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Consensus plays a paradoxical role in bioethics: Although the weight of opinion is traditionally thought to have little or no merit in the resolution of moral problems, practical moral problems beg for a modus operandi that enables activity to proceed. Upon analysis, consensus also reveals a complex conceptual structure as well as a murky etiology in the history of ideas. Yet it seems difficult, if not impossible, to avoid the pursuit of consensus in the face of a morally troubling situation, however obscure the object of that pursuit might be. The impetus for a consensus is acute in a field like bioethics, which often expresses itself in such settings as clinical or research ethics committees (Moreno, 1988) and governmental policy commissions (Walters).

The History of Consensus

It is not easy to get clear on the idea of consensus, and particularly the idea of moral consensus. One reason is that relevant discussions in the history of philosophy do not always use those terms. For example, Plato's political philosophy can be taken as a treatise on consensus, but he would understand a consensus (a Latin term, of course), as a common or shared opinion. Thus the findings of the jury in Socrates's trial represent a shared opinion, and to Plato a deeply flawed one, that led to the death of his beloved teacher and seems to have inspired his elaboration and extension of Socratic philosophy in the Republic.

Literary and philosophical references to consensus seem first to have appeared with some frequency only since the nineteenth century. By then the political conception of consent of the governed had of course been subjected to close examination prior to the American and French revolutions and played a key role in those epochal events. Consensus might be regarded as the sociological cousin of political consent, not always as explicit in its manifestation nor as definitive, but nevertheless a key element in a well-functioning society. In contrast to the philosophical notion of consensus exemplified in social contract theories, sociological understandings of consensus emphasize acquiescence to extant norms.

For social scientists consensus emerged as an important category of analysis in the era of industrialization, as it helped account for the social harmony required of complex bureaucracies in the private and public sectors. Increasingly, societies in the process of pluralizing also had reason to be more aware of consensus as they encountered an unaccustomed diversity of basic values. By the late twentieth century consensus had become very nearly an end in itself among policy makers intent on finding common ground in postmodern societies rent by divisive issues, such as abortion.

Bioethics is certainly a result of this emerging process. In the early 1960s, when dialysis machines were developed to the point that they could extend life indefinitely but remained in short supply, the need to formulate an acceptable allocation arrangement was acute. Other matters of concern followed rapidly, including organ transplants, genetic engineering, human experimentation, and discontinuing life-sustaining treatment. In each case bioethics gained social standing through its participation in the formulation of a consensus. Conspicuous in its absence from this list is abortion, and it may be significant that this is the only one of these topics that was resolved almost solely in the legal system. Although the law is often an excellent instrument for consolidating a moral consensus, this is evidently not always the case.

The Paradox of Consensus in Bioethics

The emergence of consensus as a category of moral discourse flies in the face of some deeply held cultural assumptions, at least in the West. Plato's version of consensus as shared opinion was intimately related to his devastating critique of democracy as mob rule, a view that arguably required more than a millennium to overcome. His philosopher-kings knew the Good, they did not have a mere opinion about it. The great moral heroes of Western culture, from Moses to Jesus to St. Joan to Gandhi and Martin Luther King, Jr., embodied the Platonic ideal of the individual who knows the Good, confronting the mob, possessed only of an opinion.

Although one can hardly gainsay the salutary societal effects of moral heroism, the confidence it implies has its pitfalls. What American philosopher and educator John Dewey (1859—1952) so penetratingly labeled a quest for certainty characterizes much of subsequent thought, philosophical and scientific, as well as theological, all under the sway of Platonism. With the emergence of modernity, moral certainty in particular has been in tension with what another American philosopher, Charles Sander Peirce (1839-1914), called fallibilism: the doctrine that assertions must be revisable in light of further evidence, and that in the final analysis belief statements are certified as true by a community, not an individual. Fallibilism is the underlying philosophy of experimental science. Dewey especially argued that there is an experimental quality to the moral life, and that longstanding moral values have proven themselves over long experience and cross-culturally. On this view, the adaptation of values to new circumstances requires literal re-evaluation, much as scientific communities revise hypotheses in light of new evidence. In direct contrast to Platonism, this position valorizes community opinion, or consensus.

As bioethics both draws from traditional moral values and concerns itself with emerging and often quite novel problems, this tension between Platonic and Deweyan views of moral consensus underlies all bioethical discourse. It is perhaps especially well illustrated in the contrasting outcomes of two early bioethics debates. In the recombinant DNA controversy of the 1970s, the first generation of bioethicists allied with scientists to undermine theological critiques of science unleashed on unique human qualities (Evans). By contrast, at the same time bioethicists added their voices to those protesting the high degree of discretion permitted medical scientists in human experiments (Moreno, 2001).

Modes of Consensus

The moral paradox of consensus in bioethics may therefore work itself out in surprising ways, but on the whole, and especially when it engages in developing public policy, bioethics is largely a consensus-oriented field (Moreno, 1995). These consensus processes may occur in various contexts and may be more or less self-conscious. Patient management conferences often involve ethical issues that may not be acknowledged as such, in contrast to the more formal setting of an ethics committee. The most formalized and public context for moral consensus is the governmental ethics commission. Lying somewhere in between are ethics advisory boards for private entities.

Whatever the context, insofar as consensus is the preferred outcome it can be distinguished from compromise, in which the parties seek to defend and retain certain underlying principles though they may be willing to modify elements of their viewpoints that are less central (Benjamin). In a truly consensus-oriented situation the members of the group do not arrive with fixed positions but each appreciates a genuine puzzlement at the problem and the optimal solution. They then work together to find what seems to be the most ethically justifiable way to manage the problem. Although the common language refers to seeking and achieving consensus, these terms imply a static series of events while in fact consensus is more accurately described as a process through which a certain shared sense emerges.

Considering that the problems addressed in bioethics tend to be novel in at least some important ways and are often controversial, it may be surprising that consensus is ever realized. In this respect a focus on particular cases or rather highly specified issues can be critical. Frequently consensus characterizes a group discussion of a specific moral problem though the members of the same group may harbor substantial differences concerning general moral views. One may therefore contrast deep with superficial consensus, where the latter is not dependent on the former. Various moral systems may lead to the same conclusion in particular cases. Efforts to reach a deep consensus may even backfire if they fail and the group's solidarity is thereby undermined. The somewhat counter-intuitive conclusion is that, when consensus is the concern, superficial agreement is often quite adequate and efforts to resolve deeper differences should be approached with caution.

Because bioethics is a social institution that often expresses itself in appointed or self-appointed committees, panels, task forces, commissions or some other small group, an important question arises about the relation between that group and its stakeholders. Many ethics panels include members of the community, apparently in contrast to the experts who generally make up the majority of the group. The presence of community members is presumably intended to help ensure that the views of the wider society are represented. But the precise sense of representation at work here raises further questions. One way of modeling this activity is that of democratic deliberation, in which those actually engaged in the discourse are taken to be stand-ins for all those who do not have the resources or opportunity to immerse themselves in the issues at hand.

Consensus and Its Critics

The rapid growth of the bioethics profession and its close association with consensus processes expose it to the Platonic critique of shared opinion, particularly as these opinions are often received as a kind of moral expertise (Tong). The notion of expertise suggests that there is a certain body of information available to those who have certain training and experience, but not to others. If this information is taken to be at least partly factual in nature, then the consensus of moral experts must be limited to description rather than prescription. That is, on pain of violating the fact-value distinction, moral expertise can do no more than identify what is and has in fact been valued, not what ought to be valued.

Descriptive moral consensus is a form of social science, perhaps of survey research, that leaves little room for the dynamic public and professional discourse that characterizes bioethics. Without running afoul of the fact-value distinction, it appears that bioethicists must reconstruct their activity as a kind of social reform movement (Moreno, 1995). Their expertise lies not in the privileged status of their recommendations but in the arguments they put forward in support of these recommendations. Within these arguments is evidence drawn from many sources and principles derived from various sources, secular and theological, that are viewed as more or less authoritative.

Defenders of the role of consensus in bioethics, such as D. Micah Hester and Bruce Jennings, develop the notion of the individual as inherently a member of a community, so that values are embedded in social life. Rarely does any group speak with a single voice, however, and bioethicists themselves have diverse moral understandings regarding central moral issues. Even among these ethics experts there is often no common moral vision. In fact, it may be argued that this diversity is often ideological in nature, and therefore as suspect as any assertions about morality delivered by anyone with a partisan purpose (Engelhardt, 2002).

Similarly, no professional group can hope to speak for all moral viewpoints. Bioethicists have both adopted and helped articulate a certain ethical framework that valorizes individual self-determination. But many cultural subgroups, both in the developing world and within the developed world, do not accept the standard bioethical doctrines of truth telling and informed consent. Thus even if bioethicists as a professional class share some very broad consensus, they can hardly claim to speak for those groups that do not share their liberal sentiments with respect to individualism. Even a weak consensus seems hard to achieve across the board in a pluralistic society, and it is an impoverished morality that imposes self-determination on those who reject it (Trotter).

Yet a consensus among bioethical experts, however the latter term is defined, is not guaranteed to influence social policy. As Mark Kuczewski has pointed out, in the areas of foregoing life-sustaining treatment and the conduct of biomedical research, bioethicists have had extraordinary success in helping to develop a social consensus. But, as he notes, the same cannot be said for the questions concerning universal health insurance, even though many bioethicists are on record as supportive of such a program. This fact suggests that a bioethical consensus is perhaps not as weighty in public life as the critics of consensus may fear, nor as bioethicists may wish were the case.

Constraining Consensus

Considering both the moral hazards inherent in consensus and its practical inevitability in a field of ethics oriented toward practice and group decision making, careful attention must be given to the conditions under which consensus processes take place. As Kuczewski notes, in itself agreement among bioethicists means nothing. Acquiescence to expertise for its own sake would be an instance of the naturalistic fallacy, the derivation of a normative statement from a descriptive one. At the extreme, the widespread adoption of a collective bioethical soundbite that moves the public owing to its rhetoric would be emotivism in the guise of reflection.

What does count is the quality of arguments provided. These can and should be formulated, evaluated and revised by a community of bioethical inquirers. The environment must be one that fosters the exchange of reasoned views, further presupposing the peaceful resolution of moral controversy (Engelhardt, 1995). What emerges is a set of side constraints on moral consensus processes. Besides peaceable and reasoned argument there are also elements of democratic deliberation, such as a willingness to entertain unpopular points of view, mutual respect among the protagonists, and the assurance that the voices of all stakeholders have an opportunity to be heard. Strict attention must therefore be paid to the quality of the process. A self-critical consensus process should worry not about whether the outcome approximates an objectively right solution but whether the proceedings have satisfied the requirements of fairness and accuracy.

The Future of Consensus in Bioethics

If consensus is an intrinsic part of bioethics as a social institution, especially in its capacity as a forum for the development of institutional and public policy, then there will be a continuing need to examine the way consensus processes operate both within bioethics and in the larger society that incorporates the views offered by bioethicists. A field concerned with the construction of moral standards should not be ignorant of the ways its procedures and products may be distorted, whether intentionally or not. This conclusion argues not only for a degree of self-consciousness about bioethical discourse. It also commends the need to develop a sophisticated understanding about those social psychological and political processes that set bioethics apart from other forms of moral inquiry.

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