The Foundations of Bioethics

There may not be a definitive resolution to the puzzle of whether bioethics should find its animating moral foundations within or outside medicine and biology. In any case, with time these two sources become mixed, and it seems clear that both can make valuable contributions (Brody, 1987). Perhaps more important is the problem of which moral theories or perspectives offer the most help in responding to moral issues and dilemmas.

Does an ethic of virtue or an ethic of duty offer the best point of departure? In approaching moral decisions, is it more important to have a certain kind of character, disposed to act in certain virtuous ways, or to have at hand moral principles that facilitate making wise or correct choices? The traditions of medicine, emphasizing the complexity and individuality of particular moral decisions at the bedside, have been prone to emphasize those virtues thought to be most important in physicians. They include dedication to the welfare of the patient and empathy for those in pain. Some philosophical traditions, by contrast, have placed the emphasis on principlism—the value of particular moral principles that help in the actual making of decisions (Childress; Beauchamp and Childress). These include the principle of respect for persons, and most notably respect for the autonomy of patients; the principle of beneficence, which emphasizes the pursuit of the good and the welfare of the patient; the principle of nonmaleficence, which looks to the avoidance of harm to the patient; and the principle of justice, which stresses treating persons fairly and equitably.

The advantage of principles of this kind is that, in varying ways and to different degrees, they can be used to protect patients against being harmed by medical practitioners and to identify the good of patients that decent medical and healthcare should serve. Yet how are such principles to be grounded, and how are we to determine which of the principles is more or less important when they conflict? Moral principles have typically been grounded in broad theories of ethics—utilitarianism, for example, which justifies acts as moral on the basis of the consequences of those acts (sometimes called consequen tialism). Utilitarian approaches ask which consequences of a choice or an action or a policy would promote the best possible outcome. That outcome might be understood as maximizing the widest range of individual preferences, or promoting the greatest predominance of good over evil, or the greatest good of the greatest number. Just what one should judge as a "good" outcome is a source of debate within utilitarian theory, and a source of criticism of that theory. Such an approach to healthcare rationing, for instance, would look for the collective social benefit rather than advantages to individuals.

A competing theory, deontology, focuses on determining which choices most respect the worth and value of the individual, and particularly the fundamental rights of individuals. The question of our basic obligations to other individuals is central. From a deontological perspective, good consequences may on occasion have to be set aside to respect inalienable human rights. It would be wrong, for instance, to subject a human being to dangerous medical research without the person's consent even if the consequences of doing so might be to save the lives of many others. Our transcendent obligation is toward the potential research subject.

Not all debates about moral theory come down to struggles between utilitarianism and deontology, though that struggle has been central to much of the moral philosophy that influenced bioethics in its first decades. Other moral theories, such as that of Aristotle, stress neither principles nor consequences but see a combination of virtuous character and seasoned practical reason as the most likely source of good moral judgment. For that matter, a morality centering on principles raises the problems of the kind of theory necessary to ground those principles, and of how a determination of priorities is to be made when the principles conflict (Clouser and Gert). A respect for patient autonomy, stressing the right of competent patients to make their own choices, can conflict with the principle of beneficence if the choice to be made by the patient may actually be harmful. And autonomy can also conflict with the principle of nonmaleficence if the patient's choice would seem to require that the physician be the person who directly brings harm to the patient.

Another classical struggle turns on the dilemma that arises when respect for individual freedom of choice poses a threat to justice, particularly when an equitable distribution of resources requires limiting individual choice. Autonomy and justice are brought into direct conflict. Recent debates on healthcare rationing, or setting priorities, have made that tension prominent.

Even if principles—like autonomy and justice—are themselves helpful, their value declines sharply when they are pitted against each other. What are we supposed to do when one important moral principle conflicts with another? The approach to ethics through moral principles—often called applied ethics—has emphasized drawing those principles from still broader ethical theory, whose role it is to ground the principles. Moral analysis, then, works from the top down, from theory to principles to case application. An alternative way to understand the relationship between principles and their application, far more dialectical in its approach, is the method of wide reflective equilibrium. It espouses a constant movement back and forth between principles and human experience, letting each correct and tutor the other (Daniels).

Still another approach is that of casuistry, drawn from methods commonly used in the Middle Ages. In contrast with principlism, it works from the bottom up, focusing on the practical solving of moral problems by a careful analysis of individual cases (Jonsen and Toulmin). A casuistical strategy does not reject the use of principles but sees them as emerging over time, much like the common law that has emerged in the Anglo-American legal tradition. Moral principles derive from actual practices, refined by reflection and experience. Those principles are always open to further revision and reinterpretation in light of new cases. At the same time, a casuistical analysis makes prominent use of analogies, employing older cases to help solve newer ones. If, for instance, general agreement has been reached that it is morally acceptable to turn off the respirator of a dying patient, does this provide a good precedent for withdrawing artificially provided hydration and nutrition? Is the latter form of care morally equivalent to the former, so that the precedent of the former can serve to legitimate the latter? Those are the kinds of questions that a casuistical analysis would ask. At the same time, a casuistical analysis runs the risk of being too bound to past cases and precedents. It can seem to lack the capacity to signal the need for a change of moral direction (Arras).

Still another principle-oriented approach proposes a new social contract between medicine and society (Veatch).

Such a contract would be threefold. It comprises basic ethical principles for society as a whole, a contract between society and the medical profession about the latter's social role, and a contract between professionals and laypersons that spells out the rights and prerogatives of each. This strategy is designed both to place the ethics of medicine squarely within the ethical values of the larger society and to make sure that laypeople have sufficient choice and power to determine the kind of care they, and not paternalistic physicians, choose. Still another approach, more skeptical about finding any strong consensus on ethical foundations, stresses an ethic of secular pluralism and social peace, devising a minimal ethic for the community as a whole but allowing great play to the values and choices of different religious and value subcommunities (Engelhardt).

Contemporary feminist approaches to bioethics, like casuistry, reject the top-down rationalistic and deductivist model of an ethic of principles (Baier; Sherwin). They reject even more adamantly what is seen as the tendency of an ethic of principles to universalize and rationalize. Feminist ethics lays a far heavier emphasis on the context of moral decisions, on the human relationships of those caught in the web of moral problems, and on the importance of feeling and emotion in the making of moral decisions. Feminist approaches, rooted in ways of thinking about morality that long predate the feminist movement of recent decades, also reflect a communitarian bias, reacting against the individualism that has been associated with a principle-oriented approach. Feminist thinkers commonly argue that those who lack power and status in society are often well placed to see the biases even of those societies that pride themselves on equality. While feminism has gained considerable prominence in recent years, it is only one of a number of efforts to find fresh methods and strategies for ethical analysis and understanding. These include phenomenological analyses, narrative-based strategies, and hermeneutical, interpretive perspectives (Zaner; Brody, 1987).

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