o n and j u s t i f i c a t i o n t h a t has four l e v e l s : 1. p a r t i c u l a r judgments and a c t i o n s ; 2. r u l e s ; 3. p r i n c i p l e s ; and 4. e t h i c a l t h e o r i e s (Beauchamp 1989, 6). Judgments express a d e c i s i o n , v e r d i c t , or c o n c l u s i o n about a p a r t i c u l a r a c t i o n . . . . P a r t i c u l a r judgments are j u s t i f i e d by moral r u l e s , which i n t u r n are j u s t i f i e d by p r i n c i p l e s , which u l t i m a t e l y are defended by an e t h i c a l theory ( I b i d . 7 ) . For example, a doctor might decide to t e l l h i s p a t i e n t t h a t she has a t e r m i n a l i l l n e s s because he s u b s c r i b e s to a r u l e d i c t a t i n g h i s t e l l i n g the t r u t h i n a l l but very e x c e p t i o n a l cases. T h i s r u l e might then be j u s t i f i e d by some higher l e v e l e t h i c a l p r i n c i p l e , such as "respect f o r persons." T h i s p r i n c i p l e might then be defended by a u t i l i t a r i a n or deontolog-i c a l e t h i c a l theory. I n t e r e s t i n g l y enough, although i n d i v i d u a l p h i l o s o p h e r s o f t e n a c t as i f there i s only one l e g i t i m a t e e t h i c a l theory, 40 a s i g n i f i c a n t number o f t h e o r i e s have emerged f r o m a d i v e r s i t y o f v i e w p o i n t s . Be t h a t as i t may, none o f t h e s e seems l i k e l y t o emerge as t h e c u r r e n t l y a c c e p t e d t h e o r y and none i s e n t i r e l y f r e e o f p r o b l e m s . F o r t h e i r p a r t , Beauchamp and C h i l d r e s s d i s c u s s what t h e y c o n s i d e r t o be t h e two m a j o r t y p e s o f t h e o r y , one o f w h i c h i s t e l e o l o g i c a l , t h e o t h e r d e o n t o l o g i c a l . As t o w h i c h o f t h e two t h e y r e g a r d as most s u i t a b l e f o r d e -f e n d i n g t h e p r i n c i p l e s o f b i o m e d i c a l e t h i c s , t h e y r e p l y : . . . t h e d i s t i n c t i o n b e t w e e n c o n s e q u e n t i a l i s t . . . a n d d e o n t o l o g i c a l t h e o r i e s , w h i l e i m p o r t a n t , c a n be and h a s b een o v e r e s t i m a t e d . T h e r e a r e m a j o r d i f f e r e n c e s w i t h i n e a c h t y p e o f t h e o r y — r e g a r d i n g t h e g r o u n d s o f t h e t h e o r y , t h e number o f i t s p r i n c i p l e s , a nd w h e t h e r t h e . . . t h e o r y 1 s p r i n c i p l e s a p p l y d i r e c t l y t o a c t s o r a r e m e d i a t e d t h r o u g h r u l e s . B u t t h e r e a r e a l s o m a j o r s i m i l a r i t i e s a c r o s s c e r t a i n r u l e - o r i e n t e d t h e o r i e s . ... some... c o n v e r g e on t h e same p r i n c i p l e s a nd r u l e s ( I b i d . 6 2 ) . The f o u r p r i n c i p l e s o f b i o m e d i c a l e t h i c s a r e autonomy, n o n m a l e f i c e n c e , b e n e f i c e n c e , and j u s t i c e . The l o g i c a l n a t u r e o f t h e s e p r i n c i p l e s o f f e r s c r i t i c a l f o r c e , b e c a u s e t h e y a r e i n t e n d e d t o p l a y a s i g n i f i c a n t n o r m a t i v e f u n c t i o n ( A r r a s 1986, 1 5 ) . The n o r m a t i v e f u n c t i o n must be u s e d t h o u g h t f u l l y , f o r t h e p r i n c i p l e s were i n t e n d e d t o o f f e r b o t h m o r a l c r i t i -c i s m and e v a l u a t i o n o f t h e p r a c t i c e o f m e d i c i n e and g u i d a n c e f o r p h y s i c i a n s a t t h e b e d s i d e . As w e l l w i l l s e e i n t h e n e x t c h a p t e r , h o w e v e r , t h e p r i n c i p l e s a r e m a i n l y i n e f f e c t i v e i n o f f e r i n g g u i d a n c e . T h u s , p h y s i c i a n s were bombarded w i t h c r i t i c i s m ( e . g . f o r b e i n g p a t e r n a l i s t i c , d e c e p t i v e , s e x i s t , e t c . ) , b u t were o f f e r e d v e r y l i t t l e s u p p o r t a t t h e same t i m e . N o r m a l l y , p e o p l e who a r e c r i t i c i z e d by o t h e r s who a p p e a r t o have r e l a t i v e l y l i t t l e c o n s t r u c t i v e to o f f e r soon become re s e n t f u l . T h i s resentment, no doubt, has had a negative im-pact on medicine's a t t i t u d e toward philosophy and sometimes has l e f t medicine u n w i l l i n g to pool r e s o u r c e s . Let us now tu r n t o some of the problems a s s o c i a t e d with the r o l e and resources of e t h i c s i n the h e a l t h s c i e n c e s . CHAPTER 4 BIG CHALLENGES AND BIG LIMITATIONS As a r e s u l t of i t s involvement i n the h e a l t h s c i e n c e s , normative e t h i c a l theory has come under severe a t t a c k , both from i n s i d e philosophy and without. The i n t e n s e c r i t i c i s m p hilosophy has undergone i n t h i s regard may prove b e n e f i c i a l i n the long run, f o r the backlash has made more p h i l o s o p h e r s h i g h l y s e n s i t i v e to defending the r e l e v a n c e and e f f i c a c y of t h e i r a c t i v i t i e s . However, l i k e a r a d i c a l masectomy t h a t r e -moves the good with the bad t i s s u e , many of the recent c r i t i -cisms have been i n d i s c r i m i n a t e l y hacking away at philosophy's r o l e i n the h e a l t h s c i e n c e s . I f the k n i f e i s pressed too deep-l y , i t may t u r n out t h a t most p h i l o s o p h e r s w i l l p r e f e r not to i n v o l v e themselves i n b i o m e d i c a l e t h i c s , perhaps as a r e s u l t of a l a c k of confidence i n themselves and t h e i r a r t . I t i s time to c o n s i d e r some gen e r a l c r i t i c i s m s of philosophy's r o l e i n biomedicine (and the resources philosophy has to o f f e r ) . L a t e r i n t h i s chapter, problems with Beauchamp's and C h i l d r e s s ' " a p p l i e d e t h i c s paradigm" w i l l be d i s c u s s e d . P r a c t i c e and Theory One of the most g l a r i n g d i s p a r i t i e s between medicine and philosophy i s a l s o most r e s p o n s i b l e f o r the l a c k of i n t e r -d i s c i p l i n a r y c o o p e r a t i o n between the two f i e l d s . ...the p h i l o s o p h e r remains an i n t e r l o p e r , a t h e o r i s t 42 43 i n the land of t h e r a p i s t s . . . . The p h i l o s o p h e r ' s s t o c k - i n - t r a d e i s p r i n c i p l e s , concepts, and t h e o r i e s --not therapy or guidance c o u n s e l l i n g . The p h i l o s o -pher i s concerned with foundations, arguments, and l o g i c , not with, as o f t e n seemed the r e a l agenda f o r p h y s i c i a n s , s e n s i t i z i n g h e a l t h p r o f e s s i o n a l s to v a l u e s , e t h i c s , and morals (Zaner 1988, 5). The source of many problems, of course, i s a s i g n i f i c a n t misunderstanding of the nature of moral philosophy on the p a r t of some p h y s i c i a n s . No doubt, they had hoped to be presented with a d e f e n s i b l e s e t of v a l u e s ; to be t r a i n e d t o r e c o g n i z e the moral dimensions of a case; to see what should be done; and to want to do what should be done. The e x p e c t a t i o n s of both p h i l o s o p h e r s and p h y s i c i a n s as to how the former would operate i n the h e a l t h s c i e n c e s could h a r d l y have been more opposed. As we saw i n the l a s t chapter, many p h i l o s o p h e r s (e.g. Clouser) wanted to get on with t h e i r u s ual business d e s p i t e the change of context. P h y s i c i a n s , who as a r e s u l t of t h e i r t r a i n i n g are r e s u l t s - o r i e n t e d , wanted something very d i f f e r e n t . They expected c l a r i t y , p r e c i s i o n , and c o n f i d e n c e ; i n s t e a d , they r e c e i v e d u n c e r t a i n t y , doubt, and c o n f u s i o n . The source of t h i s u n c e r t a i n t y , doubt, and c o n f u s i o n was l i k e l y the f a c t t h a t the c e n t r a l concerns of the p h i l o s o p h e r s had become so a b s t r a c t and general--above a l l , so d e f i n i t i o n a l or a n a l y t i c a l — t h a t they had, i n e f f e c t , l o s t a l l touch with the concrete and p r a c t i c a l i s s u e s t h a t a r i s e i n a c t u a l p r a c t i c e , whether i n medicine or elsewhere (Toulmin 1986, 278). L i k e a person who has been too long i n the darkness and then ventures out i n t o b r i l l i a n t sunshine, p h i l o s o p h e r s fumbled around awkwardly i n the face of medicine's needs. But, u n l i k e the person who c a n ' t h i d e the f a c t she ' s s u n - b l i n d e d , some p h i l o s o p h e r s have c o n t i n u e d to pursue b i o m e d i c a l e t h i c s as though n o t h i n g i s amis s . T h i s , i n i t s e l f , i m p l i e s any of a number of t h i n g s . Some p h i l o s o p h e r s may r e g a r d p h y s i c i a n s ' d i s s a t i s f a c t i o n w i t h normat ive e t h i c a l t h e o r y as be ing the r e s u l t of a l a c k of p h i l o s o p h i c a l a p p t i t u d e among most p h y s i -c i a n s . Other p h i l o s o p h e r s may be r e l i e v e d to have a job and u n d e r s t a n d a b l y d o n ' t want to make waves. S t i l l o t h e r s may accept the c r i t i c i s m s , ye t a t t r i b u t e them to p h i l o s o p h y ' s r e l -a t i v e i n e x p e r i e n c e i n the h e a l t h s c i e n c e s . Perhaps , w i t h t i m e , p h i l o s o p h i c a l normat ive t h e o r i e s w i l l e v o l v e i n t o e f f e c t i v e t o o l s t h a t can be a p p l i e d s a t i s f a c t o r i l y . But can med ic ine wa i t f o r p h i l o s o p h y and f o r how long? I t i s apparent t h a t medic ine needs r e s u l t s soon, and expects them to be d e f e n s i b l e . One approach open to m e d i c i n e , of c o u r s e , i s t h a t i t deve lop i t s own r e s o u r c e s f o r d e a l i n g wi th moral i s s u e s . In some c a s e s , t h i s i s , i n f a c t , what i s o c c u r -r i n g and f o r a number of good r e a s o n s . 1. As Mahowald e x p l a i n s , i n c r e a s i n g numbers of p h y s i c i a n -p h i l o s o p h e r s or n u r s e - p h i l o s o p h e r s are a p p e a r i n g i n the ranks o f the h e a l t h c a r e workers (1986, 144-145) . 2. At p r e s e n t , the m a j o r i t y of people t e a c h i n g courses i n human v a l u e s at m e d i c a l s c h o o l s a r e n ' t p h i l o s o p h e r s . In f a c t , many p h y s i c i a n s are now o f f e r i n g some form of i n s t r u c t i o n i n these m a t t e r s . 3. I n c r e a s i n g numbers of books i n b i o m e d i c a l e t h i c s are be ing w r i t t e n f o r p h y s i c i a n s and o t h e r h e a l t h care p r o f e s s i o n a l s ( e . g . B r o d y ' s E t h i c a l D e c i s i o n s i n  M e d i c i n e and C l i n i c a l E t h i c s by Jonsen , S i e g l e r , and W i n s l a d e ) . The advantage of be ing a p h y s i c i a n - p h i l o s o p h e r or a n u r s e - p h i l o s o p h e r i s t h a t you can shape philosophy's resources to meet your needs as a h e a l t h care worker. T h i s i s c l e a r l y an a t t r a c t i v e o p t i o n , s i n c e the m o d i f i c a t i o n of philosophy i s done from i n s i d e the h e a l t h s c i e n c e s and w i l l mainly be d r i v e n by f a m i l i a r , concrete concerns. A major advantage of having experienced p h y s i c i a n s g i v e courses i n human values, i s t h a t the medical school r e t a i n s c o n t r o l over what gets d i s c u s s e d and how i t gets d i s c u s s e d . Thus, i t i s p o s s i b l e to r e l y on d e t a i l e d cases to i l l u s t r a t e problems, an approach t h a t permits a s t r o n g connection between the p r a c t i c a l and e t h i c a l s i d e s of medical e d u c a t i o n . Instead of f o c u s i n g too much a t t e n t i o n on Karen Ann Quinlan and r e n a l d i a l y s i s , p h y s i c i a n - e d u c a t o r s c o u l d draw on more r o u t i n e p r o b l -ems and a l s o on p a r t i c u l a r l y d i f f i c u l t cases t h a t have j u s t o c c u r r e d . Of course, some c o n t r o l c o u l d a l s o be exerted on the a t t i t u d e s and f e e l i n g s t h a t are a c q u i r e d by the students i n response to the cases c o n s i d e r e d . As Mahowald observes, books w r i t t e n by p h y s i c i a n -p h i l o s o p h e r s f o r p h y s i c i a n s are popular, because they are an " a t t r a c t i v e a l t e r n a t i v e to the i n c o n c l u s i v e s p e c u l a t i o n s of 'pure' p h i l o s o p h e r s , and the i s o l a t e d , d e t a i l e d h i s t o r i e s of 'unique' cases by p r a c t i t i o n e r s " ( I b i d . ) . So, i f t h i s approach were fo l l o w e d (at philosophy's ex-pense), we would have before us a case of medicine saving what i t can use from philosophy, r a t h e r than medicine saving the l i f e of p hilosophy. Despite the f a c t t h a t t h i s approach has much to recommend i t , there are, however, a number of 46 s e r i o u s problems a s s o c i a t e d with i t . F i r s t and foremost of the problems t h a t w i l l c o n f r o n t t h i s approach i s the f a c t t h a t the p h y s i c i a n - p h i l o s o p h e r w i l l f e e l more s t r o n g l y drawn to the medical p r o f e s s i o n than to philosophy. The medical p r o f e s s i o n i s a t i g h t l y - k n i t , high s t a t u s body of i n d i v i d u a l s who share a common i d e n t i t y , c e r t a i n important p r o f e s s i o n a l v a l u e s , and a strong sense of f r a t e r n i t y . The s t a r t i n g p o i n t f o r most p h y s i c i a n - p h i l o s o p h e r s would be a defense of the p r a c t i c e of medicine, because a c o n s i d e r a b l e amount of s e l f - r e s p e c t and p r i d e are a s s o c i a t e d with i t . While the p h y s i c i a n - p h i l o s o p h e r might p o i n t out l i m i t a t i o n s and p l a c e s needing improvement, he or she w i l l l i k e l y f e e l some pressure to be s e l e c t i v e about how c r i t i c i s m s are o f f e r e d . In order to be welcome among one's peers, who are, i n some sense, the e l i t e of s o c i e t y , one's conduct must be a c c e p t a b l e . W i l l i a m Ruddick i s concerned t h a t p h i l o s o p h e r s i n v o l v e d i n the r o u t i n e of c l i n i c a l p r a c t i c e " w i l l be absorbed i n t o the medical c e n t e r ethos and become c o l l a b o r a t o r s i n a flawed system" (Zaner 1988, 8). P h y s i c i a n - p h i l o s o p h e r s w i l l not be c o l l a b o r a t o r s : they w i l l p r i m a r i l y be p h y s i c i a n s working with the guidance provided by t h e i r medical t r a i n i n g ("the medical center e t h o s " ) . They may t h i n k about a few t h i n g s d i f f e r e n t -l y or t r e a t people s l i g h t l y d i f f e r e n t l y , but, i n the end, they are doctors working i n s i d e the system. As they are i n s i d e r s , they are s u b j e c t to a l l of the r u l e s , laws, and e x p e c t a t i o n s of the medical p r o f e s s i o n t h a t any other bona f i d e d o c t o r i s s u b j e c t t o . Thus, t h e i r f e e l i n g s about and a t t i t u d e s toward the h e a l t h c a r e system w i l l be p r o f o u n d l y d i f f e r e n t than most, i f not a l l p h i l o s o p h e r s . One can o n l y c o l l a b o r a t e w i t h t h e enemy. I t would be an odd d o c t o r t h a t r e g a r d e d o t h e r d o c t o r s as h i s enemies. Thus, r e l y i n g on p h y s i c i a n - p h i l o s o p h e r s , as opposed t o o r d i n a r y p h i l o s o p h e r s , would d e p r i v e the m e d i c a l p r o f e s s i o n o f sometimes h i g h l y v a l u a b l e e x t e r n a l c r i t i c i s m . Even the b e s t -i n t e n t i o n e d s e l f - e n f o r c e m e n t can f a i l t o n o t i c e e v e r y problem. Whether t h i s e x t e r n a l i n p u t would t a k e p l a c e i n the h o s p i t a l c o r r i d o r or a t p o l i c y meetings would depend both on the m e d i c a l p r o f e s s i o n ' s w i l l i n g n e s s t o r e c e i v e i n p u t and on t h e q u a l i t y of t h e c r i t i c i s m . C l e a r l y , i f t h e i n p u t i s d e l i v e r e d i n a r e s p e c t f u l , but p e r s u a s i v e manner, th e n i t i s r e a s o n a b l e t o be r e c e p t i v e . But, as Caplan n o t e s , "those d o i n g a p p l i e d e t h i c s have been f a r more e f f e c t i v e i n i n f l u e n c i n g the f o r m u l a t i o n o f h e a l t h p o l i c y a t the f e d e r a l l e v e l than a t t h e b e d s i d e " (1983, 314). An o b v i o u s problem a s s o c i a t e d w i t h m e d i c i n e ' s r e l i a n c e on p h y s i c i a n - p h i l o s o p h e r s i n s t e a d o f f u l l t i m e p h i l o s o p h e r s i s t h e f a c t t h a t " i t t a k e s t i m e , c o n c e n t r a t e d d e v o t i o n , and hard i n t e l l e c t u a l l a b o r t o a c h i e v e e i t h e r moral s e n s i t i v i t y t o o r e x p e r t knowledge of e t h i c a l phenomena" (Zaner 1988, 8 ) . I t a l s o t a k e s an enormous amount of m e n t a l , p h y s i c a l , and s p i r i t u a l energy t o be a good p h y s i c i a n . As Mahowald c o r r e c t l y reminds us: The f i r s t two y e a r s of m e d i c a l s c h o o l a r e o f t e n a 48 memory f e a t , the next two years ah endurance con-t e s t . Moreover, medical students are at a p o i n t i n t h e i r l i v e s where they have zeroed i n on a very s p e c i f i c g o a l , namely, to be a d o c t o r . They are n a t u r a l l y drawn to s u b j e c t s which w i l l equip them to do t h a t , and philosophy i s not one of these (1986, 144). U n f o r t u n a t e l y , there are even drawbacks f o r a person who r e c e i v e s a Ph.D. i n b i o m e d i c a l e t h i c s and then goes on to complete a M.D. degree. T h i s p h i l o s o p h e r - p h y s i c i a n o b v i o u s l y can't pursue a medical c a r e e r f u l l t i m e i f any more than a t i n y f r a c t i o n of h i s or her time i s devoted towards e t h i c s . I f a p h y s i c i a n takes the demands of the p r o f e s s i o n s e r i o u s l y , there i s very l i t t l e time l e f t over a f t e r these demands (and f a m i l y demands) have been met. So f a r i n t h i s chapter we have c o n s i d e r e d one of medicine's responses to the problems a s s o c i a t e d with both the r o l e and resources of biomedical e t h i c s . I t i s time now to t u r n our a t t e n t i o n to the problems r e l e v a n t to Beauchamp's and C h i l d r e s s ' approach so t h a t we may examine the p h i l o s -opher's response to the l i m i t a t i o n s of b i o m e d i c a l e t h i c s . T h i s d i s c u s s i o n w i l l c a r r y over i n t o the next chapter where the a n t i - t h e o r y movement i n philosophy w i l l be b r i e f l y e x p l o r e d . The Paradigm R e v i s i t e d One of the standard c r i t i c i s m s of the paradigm theory of b iomedical e t h i c s i s t h a t i t has very l i t t l e of substance to o f f e r i n the face of the i n t e n s e demands of r o u t i n e medical p r a c t i c e . To see t h a t there i s some f o r c e t o t h i s c r i t i c i s m , 49 l e t us q u i c k l y c o n s i d e r a case i n which a twenty-one year o l d woman v i s i t s her g y n e c o l o g i s t and i n s i s t s t h a t he perform a t u b a l l i g a t i o n f o r her (she i s s i n g l e ) . She has had three a b o r t i o n s a l r e a d y and g r e a t l y f e a r s becoming pregnant again. She e x p l a i n s t h a t she i s c e r t a i n she never wants to be a mother, because she knows she would be a d i s a s t r o u s parent. Her own f a m i l y was h i g h l y d y s f u n c t i o n a l . I t ' s a l l she can do to take care of h e r s e l f . The p h y s i c i a n knows what she i s saying i s t r u e , but he i s n ' t sure t h a t t y i n g her tubes i s the r i g h t t h i n g to do. He t e l l s her t h a t h e ' l l phone her with h i s d e c i s i o n l a t e r i n the a f t e r n o o n . For the purposes of the d i s c u s s i o n , l e t us momentarily ignore o p t i o n s l i k e r e f e r r i n g her to a p s y c h i a t r i s t or to another g y n e c o l o g i s t . Let us assume t h a t the p h y s i c i a n wants to make a d e c i s i o n and wants to c h a l l e n g e i t i n order to be s u r e - i t i s proper. He has, f o r t u n a t e l y , read P r i n c i p l e s of  Biomedical E t h i c s , and has an adequate understanding of the approach i t o u t l i n e s . He beings by t r y i n g to imagine what the r e l e v a n t moral r u l e might be f o r t h i s case. U n f o r t u n a t e l y , s i n c e Beauchamp and C h i l d r e s s don't l i s t the r u l e s f o r him to c o n s u l t , he r e a l i z e s t h a t he must t h i n k one up f o r h i m s e l f . For the moment, he ignores the l e g a l and p r o f e s s i o n a l r u l e s and attempts to come up with what he takes to be a moral r u l e . He a r r i v e s at the f o l l o w i n g : "As a p h y s i c i a n , you are under a prima f a c i e o b l i g a i o n to perform the procedures t h a t w i l l b e n e f i t your p a t i e n t s . " Since he deems the p a t i e n t to be competent and 50 s i n c e the procedure i s l e g a l i n t h i s case, he decides t h a t he ought t o perform the t u b a l l i g a t i o n . Of course, the d e c i s i o n i s j u s t i f i e d by the moral r u l e he has thought up only i f the moral r u l e i s j u s t i f i e d by one of the p r i n c i p l e s . He decides t h a t the p r i n c i p l e of beneficence j u s t i f i e s h i s moral r u l e , f o r he b e l i e v e s some good i s done by pr e v e n t i n g h i s p a t i e n t from having f u r t h e r a b o r t i o n s and from r a i s i n g a mi s e r a b l e c h i l d . Since he i s a r u l e u t i l i t a r i a n , he defends h i s p r i n c i p l e s with t h a t theory. A f t e r he f i n i s h e s t h i s process, he i s l e f t with a nagging doubt t h a t i t was too s u p e r f i c i a l , too remote, and f a r too m e c h a n i s t i c . He decides to t r y to reach the op p o s i t e d e c i s i o n as a t e s t - - j u s t f o r h i s own peace of mind. He t r i e s to t h i n k of a moral r u l e t h a t would j u s t i f y h i s d e c i s i o n not to perform the procedure. He f i x e s upon: "As a human being who knows t h a t l i f e i s d i f f i c u l t but a l s o t h a t help i s a v a i l a b l e and a d v e r s i t y can l e a d to s t r e n g t h of c h a r a c t e r , m a t u r i t y , and compassion, you are under a prima f a c i e o b l i g -a t i o n not to a i d others who r e s o r t t o desperate measures to r e s o l v e t h e i r problems." He t r i e s to t h i n k of c o n f l i c t i n g o b l i g a t i o n s t h a t would undermine the o b l i g a t i o n s t a t e d by the r u l e , but he can't. Again, he r e l i e s on the p r i n c i p l e of beneficence to j u s t i f y the r u l e and on r u l e u t i l i t a r i a n i s m t o defend the p r i n c i p l e . To be c a r e f u l , he c o n s i d e r s i n what ways he might behave b e n e f i c e n t l y towards h i s p a t i e n t i f he r e f u s e s her request . To begin with, he comes across the n o t i o n t h a t he might 51 promote her autonomy by denying her t h i s procedure. I f he recommends, i n s t e a d , t h a t she sees a p s y c h i a t r i s t t o d e a l with her l i f e ' s problems, she may l a t e r be g l a d t h a t she was denied t h i s o p t i o n . I t a l s o occurs to him t h a t by t y i n g her tubes he would be " f i x i n g " her r e p r o d u c t i v e system but not her emotional d i f f i c u l t i e s . The best outcome he c o u l d wish f o r her would be to have her c o n s i d e r h e r s e l f as a person with f e e l i n g s , f e a r s , and needs, r a t h e r than simply as a p h y s i o l o g i c a l mechanism. C l e a r l y , i n at l e a s t one sense, he would be e x p r e s s i n g r e s p e c t f o r her as a person by t r y i n g to help her see "the b i g p i c t u r e . " Both of these c o n s i d e r a t i o n s convince him t h a t he does behave b e n e f i c e n t l y i f he r e f u s e s her request. N a t u r a l l y , as a r e s u l t of these d e l i b e r j a t i o n s , he i s p u z z l e d . Can t h i s process o f f e r him any confidence t h a t he does what should be done? Or, as seems more l i k e l y , do h i s p e r s o n a l values shape the r u l e s and guide him through the deductive pro-cess of j u s t i f i c a t i o n ? Perhaps i n a c t u a l f a c t t h i s method i s s u p e r f l u o u s to the process of moral reasoning or perhaps i t i s merely a comfortable means of f e e l i n g good about whatever one has decided. Of course, one c o u l d proceed i n many d i f f e r e n t ways u n t i l the d e s i r e d j u s t i f i c a t i o n has been found. The wording of the r u l e s can be changed to r e f l e c t s u b t l e nuances of one's v a l u e s . The i n t e r p r e t a t i o n s of the p r i n c i p l e s can be a l t e r e d so t h a t one seems to outweigh another. Since n e i t h e r the r u l e deon-t o l o g i s t nor the r u l e u t i l i t a r i a n can p r o v i d e a u n i v e r s a l l y accepted l i s t of the moral r u l e s (who c o u l d ? ) , i n d i v i d u a l s w i l l s u b s c r i b e to w i l d l y v a r i a n t codes of conduct. We can imagine t h a t one p h y s i c i a n would t i e the tubes f o r the reasons we saw and another wouldn't f o r yet d i f f e r e n t reasons. Should the woman shop around u n t i l she gets what she wants? Those who value l i b e r t y and autonomy above a l l e l s e w i l l l i k e l y b e l i e v e she should. But, f o r Beauchamp and C h i l d r e s s , auto-nomy i s but one p r i n c i p l e among f o u r . They c l a i m t h a t how much weight i t r e c e i v e s depends on the circumstances of the case. I c l a i m t h a t t h i s approach i s f a r too a r b i t r a r y . F u r t h e r Problems with the Paradigm Jonsen and Toulmin r a i s e other c r i t i c i s m s t h a t are r e l e v -ant to our assessment of the paradigm theory. In t h e i r d i s c u -s s i o n of the problems a s s o c i a t e d with p r i n c i p l e s and r u l e s , they c o n s i d e r cases where no appeal can be made to any s i n g l e simple r u l e , and observe t h a t these are the source of genuine moral problems (Jonsen 1988, 7). They o f f e r the f o l l o w i n g example: I f I go next door and borrow a s i l v e r soup tureen, i t goes without saying t h a t I am expected to r e t u r n i t . . . t h a t i s not an i s s u e and g i v e s r i s e to no problem. I f , however, i t i s a p i s t o l t h a t I borrow and i f , while i t i s i n my p o s s e s s i o n , the owner becomes v i o l -e n t l y enraged and threatens to k i l l . . . [ s o m e o n e j ...as soon as he gets back the p i s t o l , I s h a l l f i n d myself i n a genuinely problematic s i t u a t i o n . I cannot escape from i t by lamely i n v o k i n g the g e n e r a l maxim t h a t bor-rowed property ought to be r e t u r n e d promptly ( I b i d . ) . As they observe, the p i s t o l case i n v o l v e s a c o n f l i c t between the o b l i g a t i o n to r e t u r n borrowed property and the o b l i g a t i o n to prevent needless v i o l e n c e or homicide ( I b i d . ) . 53 Jonsen and Toulmin a l s o d i s c u s s the problems t h a t 1 a r i s e when simple r u l e s apply only m a r g i n a l l y or ambiguously. I f I go to the pet s t o r e and b r i n g home a t o r t o i s e s h e l l tomcat or a c o l l i e puppy, i t i s taken f o r granted t h a t I w i l l ensure t h a t i t i s f e d and cared f o r r a t h e r than abandoned to fend f o r i t s e l f . Once again, t h i s i s both l e g a l l y and m o r a l l y "beyond q u e s t i o n . " But i f a c h i l d goes out to the pond with a jam j a r of water and comes back with f r o g s ' eggs i n the jam j a r , i t i s not e q u a l l y obvious t h a t general maxims about the r i g h t s of innocent l i f e and the need to a v o i d c r u e l t y to animals have the same unambiguous f o r c e as before ( I b i d . 7-8). They c l a i m t h a t cases of t h i s s o r t are as p r o b l e m a t i c as s i t u a t i o n s i n which d i f f e r e n t r u l e s c l a s h . The important t h i n g t o r e a l i z e , they i n s i s t , i s t h a t "no r u l e can be e n t i r e l y s e l f - i n t e r p r e t i n g " ( I b i d . ) . Whether our g y n e c o l o g i s t i s the author of the moral r u l e s i n a given case, or whether he i s a p p l y i n g someone e l s e ' s r u l e s , [tjhe c o n s i d e r a t i o n s t h a t weigh with us i n r e s o l v i n g the a m b i g u i t i e s t h a t a r i s e i n marginal cases, l i k e those t h a t weigh with us i n b a l a n c i n g the claims of c o n f l i c t -i n g p r i n c i p l e s , are never w r i t t e n i n t o the r u l e s them-s e l v e s ( I b i d . ) . Although approaches to moral reasoning t h a t resemble the paradigm are commonly a p p l i e d i n many f i e l d s , d i s s a t i s f a c t i o n with them i s widespread throughout philosophy. Let us c o n s i d e r two kinds of c r i t i c i s m s to r e v e a l the source of the d i s s a t i s -f a c t i o n . F e m i n i s t p h i l o s o p h e r s c r i t i c i z e these t h e o r i e s f o r t h e i r f a i l u r e to take i n t o account the s i g n i f i c a n t i n t e r -How Jonsen and Toulmin t h i n k these d e f i c i e n c i e s can be d e a l t with w i l l be c o n s i d e r e d i n chapter s i x . p e r s o n a l r e l a t i o n s h i p s t h a t make up the s o c i a l order- The bonds and a s s o c i a t i o n s among i n d i v i d u a l s should be the s t a r t -i n g p o i n t f o r m o r a l i t y , they argue, not a b s t r a c t p r i n c i p l e s t h a t are b l i n d t o s o c i a l r e a l i t i e s . I t i s n ' t hard to see the r e l e v a n c e of such c r i t i c i s m s f o r b i o m e d i c a l e t h i c s . The c l i n i c a l encounter i n v o l v e s an enormously complicated nexus of r o l e s and e x p e c t a t i o n s . Our conduct i s determined, to a c o n s i d e r a b l e e x t e n t , by our s o c i a l i z a t i o n , t r a i n i n g , psycho-l o g i c a l c o n d i t i o n i n g , and economic s t a t u s , not by the amorph-ous d i c t a t e s of a p r i n c i p l e . For many i n d i v i d u a l s , e t h i c a l p r i n c i p l e s c a r r y l i t t l e or no f o r c e . Barry Hoffmaster doubts t h a t general p r i n c i p l e s such as the p r i n c i p l e of n o r m a l i z a t i o n and the p r i n c i p l e of the l e a s t r e s t r i c t i v e a l t e r n a t i v e p r o v i d e much help i n r e s o l v i n g moral i s s u e s r e l a t e d to mentally handicapped i n d i v i d u a l s . The p r i n c i p l e of n o r m a l i z a t i o n s t a t e s t h a t the r e t a r d e d have the r i g h t to a range of goods and s e r v i c e s t h a t make t h e i r l i v e s as normal as p o s s i b l e (Hoffmaster 1981, 319). The p r i n c i p l e of the l e a s t r e s t r i c t i v e a l t e r n a t i v e can be under-stood as r e q u i r i n g t h a t the care, treatment, and h a b i l i t a t i o n p r o vided to the mentally r e t a r d e d , as w e l l as the s e t t i n g i n which i t i s provided be the l e a s t r e s t r i c t i v e of the person's p e r s o n a l l i b e r t y ( I b i d . ) . His c r i t i c i s m s of the p r i n c i p l e s are important: ...the p r i n c i p l e of n o r m a l i z a t i o n seems to have a c q u i r e d the s t a t u s of dogma. The kinds of d i f f i c u l t i e s and questions j u s t r a i s e d [how to i n t e r p r e t and apply the p r i n c i p l e ^ are not being addressed because of the dogmatic s t a t u s of the p r i n c i p l e . More i m p o r t a n t l y , other value 55 questions are being obscured by a dogmatic a l l e g i a n c e to the p r i n c i p l e ( I b i d . 323). The p r i n c i p l e s of biomedical e t h i c s have, f o r many, a l s o become dogma and o f t e n obscure important value q u e s t i o n s . Since we are not t o l d i n very much d e t a i l how to a s s i g n weights to the p r i n c i p l e s , i t i s very d i f f i c u l t to answer quest i o n s l i k e : "Why am I r e s p e c t i n g her autonomy a t the expense of my a c t i n g b e n e f i c e n t l y ? " I t i s important t o note t h a t one's per s o n a l values w i l l i n f l u e n c e how much weight i s attached t o a given p r i n c i p l e f o r a given case. I f we d o g m a t i c a l l y apply the p r i n c i p l e s , questions about the j u s t i f i c a t i o n f o r the weights given to the p r i n c i p l e s w i l l be overlooked. Hoffmaster a l s o argues t h a t problems a r i s e when attempts are made to apply the p r i n c i p l e of n o r m a l i z a t i o n to concrete problems. The d i f f i c u l t y i s t h a t the p r i n c i p l e i s too gen e r a l or too vague to handle concrete problems, and i n some cases i t may come up with an i n t u i t i v e l y c o r r e c t answer ( I b i d . 323). He r e l a t e s an i n c i d e n t i n v o l v i n g a mentally handicapped i n -d i v i d u a l to i l l u s t r a t e the d i f f i c u l t y . A r e t a r d e d person had found an apartment t h a t over-looked a cemetery. But an o b j e c t i o n , founded on the p r i n c i p l e of n o r m a l i z a t i o n , was r a i s e d to a l l o w i n g t h i s person t o l i v e i n the apartment. The argument was t h a t i t was not c u l t u r a l l y normative to l i v e i n an apartment t h a t over-looked a cemetery. Since most people do not l i v e i n pl a c e s t h a t over-look cemeteries, mentally r e t a r d e d people should not be allowed t o . . . . T h i s example i l l u s t r a t e s both problems with the p r i n c i p l e . Does such a s p e c i f i c c o n c l u -s i o n a c t u a l l y f o l l o w from the p r i n c i p l e , and i f i t does, i s i t a c o n c l u s i o n t h a t i s accept a b l e ( I b i d . ) ? 56 Departing from the Paradigm Or Abandoning I t ? In the example of the g y n e c o l o g i s t c o n s i d e r e d above, which of the c o n f l i c t i n g d e c i s i o n s f o l l o w s from the p r i n c i p l e and how do we t e l l ? Perhaps, i t i s , as was suggested, the d e c i s i o n t h a t i s most i n accord with our v a l u e s . T h i s view, however, i s c l e a r l y unacceptable. Can Beauchamp and C h i l d r e s s o f f e r a more d e f e n s i b l e account i f they f a i l t o : 1. O f f e r a "complete" l i s t of r u l e s ; 2. O f f e r s e l f - i n t e r p r e t i n g r u l e s (and p r i n c i p l e s ) ; 3. O f f e r complete d i r e c t i v e s about how to apply them; 4. O f f e r a s a t i s f y i n g account of what r o l e values w i l l p l a y i n t h e i r scheme of moral reasoning? No doubt, they may continue to r e f i n e t h e i r theory i n the years to come; n e v e r t h e l e s s , i t i s d i f f i c u l t to b e l i e v e they w i l l succeed i n overcoming i t s many l i m i t a t i o n s . I t may be o b j e c t e d t h a t Beauchamp and C h i l d r e s s aren't major e t h i c a l t h e o r i s t s and so d i s c r e d i t i n g t h e i r work says very l i t t l e about e t h i c a l theory. T h i s i s not the case, however, s i n c e no other e t h i c a l t h e o r i s t s have been able to a t t a i n the degree of success i n biomedical e t h i c s t h a t these authors have. Admittedly, the kind of success Beauchamp and C h i l d r e s s have enjoyed i s undeserved; but i t i s s t i l l t r u e t h a t no one e l s e has advanced a more s u c c e s s f u l approach to date. As we s h a l l see i n the next chapter, some p h i l o s o p h e r s argue t h a t i t i s because of problems i n h e r e n t to normative e t h i c a l theory t h a t success i n a p p l i e d f i e l d s has been so e l u s i v e . 57 One of the most s i g n i f i c a n t problems c o n f r o n t i n g the a p p l i e d e t h i c s paradigm i s r a i s e d by Jonsen; namely, "Is the r e l a t i o n s h i p between e t h i c a l theory and moral d i s t i n c t i o n s as c l e a r as Beauchamp and C h i l d r e s s seem to suggest?" (1990, 33). In the e a r l y p a r t of t h e i r d i s c u s s i o n , Beauchamp and C h i l d r e s s s e t out the t e s t s f o r the adequacy of an e t h i c a l theory. These are, roughly, as f o l l o w s . 1. An e t h i c a l theory should be as c l e a r as p o s s i b l e , as a whole and i n i t s p a r t s (Beauchamp 1989, 14). 2. An e t h i c a l theory should be i n t e r n a l l y c o n s i s t e n t and coherent. 3. A theory should be as complete and comprehensive as p o s s i b l e i n l i s t i n g moral p r i n c i p l e s , r u l e s , and t h e i r connections ( I b i d . 15). 4. A theory should be simple to l e a r n and apply. 5. A theory must be able to account f o r the whole range of moral experience, i n c l u d i n g the p r i n c i p l e s , r u l e s , and judgments a f f i r m e d i n common m o r a l i t y ( I b i d . ) . Quoting from a l l three e d i t i o n s of P r i n c i p l e s of  Biomedical E t h i c s , Jonsen t r a c e s the authors' deepening doubt about whether any e t h i c a l theory s a t i s f i e s a l l of the above t e s t s . By the t h i r d e d i t i o n , they are reduced t o the view t h a t "[e]ven i f no e t h i c a l theory s a t i s f i e d a l l of these t e s t s --and we t h i n k no c u r r e n t l y a v a i l a b l e theory does—we can l e g i t i m a t e l y appeal to them..." (Beauchamp 1989, 14). I t i s extremely unfortunate t h a t Beauchamp and C h i l d r e s s never e x p l a i n what they mean by saying t h a t an e t h i c a l theory i s "adequate." Perhaps by "adequate" they simply mean t h a t the theory has passed a l l of t h e i r f i v e t e s t s . Be t h a t as i t may, what are the i m p l i c a t i o n s of t h e i r 58 a d m i s s i o n t h a t no c u r r e n t l y a v a i l a b l e e t h i c a l t h e o r y s a t i s i f i e s a l l o f t h e i r t e s t s ? Beauchamp and C h i l d r e s s r e l y on e i t h e r a u t i l i t a r i a n o r d e o n t o l o g i c a l t h e o r y t o defend t h e i r p r i n c i p l e s . As t h e y argue, "fej ach t y p e o f t h e o r y o f f e r s an i m p o r t a n t moral p e r s p e c t i v e from which we s t a n d t o l e a r n , and t h e r e i s no r e a s o n why o n l y one t y p e o f t h e o r y must be s e l e c t e d as preeminent" (Beauchamp 1989, 4 7 ) . But i f n e i t h e r o f t h e s e k i n d s o f e t h i c a l t h e o r y (nor any o t h e r ) i s adequate, then how w e l l - d e f e n d e d a r e t h e p r i n c i p l e s of b i o m e d i c a l e t h i c s ? With p o o r l y , o r even undefended p r i n c i p l e s , one's moral r u l e s l a c k j u s t i f i c a t i o n . F a i l i n g t o j u s t i f y one's moral r u l e s r e s u l t s i n u n j u s t i f i e d d e c i s i o n s . Perhaps, the s o l u t i o n t o t h i s problem w i l l be found a f t e r n o r m a t i v e e t h i c a l t h e o r i e s e v o l v e t o a more s o p h i s t i c a t e d l e v e l . W h i l e some p h i l o s o p h e r s f a v o u r t h i s view (e.g. R a w l s ) , i n c r e a s i n g numbers a r e a d o p t i n g an a n t i - t h e o r y s t a n c e . I f no adequate e t h i c a l t h e o r y i s ever p o s s i b l e , then approaches v e r y d i f f e r -ent from the paradigm a r e r e q u i r e d . In t h e next c h a p t e r , the a n t i - t h e o r y p o s i t i o n w i l l be b r i e f l y o u t l i n e d i n o r d e r t o d e c i d e which, i f any, r e s o u r c e s p h i l o s o p h y can l e g i t i -m a tely o f f e r m e d i c i n e t o a i d i t s d e t e r m i n a t i o n of what s h o u l d be done. CHAPTER 5 ANTI-THEORY Modern moral p h i l o s o p h e r s have mainly focused on a s i n g l e g o a l : to come up with a theory t h a t o f f e r s u n i v e r s a l p r i n c i p l e s t h a t apply s y s t e m a t i c a l l y to p a r t i c u l a r cases. This was, of course, the goal Beauchamp and C h i l d r e s s were s t r i v i n g f o r when they developed t h e i r paradigm. I n c r e a s i n g numbers of p h i l o s o p h e r s , however, have broken away from t h i s venture and have begun to focus a t t e n t i o n i n s t e a d on "forms of moral conservatism t h a t regard l o c a l moral p r a c t i c e s as primary i n moral reasoning" (Clarke 1989, 1). Rather than busying themselves with a b s t r a c t p r i n c i p l e s which seem to have so l i t t l e r e l e v a n c e to concrete problems, more and more p h i l -osophers are devoting t h e i r a t t e n t i o n to the context i n which moral problems a r i s e . Although there are s e v e r a l f a c e t s of the " a n t i - t h e o r y movement," each of which has i t s own unique approach and c r i t -i c i s m s , there are a number of u n i f y i n g f e a t u r e s t h a t g i v e the movement i t s coherence. F i r s t and foremost of these i s t h e i r divergence from the f o l l o w i n g understanding of m o r a l i t y . j^ Some ph i l o s o p h e r s 3 seek to a r t i c u l a t e normative t h e o r i e s t h a t can guide our behavior by s y s t e m a t i z i n g and extending our moral judgments. These judgments... can be thought of as consequences of a p p l y i n g a b s t r a c t p r i n c i p l e s i n an almost computational way, g i v i n g a procedure f o r deducing the m o r a l l y c o r r e c t answer i n any given circumstances. The dominant conception of m o r a l i t y they r e p r e s e n t r e q u i r e s i t to i d e n t i f y u n i v e r a l l y b i n d i n g p r i n c i p l e s which govern a l l r a t i o n a l persons ( I b i d . 2). Adherents to the a n t i - t h e o r y movement r e j e c t r a t i o n a l i s m of t h i s s o r t , and, i n s t e a d , c l a i m t h a t very d i f f e r e n t ways of moral reasoning are r e q u i r e d . While they can acknowledge the u n d e r l y i n g motive f o r seeking p r i n c i p l e s (to have good reasons f o r one's a c t i o n s ) , they can a l s o take i s s u e with the i n d e n t i -f i c a t i o n of these reasons. In t h e i r r e j e c t i o n of a b s t r a c t p r i n c i p l e s (which are, i t i s argued, inadequate i n p r a c t i c a l a p p l i c a t i o n s ) , a n t i - t h e o r i s t s aren't thereby committed t o s k e p t i c i s m about the r a t i o n a l i t y of moral p r a c t i c e , because they i n s i s t t h a t other conceptions of moral reasoning are a v a i l a b l e (Hampshire 1989, 140). While c o n s i d e r i n g the case presented by the a n t i -t h e o r i s t s , i t i s important to keep i n mind t h a t most p h i l o s o p h -ers who o f f e r e t h i c a l t h e o r i e s wouldn't c l a i m t h a t t h e i r p r i n c i p l e s can be a p p l i e d i n an almost computational way. As Arras notes, the a p p l i e d e t h i c s paradigm (at l e a s t i n i t s deductive-computational v e r s i o n ) "represents nothing more than a straw man" (1986, 21). Arras claims t h a t [t]here may...be a few w r i t e r s i n t h i s f i e l d who would be w i l l i n g to stand under the shakey banner of deductivism, but the vast m a j o r i t y appear to em-ploy a much more complicated and s o p h i s t i c a t e d method of a p p l y i n g p r i n c i p l e s to cases ( I b i d . ) . Of p a r t i c u l a r i n t e r e s t t o us i n t h i s chapter, are the a l t e r n a t e conceptions of m o r a l i t y t h a t have emerged from the a n t i - t h e o r i s t viewpoint. These a l t e r n a t i v e s o f t e n i n v o l v e a negative c h a r a c t e r i z a t i o n . The e x p r e s s i o n " a n t i - t h e o r y " emphasizes o p p o s i t i o n 61 to any a s s e r t i o n (whether i n the form of a substan-t i v e moral p r i n c i p l e or a m e t a - e t h i c a l theory about the nature of moral claims) t h a t m o r a l i t y i s r a t i o n a l only i n s o f a r as i t can be formulated i n , or grounded on, a system of u n i v e r s a l p r i n c i p l e s . I t a l s o denies t h a t the i n t e l l e c t u a l v i r t u e s of t h e o r i z i n g , such as u n i v e r s a l i t y , e x p l i c i t n e s s , c o n s i s t e n c y , and complete-ness, are e s s e n t i a l to the moral l i f e ( C l arke 1989, 2 - 3 ) . As we s h a l l see l a t e r i n the chapter, broader o p t i o n s are a v a i l a b l e to r a t i o n a l i s t s who are w i l l i n g to drop the c o n s i s t e n c y requirement. The a l t e r n a t i v e s then o f f e r p o s i t i v e accounts of moral-i t y i n terms of custom and p r a c t i c e , and i n a manner t h a t i s both normative and d e s c r i p t i v e . Moral r a t i o n a l i t y i s c h a r a c t e r -i z e d i n terms of c r i t i c a l r e f l e c t i o n which r e c e i v e s no support from f i r s t p r i n c i p l e s of any k i n d (Williams 1989, 7 8 ) . In o p p o s i t i o n to the dominant r a t i o n a l i s t paradigm, a n t i - t h e o r i s t s emphasize two f e a t u r e s of m o r a l i t y : 1. A c o n t e x t u a l i s m t h a t favours s p e c i f i c r a t i o n a l e s f o r p a r t i c u l a r cases and s t r e s s e s the ways i n which the p r a c t i c e s of a community determine the meaning and a p p r o p r i a t e n e s s of d e l i b e r a t i o n and a p p r a i s a l . No a p p l i c a t i o n of u n i v e r s a l l y v a l i d p r i n c i p l e s i s r e q u i r e d . 2. A p l u r a l i s m t h a t d e r i v e s from the way i n which prac-t i c e s determine conceptions of goods. Conceptions vary among communities and there are a p l u r a l i t y of p r a c t i c e s w i t h i n each community (each c o n t a i n i n g i t s own ends) (Clarke 1989, 3 ) . A n t i - t h e o r i s t s a l s o s t r e s s t h a t there are s e v e r a l goods and t h a t they a r e n ' t r e d u c i b l e to a s i n g l e good (e.g. u t i l i t y ) . In a d d i t i o n , such p l u r a l i s m about goods permits the acceptance of p r i n c i p l e s t h a t are n e u t r a l between competing conceptions of the good (Hampshire 1989, 1 5 4 - 1 5 7 ) . Of most importance, however, i s the a n t i - t h e o r i s t s ' i n s i s t a n c e t h a t m o r a l i t y i s 62 p r i m a r i l y concerned with the p a r t i c u l a r v i r t u e s of p a r t i c u l a r c u l t u r e s — t r a i t s of behaviour whose s a n c t i o n has nothing to do with u n i v e r s a l p r i n c i p l e s (McDowell 1 9 8 9 , 9 3 ) . An impor-t a n t q u e s t i o n t h a t ought to be d e a l t with by the a n t i - t h e o r -i s t s i s whether c u l t u r a l values are immune to c r i t i c i s m ? I f they hold t h a t they are immune, much of the i n i t i a l p l a u s i b i l i t y of t h e i r view i s soon d i m i n i s h e d . C l e a r l y , the values of some c u l t u r e s w i l l not remain i n t a c t a f t e r c a r e f u l , r a t i o n a l c r i t i c i s m . What Do the A n t i - T h e o r i s t s Have A g a i n s t Theory? I t i s time to examine i n more d e t a i l the a n t i - t h e o r i s t s ' r e j e c t i o n of normative theory. Any or a l l of three reasons are commonly o f f e r e d f o r t h i s r e j e c t i o n : normative theory i s unnecessary, u n d e s i r a b l e , or i m p o s s i b l e . However, because the use of "normative theory" i n the l i t e r a t u r e i s not very p r e c i s e , i t i s sometimes d i f f i c u l t to assess the success of c e r t a i n c r i t i c i s m s . Two conceptions of normative theory have become widely accepted by moral p h i l o s o p h e r s : a r a t i o n a l i s t i c form-u l a t i o n (e.g. c o n t r a c t u a l i s t and u t i l i t a r i a n accounts) and, what may be b e t t e r regarded as a methodology, the conception advanced by Rawls ( v i z . r e f l e c t i v e e q u i l i b r i u m ) . On some oc c a s i o n s , a n t i - t h e o r i s t s are c l e a r l y a t t a c k i n g such p o s i t i o n s ; but on others they seem to be attempting to r e f u t e "any set of claims t h a t c o u l d s e n s i b l y be s a i d to c o n s t i t u t e a 'theory'" (Clarke 1 9 8 9 , 4 ) . Be t h a t as i t may, l e t us examine some of the a n t i -63 t h e o r i s t s ' b a s i c arguments a g a i n s t r a t i o n a l i s t moral theory. Normative theory i s intended to systematize the j u s t i f i c a t i o n of moral a c t i o n s and p r a c t i c e s . That r a t i o n a l i s t moral theory can't achieve t h i s (because of i t s own t h e o r e t i c a l r e q u i r e -ments) i s suggested by three main c r i t i c i s m s . In f a c t , some a n t i - t h e o r i s t s deny t h a t the r a t i o n a l i s t s even succeed i n producing a theory. But the three main c r i t i c i s m s are as f o l l o w s : 1. The semantic f e a t u r e s r e q u i r e d of p r i n c i p l e s by r a t i o n a l i s t theory are incompatible with those of norms as they f u n c t i o n i n moral p r a c t i c e s ( I b i d . 5). (This c r i t i c i s m i s h i g h l y confused and obscure. C l a r k e and Simpson would have done b e t t e r to have focused t h e i r a t t e n t i o n on the problems of a p p l i c a t i o n of p r i n c i p l e s . Other p h i l o s o p h e r s draw a t t e n t i o n to the f a c t t h a t t h i s c r i t i c i s m i s not supported with very s u b s t a n t i a l argumentation.) 2. A r a t i o n a l i s t theory r e q u i r e s an account of the v i r -tues which i s incompatible with the f e a t u r e s they a c t u a l l y e x h i b i t ( I b i d . 6 ) . 3. Moral p r a c t i c e s e x h i b i t irremovable c o n f l i c t s and dilemmas t h a t confound r a t i o n a l i s t t h e o r i e s ( I b i d . 8 ) . Let us b r i e f l y c o n s i d e r each of these i n t u r n i n order to o b t a i n g r e a t e r f a m i l i a r i t y with the a n t i - t h e o r y movement. The f i r s t c r i t i c i s m attempts to show t h a t the vast semantic d i s t a n c e between p r i n c i p l e s and norms c r e a t e s a s e r i o u s problem f o r normative theory because the gap r e v e a l s t h a t p r i n c i p l e s are u s e l e s s i n t h e i r purported j u s t i f y i n g r o l e (Baier 1989, 34) . U n l i k e norms, which are i n t e r p r e t e d by d i f f i c u l t - t o - s p e c i f y r u l e s of background i n s i t u t i o n s and ways of l i f e , p r i n c i p l e s must be d e f i n i t e i n t h e i r meaning " i n order f o r them to play t h e i r r o l e i n the deduction of p a r t i c u l a r moral judgments" ( I b i d . 5). Norms, on the other hand, have to be vague i n order t o guide d a i l y conduct. As Annette B a i e r argues, moral i n j u n c t i o n s l i k e "Don't s t e a l " have t o be enmeshed i n a .network of c u l t u r a l assumptions i f they are to a c t u a l l y p r o h i b i t anything ( I b i d . ) . I t i s impor-t a n t t o remember, however, t h a t i f norms are too vague, they w i l l have l i t t l e value as a means of g u i d i n g one's conduct. In a d d i t i o n , i t seems reasonable to hold t h a t p r i n c i p l e s are much more complex than they appear t o be on the s u r f a c e because they take account of these c u l t u r a l assumptions. F i n a l l y , i t i s hard to see how r e l i a n c e on norms would be h e l p f u l s i n c e the v i r t u e of norms as opposed to p r i n c i p l e s i s supposed to be the vagueness of norms, and i t ' s d i f f i c u l t to see how vagueness can help. I f one i n s t e a d throws i n c u l t u r a l assumptions, then the p r i n c i p l e s become more complex, which i s acc e p t a b l e ; how-ever, t h a t i s not to r e p l a c e p r i n c i p l e s with norms nor to supplement p r i n c i p l e s with norms. One should a l s o not f o r g e t t h a t the c u l t u r a l assumptions are open to c r i t i c i s m , even though one may be i n c l i n e d to place the onus on the c r i t i c . The semantic d i s t a n c e between a b s t r a c t p r i n c i p l e s and concrete ways of l i f e a l s o prevents the r a t i o n a l i s t s from using theory to generate c o r r e c t answers independently of any r e l i a n c e on norms (Clarke 1989, 5-6). Unless one invokes the i n t e r p r e t i v e background of c u l t u r a l i n s t i t u t i o n s and moral p r a c t i c e s , one's p r i n c i p l e s won't y i e l d d e f i n i t e c o n c l u s i o n s . Some r a t i o n a l i s t p h i l o s o p h e r s have acknowledged the semantic d i s t a n c e , but have claimed t h a t normative p r i n c i p l e s 65 j u s t i f y the norms of moral p r a c t i c e s , thus p r o v i d i n g i n d i r e c t j u s t i f i c a t i o n f o r the moral judgments conforming to these norms. T h i s approach i s much l i k e Rawl 1s wide r e f l e c t i v e e q u i l i b r i u m methodology, one of the most popular v e r s i o n s of moral theory b u i l d i n g today. T h i s response won't work, however, s i n c e an appeal to p r i n c i p l e s won't j u s t i f y the background i n s t i t u t i o n s and c u l t u r a l e x p e c t a t i o n s t h a t shape the norms. I f one attempts to j u s t i f y the background i n t e r -p r e t a t i o n s with e x p l i c i t p r i n c i p l e s , one w i l l s t i l l be faced with the problem of j u s t i f y i n g the background i n t e r p r e t a t i o n s f o r these p r i n c i p l e s and so on. In the end, s i n c e one can't c l o s e the gap between what can be j u s t i f i e d by appeal to ex-p l i c i t p r i n c i p l e s and what i s c o n t r i b u t e d to norms through i n t e r p r e t a t i o n , i t f o l l o w s t h a t "a r a t i o n a l i s t f o r m u l a t i o n of normative p r i n c i p l e s cannot f u n c t i o n to f u l l y j u s t i f y the norms of moral p r a c t i c e " ( I b i d . 6). In some cases, the semantic d i f f e r e n c e between p r i n c i p l e s and norms i s denied because i t i s claimed t h a t the l a t t e r must a l s o be p r e c i s e ( I b i d . ) . T h i s f i n a l approach a l s o f a i l s s i n c e both norms and p r i n c i p l e s would be too a b s t r a c t to be a p p l i e d e f f e c t i v e l y . Without r e f e r e n c e to the background i n s t i t u t i o n s and ways of l i f e which shape t h e i r meaning, norms and p r i n c i p l e s aren't able to serve i n deductive j u s t i f i c a t i o n s . The f e a t u r e s t h a t r a t i o n a l i s t s r e q u i r e of p r i n c i p l e s make them unable to j u s t i f y moral p r a c t i c e s , and i n t h i s sense r a t i o n a l i s t normative theory i s not theor-e t i c a l l y p o s s i b l e . Conventional p r a c t i c e s a r i s e from s o c i a l h i s t o r y and agreement; no other s a n c t i o n i s needed... ( I b i d . ) . The second argument attem p t s t o show t h a t the r a t i o n a l -i s t account o f moral language i n v o l v e s a l i m i t e d and i n a c c u r -a t e account o f moral p r a c t i c e s . In t h e i r attempt t o d e a l w i t h the l a c k of c o n n e c t i o n between u n i v e r s a l p r i n c i p l e s and many terms i d e n t i f y i n g v i r t u e s , r a t i o n a l i s t s c l a i m t h e s e terms a r e c u l t u r a l l y s p e c i f i c and m o r a l l y i r r e l e v a n t . But t h i s s t r a t e g y c r e a t e s more problems than i t s o l v e s , f o r s t a t e m e n t s of c h a r -a c t e r assessment a r e v i t a l i n e x p r e s s i o n s o f moral concern ( B a i e r 1985, 214). B e s i d e s , because v i r t u e s impose s i g n i f i c a n t o b l i g a t i o n s on us much l i k e t h e "oughts" do, r a t i o n a l i s t s c a n ' t s i m p l y d i s m i s s them i f t h e y pose d i f f i c u l t i e s (McDowell 1989, 101-104). I t i s i m p o r t a n t not t o f o r g e t the s i g n i f i c a n t n o r m a t i v e c h a r a c t e r o f much o f our o r d i n a r y speech. To i g n o r e or deny i t i s t o pursue p h i l o s o p h y i n a way t h a t i s o b l i v i o u s t o what i s a c t u a l l y the c a s e . B a i e r c l a i m s t h a t many v i r t u e s f u n c t i o n i n d e p e n d e n t l y of p r i n c i p l e s and a r e , i n f a c t , " i n h o s p i t a b l e t o them" (1989, 7 ) . She c l a i m s t h a t when we a i d someone i n d i s t r e s s we a r e not g u i d e d by p r i n c i p l e s t h a t we know i n advance of t h e c r i s i s . I n s t e a d , we e n t e r the s i t u a t i o n w i t h good i n t e n t i o n s and our response i s shaped by the c i r c u m s t a n c e s of t h e case (e.g. the v i c t i m ' s i n g r a t i t u d e , t h e o n l o o k e r ' s p a r t i c i p a t i o n , e t c . ) . S i n c e c i r c u m s t a n c e s and i n d i v i d u a l s v a r y enormously, i t i s not p o s s i b l e t o a p p l y a b s t r a c t r u l e s b e forehand t o determine how one s h o u l d behave. I t i s i m p o r t a n t t o n o t e , however, t h a t B a i e r f a i l s t o d i s t i n g u i s h t h e problem o f p r e d i c t i n g how an i n d i v i d u a l w i l l behave i n such a case from t h e problem o f 67 determining how an in d i v i d u a l should behave. Of course, only the l a t t e r i s relevant for our purposes. As for ingratitude, one can have p r i n c i p l e s dealing with that and also for the role of the onlookers. Naturally, there i s a l i m i t to just how many pr i n c i p l e s any t y p i c a l person can learn and apply e f f e c t i v e l y . Perhaps, Baier would have made a better case i f she had claimed that i n many circumstances one doesn't have a l o t of time to remember p r i n c i p l e s . S i m i l a r l y , trying to decide which single principle—assuming one i s burdened with many—is the one upon which one should act may not always be very simple i f a number of them seem appropriate. What follows from Baier's example i s the view that there are virtuous practices which can't be stated in terms of pri n c i p l e s (Ibid.). Since r a t i o n a l i s t s are unable to include actions j u s t i f i e d only by the virtues expressed by t h e i r per-formance, they can't provide a complete theory of the virtues without a r b i t r a r i l y excluding some as i r r e l e v a n t to r a t i o n a l moral behaviour and reasoning (Ibid. 8 ) . The t h i r d argument i s meant to show that the r a t i o n a l i s t theories can't handle the c o n f l i c t s and dilemmas that commonly arise from moral practices. Since practices involve norms that lead to mutually incompatible obligations (e.g. the King of Jordan's r e s p o n s i b i l i t i e s to both the survival of his people and the Palestinian cause), c o n f l i c t i s an unavoidable conseq-uence . Once we begin to think of morality in terms of practices and virtues rather than cal c u l a t i o n and deduction from 68 p r i n c i p l e s , there i s no reason to expect r e c o n c i l -a b i l i t y to be b u i l t i n t o moral thought i n advance (Clarke 1989, 8). Support f o r t h i s view i s o f f e r e d by S t u a r t Hampshire's c l a i m t h a t c o n f l i c t can be r e l a t e d t o the c o n v e n t i o n a l s t a t u s of much of m o r a l i t y (1989, 150). While f o r example the r e -quirements of j u s t i c e and benevolence can be p a r t i a l l y ground-ed i n u n i v e r s a l f e a t u r e s of human nature, he observes t h a t c e r t a i n norms d e r i v e from h i s t o r i c a l l y s p e c i f i c ways of un-ders t a n d i n g human needs and c a p a c i t i e s ( I b i d . ) . The upshot of t h i s s p e c i f i c i t y i s t h a t the p l u r a l i t y of conventions i n any s o c i e t y means the p o s s i b i l i t y of c o n f l i c t t h a t can't be r e s o l v e d by r a t i o n a l p r i n c i p l e s . What f o l l o w s from t h i s l i n e of argument i s t h a t r a t i o n a l i s t normative theory makes demands of m o r a l i t i e s t h a t can't be met. One response to t h i s i s to hold t h a t m o r a l i t i e s with c o n f l i c t i n g p r i n c i p l e s should be modified to avoid the c o n f l i c t . The a n t i - t h e o r i s t s seem to hold t h a t such a response i s auto-m a t i c a l l y r u l e d out, but s u b s t a n t i a l arguments are needed to support t h i s view. In a d d i t i o n , a s o p h i s t i c a t e d form of r u l e u t i l i t a r i a n i s m might hold t h a t the most b e n e f i c i a l s o r t of m o r a l i t y would have f a i r l y s p e c i f i c r u l e s and t h a t the p r i c e one must pay f o r t h a t i s the p o s s i b i l i t y of c o n f l i c t between some of the r u l e s . In t h a t case, one would have a theory t h a t d i d n ' t s a c r i f i c e an advantage that i s claimed to be incompatible with t h e o r i e s . If one accepts the c o n c l u s i o n s of the three arguments j u s t c o n s i d e r e d , i t i s n ' t necessary t o become an advocate of i r r a t i o n a l i s m . C l e a r l y , i f p h i l o s o p h e r s were to recommend i r r a t i o n a l i s m t o p h y s i c i a n s , the l a t t e r might j u s t as w e l l d i s m i s s philosophy and go buy a pack of t a r o t cards. But i f one denies the l e g i t i m a c y of r a t i o n a l i s t t h e o r i e s and p r i n -c i p l e s , what s o r t of moral reasoning i s p o s s i b l e ? In the next chapter, we w i l l examine c a s u i s t r y , a method of e t h i c s t h a t r e c e n t l y has d e a l t s u c c e s s f u l l y with c e r t a i n s u b s t a n t i v e problems of biomedicine. CHAPTER 6 THE CONVALESCENCE OF CASUISTRY In l i g h t of the d i f f i c u l t i e s c o n f r o n t i n g e t h i c a l theory and other p h i l o s o p h i c a l resources (the s u b j e c t of the l a s t two c h a p t e r s ) , i t i s not s u r p r i s i n g t h a t some p h i l o s o p h e r s have urged a change of focus from a b s t r a c t matters of theory to concrete i s s u e s of p r a c t i c e . As a r e s u l t of t h e i r exper-iences with the N a t i o n a l Commission f o r the P r o t e c t i o n of Human Subjects of Biomedical and B e h a v i o r a l Research (1975 to 1978), A l b e r t Jonsen and Stephen Toulmin became convinced of the need to r e h a b i l i t a t e the p r a c t i c a l r e s o l u t i o n of p a r t i c u l a r moral p e r p l e x i t i e s , or "cases of conscience" (Jonsen 1988, 13). This approach i s more commonly r e f e r r e d to as " c a s u i s t r y . " Despite the f a c t t h a t B l a i s e P a s c a l thoroughly d e n i g r a t e d cas-u i s t r y i n the seventeenth century, more and more p h i l o s o p h e r s have come to see c o n s i d e r a b l e merit i n i t . To see why t h i s i s so, we w i l l b r i e f l y c o n s i d e r the a c t i v i t i e s and successes of the commission. Next, we w i l l examine Jonsen's and Toulmin's account of c a s u i s t r y so t h a t we may assess i t s value f o r b i o -medicine (chapter seven). The Commission: Success At Las t The commission was e s t a b l i s h e d i n response to c e r t a i n un-s e t t l i n g press r e p o r t s about o b j e c t i o n a b l e experiments on human 70 71 f e t u s e s i n Scandinavia and on r u r a l b lack men i n Tuskegee, Alabama ( I b i d . 16 ) . Because of the p o s s i b i l i t y of t e r r i b l e abuses of experimental s u b j e c t s , the commission was t o l d t o review f e d e r a l r e g u l a t i o n s ( i n the U.S.) about r e s e a r c h to ensure t h a t the s u b j e c t s ' r i g h t s and w e l f a r e were p r o t e c t e d . The commission a l s o examined the e t h i c a l i s s u e s r e l e v a n t to r e s e a r c h i n v o l v i n g p r i s o n e r s , c h i l d r e n , the mentally d i s a b l e d , and human f e t u s e s . T h e i r goal was to produce ge n e r a l s t a t e -ments of e t h i c a l p r i n c i p l e t h a t would o f f e r guidance i n the f u t u r e development of biomedical and b e h a v i o r a l r e s e a r c h ( I b i d . 17) . In response to these c h a l l e n g e s , the commissioners came to r e a l i z e t h a t they had to begin w i t h i n the context of the kinds of r e s e a r c h and the d e t a i l s of the p a r t i c u l a r cases. I t i s important to p o i n t out, however, t h a t the e t h i c a l p r i n -c i p l e s the commission uses and supports are those of the para-digm theory. In f a c t , Beauchamp and C h i l d r e s s c l a i m t h a t the Commission Reports are a v i n d i c a t i o n of t h e i r work. As f a r as the new c a s u i s t s are concerned, . . . e t h i c a l p r i n c i p l e s t u r n out to be nothing more than summaries of meanings a l r e a d y embedded i n our a c t u a l p r a c t i c e s . Rather than s e r v i n g as a j u s t i f i c a t i o n f o r c e r t a i n p r a c t i c e s , p r i n c i p l e s w i t h i n the new c a s u i s t r y merely r e p o r t i n summary f a s h i o n what we have a l r e a d y decided (Arras 1986, 43) . A r i s t o t l e , Jonsen and Toulmin c l a i m , i s the key to under-standing why the commissioners' approach evolved as i t d i d . Far from being based on general a b s t r a c t p r i n c i p l e s t h a t can at one and the same time be u n i v e r s a l , i n -v a r i a b l e , and known with c e r t a i n t y . . . , e t h i c s deals with a m u l t i t u d e of p a r t i c u l a r concrete s i t u a t i o n s , 72 which are themselves so variable that they r e s i s t a l l attempts to generalize about them i n universal terms (Ibid. 19). It i s d i f f i c u l t to see how Jonsen and Toulmin can reconcile the previous quote with the fact that they r e l y on the p r i n c i p l e s of biomedical ethics. Either the p a r t i c u l a r p r i n -c i p l e applies to a l l cases of a p a r t i c u l a r kind or i t doesn't. A given p r i n c i p l e won't apply to irr e l e v a n t cases, but i t w i l l apply to any and a l l cases that are appropriate. We w i l l examine further d i f f i c u l t i e s with the casuists' methods in the next chapter. For the moment, l e t us explore t h e i r a-pproach in more d e t a i l . Most e f f e c t i v e as a means of c l a s s i f y i n g the morally relevant s i m i l a r i t i e s and differences between the various kinds of research was an approach that u t i l i z e d moral taxon-omies. Their reliance on moral taxonomies, Jonsen and Toulmin i n s i s t , was "one c r u c i a l factor in the commission's a b i l i t y to agree on recommendations about s p e c i f i c types of cases" (Ibid. 44). New and problematic types of cases were subjected to analogical reasoning i n an e f f o r t to f i t them into a taxonomy. The commissioners appealed to understood and accepted paradigms in order to decide how to handle the unfamiliar and d i f f i c u l t . Thus, "they developed a 'casuistry' of biomedical and behav-i o r a l research using shared c r i t e r i a by which to discriminate among research projects of morally d i s t i n c t kinds" (Ibid. 265). Even though each of the commissioners d i f f e r e d from every other in certain important respects (race, r e l i g i o n , gender, profession, e t c . ) , the commission produced concrete r e s u l t s . To do so, they had to come to agreement on how to r e s o l v e p r a c t i c a l i s s u e s . T h i s was a r e a l p o s s i b i l i t y p r ovided the commissioners remained at the l e v e l of taxonomy. what are the important f e a t u r e s of c a s u i s t r y t h a t permit i n d i v i d u a l s from a d i v i s i v e s o c i e t y to come to c l o s e agreement? M o r a l i t y f o r the P r a c t i c a l l y - I n c l i n e d That c a s u i s t r y has begun to i n t e r e s t more and more p h i l -osophers i s n ' t s u r p r i s i n g . Jonsen and Toulmin c l a i m t h a t when i t i s w e l l - d i r e c t e d i t "remains the s i n g l e most powerful t o o l of p r a c t i c a l a n a l y s i s i n e t h i c s " ( I b i d . 16). They d e f i n e " c a s u i s t r y " as being jt]he a n a l y s i s of moral i s s u e s , using procedures of reason-in g based on paradigms and a n a l o g i e s , l e a d i n g to the form-u l a t i o n of expert o p i n i o n s about the e x i s t e n c e and s t r i n -gency of p a r t i c u l a r moral o b l i g a t i o n s , framed i n terms of r u l e s t h a t are g e n e r a l but not u n i v e r s a l or i n v a r i a b l e , s i n c e they hold good with c e r t a i n t y only i n the t y p i c a l c o n d i t i o n s of the agent and circumstances of a c t i o n ( I b i d . 257). Let us examine i n more d e t a i l the v a r i o u s elements of the c a s u i s t s ' method so as to b e t t e r a p p r e c i a t e the kind of moral reasoning Jonsen and Toulmin are a d v o c ating. Since the c a s u i s t s wrote very l i t t l e about t h e i r method, i t i s necessary to i n f e r i t from t h e i r p r a c t i c e ( I b i d . 251). The c a s u i s t s r e l i e d on the Ten Commandments or the Seven Deadly Sins to d i s t i n g u i s h one type of case from another. One can reasonably c l a i m t h a t these p r i n c i p l e s were f o r the a n c i e n t c a s u i s t s what the p r i n c i p l e s of b i o m e d i c a l e t h i c s have become f o r the new c a s u i s t s . The former p o s i t i o n e d t h e i r types of cases i n o r d e r l y taxonomies, ones t h a t r e f l e c t e d the connec-74 t i o n between a s p e c i f i c k i n d of case and a given p r i n c i p l e . For each of these kinds of cases, they c o n s t r u c t e d a paradigm case t h a t was meant to be a c l e a r i n d i c a t i o n of what was a t i s s u e ( I b i d . ) . For each paradigm case, they c o n s t r u c t e d a s e r i e s of cases such t h a t each s u c c e s s i v e case i n the s e r i e s bore l e s s s i m i l a r i t y to the paradigm. T h i s d i s s i m i l a r i t y i n c -reased i n d i r e c t p r o p o r t i o n to the a l t e r a t i o n of the circum-stances and motives surrounding the case, with the r e s u l t t h a t the o f f e n s e became l e s s apparent as one moved away from the paradigm. T h i s gradual movement from c l e a r and simple cases to the more complex and obscure ones was standard pro-cedure f o r the c a s u i s t ; indeed, i t might be s a i d to be the essence of the c a s u i s t i c mode of t h i n k i n g ( I b i d . 252). To decide, f o r example, i f a woman's k i l l i n g her abusive husband i s m o r a l l y o f f e n s i v e r e q u i r e s f i n d i n g the r e l e v a n t paradigm ( k i l l i n g i n s e l f - d e f e n s e , perhaps) and d e c i d i n g how d i f f e r e n t t h i s p a r t i c u l a r case i s from the paradigm. To make t h i s judgment about the two cases, one f a c t o r s i n the r e l e v a n t circumstances and motives, and then reasons by analogy. The c a s u i s t s used general moral p r i n c i p l e s to c l a s s i f y cases (e.g. the p r i n c i p l e s of biomedical e t h i c s ) ; however, they used moral maxims to b o l s t e r t h e i r arguments p e r t a i n i n g to s p e c i f i c cases. Numerous sources provided many maxims con-s i d e r e d s u i t a b l e f o r the d i v e r s i t y of cases encountered. Commonly, the B i b l e , t h e o l o g i c a l w r i t i n g s , and the c l a s s i c s ( C i c e r o , V i r g i l , e t c .) were depended on to provide support f o r the c a s u i s t s ' arguments ( I b i d . 253). Foremost among the elements of the c a s u i s t s ' approach to moral reasoning was the n o t i o n t h a t circumstances c r e a t e the case and n e a r l y always modify moral judgment about i t . I f we vary a few circumstances i n a case, we may no longer be c o n f i d e n t t h a t a given moral o f f e n s e has o c c u r r e d or we may decide t h a t the o f f e n s e i s reduced f o r one reason or another ( I b i d . 254). As Toulmin observes, [JpJ r a c t i c a l reasoning i n e t h i c s . . . i s a matter of jud-gment, of weighing d i f f e r e n t c o n s i d e r a t i o n s a g a i n s t one another, never a matter of formal t h e o r e t i c a l deduction from s t r i c t or s e l f - e v i d e n t axioms. I t i s a task l e s s f o r the c l e v e r arguer than f o r the anthropos megalopsychos, the " l a r g e - s p i r i t e d human being" (Toulmin 1981, 37). Making such judgments about the r e l e v a n c e and s i g n i f -i c a n ce of circumstances r e q u i r e s c o n s i d e r a b l e experience, and impressive powers of i m a g i n a t i o n . A l s o important are the sympathy and empathy one f e e l s i n one's d e a l i n g s with o t h e r s . In a c r u c i a l sense, then, to be a moral expert of c a s u i s t r y r e q u i r e s f a r more than a graps of a b s t r a c t t h e o r i e s and p r i n -c i p l e s . Of f a r more value are the i n s i g h t s and understanding one can b r i n g to bear i n case s t u d i e s . Whether p h i l o s o p h e r s w i l l be b e t t e r at t h i s than others i s moot. Another i n t e r e s t i n g f e a t u r e of the c a s u i s t s ' method i s t h e i r q u a l i f i c a t i o n of the p r o b a b i l i t y of the c o n c l u s i o n s o f f e r e d f o r v a r i o u s cases. While the c o n c l u s i o n s f o r the paradigm are c e r t a i n , those f o r cases more remote from the paradigms became much l e s s c e r t a i n . The f a r t h e r one moved away from the paradigm (a case f o r which there was wide-76 spread agreement), the g r e a t e r the divergence of views about the case (Jonsen 1988, 254). P l a u s i b l e arguments f o r v a r i o u s o p i n i o n s about the case o f t e n came from a number of c a s u i s t s . These c o u l d only be assessed i n terms of t h e i r i n t r i n s i c argu-ments and e x t r i n s i c a u t h o r i t y . In other words,. both how the o p i n i o n was argued f o r and who o f f e r e d i t were con s i d e r e d r e l e v a n t to i t s p r o b a b i l i t y . Jonsen and Toulmin c l a i m t h a t [t]he movement from paradigm through a n a l o g i e s , marked by s l i g h t l y v a r y i n g i n t e r p r e t a t i o n s of accepted max-ims, as a p p l i e d to d i f f e r i n g circumstances, gave the c a s u i s t s a r e f i n e d s e n s i t i v i t y to the m a n i f o l d ways i n which cases d i f f e r e d from one another ( I b i d . 255). Since the c a s u i s t s weren't r e l y i n g on a g e o m e t r i c a l l y p r e c i s e deductive system, the support f o r t h e i r o p i n i o n s came as a r e s u l t of the accumulation of reasons. C a s u i s t s would o f f e r as many good reasons of d i v e r s e kinds as was deemed necessary to i n c r e a s e the p r o b a b i l i t y of t h e i r c o n c l u -s i o n s . They d i d n ' t t r y to i n t e g r a t e the support f o r t h e i r views i n t o coherent arguments; i n s t e a d , they were content to merely sketch the shape of the r e l e v a n t c o n s i d e r a t i o n s ( I b i d . ) . When someone wanted to know what to do, she assessed the q u a l i t y of the i n t r i n s i c arguments i n favour of v a r i o u s o p t i o n s , and took n o t i c e of who o f f e r e d them, s i n c e both of these de-termined the p r o b a b i l i t i e s of the o p i n i o n s . I n t e r e s t i n g l y enough, the d o c t r i n e of p r a b a b i l i s m p e r m i t t e d her to s e l e c t a l e s s probable o p i n i o n i n favour of a more probable one. T h i s was so because c a s u i s t s acknowledged t h a t a l l o p i n i o n s are s u b j e c t to change i n the face of new circumstances. Since very few a c t i o n s are i n t r i n s i c a l l y e v i l (e.g. basphemy), 77 an agent couldn't hope f o r more assurance than t h a t o f f e r e d by c a s u i s t r y . The Area of Concern of T r a d i t i o n a l C a s u i s t r y I t i s important t o be c l e a r about what matters c a s u i s t r y was intended to d e a l with. . . . c a s u i s t r y had never been intended as a s u b s t i t u t e f o r e t h i c a l t h eory.... I t was not, i n i t s e l f , a doc-t r i n e about what i s the best l i f e f o r man, what v i r t u e s c h a r a c t e r i z e the good person, or what i d e a l s humans should s t r i v e f o r . I t d i d not even o f f e r a ge n e r a l or f u l l y e l a b o r a t e d d o c t r i n e about what s o r t s of a c t s are r i g h t , or about how p r i n c i p l e s and r u l e s are to be j u s t i f i e d . I t was a simple p r a c t i c a l e x e r c i s e d i r e c t e d a t attempting a s a t i s f a c t o r y r e s o l u t i o n of p a r t i c u l a r moral problems. In t h i s r e s p e c t , i t resembles p h i l -osophy ... l e s s than i t d i d present-day " c o u n s e l i n g " . . . ( I b i d . 242). C e r t a i n l y , because the c a s u i s t s were p r i m a r i l y i n t e r -e s ted i n d i s p e n s i n g advice from the c o n f e s s i o n a l , i t i s not s u r p r i s i n g that t h e i r concerns were very much the c o n f l i c t s of o r d i n a r y people. t h i s perhaps accounts f o r the c a s u i s t s ' minimal r e l i a n c e on t h e o r e t i c a l r e s o u r c e s . Jonsen and Toulmin. c l a i m t h a t no e x p l i c i t methodology was ever developed by the c a s u i s t s ( I b i d . 250). Nor d i d they c o n s t r u c t a formal theory of c a s u i s t r y . At most, they r e l i e d on theology and j u r i s p r u d -ence to provide them with the d o c t r i n e of n a t u r a l law (with i t s h i e r a r c h y of moral p r i n c i p l e s ) , and to o f f e r a t h e o r e t i c a l j u s t i f i c a t i o n f o r t h e i r a c t i v i t i e s . In e f f e c t , c a s u i s t r y was l e g i t i m i z e d because i t drew upon o f f i c i a l l y s a n c tioned i n s t i t u t i o n s and t h e i r r e s o u r c e s . To a i d t h e i r a c t i v i t i e s , c a s u i s t s developed a d o c t r i n e of "conscience" t h a t d i s t r i b u t e d the moral p r i n c i p l e s taken from the n a t u r a l law to i n d i v i d u a l 78 cases of moral c h o i c e ( I b i d . ) . They a l s o developed a doc-t r i n e of "circumstances" i n order to c l a r i f y the r e l a t i o n s h i p between exceptions and excuses and the weight of the o b l i -g a t i o n s imposed by gen e r a l p r i n c i p l e s ( I b i d . ) . When one co n s i d e r s how important these two d o c t r i n e s appear t o be to the c a s u i s t s ' method, i t i s unfortunate, indeed, t h a t Jonsen and Toulmin have so l i t t l e to say about them. Be t h a t as i t may, given the long history, of c a s u i s t r y and how very few of i t s p r a c t i t i o n e r s were i n t e r e s t e d i n theory, i t i s c l e a r t h a t c a s u i s t s were more i n t e r e s t e d to hear what someone had to say about a case than why and how he a r r i v -ed at h i s o p i n i o n . I t was, i n f a c t , the wide range of o p i n i o n s a v a i l a b l e f o r many cases, p l u s the d o c t r i n e of p r o b a b i l i s m (any o p i n i o n i s f i n e provided i t ' s p r o b a b l e ) , t h a t l e d to the f a l l of c a s u i s t r y ( I b i d . 237). Quo V a d i s , C a s u i s t r y ? Despite what may be apparent d e f i c i e n c e s a s s o c i a t e d with c a s u i s t r y , we are l e f t with the success of the commission. I t i s hard to deny the value of p r a c t i c a l r e s u l t s emerging from a f i e l d ( v i z . b i o m e d i c a l e t h i c s ) c h a r a c t e r i z e d by s t r i f e and d i s u n i t y . Not s u r p r i s i n g l y , given the success of the commiss-i o n , Jonsen and Toulmin b e l i e v e t h a t c a s u i s t r y has a gre a t deal to o f f e r biomedicine. When p r o p e r l y conceived..., c a s u i s t r y r e d r e s s e s the exc e s s i v e emphasis placed on u n i v e r s a l r u l e s and i n -v a r i a n t p r i n c i p l e s by moral p h i l o s o p h e r s . . . . In-stead we s h a l l take s e r i o u s l y c e r t a i n f e a t u r e s of moral d i s c o u r s e t h a t r e c e n t moral p h i l o s o p h e r s have too l i t t l e a p p r e c i a t e d : the concrete circumstances 79 of a c t u a l cases, and the s p e c i f i c maxims t h a t people invoke i n f a c i n g a c t u a l moral dilemmas. I f we s t a r t by c o n s i d e r i n g s i m i l a r i t i e s and d i f f e r e n c e s between p a r t i c u l a r types of cases on a p r a c t i c a l l e v e l , we open up an a l t e r n a t i v e approach t o e t h i c a l theory t h a t i s wholly c o n s i s t e n t with our moral p r a c t i c e ( I b i d . 13). The next chapter w i l l d e a l i n some depth with some of the problems a s s o c i a t e d with c a s u i s t r y so t h a t we may b e t t e r assess the value of t h i s approach i n d e a l i n g with the prob-lems of biomedicine. CHAPTER 7 LIMITATIONS OF CASUISTRY Among the str e n g t h s of c a s u i s t r y i s i t s in h e r e n t sim-p l i c i t y . C a s u i s t s were mainly concerned with o f f e r i n g t h e i r o p i n i o n s about v a r i o u s cases, along with a rough idea of how these o p i n i o n s were a r r i v e d a t . N a t u r a l l y , most c a s u i s t s were i n t e r e s t e d i n what other prominent c a s u i s t s had to say about c e r t a i n i n t e r e s t i n g cases. But, i n the end, no one's opi n i o n s about non-paradigm cases were co n s i d e r e d t o be more than probable. I t was, i n p a r t , the c a s u i s t s ' i n a b i l i t y to judge with any p r e c i s i o n the weight of the support i n favour of most op i n i o n s t h a t made the e x t r i n s i c a u t h o r i t y matter so much. Thus, the s i m p l i c i t y of the c a s u i s t s ' method a l s o d i d much to hasten i t s d e c l i n e . Perhaps how c a s u i s t r y evolved p r i o r to i t s d e c l i n e was a n a t u r a l consequence of the nature of i t s suppo r t i n g i n s t i -t u t i o n s . The C a t h o l i c Church i s not o r i o u s f o r i t s h i e r a r c h y of power and a u t h o r i t y . For many c e n t u r i e s i n C a t h o l i c i s m , who has s a i d something i s o f t e n more s i g n i f i c a n t than why i t was s a i d . T r a d i t i o n a l l y , appeals to a u t h o r i t y ( A r i s t o t l e , Augustine, and Aquinas) were used to render a p o s i t i o n beyond c r i t i c i s m and doubt. For c a s u i s t r y , e x c e s s i v e concern f o r who s a i d what meant t h a t e x t r i n s i c a u t h o r i t y s t i f l e d i n t r i n s i c argumentation. 80 81 But there i s nothing about c a s u i s t r y t h a t r e q u i r e s i t to be only u t i l i z e d by C a t h o l i c s . Given the d e c l i n e of the Church i n r e c e n t c e n t u r i e s , i t seems c l e a r t h a t c a s u i s t r y must be adapted to meet the needs of a s e c u l a r and p l u r a l i s t i c s o c i e t y . The commission's success suggests c a s u i s t r y may be an e f f e c t i v e form of moral reasoning f o r our times, s i n c e each of the commissioners came from very d i f f e r e n t backgrounds. Apparently, expert o p i n i o n s are among the most important t h i n g s c a s u i s t r y has to o f f e r . We t u r n now to an examination of the nature of these expert o p i n i o n s . Some Fundamental Doubts About the Commission In t h e i r d e f i n i t i o n of " c a s u i s t r y , " Jonsen and Toulmin d e s c r i b e i t as "the a n a l y s i s of moral i s s u e s , using procedures of reasoning based on paradigms and a n a l o g i e s , l e a d i n g to the f o r m u l a t i o n of expert o p i n i o n s . . . " (Jonsen 1988, 257). I t seems wise to c o n s i d e r what might be meant by "expert o p i n i o n s , " f o r t h i s n o t i o n , i n c o n j u n c t i o n with some r e f l e c t i o n on the nature of the commission, r a i s e s a number of t r o u b l i n g q u e s t i o n s . The most d i s t u r b i n g of these questions i s suggested by the f i n d i n g s of s o c i a l psychology, which o f f e r s an i n s i g h t f u l e x p l a n a t i o n of the commission's convergence on c e r t a i n o p i n i o n s . The q u e s t i o n i s , q u i t e simply, "Was t h i s convergence the r e s u l t of the methodology employed ( v i z . c a s u i s t r y ) or was i t a product of group dynamics?" I t i s extremely l i k e l y t h a t t h i s convergence was the r e s u l t of some or a l l of the commiss-i o n e r s ' responses to s o l v i n g group t a s k s . S o c i a l psycholog-82 i c a l s t u d i e s suggest t h a t how, groups s o l v e tasks depends mainly on the i n d i v i d u a l members' appearances, p e r s o n a l i t i e s and h i s t o r i e s . C e r t a i n i n d i v i d u a l s are h i g h l y s k i l l e d at man-i p u l a t i n g others to see t h i n g s t h e i r way. Males tend to form a l l i a n c e s with females they are a t t r a c t e d t o . Women o f t e n s i d e with outgoing and c o n f i d e n t men. Passive i n d i v i d u a l s p r e f e r to l e t events develop i n an undesired way r a t h e r than c a l l undue a t t e n t i o n to themselves. Does c a s u i s t r y , as e x e m p l i f i e d by the commission, exclude the p o s s i b i l i t y of such a r b i t r a r y and m orally d i s t u r b i n g means of generating expert o p i n i o n s ? Of what value i s consensus i f these p s y c h o l o g i c a l f a c t o r s are p r i m a r i l y i t s source? Determining whether there i s any f o r c e to these c r i t i -cisms i s p o s s i b l e i n both p r i n c i p l e and p r a c t i c e . I f we were to s imultaneously run twelve c a r e f u l l y segregated commissions, each of which had v a r i a t i o n s i n the appearances, p e r s o n a l i t i e s , and h i s t o r i e s of i t s members, we would be able to c o l l e c t and compare the twelve s e t s of o p i n i o n s . I t seems l i k e l y t h a t we would not r e c e i v e twelve copies of one set of o p i n i o n s . In a l l p r o b a b i l i t y , we would have a number (twelve?) of d i s t i n c t s e t s . I f the convergence w i t h i n any given commission i s the r e s u l t of the method and not group dynamics, why would we f a i l to produce twelve copies of the same s e t of o p i n i o n s ? I t seems reasonable to conclude t h a t group dynamics may have had a c o n s i d e r a b l e impact on the commission's r e s u l t s . T h i s r a i s e s an important q u e s t i o n : Would any of the sets of o p i n i o n s produced be more expert than the others? 83 In the previous chapter, we noted t h a t the e t h i c a l p r i n c i p l e s t h a t the commission uses and supports are those of the paradigm theory. I f one accepts the c r i t i c i s m s of the paradigm theory, and supports the view t h a t i t s r e s u l t s are too a r b i t r a r y and l a c k i n g i n s u b s t a n t i a l j u s t i f i c a t i o n , i s n ' t one thereby committed to viewing the new c a s u i s t s ' r e l i a n c e on some or a l l of the paradigm theory as being problematic? To the extent t h a t the c a s u i s t s r e l y on i n d e f -e n s i b l e methods and r e s o u r c e s , they weaken t h e i r own approach. U n l i k e Beauchamp and C h i l d r e s s , who regard the Commission Reports as a v i n d i c a t i o n of t h e i r work, we might p r e f e r to regard the r e l i a n c e on the paradigm theory as a s i g n of t r o u b l e or even f a i l u r e . Problems with the Paradigm Let us assume f o r a moment t h a t our commissioners are beginning to d i s c u s s t h e i r paradigm cases. I f Paul Ramsey and Richard A. McCormick were ever on the same commission, i t seems reasonable to not expect them to agree on the moral j u s t i f i a b i l i t y of nontherapeutic p e d i a t r i c research' ( i . e . the c h i l d r e c e i v e s no b e n e f i t from p a r t i c i p a t i n g ) . C l e a r l y , these two i n d i v i d u a l s would not want to have i d e n t i c a l moral taxon-omies and would o f t e n have d i f f e r e n t o p i n i o n s about c e r t a i n cases. C o n t r a s t t h i s s i t u a t i o n with the C a t h o l i c c a s u i s t s who widely accepted the Ten Commandments and the Seven Deadly Sins as models f o r t h e i r paradigms. Why d i d the C a t h o l i c s accept these models? They are an i n h e r e n t p a r t of t h e i r f a i t h . 84 In order to be C a t h o l i c , one has to take on many of i t s b e l i e f s , v a l u e s , r i t u a l s , e t c . But would e i t h e r McCormick or Ramsey have to give up many of h i s p e r s o n a l views i n order t o share the same moral taxonomies as the other commissioners? I f someone o b j e c t e d t o c e r t a i n paradigms but was too p a s s i v e t o say so, the f a c t t h a t he concurred i n the s e l e c t i o n of the moral taxonomies should be d i s t u r b i n g , not p o s i t i v e . Of course, f o r the p a r t i c u l a r combination of commissioners who were, i n f a c t , present, the paradigm cases may have been as a c c e p t a b l e as were the Ten Commandments to the C a t h o l i c c a s u i s t s . However, had the commission d e a l t with f a r more d i v i s i v e i s s u e s (e.g. a b o r t i o n and euthanasia) and had i t been h i g h l y p o l a r i z e d , i t seems u n l i k e l y t h a t the commissioners would have agree about a paradigm case f o r , say, a m o r a l l y i n d e f e n s i -b l e a b o r t i o n . I f commissioners can't agree on paradigm cases, divergence of o p i n i o n s seems to be a l i k e l y r e s u l t . In f a c t , i t i s hard to see how the commission c o u l d have remained i n t a c t i f i t was unable to produce at l e a s t one widely accepted moral taxonomy. R e f l e c t i o n s of t h i s kind r a i s e a number of ques-t i o n s . Did the commission succeed because i t s moral taxonomies were pre-shaped f o r i t by s o c i e t y ' s v a l u es, laws, et c . ? Or d i d i t succeed because the v a r i o u s commissioners d i d n ' t b r i n g t h e i r own v a l u e s , p r e j u d i c e s , f e a r s , e t c . i n t o the process? To what extent d i d the group produce r e s u l t s at the expense of moral j u s t i f i c a t i o n by f a i l i n g to ask what are the reasons f o r a c c e p t i n g t h i s moral taxonomy i n s t e a d of t h a t one? Let us pursue the matter of j u s t i f i c a t i o n a l i t t l e f u r -t h e r . In the case of the C a t h o l i c t r a d i t i o n , God was the j u s t i f i c a t i o n f o r e v e r y t h i n g t h a t l e g i t i m i z e d c a s u i s t r y . But what l e g i t i m i z e d the commissioners' paradigm cases and t h e i r moral taxonomies? C e r t a i n l y not God. I t may have been the United States Congress (at l e a s t as f a r as the commission-ers were concerned). But we are i n t e r e s t e d i n moral j u s t i f i c -a t i o n . Somewhere i n the c a s u i s t r i c a l process i t i s reasonable to expect s u b s t a n t i a l moral j u s t i f i c a t i o n to be p r o v i d e d . I t would be unfortunate i t , l i k e the C a t h o l i c c a s u i s t s , the commission devoted l i t t l e or no a t t e n t i o n t o i n t r i n s i c argu-mentation because of the " l e g i t i m a c y " c o n f e r r e d upon t h e i r f i n d i n g s by an e x t e r n a l a u t h o r i t y ( v i z . Congress). At v a r i o u s stages of t h e i r a c t i v i t i e s , the commission-ers should have been g r e a t l y concerned with p r o v i d i n g moral j u s t i f i c a t i o n . Did the commissioners review the moral j u s t -i f i c a t i o n s f o r the previous f e d e r a l r e g u l a t i o n s ? Did they agree with them or not? I f these were l a c k i n g , d i d they attempt to supply them? I t i s one t h i n g to observe t h a t a given kind of r e s e a r c h i s p r o h i b i t e d by law. I t i s a very d i f f e r e n t task to enquire whether i t should be and to ask f o r the moral j u s t i f i c a t i o n of the p r o h i b i t i o n . When the comm-i s s i o n e r s developed t h e i r own general statements of e t h i c a l p r i n c i p l e s ( v i z . the p r i n c i p l e s of the paradigm t h e o r y ) , d i d they accept someone e l s e ' s defense of those p r i n c i p l e s , or d i d they defend them themselves? To defend them, d i d they r e l y on argument or i n t u i t i o n ? Since only the former i s p o t e n t i a l l y immune to group dynamics, we must hope t h a t argu-86 merits played an important part in the commissioners' a c t i v -i t i e s . How did the commissioners assign weights to the cases that were being compared with the paradigms? Did they re l y on a principled method or did they survey opinions u n t i l everyone came to some kind of agreement? Could they defend the i r finding case B similar to A i f an independent group claimed that B was, i n fact, more similar to C? Jonsen and Toulmin have very l i t t l e to say on thi s l a s t point: ...anyone who has occasion to consider moral issues in actual d e t a i l knows that morally s i g n i f i c a n t d i f f -erences between cases can be as v i t a l as the i r l i k e -nesses . We need to respect not only the general p r i n -c i p l e s that require us to treat similar cases a l i k e but also thos c r u c i a l d i s t i n c t i o n s that j u s t i f y treat-ing d i s s i m i l a r cases d i f f e r e n t l y (Ibid. 14). How d i s s i m i l a r must case B be from A before we are no longer j u s t i f i e d in treating i t l i k e case A? Is there a defensible means of determining t h i s or i s i t up to the opinions of the commission? In the event that A i s similar to both B and C, how do we determine which of the two i s most similar? If A doesn't r e a l l y resemble B very closely, but we have nothing else to compare i t with, are we j u s t i f i e d . i n treating A l i k e B? Who makes these choices? How are they madec Why these decisions instead of those? Casuistry and Biomedicine It i s time to b r i e f l y consider whether casuistry has, i n fact, a great deal to offer biomedicine. As we have seen, casuistry offers results and i t appears to summon consensus 87 w i t h i n a d i v i s i v e s o c i e t y . I t deal s with p r a c t i c a l matters by o f f e r i n g concrete ways of hand l i n g d i f f i c u l t problems. At f i r s t s i g h t , i t seems hard t o f a u l t people f o r f i n d i n g c a s u i s t r y t o be an a t t r a c t i v e a l t e r n a t i v e t o the a p p l i e d e t h i c s paradigm. But, given the c a s u i s t s ' r e l i a n c e on c e r t a i n elements of the paradigm theory ( i n p a r t i c u l a r , the p r i n c i p l e s ) , how very d i f f e r e n t i s c a s u i s t r y from the p r i n c i p l e - d r i v e n approach i t attempts to r e f u t e ? I f p h y s i c i a n s wish t o be c o n f i d e n t t h a t t h e i r e t h i c a l resources are r e l i a b l e , they must ensure t h a t the r e s u l t s produced are m o r a l l y j u s t i f i e d . I f p h y s i c i a n s were to press the c a s u i s t s to j u s t i f y the v a r i o u s elements of t h e i r method, I suspect t h a t they (and others) might be a l i t t l e l e s s con-f i d e n t about the d e f e n s i b i l i t y of the c a s u i s t s ' r e s u l t s . Simply a r r i v i n g at " s o l u t i o n s " to p e r p l e x i n g problems should-n't be viewed as a measure of success (or of moral j u s t i f i c -a t i o n ) . I f one chose, say, to decide moral i s s u e s by survey-i n g c i t i z e n s about t h e i r views, one would, no doubt, come up with r e s u l t s of some k i n d . Deciding the c a p i t a l punishment i s s u e based on the data gathered by telephone or mail might be accep t a b l e to some; but there w i l l always be a few who w i l l c h a l l e n g e the m o r a l i t y of such expedient means. S o c i e t y i s , indeed, pressured to take a stand on many d i f f i c u l t i s s u e s . The stand taken, however, i s of c o n s i d e r a b l e importance and great care must be taken to ensure t h a t our p o l i c i e s and values are r a t i o n a l and m o r a l l y a c c e p t a b l e . In the next chapter, I w i l l o f f e r my suggestions toward the r e s o l u t i o n of the problem of the f i t between theory and and p r a c t i c e i n biomedical e t h i c s . C o n s i d e r a b l e progress can be achieved i f one r e l i e s on r u l e u t i l i t a r i a n i s m , with s u i t a b l e emphasis p l a c e d on the concrete circumstances of p r a c t i c a l cases. CHAPTER 8 PHILOSOPHERS AND BIOMEDICINE In t h i s chapter I w i l l o u t l i n e the s o r t of r o l e p h i l -osophers should p l a y i n biomedical e t h i c s . In order to do so, however, I w i l l a l s o need to o u t l i n e the r o l e s of many other h e a l t h care workers, lawyers, e t c . so t h a t what I have i n mind w i l l be c l e a r . I w i l l r e l y on a worst case s c e n a r i o ( v i z . an AIDS epidemic equal i n magnitude to the plague) to dramatize the need f o r p h y s i c i a n s to not d e f a u l t on making d e c i s i o n s about moral i s s u e s . I am going to accept the c r i t i c i s m r a i s e d a g a i n s t the paradigm theory and c a s u i s t r y i n the previous chapters, and take i t as a given t h a t these resources s u f f e r profound l i m i t a t i o n s . Despite these problems, I hope to show t h a t moral philosophy s t i l l has something v a l u a b l e to c o n t r i b u t e . To t h i s end, I w i l l b r i e f l y d i s c u s s how r u l e u t i l i t a r i a n i s m c o u l d succeed i n the method I am proposing. Biomedicine and P u b l i c P o l i c y AIDS i s t e r r i f y i n g because i t i s a m e r c i l e s s k i l l e r and because i t i s i n c u r a b l e thus f a r . Of course, i f we c o u l d be c o n f i d e n t t h a t a cure w i l l emerge i n f i v e years or l e s s , we might f e e l t h a t the problem w i l l e v e n t u a l l y go away and t h a t AIDS w i l l come to be seen as not much worse than the p r e - p e n i -c i l l i n deaths. Biomedical r e s e a r c h and technology j u s t might 89 see us through the p e r i l s of t h i s syndrome. But l e t us imag-ine t h a t no cure emerges f o r f i f t e e n or even t w e n t y - f i v e years. I f the v i r u s spreads at i t s present r a t e (which i s alarming indeed), we might f i n d o u r s e l v e s having to d e a l with some k i n d of worst case s c e n a r i o as suggested by epidemiology. Science, s t a t i s t i c s , and a l i t t l e i m a g i n a t i o n p a i n t an alarming p i c t u r e of what an AIDS epidemic would be l i k e . I i n t e n d to focus on how a worst case s c e n a r i o would a f f e c t h e a l t h care workers and the t e c h n o l o g i e s they operate so t h a t I can b r i e f l y e x p l o r e c e r t a i n key moral i s s u e s and how they should be r e s o l v e d . To begin with, l e t us assume t h a t about a t h i r d of the n a t i o n ' s p o p u l a t i o n have c o n t r a c t e d the HIV v i r u s and t h a t a l l of these w i l l e v e n t u a l l y d i e p r i o r to the d i s c o v e r y of a cure. At t h i s time, the death r a t e from AIDS i s a l r e a d y very high and i s c l i m b i n g r a p i d l y . The vast m a j o r i t y of those i n -f e c t e d with the v i r u s are younger than f i f t y years of age. T h i s i s a major problem s i n c e the nation's p o p u l a t i o n has grown i n c r e a s i n g l y o l d e r . An o l d e r p o p u l a t i o n p l a c e s heavy demands on the h e a l t h care resources of the country. I t i s apparent to a l l t h a t these resources won't manage both the g e r i a t r i c boom and an AIDS epidemic. F u r t h e r demographic c o n s i d e r a t i o n s r e v e a l t h a t the i n f e c t e d t h i r d of the popu-l a t i o n can't reproduce anymore without p a s s i n g on the v i r u s , so there w i l l be a s u b s t a n t i a l d e c l i n e i n the numbers of young people who w i l l be a v a i l a b l e to fund h e a l t h care and to supp-o r t the e l d e r l y . Everyone agrees t h a t a c r i s i s t h reatens to engulf them, but not everyone agrees about what should be done. Not e n t i r e l y s a t i s f i e d with philosophy's past e f f o r t s , and unconvinced of the moral j u s t i f i a b i l i t y of c a s u i s t r y ' s r e s u l t s , p h y s i c i a n s decide t o assume a str o n g e r r o l e i n the moral debate, t a k i n g c o n s t r u c t i v e input whenever p o s s i b l e . To begin with, p h y s i c i a n s decide they can no longer a f f o r d to d e f a u l t i n making d i f f i c u l t d e c i s i o n s . Given the depth of the coming c r i s i s (which they can only e s t i m a t e ) , they are aware t h a t they must make the most of t h e i r time and r e s o u r c e s . Since the c r i s i s i s a l r e a d y p a r t l y upon them, they r e c o g n i z e t h a t now, more than ever, d e c i s i v e n e s s w i l l be a medical v i r t u e . P h y s i c i a n s must make ch o i c e s and l i v e with the consequences. In the past, t h e i r d e c i s i o n s have been shaped by codes of e t h i c s , laws, r u l e s , r e g u l a t i o n s . Now, however, few of these g u i d e l i n e s seem adequate to meet the demands of the c r i s i s . In response t o these inade-quacies, p h y s i c i a n s decide t o i n i t i a t e a p u b l i c forum t o a s s i s t them i n c o n f r o n t i n g moral i s s u e s . The forum, i t i s decided, w i l l be comprised of nurses, p a t i e n t s , p h i l o s o p h e r s , lawyers, p u b l i c i n t e r e s t groups, t h e o l o g i a n s , e t c . How w i l l the forum operate? I t w i l l c h a l l e n g e the r u l e s , r e g u l a t i o n s , and d e c i s i o n s made i n response to the c r i s i s by p h y s i c i a n s and a small group of i n d i v i d u a l s (lawyers, p h i l o s o p h e r s , etc.) who w i l l a d vise them. Before c o n s i d e r i n g t h i s forum i n more de-t a i l , l e t us c o n s i d e r how p h y s i c i a n s would d e a l with moral i s s u e s . Given t h e i r l i m i t e d time and resources and the i n t e n s e f u t u r e demands expected to be placed on them, p h y s i c i a n s would, i n a s s o c i a t i o n with t h e i r a d v i s o r y group, c o l l e c t i v e l y decide how those resources would be a l l o c a t e d . The reasons f a v o u r i n g v a r i o u s a l t e r n a t i v e s would be c o n s i d e r e d , but, i n the end, the options most l i k e l y to maximize u t i l i t y would be chosen. In the case of an AIDs epidemic, a l l o w i n g people to d i e i n t h e i r homes might be s e l e c t e d . For the e l d e r l y , not i n i t i a t i n g c e r t a i n treatments might appear wise. These a l t e r n a t i v e s would then be used to formulate r u l e s , r e g u l a t i o n s , e t c . t h a t would be a p p l i e d u n i f o r m l y throughout the n a t i o n a l h e a l t h care system. For some cases, i f a doctor o b j e c t s to the r u l e s , he or she w i l l be f r e e to s e l e c t another o p t i o n . However, other cases w i l l be such t h a t one w i l l have no c h o i c e but to com-p l y . For example, i f a l l of the a v a i l a b l e resources have gone to keeping HIV negative i n f a n t s a l i v e , then a p h y s i c i a n w i l l have to accept t h a t an AIDS p a t i e n t may have to be d e a l t with i n accordance with the e s t a b l i s h e d g u i d e l i n e s . In another case, i f a v a i l a b l e resources are being used to keep a donor's organs a l i v e , then, again, not enough may be l e f t f o r AIDS cases. The r u l e s , g u i d e l i n e s , e t c . ("the r u l e s " ) w i l l be de-signed t o shape the c h o i c e s p h y s i c i a n s w i l l make i n both r o u t i n e and p e r p l e x i n g cases. The r u l e s w i l l be an e f f e c t i v e means to guide and s t a n d a r d i z e conduct ( e s p e c i a l l y among new and l e s s - s k i l l e d p h y s i c i a n s ) . Of course, no matter how thorough and c a r e f u l l y thought-out the r u l e s might be, they c o u l d never cover every contingency. In the event t h a t the r u l e s don't apply c l e a r l y (or not a t a l l ) , the Canadian Medical A s s o c i a t i o n c o u l d have a c o n s u l t a t i o n s e r v i c e s t a f f e d by "experts" to o f f e r s uggestions. Since these would only be o f f e r e d as suggestions, the doctor c o u l d take or leave the a d v i c e . I f there i s no time to seek a d v i c e , the doctor should a c t as she sees f i t . The case would then be s t u d i e d afterwards to permit the s t r u c t u r i n g of d e s i r a b l e r u l e s . The advantages of having p h y s i c i a n s help shape the r u l e s t h a t w i l l guide t h e i r conduct are numerous. In choosing to be a p h y s i c i a n , i n d i v i d u a l s w i l l be expected to conduct them-s e l v e s i n accordance with the standards of the p r o f e s s i o n . I f these standards are backed by good reasons, an i n d i v i d u a l w i l l h o p e f u l l y f e e l a strong sense of o b l i g a t i o n toward them. Rules of conduct t h a t are c l e a r l y going to maximize u t i l i t y o f -f e r g r e a t e r motivation, than the amorphous d i c t a t e s of theory. Thus, a u t i l i t a r i a n j u s t i f i c a t i o n of the r u l e s w i l l permit p h y s i c i a n s to see "the p o i n t " of having the r u l e s , u n l i k e vague d i r e c t i v e s l i k e , "Always do your duty" or "Always r e s p e c t persons. " An obious advantage of having p h y s i c i a n s i n v o l v e themselves more i n g u i d i n g t h e i r own conduct i s the f a c t t h a t they, more than anyone e l s e , know medicine. P h y s i c i a n s c o u l d work with others toward c l a r i f y i n g s o c i a l goals with r e s p e c t to the p r a c t i c e and outcomes of medicine. Medical and economic c o n s i d e r a t i o n s , as w e l l as e t h i c a l and s o c i a l f a c t o r s , need to be c a r e f u l l y weighed when one i s f o r m u l a t i n g s o c i a l p o l i c y . Doctors should have some say i n the d e f i n i t i o n of t h e i r r o l e . Another advantage of having some c o n t r o l over t h e i r own conduct i s no doubt c o n t r o v e r s i a l but important f o r p h y s i c i a n s to c o n s i d e r . P h y s i c i a n s must ask themselves questions l i k e , "What w i l l i t be l i k e to p r a c t i c e medicine under c o n d i t i o n s of i n t e n s e c r i s i s ? " and "What can s o c i e t y reasonably expect of me?" While acknowledging t h a t p h y s i c i a n s have s p e c i a l s k i l l s and t r a i n i n g , and t h a t good f o r t u n e o b l i g a t e s (chapter one), how heavy can the demands we p l a c e on p h y s i c i a n s be before they become c r i p p l i n g ? P h y s i c i a n s need to take care of t h e i r p a t i e n t s , i t i s t r u e , but they must a l s o take care of themselv-es and the h e a l t h care system. Indeed, i t i s a v i c i o u s c i r -c l e , f o r i f the h e a l t h care system c o l l a p s e s p h y s i c i a n s w i l l be unable to take very good care of anyone. Moreover, i f p h y s i c i a n s aren't s a t i s f i e d i n t h e i r work, they w i l l be l e s s motivated to show concern f o r o t h e r s . The P u b l i c Forum I t i s time to c o n s i d e r the a c t i v i t i e s and goals of the p u b l i c forum. Of c o n s i d e r a b l e importance i s the forum's f u n c t i o n as an e x t e r n a l c r i t i c of the r u l e s , p o l i c i e s , e t c . adopted by the medical p r o f e s s i o n . Even i f i t were the case t h a t p h y s i c i a n s acted with the best i n t e n t i o n s , from a deep sense of a l t r u i s m , and a f t e r c o n s i d e r a b l e d e l i b e r a t i o n , they would s t i l l be f a l l i b l e . C e r t a i n r u l e s might be c h a l l e n g e d by the forum because they do not appear to be the ones t h a t w i l l , i n f a c t , maximize u t i l i t y . The onus would f a l l on the forum to provide a r u l e t h a t would maximize u t i l i t y and i f i t c o u l d do so, then the CM.A. ought to acknowledge the s u p e r i o r i t y of the new r u l e and, more i m p o r t a n t l y , adopt i t . Of course, not every c r i t i c i s m r a i s e d by the forum would l e a d to the adoption of a new r u l e . In order f o r a c r i t i c i s m to merit s e r i o u s a t t e n t i o n , some kind of consensus must emerge from the forum i n support of the complaint. I f , f o r example, some p h i l o s o p h e r s p r o t e s t t h a t denying h o s p i t a l resources to dying AIDS p a t i e n t s doesn't r e s p e c t them as persons, but others i n s i s t t h a t t h i s p o l i c y maximizes e f f i c i e n c y , the c h a l l e n g e posed to the r u l e may not be very focused or r e s o l u t e . P h y s i c i a n s could, perhaps, counter the c h a l l e n g e by s a y i n g , " I f you want more resources a v a i l a b l e f o r AIDs p a t i e n t s , y o u ' l l have to come up with more money." Th i s s o r t of response takes the problem from the bedside and b r i n g s i t up to the macro l e v e l where i t belongs. Because p h y s i c i a n s ' r u l e s have, i n p a r t , been shaped by macro d e c i s i o n s made by taxpayers, v o t e r s , and government, i t seems a p p r o p r i a t e f o r these people to r e c o n s i d e r t h e i r values i f they're un-happy with the h e a l t h care system. As we have a l r e a d y seen, the forum would be comprised of nurses, p h i l o s o p h e r s , lawyers, t h e o l o g i a n s , p a t i e n t s , e t c . While not a l l of these are considered to possess moral exper-t i s e (as Singer d e f i n e s i t ) , there i s c o n s i d e r a b l e advantage to i n v o l v i n g d i v e r s e kinds of people i n the forum. Nurses, probably even more so than p a t i e n t s and d o c t o r s , know the l i m i t a t i o n s and f a i l i n g s of the h e a l t h care system. T h e i r c r i t i c i s m s and advice deserve d e t a i l e d and lengthy c o n s i d e r -a t i o n . Lawyers c o u l d o f f e r a l e g a l i n t e r p r e t a t i o n of the problems. P h i l o s o p h e r s c o u l d t r y to suggest the moral dim-ensions of what i s being d e s c r i b e d . Since p a t i e n t s have a s i g n i f i c a n t stake i n how the h e a l t h care system e v o l v e s , t h e i r experiences, problems, e t c . would a l s o serve as data f o r the forum. In the end, however, everyone would be i n t e r -dependent, s i n c e e f f e c t i v e c r i t i c i s m and c o n s t r u c t i v e a l t e r -n a t i v e s c o u l d only emerge i f the input and s k i l l s of a l l of the r e l e v a n t p a r t i e s are employed. In the forum, there would be no p l a c e f o r antagonism and competition; i n s t e a d , i t s members would have to work c o o p e r a t i v e l y , sometimes with a sense of urgency, to r e s o l v e p r a c t i c a l d i f f i c u l t i e s . In the case of examining e x i s t i n g p o l i c i e s , e t c . , the forum would f u n c t i o n as an e x t e r n a l c r i t i c . A number of other r o l e s suggest themselves as w e l l . In the event t h a t p h y s i c i a n s were unclear about proposed r u l e s f o r new problems (or a n t i c -i p a t e d ones), they could submit them to the forum f o r a n a l y s i s . However, unless the forum could come up with b e t t e r r u l e s ( i . e . ones more l i k e l y to maximize u t i l i t y ) , those being pro-posed would be i n s t i t u t e d t o permit everyone to study the consequences they produce. As we saw above, sometimes p h y s i c i a n s must make d e c i -s i ons i n the midst of c r i s i s . The CM.A. might agree with the choices made by a p a r t i c u l a r doctor, but want an e x t e r n a l view of the case. Asking the r e l e v a n t nurses, p a t i e n t s , f a m i l i e s , e t c . to o f f e r t h e i r view of t h i n g s i s an important means of not o v e r l o o k i n g anything. 97 The forum could a l s o f u n c t i o n to d i s c u s s the important value questions emerging as the consequences of the r u l e s become apparent. P h y s i c i a n s might not i s o l a t e the i s s u e s very s u c c e s s f u l l y i f they are p r i m a r i l y concerned with pushing the h e a l t h care system to d e l i v e r to the l i m i t . The value questions must not be obscured by economic s h o r t -ages or b u r e a u c r a t i c i n d i f f e r e n c e . As the value questions become c l e a r e r , the c r i t i c i s m o f f e r e d by the forum w i l l l i k e l y become more s u b s t a n t i a l . P h i l o s o p h e r s and Moral E x p e r t i s e In chapter t h r e e , the q u e s t i o n of whether moral p h i l -osophers can l e g i t i m a t e l y be regarded as moral experts was b r i e f l y explored. I t i s time to s e t t l e t h i s q u e s t i o n , f o r a d e f i n i t e answer to i t w i l l help d e f i n e the nature of the r o l e p h i l o s o p h e r s ought to p l a y i n the p u b l i c forum. I f i t turns out t h a t only p h i l o s o p h e r s possess moral e x p e r t i s e , and t h a t only t h e i r s k i l l s and t a l e n t s are r e l e v a n t and e f f e c t i v e i n s o l v i n g moral problems, then, perhaps, there i s no need to i n v o l v e nurses, p a t i e n t s , e t c . i n the process a l r e a d y o u t l i n e d i n t h i s chapter. I f on the other hand, p h i l o s o p h e r s have nothing of value to o f f e r t h i s process, then there may be no sense i n i n v o l v i n g them. Among ph i l o s o p h e r s at l e a s t there i s a f a i r amount of agreement t h a t there are some advantages to studying moral philosophy. Although there may be a few p h i l o s o p h e r s who b e l i e v e they are much b e t t e r a t s o l v i n g moral problems than 98 o r d i n a r y p e o p l e , t h e r e a r e p r o b a b l y none who m a i n t a i n t h a t o n l y p h i l o s o p h e r s c a n f i n d s o l u t i o n s f o r m o r a l p r o b l e m s . P e t e r S i n g e r i s , f o r e x a m p l e , q u i c k t o deny " t h a t o n l y p h i l o s o p h e r s a r e c a p a b l e o f s e t t l i n g m o r a l p r o b l e m s " ( 1 9 8 2 , 1 0 ) . S i n c e S i n g e r has a number o f p l a u s i b l e t h i n g s t o s a y a b o u t m o r a l e x p e r t i s e , i t w o u l d be w i s e t o e x a m i n e h i s p o s -i t i o n . S i n g e r t h o u g h t f u l l y e m p h a s i z e s t h e f a c t t h a t t h i s a l l e g e d e x p e r t i s e d o e s n o t c o n s i s t i n t h e p o s s e s s i o n o f s p e c i a l m o r a l w isdom, o r p r i v i l e g e d i n s i g h t s i n t o mor-a l t r u t h , b u t i n u n d e r s t a n d i n g t h e n a t u r e o f m o r a l t h e o r -i e s and t h e p o s s i b l e methods o f m o r a l a r g u m e n t ( 1 9 8 2 , 9 ) . Of c o u r s e , t h i s s o r t o f c l a i m w i l l n o t t a k e us v e r y f a r , s i n c e e v e n Beauchamp and C h i l d r e s s c a n be r e g a r d e d as h a v i n g an u n d e r s t a n d i n g o f t h e n a t u r e o f m o r a l t h e o r i e s and t h e p o s s i b l e methods o f m o r a l a r g u m e n t t h a t i s s u p e r i o r t o t h e m a j o r i t y o f n u r s e s , d o c t o r s , p a t i e n t s , e t c . D e s p i t e t h i s a d v a n t a g e , h o w e v e r , n e i t h e r Beauchamp n o r C h i l d r e s s has p r o v e n t h e v a l u e o f t h i s a l l e g e d e x p e r t i s e . Can we r e a s o n a b l y c l a i m t h a t a p h i l o s o p h e r who r e l i e s on t h e i r m e t h o d o l o g y and g e t s nowhere and a d o c t o r who r e l i e s on h e r c o n s c i e n c e and g e t s nowhere d i f f e r as t o t h e i r r e l a t i v e l e v e l s o f e x p e r t i s e ? O b v i o u s l y t h e q u a n t i t y and q u a l i t y o f e x p e r t i s e must be a s -s e s s e d i n t e r m s o f how s u c c e s s f u l i t i s i n m e e t i n g c e r t a i n g o a l s . I f t h e a l l e g e d e x p e r t i s e c o n f e r s no p r a c t i c a l a d v a n -t a g e on i t s b e a r e r , t h e n t h e u s e o f " e x p e r t i s e " t o r e f e r t o w h a t e v e r s k i l l s , e t c . h a v e been i s o l a t e d f o r c o m p a r i s o n i s o d d . Let us e x p l o r e how a p h i l o s o p h e r might d i f f e r from an o r d i n a r y person who happens to face a moral problem. Singer claims t h a t moral p h i l o s o p h e r s have four d i s t i n c t advantages over others when i t comes to d e a l i n g with d i f f i c u l t moral i s s u e s . 1. P h i l o s o p h e r s are t r a i n e d to understand l o g i c a l arguments and to d e t e c t f a l l a c i e s . 2. Undergraduate courses i n meta-ethics ( i . e . the study of what i t i s to make a moral judgment) provide s p e c i f i c understanding of moral concepts. Being d e a i about what t r y i n g to r e s o l v e d i f f i c u l t moral i s s u e s i n v o l v e s helps us to a v o i d c o n f u s i o n . 3. Undergraduate philosophy courses i n t r o d u c e students to moral t h e o r i e s . Knowledge of these t h e o r i e s , and of t h e i r i m p l i c a t i o n s and l i m i t a t i o n s , i s use-f u l i n d i s c u s s i n g p r a c t i c a l e t h i c a l problems. 4. Moral p h i l o s o p h e r s can t h i n k f u l l time about e t h i c s , u n l i k e other people who are too busy with t h e i r own c a r e e r s ( I b i d . ) . S inger's d i s c u s s i o n of these four advantages i s par-t i c u l a r l y u s e f u l because i t serves to h i g h l i g h t some of the l i m i t a t i o n s of moral philosophy. Before addressing these l i m i t a t i o n s , l e t us c o n s i d e r c e r t a i n aspects of Singer's view which render i t very p l a u s i b l e . E a r l Winkler d i s c u s s e s the p l a u s i b i l i t y of Singer's view as f o l l o w s : ... suppose... there are o f t e n b e t t e r and worse answers to important moral problems, even i f there are seldom uniquely c o r r e c t answers. T h i s d i f f e r e n c e among an-swers to moral questions must be a f u n c t i o n of d i f f e r -ences i n adequacy and s e n s i t i v i t y i n f a c t u a l understan-d i n g , together with d i f f e r e n c e s i n q u a l i t y and depth of reasoning and j u s t i f i c a t i o n . Suppose f u r t h e r t h a t t r a i n i n g i n philosophy does advance powers of a n a l y s i s and c l a r i f i c a t i o n , and t h a t i t i n c r e a s e s s k i l l i n moral reasoning and argument. T h i s i s the main burden of Singer's claims f o r the prolonged study of moral p h i l o s -ophy. I f we now add Singer's f i n a l p o i n t , t h a t the p h i l o s o p h e r has the time to study and ponder p r a c t i c a l 100 i s s u e s i n depth, drawing on the researches and c o n s i d e r -ed p o s i t i o n s of o t h e r s , why should we not conclude t h a t there i s , i n g e n e r a l , an i n c r e a s e d l i k e l i h o o d of " b e t t e r answers" to moral i s s u e s when philosophy i s consulted? (1991, 6-7). As Winkler p o i n t s put, i f we deny t h a t c o n s u l t i n g p h i l -osophy makes b e t t e r answers f o r moral i s s u e s more l i k e l y , then we have to hold t h a t "conceptual c l a r i t y , power i n reasoning and f a m i l i a r i t y with our moral t r a d i t i o n s are of no p a r t i c u l a r value i n moral a f f a i r s " ( I b i d . 7). Winkler argues we shouldn't deny t h i s ; i n s t e a d , we should emphasize t h a t i t i s the s k i l l s i n q u e s t i o n t h a t matter and they can be a c q u i r e d even by non-philosophers ( I b i d . ) . More important-l y , Winkler draws a t t e n t i o n to the p o s s i b i l i t y t h a t philosophy has " r a d i c a l l y misconceived the r e a l nature of moral reason-ing and j u s t i f i c a t i o n , with consequent d i s t o r t i o n s of i t s own powers ( I b i d . ) . Let us t u r n to a d i s c u s s i o n of an a c t u a l case i n order to i l l u s t r a t e some of the p r a c t i c a l and t h e o r e t i c a l l i m i t a t i o n s of biomedical e t h i c s . T h i s d i s c u s s i o n w i l l show t h a t the standard approach of b i o m e d i c a l e t h i c s o f t e n y i e l d s unaccep-t a b l e answers, because i t operates with a l i m i t e d i n t e r p r e -t a t i o n of cases. A t h i r t y year o l d male was e n j o y i n g a s a t i s f y i n g and rewarding l i f e . He had an e x c e l l e n t education, was i n v o l v e d i n a s u c c e s s f u l business, and was planning to marry and r a i s e a f a m i l y . He was extremely a c t i v e i n s p o r t s , p a r t i c u l a r l y f o o t b a l l and b a s k e t b a l l , and had enjoyed e x c e p t i o n a l h e a l t h f o r most of h i s l i f e . His l a t e s t i n t e r e s t was f l y i n g : he 101 had r e c e i v e d h i s p i l o t ' s l i c e n c e about a year ago. I t was, u n f o r t u n a t e l y , f l y i n g t h a t l e d to h i s t e r r i b l e predicament, f o r he was i n v o l v e d i n a f i e r y crash t h a t l e f t him both badly burned and p a r a l y z e d from the waist down. His doctor and nurses informed him as c a r e f u l l y as p o s s i b l e about h i s c o n d i t i o n , and about the treatments and t h e r a p i e s necessary f o r h i s s u r v i v a l and p a r t i a l recovery. They d i d n ' t hide the f a c t t h a t h i s l i f e would never be q u i t e the same again. I t was t h i s i nescapable f a c t t h a t prompted him to ask what would happen i f he wasn't t r e a t e d . He was q u i c k l y t o l d t h a t i n f e c t i o n would s t r i k e throughout the burned t i s s u e s , l e a v i n g him with at most two weeks of l i f e . Needless to say, the doctor and nurses were dismayed when he t o l d them not to t r e a t him. Because h i s doctor doubted h i s competence, a p s y c h i a t r i s t was brought i n t o the case. A f t e r a f a i r l y lengthy c o n s u l -t a t i o n , the p s y c h i a t r i s t was s a t i s f i e d t h a t the young man knew what he was doing, so the doctor was t o l d to r e s p e c t the p a t i e n t ' s wishes. P r e d i c t a b l y , the doctor d i d n ' t want t o , so he took h i s s i d e of the case to c o u r t . Of course, as a r e s u l t of the case going to c o u r t , the p s y c h i a t r i s t gained a l i t t l e time. He managed to convince the p a t i e n t to accept a few burn t r e a t m e n t s — j u s t to have something to do while the c o u r t heard the case. The c o u r t , not s u r p r i s i n g l y , e v e n t u a l l y s i d e d with the p a t i e n t , but while i t d e l i b e r a t e d he r e c e i v e d a number of treatments. The end r e s u l t was the doctor had to r e s p e c t the p a t i e n t ' s wishes and the p a t i e n t began to accept more and more 102 treatments. I f we had approached t h i s case from the standard vantage p o i n t of biomedical e t h i c s , we would have agreed with the c o u r t t h a t the doctor should not a c t p a t e r n a l i s t i c a l l y i n t h i s case and the young man's autonomous wishes should be respected. In s h o r t , he should be allowed to r e f u s e treatment and to d i e . In order to be c l e a r about the p r a c t i c a l and t h e o r e t i c a l l i m i t a t i o n s of biomedical e t h i c s i n cases l i k e these, l e t us focus on the r o l e of the p s y c h i a t r i s t , who represents one of the " c a r i n g p r o f e s s i o n s . " The p s y c h i a t r i s t ' s r o l e i s important, f o r i t emphasizes the v i t a l s i g n i f i c a n c e of c a r e f u l l y i n t e r p r e t i n g the under-l y i n g moral dimensions of even the a p p a r e n t l y most c l e a r - c u t cases. Because of h i s s p e c i a l t r a i n i n g and experience, the p s y c h i a t r i s t was very good at i n t e r p r e t i n g what was r e a l l y mot-i v a t i n g the p a t i e n t . According to the p s y c h i a t r i s t , the young man s u f f e r e d from a t e r r i b l e sense of powerlessness and of not being i n c o n t r o l of h i s own l i f e (see chapter two). By r e f u s i n g treatment and by a l l o w i n g the d i s p u t e to go to c o u r t , the p a t i e n t f e l t more i n c o n t r o l of h i m s e l f . He was able to agree to some treatments only a f t e r he began to r e g a i n some p o s i t i v e f e e l i n g s about h i s r o l e i n the tragedy. As a r e s u l t of h i s a c c e p t i n g the treatments and l a t e r t a k i n g p a r t i n physiotherapy, the p a t i e n t ' s c o n d i t i o n improved c o n s i d e r a b l y . A f t e r about a year, h i s burns were f u l l y t r e a t e d and he was able to get around on h i s own i n a wheelchair. I t i s important i n t h i s case not to deny the extent to which 103 the p s y c h i a t r i s t ' s h e l p f u l i n put improved the outcome of t h i s case. I t seems reasonable to c l a i m t h a t h i s involvement h e l p -ed ensure a moral outcome to the tragedy. Can one r e t a i n f u l l confidence i n cases l i k e these i f only the standard approach of biomedical e t h i c s i s r e l i e d upon? Probably not, s i n c e t h i s approach o f t e n leads to an u n d e r - i n t e r p r e t e d view of the case. In order to ensure an outcome t h a t i s i n accordance with the p a t i e n t ' s best i n -t e r e s t s and t r u e d e s i r e s , i t i s necessary to adopt an approach t h a t i n v o l v e s a s o p h i s t i c a t e d form of i n t e r p r e t a t i o n . Is there any reason to b e l i e v e t h a t moral p h i l o s o p h e r s (even those f i r m l y i n po s s e s s i o n of Singer's four advantages) w i l l be b e t t e r at t h i s than p s y c h i a t r i s t s , s o c i a l workers, c h a p l a i n s etc.? Of course not. In order to get the best i n t e r p r e t a t i o n of many cases i t w i l l be necessary t o combine d i v e r s e forms of t a l e n t with the p h i l o s o p h e r ' s s k i l l s . I n d i v i d u a l s from backgrounds as v a r i e d as psychology and l i t e r a t u r e have a grea t deal t o o f f e r towards improving the i n t e r p r e t a t i o n s of cases. I f these other i n d i v i d u a l s work with p h i l o s o p h e r s , then many of the p r a c t i c a l and t h e o r e t i c a l l i m i t a t i o n s of b i o -medical e t h i c s w i l l e v e n t u a l l y be overcome. P h i l o s o p h e r s , of course, have a gre a t d e a l t o c o n t r i b u t e i n cases l i k e these, s i n c e , f o r example, an a n a l y s i s of "best i n t e r e s t s " and "true d e s i r e s " i s necessary. C o n s i d e r a b l e c l a r i f i c a t i o n of these notions i s r e q u i r e d , plus some suggestions about what should count as being i n the p a t i e n t ' s best i n t e r e s t s and which d e s i r e ought to be acknowledged and res p e c t e d . 104 P h i l o s o p h e r s and P o l i c y The case d i s c u s s e d i n the previous s e c t i o n underscores the importance of drawing a c l e a r d i s t i n c t i o n between p o l i c y questions and c l i n i c a l q u e s t i o n s . What are c l i n i c a l questions? In the burn v i c t i m case, they center around what treatments and t h e r a p i e s w i l l b r i n g the p a t i e n t from poor to improved h e a l t h . In s h o r t , c l i n i c a l questions probe the options a v a i l -able to an i n d i v i d u a l based on h i s p h y s i o l o g y , metabolism, age, weight, e t c . Questions about which a n t i b i o t i c to use or how to heal burned t i s s u e s are best handled by p h y s i c i a n s . Questions about whether a p a t i e n t should be t r e a t e d or not do i n v o l v e an important c l i n i c a l component, but a l s o have a s i g n i f i c a n t e t h i c a l dimension. For the most p a r t , p h i l o s o p h e r s are extremely u s e f u l f o r d e a l i n g with the e t h i c a l questions a r i s i n g from medical p r a c t i c e . In p a r t i c u l a r , p h i l o s o p h e r s are very e f f e c t i v e i n d e a l i n g with p o l i c y q u e s t i o n s . What are p o l i c y questions? Quite simply, p o l i c y ques-t i o n s a r i s e when h o s p i t a l s t r y to i n s t i t u t e r u l e s f o r d e a l i n g with the d i v e r s i t y of cases t h a t c o n f r o n t d o c t o r s , nurses, e t c . In the burn v i c t i m case, a p o l i c y i s needed to help h e a l t h care workers d e a l with p a t i e n t s who r e f u s e treatment. The p o l i c y chosen, of course, would be very g e n e r a l , because i t would cover many d i f f e r e n t kinds of treatment r e f u s a l . P h i l -osophers c o u l d p l a y an important r o l e i n h e l p i n g h e a l t h care workers understand the v a r i o u s p o l i c i e s and a p p l y i n g general p o l i c i e s t o p a r t i c u l a r cases. More imp o r t a n t l y , p h i l o s o p h e r s c o u l d help form p o l i c i e s and recommend standards to j u s t i f y 105 the p o l i c i e s chosen. How much p h i l o s o p h e r s have to c o n t r i b u t e to the p o l i c y process depends on whether there are r a t i o n a l l y compelling moral t h e o r i e s and concepts. I f , f o r example, p h i l o s o p h e r s can provide a r a t i o n a l l y compelling concept f o r personhood, one supported by str o n g r a t i o n a l arguments, then p a r t i c u l a r i s s u e s of biomedicine (e.g. a b o r t i o n and euthanasia) can be s e t t l e d . I f p h i l o s o p h e r s can provide r a t i o n a l l y compelling arguments f o r , say, r u l e u t i l i t a r i a n i s m ( e f f e c t i v e l y showing i t i s a t r u e moral t h e o r y ) , then they have a great deal to c o n t r i b u t e to p o l i c y formation. T h i s i s c l e a r l y so, f o r i f there are b e t t e r t h e o r i e s and b e t t e r concepts, then there i s the p o s s i b i l i t y of a r r i v i n g at b e t t e r answers t o moral prob-lems. As the q u a l i t y of the arguments i n favour of c e r t a i n t h e o r i e s and concepts i n c r e a s e s , the l i k e l i h o o d t h a t one has found the r i g h t answer a l s o i n c r e a s e s . A r a t i o n a l l y compelling approach to e t h i c s a f f o r d s one a great d e a l of confidence i n the p o l i c i e s t h a t are chosen. I t seems obvious t h a t some e t h i c a l t h e o r i e s are b e t t e r than o t h e r s . As a r e s u l t of c a r e f u l p h i l o s o p h i c a l argument, we might reasonably p r e f e r one over another. C l e a r l y , any theory t h a t i n v o l v e s f a l s e p r i n c i p l e s or i s defended by weak arguments should be abandoned, f o r to r e l y on i t i n p o l i c y formation c o u l d be d i s a s t r o u s . To determine how e f f e c t i v e a given theory i s f o r p o l i c y formation, one c o u l d simply con-s i d e r the consequences of the p o l i c i e s . I f the p o l i c i e s im-prove the q u a l i t y of l i f e f o r p a t i e n t s , reduce s u f f e r i n g , and 106 minimize dehumanization, then one would reasonably be i n c l i n e d to favour the theory defending the p o l i c i e s . Of course, p h i l o s o p h e r s c o u l d help determine what counts as good out-comes of the p o l i c i e s . The d i s c u s s i o n i n the previous paragraph r a i s e s an important q u e s t i o n , one t h a t was b r i e f l y d e a l t with i n chap-t e r t h r e e . The q u e s t i o n , q u i t e simply, i s "Why has b i o -medicine focused so much on what i n d i v i d u a l p h i l o s o p h e r s have to o f f e r ? " T h i s i s an odd t h i n g to focus upon, s i n c e there are so many d i f f e r e n t kinds of p h i l o s o p h e r s , with so many d i f f e r e n t p o i n t s - o f - v i e w , t h a t i s shouldn't be s u r p r i s i n g t h a t some answers t o t h i s q u e s t i o n have l e f t h e a l t h care wor-kers d i s s a t i s f i e d . A more i n t e r e s t i n g q u e s t i o n , of course, i s , "What does normative e t h i c a l theory have t o o f f e r ? " I t i s p o s s i b l e t o provide an answer to t h i s q u e s t i o n . As we have seen, i f there were r a t i o n a l l y compelling e t h i c a l t h e o r i e s , p h i l o s o p h e r s would have a great d e a l to c o n t r i b u t e to p o l i c y formation. But, s u r p r i s i n g l y , even i f t h i s i s not p o s s i b l e , p h i l o s o p h e r s s t i l l have a great d e a l to o f f e r b i o -medicine. As we have a l r e a d y seen, p h i l o s o p h e r s c o u l d o f f e r r a t -i o n a l l y compelling analyses of many important concepts i n biomedicine. T h i s , i n i t s e l f , i s a major achievement and would make p o s s i b l e the r e s o l u t i o n of many d i f f i c u l t moral i s s u e s . Another important r o l e p h i l o s o p h e r s c o u l d play would be to organize and s t r u c t u r e the e t h i c a l views of h e a l t h care workers. For example, a u t i l i t a r i a n c o u l d organize and s t r u c t u r e the e t h i c a l views of two doctors presented i n a debate, so t h a t these views would be coherent. The u t i l i t a r i a n c ould h i g h l i g h t what t h e i r choices mean at the a b s t r a c t l e v e l of p r i n c i p l e and r e v e a l what t h e i r fundamental oppos-i t i o n s are. Thus, the ph i l o s o p h e r c o u l d use e t h i c a l p r i n c -i p l e s to c l e a r l y e x p l a i n the responses and views of o r d i n a r y people. Such c l a r i f i c a t i o n permits non-philosophers to see what e t h i c a l views they're committed to and to con f r o n t the i m p l i c a t i o n s of t h e i r c h o i c e s . I t i s important t o r e a l i z e , however, t h a t even i f there are r a t i o n a l l y compelling arguments f o r , say, r u l e u t i l i t a r i a n i s m , p h i l o s o p h e r s would s t i l l depend on others fo input f o r p o l i c y formation. P h i l o s o p h e r s would provide the approach needed to get the answers f o r p o l i c y q u e s t i o n s , but, as one moved f u r t h e r from the a b s t r a c t to the concrete, more and more input from non-philosophers would be r e q u i r e d . The input needed would depend on the cases being considered and would, no doubt, come from many d i f f e r e n t kinds of occupations. In many cases, the i n t e r p r e t i v e s k i l l s of non-phi l o s o p h e r s would be v a l u a b l e i n choosing p o l i c i e s t h a t are mor a l l y a c c e p t a b l e . Cases i n Which A Philosopher W i l l Be of P a r t i c u l a r Value While the i n t e r p r e t i v e s k i l l s of non-philosophers are i n v a l u a b l e , there are many cases i n biomedicine t h a t demand more than a non-philosopher can o f f e r . For many cases i n the h e a l t h s c i e n c e s , a p h i l o s o p h e r ' s involvement w i l l o f t e n 10 ensure a moral outcome. We w i l l now c o n s i d e r a number of very d i f f e r e n t cases so t h a t the k i n d of advantages a p h i l -osopher has to o f f e r w i l l be c l e a r . Let us imagine t h a t a h o s p i t a l a d m i n i s t r a t o r i s se a r c h i n g f o r ways to save money. She i s w e l l aware t h a t much of the h o s p i t a l budget i s being spent on keeping people a l i v e i n the i n t e n s i v e care u n i t s . Many of these people are r e s u s i t a t e d two or three times, only to r e t u r n to a miserable few more days or weeks. Other p a t i e n t s don't ever r e g a i n consciousness; n e v e r t h e l e s s , they are l e f t a ttached to machines f o r months and even years. She c a l l s i n a moral p h i l o s o p h e r to get some a s s i s t a n c e with these prob-lems . The p h i l o s o p h e r p o i n t s out t h a t i t i s senseless to r e s u s i t a t e people j u s t to maximize the q u a n t i t y of l i f e they w i l l have. Instead, the h o s p i t a l should p r i m a r i l y focus on p r o v i d i n g a s u f f i c i e n t l y high q u a l i t y of l i f e f o r i t s p a t i e n t s . I f h e a l t h care workers must j e o p a r d i z e a p a t i e n t ' s q u a l i t y of l i f e i n order to r a i s e the q u a n t i t y , medical treatment appears unwise. Regarding the p a t i e n t s who w i l l never r e g a i n conscious-ness, the p h i l o s o p h e r has a couple of t h i n g s to say. He ob-serves t h a t a stream of consciousness i s what makes l i f e worth l i v i n g . Since these i n d i v i d u a l s w i l l almost c e r t a i n l y never r e g a i n a stream of consciousness, t h e i r l i v e s aren't worth l i v i n g . Thus, i t makes no sense to keep them a l i v e . He argues t h a t the money being spent on those who w i l l b e n e f i t 109 from medical treatment i s o f t e n j u s t i f i a b l y spent. However, the money being spent on those who w i l l never r e g a i n a stream of consciousness can't be j u s t i f i e d . The a d m i n i s t r a t o r decides t o present a number of other cases t o the p h i l o s o p h e r so t h a t he can make some recommend-a t i o n s . She asks f o r h i s view on the qu e s t i o n of whether i t i s m o r a l ly acceptable t o k i l l some f e t u s e s but not o t h e r s . He e x p l a i n s t h a t s i n c e the f e t u s i s not a person i t i s mor-a l l y a cceptable t o k i l l i t . Of course, k i l l i n g i t must be i n accord with the woman's wishes and be done as humanely as p o s s i b l e . Since only very e a r l y f e t u s e s don't f e e l p a i n , k i l l i n g them i s never a problem and can be done with the usual a b o r t i o n techniques. However, s i n c e mid to l a t e f e t u s e s have the c a p a c i t y t o f e e l p a i n , k i l l i n g them must be done much more humanely. Because w e l l over f i f t y - f i v e m i l l i o n a b o r t i o n s are performed i n the world per year, k i l l i n g mid to l a t e f e t u s e s i n the usual manner causes a t e r r i b l e amount of pai n and s u f f e r i n g . The ph i l o s o p h e r suggests t h a t the pain and s u f f e r i n g of such f e t u s e s are s i g n i f i c a n t and must be weighed a l o n g s i d e the woman's mental and p h y s i c a l s u f f e r i n g . I f the f e t u s c o u l d be k i l l e d humanely, c o n s i d e r a t i o n s such as these would be unnecessary. Given the dramatic i n c r e a s e i n the g e r i a t r i c p o p u l a t i o n , and the i n c r e a s e i n the number of s e n i l e p a t i e n t s , the admin-i s t r a t o r asks him what they should do about the extreme expen-se of c a r i n g f o r s e n i l e p a t i e n t s . He asks her whether the s e n i l e have l i v e s of q u a l i t y and p l e a s u r e . She informs him 110 t h a t many of them l e a d miserable l i v e s . He p o i n t s out t h a t t h i s i s , again, a case of maximizing q u a n t i t y at the expense of q u a l i t y . He argues t h a t i t would be morally acceptable f o r people to commit s u i c i d e before they d e t e r i o r a t e so f a r . C e r t a i n l y , i t would be an o p t i o n t h a t deserves s e r i o u s con-s i d e r a t i o n . The a d m i n i s t r a t o r e x p l a i n s t h a t there are many p a t i e n t s i n the h o s p i t a l i n the f i n a l stages of AIDS. She asks wheth-er i t would be e t h i c a l t o allow them to commit s u i c i d e . The p h i l o s o p h e r asks what i t i s l i k e to be dying from AIDS and i s t o l d i t i s t e r r i b l e . He reminds her of the views he presented e a r l i e r : a good shor t l i f e i s b e t t e r than a miserable long l i f e . Since an AIDS p a t i e n t ' s q u a l i t y of l i f e i s d e c i d e d l y negative towards the end, i t makes no sense whatsoever to s t r i v e f o r q u a n t i t y . As a r e s u l t of changing s o c i a l c o n d i t i o n s , the h o s p i t a l has s u b s t a n t i a l numbers of i n f a n t s whose mothers abuse a l c o h o l or crack. Because of an e a r l y exposure to these substances while s t i l l i n the uterus, these i n f a n t s w i l l l i k e l y have few or no prospects f o r a happy l i f e , and because they w i l l even-t u a l l y cause major problems f o r s o c i e t y , the p h i l o s o p h e r argues t h a t at the very l e a s t i t makes no sense to implement e x t r a o r d i n a r y l i f e s a v i n g measures on t h e i r b e h a l f . The a d m i n i s t r a t o r asks f o r h i s views on some of the e x o t i c t r a n s p l a n t s u r g e r i e s being performed. She t e l l s him t h a t the o p e r a t i o n s are expensive, the p a t i e n t s ' q u a l i t y of l i f e i s n ' t always very good, and even the q u a n t i t y i s some-I l l times only i n c r e a s e d by a year or s l i g h t l y longer. She e x p l a i n s t h a t most of the o p e r a t i o n s are being done with the hopes t h a t the procedures w i l l be more s u c c e s s f u l i n the f u t u r e . The p h i l o s o p h e r asks the obvious q u e s t i o n , "Could the money be b e t t e r spent elsewhere?" He notes t h a t such op e r a t i o n s could s t i l l be improved i f much fewer of them are performed. Perhaps, the number of doctors doing such procedures should be l i m i t e d . In t h i s way, a few doctors g a i n e x p e r t i s e i n these techniques, s t u d i e s can be done, and much l e s s money w i l l be spent, with the r e s u l t t h a t advances can s t i l l be made without r a i s i n g the p u b l i c ' s e x p e c t a t i o n s u n j u s t i f i a b l y . The a d m i n i s t r a t o r asks whether p h i l o s o p h e r s have much to say about the d i s t i n c t i o n between p a s s i v e and a c t i v e euthanasia. He t e l l s her t h a t a great d e a l has been w r i t t e n on the d i s t i n c t i o n between k i l l i n g and l e t t i n g d i e . He e x p l a i n s t h a t t h i s work i s h i g h l y r e l e v a n t to many areas of biomedicine. Being c l e a r on t h i s d i s t i n c t i o n i s necessary to avo i d many e r r o r s and to make r a t i o n a l d e c i s i o n s . Because of the long w a i t i n g l i s t s and the shortages of personnel and r e s o u r c e s , the a d m i n i s t r a t o r asks whether he can recommend a d e f e n s i b l e a l l o c a t i o n scheme f o r e x o t i c medical l i f e s a v i n g t h e r a p i e s . He suggests t h a t she reads N i c h o l a s Rescher's work on t h a t s u b j e c t to get an i d e a of the elements of such a scheme. He informs her t h a t many other p h i l o s o p h e r s have a l s o had a great d e a l to say on these matters. The a d m i n i s t r a t o r e x p l a i n s t h a t the h o s p i t a l conducts 112 a l a r g e amount of r e s e a r c h i n v o l v i n g o r d i n a r y people. Re-c e n t l y , however, there has been some concern t h a t mainly poor people are t a k i n g p a r t i n the s t u d i e s . She says t h a t while the r i s k s are mostly s l i g h t , there are some s t u d i e s t h a t i n v o l v e p a i n and d i s c o m f o r t f o r the s u b j e c t s . He asks what the inducements are f o r the s t u d i e s and i s t o l d they are mainly money. She t e l l s him t h a t the amounts vary, but are a p p e a l i n g , e s p e c i a l l y to a poor person. He suggests t h a t the amounts ought to be r a t h e r s m a l l , to en-sure t h a t the p a r t i c i p a n t s are there f o r reasons other than the money. Again, some p h i l o s o p h e r s have w r i t t e n on the e t h i c s of i n d u c i n g people to take p a r t i n such s t u d i e s , and he suggests she read up on the t o p i c . The a d m i n i s t r a t o r asks whether there would be any ad-vantages to having p h i l o s o p h e r s work i n s i d e the h o s p i t a l . The p h i l o s o p h e r notes t h a t people accustomed to the hosp-i t a l r o u t i n e or worried about l o s i n g t h e i r jobs aren't l i k e l y t o asks the kinds of questions a p h i l o s o p h e r would. A p h i l -osopher enjoys the advantage of being an o u t s i d e r , an e x t e r n a l c r i t i c of what has become too f a m i l i a r t o h e a l t h care workers. A f t e r even a b r i e f d i s c u s s i o n of these many d i f f e r e n t cases, i t should be apparent t h a t p h i l o s o p h e r s have a s i g n i f -i c a n t r o l e to play i n biomedicine. Undoubtedly, the nature of t h a t r o l e w i l l change d r a m a t i c a l l y over the coming years i n response to the c h a l l e n g e s posed by the h e a l t h s c i e n c e s . P h i l o s o p h e r s w i l l become i n c r e a s i n g l y e f f e c t i v e i n t h e i r r o l e i n d i r e c t p r o p o r t i o n t o the degree of c l a r i t y they a t t a i n about the p r a c t i c a l and t h e o r e t i c a l l i m i t a t i o n s of t h e i r f i e l d . C o nsiderable progress can be made toward such c l a r -i f i c a t i o n , a view supported by the r a p i d e v o l u t i o n of b i o -medical e t h i c s i n r e c e n t years. CONCLUSION Medicine i s an i n h e r e n t l y moral e n t e r p r i s e because i t seeks to do what should be done f o r a p a t i e n t . P h y s i c i a n s have an o b l i g a t i o n to provide t h e r a p e u t i c b e n e f i t s f o r t h e i r p a t i e n t s , but they are a l s o o b l i g a t e d to serve humanity f o r other important reasons. Chief among these are the f a c t t h a t good fortune o b l i g a t e s and the experience of s u f f e r i n g should awaken one's moral sense. Knowing what should be done has become i n c r e a s i n g l y d i f f i c u l t . The impact of technology on the l i v e s of p a t i e n t s and t h e i r f a m i l i e s has r e s u l t e d i n a f e e l i n g of h e l p l e s s n e s s and a l o s s of d i g n i t y . Health care workers appear to be absorbed by the mechanisms they operate, with the r e s u l t t h a t they no longer see the persons i n the cases they process. Some of the approaches t o biomedical e t h i c s have a l s o f a i l e d to acknowledge the persons i n v o l v e d because of problems of u n d e r - i n t e r p r e t a t i o n of cases. Non-philosophers have found many of the i s s u e s a r i s i n g out of the cases they c o n f r o n t on a d a i l y b a s i s to be p e r p l e x i n g . T h i s i s p a r t l y because they •lack p h i l o s o p h i c a l s k i l l s and p a r t l y because they have not always been very s u c c e s s f u l at i s o l a t i n g the important value questions the i s s u e s c r e a t e . P h i l o s o p h e r s seemed t o be n a t u r a l candidates f o r d e a l i n g with such d i f f i c u l t value q u e s t i o n s . P h i l o s o p h e r s had a 114 115 number of s k i l l s and resources t h a t they attempted to apply i n the context of biomedicine. These resources have not always been r e c e i v e d with much i n t e r e s t or enthusiasm by h e a l t h care workers. (Two notable exceptions are the a p p l i e d e t h i c s paradigm and c a s u i s t r y . ) Even though the moral e x p e r t i s e p h i l o s o p h e r s have made a v a i l a b l e has been c a l l e d i n t o q u e s t i o n by both p h i l o s o p h e r s and ot h e r s , some ph i l o s o p h e r s don't seem to have a c l e a r sense of t h e i r l i m i -t a t i o n s . One example of a l i m i t a t i o n i s t h a t p h i l o s o p h e r s might not work with s u f f i c i e n t l y s o p h i s t i c a t e d analyses of cases i f the cases haven't i n t e r p r e t e d very c a r e f u l l y . Those i n the c a r i n g p r o f e s s i o n s can help augment the i n t e r -p r e t a t i o n s of both r o u t i n e and b i z a r r e cases. Many of philosophy's problems are a r e s u l t of the dramatic d i f f e r e n c e between biomedicine and philosophy. The former i s p r i m a r i l y a p r a c t i c a l endeavor, while the l a t t e r has long been a t h e o r e t i c a l f i e l d . The medical community's response, i n p a r t , has been to develop i t s own moral resources, ones t h a t are b e l i e v e d to be tailor-made f o r i t s needs. T h i s response i s n ' t without i t s own d i f f i c u l t i e s , however. In p a r t i c u l a r , medicine should not abandon having an e x t e r n a l e v a l u a t i o n of i t s goals and purposes. In a d d i t i o n , most of the approaches medicine has considered are dependent upon people who have had some p h i l o s o p h i c a l t r a i n i n g . While many p h i l o s o p h e r s acknowledge the l i m i t a t i o n s of t h e i r r e s o urces, not a l l agree about the i m p l i c a t i o n s . Some ph i l o s o p h e r s , l i k e Rawls, t h i n k p h i l o s o p h i c a l theory i s 116 p r e s e n t l y too p r i m i t i v e to d e a l e f f e c t i v e l y with p r a c t i c a l problems. Many p h i l o s o p h e r s , however, have become pa r t of an a n t i - t h e o r y movement t h a t regards any e f f o r t s i n the area of t h e o r i z i n g as being wasted. I t i s apparent t h a t the a n t i -t h e o r i s t s w i l l have a great d e a l to say about other conceptions of moral reasoning, ones t h a t are very d i f f e r e n t from r a t i o n -a l i s t moral t h e o r i e s . Whether these a l t e r n a t i v e s w i l l be more e f f e c t i v e i n a biomedical context i s moot. I t i s prob-ably too e a r l y to pass judgment on t h e i r e f f o r t s , but i t i s apparent t h a t c o n s i d e r a b l e work needs to be done by the a n t i -t h e o r i s t s . C a s u i s t r y i s an example of a method of moral, reasoning t h a t proceeds with no e x p l i c i t emphasis on normative e t h i c a l t h e o r i e s . T h i s i s , i n s h o r t , an example of a c o n t e x t u a l i s t method t h a t depends on new ways of understanding moral j u s t -i f i c a t i o n . C a s u i s t r y produces r e s u l t s , but probably only under s t r i c t l y c o n t r o l l e d circumstances. The c a s u i s t s of today, j u s t l i k e those of P a s c a l ' s day, need to defend t h e i r method a g a i n s t charges of a r b i t r a r i n e s s and inadequate argu-mentation. T h e i r r e s u l t s don't appear to be supported by any s u b s t a n t i a l r a t i o n a l arguments. Instead, s i m i l a r i t y , d i s s i m i l a r i t y , and consensus seem to be the important elements of the c a s u i s t s ' method. Studies of the commission (and ven-t u r e s l i k e i t ) would no doubt undermine c o n s i d e r a b l e confidence i n the r a t i o n a l i t y and d e f e n s i b i l i t y of the whole approach. Despite the shortcomings of philosophy and i t s resources, i t should not withdraw from biomedical e t h i c s . Rather, p h i l -117 osophers must be content to ( f o r the present at l e a s t ) be adherents of a s o f t s c i e n c e and they must be w i l l i n g t o s o f t - p e d a l t h e i r claims to moral e x p e r t i s e . Those who are adept at p r o v i d i n g s o p h i s t i c a t e d moral i n t e r p r e t a t i o n s f o r r o u t i n e and p e r p l e x i n g cases ( v i z . p s y c h i a t r i s t s , s o c i a l workers, nurses, etc.) can help deepen the analyses of biomed-i c a l e t h i c i s t s . Despite these l i m i t a t i o n s , p h i l o s o p h e r s have a gre a t deal to c o n t r i b u t e t o biomedicine, mainly because of t h e i r e f f o r t s to come up with r a t i o n a l l y compelling moral t h e o r i e s and con-c e p t s . I f p h i l o s o p h e r s can provide strong r a t i o n a l arguments i n favour of a moral theory, then i t i s reasonable f o r one to adopt i t . R e l i a n c e on a well-defended moral theory w i l l make b e t t e r answers p o s s i b l e i n biomedical e t h i c s . I f p h i l -osophers can provide r a t i o n a l l y compelling moral concepts, then c o n s i d e r a b l e progress can be made towards r e s o l v i n g p a r t i c u l a r moral i s s u e s (e.g. euthanasia and i n f a n t i c i d e ) . A strong i n t e r p l a y between p h i l o s o p h e r s and non-philosophers (who w i l l supply necessary e m p i r i c a l input) w i l l permit the r a p i d growth and development of biomedical e t h i c s . SOURCES CONSULTED A r r a s , J o h n D. " M e t h o d o l o g y i n B i o e t h i c s : A p p l i e d E t h i c s v e r s u s t h e New C a s u i s t r y . " ( P r e s e n t e d a t t h e I n -s t i t u t e f o r t h e M e d i c a l H u m a n i t i e s o f t h e U n i v e r -s i t y o f T e x a s , G a l v e s t o n , f o r u m on " B i o e t h i c s as an I n t e l l e c t u a l F i e l d , " 1 9 8 6 ) . B a i e r , A n n e t t e . " T h e o r y and R e f l e c t i v e P r a c t i c e s . " P o s t u r e s o f t h e M i n d . M i n n e a p o l i s : U n i v e r s i t y o f M i n n e s o t a , 1985. . " D o i n g w i t h o u t M o r a l T h e o r y ? " I n A n t i - T h e o r y i n E t h i c s and M o r a l C o n s e r v a t i s m , e d i t e d by S.G. C l a r k e and Evan S i m p s o n . New Y o r k : S t a t e U n i v e r s i t y o f New Y o r k P r e s s , 1989. Beauchamp, Tom L., and James F. C h i l d r e s s . P r i n c i p l e s o f  B i o m e d i c a l E t h i c s . 3 r d e d . New Y o r k : O x f o r d U n i v e r -s i t y P r e s s , 1989. C a p l a n , A r t h u r L. " E t h i c a l E n g i n e e r s Need N o t A p p l y : The S t a t e o f A p p l i e d E t h i c s T oday." S c i e n c e , T e c h n o l o g y , and Human V a l u e s , v o l . 6, No. 33, F a l l 1980. . "Can A p p l i e d E t h i c s Be E f f e c t i v e i n H e a l t h C a r e and S h o u l d I t S t r i v e t o B e ? " E t h i c s , v o l . 93, No. 2, J a n u a r y 1 983. C a s s e l l , E r i c J . " M a k i n g a n d E s c a p i n g M o r a l D e c i s i o n s . " H a s t i n g s C e n t r e R e p o r t 1, 1973. C a n a d i a n B r o a d c a s t i n g C o r p o r a t i o n R a d i o I n t e r v i e w , 20 J a n u a r y 1 9 9 1 . The New Y o r k p s y c h i a t r i s t R o b e r t J a y L i f t o n was i n t e r v i e w e d by t e l e p h o n e f r o m New Y o r k . C a n a d i a n B r o a d c a s t i n g C o r p o r a t i o n T e l e v i s i o n I n t e r v i e w , 23 J a n u a r y 1 9 9 1 . R . J . L i f t o n was i n t e r v i e w e d f r o m t h e i r New Y o r k s t u d i o . C l a r k e , S t a n l e y G. and Evan S i m p s o n , e d i t o r s . A n t i - T h e o r y  i n E t h i c s and M o r a l C o n s e r v a t i s m . New Y o r k : S t a t e C l o u s e r , K. D a n n e r . " B i o e t h i c s , " i n W. R e i c h , e d . , The E n c y c l o p e d i a o f B i o e t h i c s , v o l . 1. New Y o r k : The F r e e P r e s s , 1978. 119 119 Engelhardt, H.T., J r . "The Philosophy of Medicine: A New Endeavor." Texas Reports on B i o l o g y and Medicine 3, 1973. Fox, Richard M. and Joseph P. DeMarco. New D i r e c t i o n s i n  E t h i c s . New York: Routledge and Kegan Paul, 1986. Hampshire, S t u a r t . " M o r a l i t y and C o n f l i c t , " i n Anti-Theory  i n E t h i c s and Moral Conservatism, e d i t e d by S.G. C l a r k e and Evan Simpson. New York: State U n i v e r s i t y of New York Press, 1989. Hare, R.M. "Medical E t h i c s : Can the Moral Philosopher Help?" In P h i l o s o p h i c a l Medical E t h i c s : I t s Nature and S i g -n i f i c a n c e , e d i t e d by S.F. Spicker and H.T. Engelhardt, J r . Boston and Dordrecht: D. R e i d e l P u b l i s h i n g Co., 1977. Hoffmaster, Barry. "Caring f o r Retarded P e r s o n s — E t h i c a l Ideals and P r a c t i c a l Choices," i n Biomedical E t h i c s , e d i t e d by Thomas A. Mappes and Jane S. Zembaty. New York: McGraw-Hill Book Co., 1986. Jonsen, A l b e r t R. and Stephen Toulmin. The Abuse of C a s u i s t r y . Berkley and Los Angeles: U n i v e r s i t y of C a l i f o r n i a Press, 1988. Jonsen, A l b e r t R. " P r a c t i c e versus Theory." Hastings Centre  Report, July/August 1990. Maclntyre, A l i s d a i r . " O b j e c t i v i t y i n M o r a l i t y and O b j e c t i v i t y i n Science," i n Morals, Science, and S o c i a l i t y , e d i t e d by H. T r i s t r a m Engelhardt, J r . and D a n i e l C a l l a h a n . New York: Hastings Centre, 1978. Mahowald, Mary B. "Biomedical E t h i c s : A Precocious Youth," i n New D i r e c t i o n s i n E t h i c s , e d i t e d by R.M. Fox and Joseph DeMarco. New York: Routledge and Kegan Paul, 1986. McDowell, John. " V i r t u e and Reason," i n Anti-Theory i n E t h i c s  and Moral Conservatism, e d i t e d by S.G. C l a r k e and Evan Simpson. New York: State U n i v e r s i t y of New York Press, 1989. P e l l e g r i n o , E.D. "The Anatomy of C l i n i c a l Judgments: Some Notes on Right Reason and Right A c t i o n , " i n C l i n i c a l  Judgment: A C r i t i c a l A p p r a i s a l , e d i t e d by H.T. Engel-hardt, J r . et a l . Boston and Dordrecht: D. R e i d e l P u b l i s h i n g Co., 1979. 120 . T e a c h i n g E t h i c s , t h e H u m a n i t i e s , and Human V a l u e s i n M e d i c a l S c h o o l s : A T e n - Y e a r O v e r v i e w . W a s h i n g t o n , D.C.: I n s t i t u t e on Human V a l u e s i n M e d i c i n e , S o c i e t y f o r H e a l t h and Human V a l u e s , 1981. P i l g e r , R i c k . " G r a d u a t e ' s N o b e l A c h i e v e m e n t . " New T r a i l , U n i v e r s i t y o f A l b e r t a ' s A l u m n i A s s o c i a t i o n Maga-z i n e , W i n t e r 1990. S i n g e r , P e t e r . "How Do We D e c i d e ? " The H a s t i n g s C e n t r e  R e p o r t , v o l . 12, No. 3, J u n e 1982. S p i e g e l b e r g , H e r b e r t . "A D e f e n s e o f Human E q u a l i t y . " P h i l o s o p h i c a l R e v i e w , 53, 1944. . " E t h i c s f o r F e l l o w s i n t h e F a t e o f E x i s t e n c e , " i n P h e n o m e n o l o g y : P u r e and A p p l i e d , e d i t e d by P. B e r t o c c i . P i t t s b u r g h : Duquesne U n i v e r s i t y P r e s s , 1974. . "Good F o r t u n e O b l i g a t e s : A l b e r t S c h w e i t z e r ' s S e c o n d E t h i c a l P r i n c i p l e . " E t h i c s 8 5, 1975. T o u l m i n , S t e p h e n . "The T y r a n n y o f P r i n c i p l e s . " The H a s t i n g s  C e n t r e R e p o r t , v o l . 1 1 , No. 6, December 1 9 8 1 . . "How M e d i c i n e S a v e d t h e L i f e o f E t h i c s , " i n New D i r e c t i o n s i n E t h i c s , e d i t e d by R.M. Fox and J o s e p h DeMarco. New Y o r k : R o u t l e d g e a n d Kegan P a u l , 1986. W i l l i a m s , B e r n a r d . "The S c i e n t i f i c and t h e E t h i c a l , " i n A n t i - T h e o r y i n E t h i c s and M o r a l C o n s e r v a t i s m , e d i t e d by S.G. C l a r k e a n d Evan S i m p s o n . New Y o r k ; S t a t e U n i v e r s i t y o f New Y o r k P r e s s , 1989. W i n k l e r , E a r l . "Fom K a n t i a n i s m t o C o n t e x t u a l i s m : The R i s e and F a l l o f t h e P a r a d i g m T h e o r y i n B i o e t h i c s . " D r a f t , 1 9 9 1 . Z a n e r , R i c h a r d M. E t h i c s and t h e C l i n i c a l E n c o u n t e r . E n g l e w o o d C l i f f s , N . J . : P r e n t i c e H a l l , 1988. 

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