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— AMERICAN medicine is not well. Though it remains the most widely respected of professions, though it has never been more competent technically, it is in trouble, both from without and from within....
— On mortality, freedom, suffering, and the generations
— In our postmodern, secular, and liberal society, many individuals are struggling with a crisis of meaningful desire. In response, the goal of preaching Catholic bioethics should be to help people to order their desires so that they are all oriented toward their authentic good. This is done by infusing their intellects with truth and by exhorting them to order their appetites and emotions with virtue. Specifically, preachers should speak about bioethics in a way that shows our brothers and sisters that the moral truths of the Gospel will help them to find joy. However, it is not enough to speak about joy. One should never speak about these controversial and deeply personal issues without also speaking about the mercy of God. National Catholic Bioethics Quarterly 14.2 (Summer 2014): 217–226.
— Today's medicine is spiritually deflated and morally adrift; this book explains why and offers an ethical framework to renew and guide practitioners in fulfilling their profession to heal. What is medicine and what is it for? What does it mean to be a good doctor? Answers to these questions are essential both to the practice of medicine and to understanding the moral norms that shape that practice. The Way of Medicine articulates and defends an account of medicine and medical ethics meant to challenge the reigning provider of services model, in which clinicians eschew any claim to know what is good for a patient and instead offer an array of "health care services" for the sake of the patient's subjective well-being. Against this trend, Farr Curlin and Christopher Tollefsen call for practitioners to recover what they call the Way of Medicine, which offers physicians both a path out of the provider of services model and also the moral resources necessary to resist the various political, institutional, and cultural forces that constantly push practitioners and patients into thinking of their relationship in terms of economic exchange. Curlin and Tollefsen offer an accessible account of the ancient ethical tradition from which contemporary medicine and bioethics has departed. Their investigation, drawing on the scholarship of Leon Kass, Alasdair MacIntyre, and John Finnis, leads them to explore the nature of medicine as a practice, health as the end of medicine, the doctor-patient relationship, the rule of double effect in medical practice, and a number of clinical ethical issues from the beginning of life to its end. In the final chapter, the authors take up debates about conscience in medicine, arguing that rather than pretending to not know what is good for patients, physicians should contend conscientiously for the patient's health and, in so doing, contend conscientiously for good medicine. The Way of Medicine is an intellectually serious yet accessible exploration of medical practice written for medical students, health care professionals, and students and scholars of bioethics and medical ethics.
— Science Speaks: When Human Life Begins BIOETHICS DEFENSE FUND Law In The Service Of Life BDF Bioethics Briefing: 2021 Science Speaks on When Human Life Begins: Quotes Compiled from Medical Textbooks and Peer-Reviewed Scientific Literature Compiled by Maureen L. Condic, Ph.D. For Policy Consultation, contact: Nikolas T. Nikas, JD, [email protected] Dorinda C. Bordlee, JD, [email protected] (504) 231-7234 Bioethics Defense Fund, March 2021. Material may be reproduced with attribution. Requests to contact Dr. Condic may be directed to [email protected] or (801) 712-3590. Dr. Maureen L. Condic BDF Bioethics Briefing: 2021 Science Speaks on When Human Life Begins: Quotes Compiled from Medical Textbooks and Peer-Reviewed Scientific Literature Bioethics Defense Fund Policy Overview The public debates surrounding bioethics issues are perceived as thorny and confusing because of the widespread misperception that we do not or cannot know when human life begins. This line of thought commonly claims that the question is a matter of faith or religion. But if our nation is committed to restoring science to its rightful place, we must confront the reality that the question of when human life begins is simply a matter of science – in particular, the inconvenient science known as human embryology. Bioethics Defense Fund www.BDFund.org This resource is comprised solely of short and direct quotations found in medical textbooks and peer-reviewed journals as compiled by neuroscientist Maureen L. Condic, Ph.D. It is intended to inform policy debates and judicial determinations on a host of issues where we face the question of "who counts," including abortion, destructive human embryo research, human cloning, and the healthcare rights of conscience that surround these practices. NIKOLAS T. NIKAS President, General Counsel [email protected], 602-751-7234 Once we have the intellectual integrity to squarely acknowledge the objective scientific facts of human embryology, only then can we have an honest debate in the democratic process and in the courts regarding unsettled moral questions of paramount concern. Chief among those questions is whether we have an obligation to respect and legally protect human beings at their earliest and most vulnerable states of being. For pro bono consultation of matters of law and public policy, contact: DORINDA C. BORDLEE Vice President, Chief Counsel [email protected], 504-231-7234 BIOETHICS DEFENSE FUND www.BDFund.org March 2021 OTHER BDF POLICY GUIDES www.BDFund.org ● 3 Parent Embryos as Reproductive Cloning Surrogacy as Reproductive Trafficking Human Embryo Trafficking Ban Prohibiting Abortion Providers in Schools Signs of Hope - Abortion Clinic Signage ● Abortion Clinics as Points of Rescue for Sex Trafficking Victims POLST: Keeping Control Over Your End of Life Decision Making Custom consultation Science Speaks on When Human Life Begins: Quotes Compiled from Medical Textbooks and Peer-Reviewed Scientific Literature¹ Table of Contents The meaning of scientific terminology for human development. I. Medical Textbooks (10 cites).…...... II. Peer-reviewed scientific literature (75 cites).. .….......... 1 The meaning of scientific terminology for human development "Organism" is the scientific name for a living human being. Only organisms undergo development. “Zygote” is the one-cell human organism produced by sperm-egg fusion. "Embryo" is a human organism during the first eight weeks of development. I. Medical Textbooks (10 cites) The origin of human life at fertilization: The following quotes are from Medical Textbooks on Human Embryology/Reproduction. 1. Keith L. Moore, The Developing Human: Clinically Oriented Embryology, 10th edition. Philadelphia, PA: Saunders, 2016. p. 11 "Human development begins at fertilization, when a sperm fuses with an oocyte to form a single cell, the zygote. This highly specialized, totipotent cell (capable of giving rise to any cell type) marks the beginning of each of us as a unique individual.” ¹ Compiled by Dr. M.L. Condic, Associate Professor of Neurobiology and Anatomy, University of Utah, School of Medicine, 20 N 1900 E Salt Lake City, Utah 84132-3401 (emphasis added in quotes). In some cases, a few words of clarification for the non-technical reader have been added in brackets []. BDF Bioethics Briefing: 2021 3 1 2. Schoenwolf, G. C. Larsen's Human Embryology, 5th edition. Philadelphia, PA: Elsevier, Saunders, 2015. p. 2, 14. “All of us were once human embryos, so the study of human embryology is the study of our own prenatal origins and experiences.” (p. 2) "Fertilization, the uniting of egg and sperm, takes place in the oviduct. After the oocyte finishes meiosis, the paternal and maternal chromosomes come together, resulting in the formation of a zygote containing a single diploid nucleus. Embryonic development is considered to begin at this point.” (p.14) 3. Jones, R. E. Human Reproductive Biology, 4th edition. Waltham, MA. Elsevier, Academic Press, 2014, p. 169. "the fertilized egg (zygote) is the beginning of a new diploid individual." 4. Keith L. Moore, Before We Are Born: Essentials of Embryology, 7th edition. Philadelphia, PA: Saunders, 2008. p. 2: "[The zygote], formed by the union of an oocyte and a sperm, is the beginning of a new human being." 5. Keith L. Moore, Before We Are Born: Essentials of Embryology, 9th edition. Philadelphia, PA: Saunders, 2016. p. 1. "Human development begins at fertilization when an oocyte (ovum) from a female is fertilized by a sperm (spermatozoon) from a male... Embryology is concerned with the origin and development of a human being from a zygote to birth." 6. Sadler, T. W. Langman's Medical Embryology, 10th edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2006. p. 11: "Development begins with fertilization, the process by which the male gamete, the sperm, and the female gamete, the oocyte, unite to give rise to a zygote." 7. Sadler, T. W. Langman's Medical Embryology, 13th edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2015. p. 42 (emphasis added). "The main results of fertilization are as follows: Restoration of the diploid number of chromosomes, half from the father half from the mother. Hence, the zygote contains a new combination of chromosomes different from both parents. Determination of the sex of the new individual. An X-carrying sperm produces a female (XX) embryo and a Y- carrying sperm produces a male (XY) embryo. Therefore, the chromosomal sex of the embryo is determined at fertilization." BDF Bioethics Briefing: 2021 2 8. Dudek, R. W. Embryology, 4th edition. Philadelphia, PA. Lippincott Williams and Wilkins, 2008, p. 1. "Sexual reproduction occurs when female and male gametes (oocyte and spermatozoon, respectively) unite at fertilization." 9. Ronan O'Rahilly and Fabiola Miller, Human Embryology and Teratology, 3rd edition. New York: Wiley-Liss, 2001. p. 8. "Although life is a continuous process, fertilization... is a critical landmark because, under ordinary circumstances, a new genetically distinct human organism is formed when the chromosomes of the male and female pronuclei blend in the oocyte." 10. Carlson, B. M. Human Embryology and Developmental Biology, 5th edition. Philadelphia, PA. Elsevier, Saunders, 2014, p. 2. II. "Human pregnancy begins with the fusion of an egg and a sperm within the female reproductive tract" Peer-reviewed scientific literature (75 cites) The following 75 citations of peer-reviewed articles are from a search of scientific literature dated 2001-present, listed in chronological order. 1. A profile of fertilization in mammals. Wassarman PM, Jovine L, Litscher ES. Nat Cell Biol. 2001.3(2):E59-64. "When mammalian eggs and sperm come into contact in the female oviduct, a series of steps is set in motion that can lead to fertilization and ultimately to development of new individuals." 2. Penetration, adhesion, and fusion in mammalian sperm-egg interaction. Primakoff P, Myles DG. Science. 2002. 296(5576):2183-5. "Fertilization is the sum of the cellular mechanisms that pass the genome from one generation to the next and initiate development of a new organism." 3. Egg activation at fertilization: where it all begins. Runft LL, Jaffe LA, Mehlmann LM. Dev Biol. 2002. 245(2):237-54. BDF Bioethics Briefing: 2021 3
— Old age: our future. The Elderly after the pandemic, 2 February 2021
— Prof Alexander Pruss is a professor of philosophy and director of graduate studies at Baylor University. He has published in many areas of philosophy as well as mathematics and his books include The Principle of Sufficient Reason: A Reassessment (2006), Actuality, Possibility and Worlds (2011) and One Body: A Study in Christian Sexual Ethics (2012). His blog can be found here: alexanderpruss.blogspot.com
— Pope Francis got himself involved with the ongoing debate over the decriminalization of abortion in his Argentinian homeland, sending a handwritten letter to a group of women from Buenos Aires’ slums asking, “Is it fair to hire a hitman to resolve a problem?”
— Stanford Encyclopedia of Philosophy Menu Browse Table of Contents What's New Random Entry Chronological Archives About Editorial Information About the SEP Editorial Board How to Cite the SEP Special Characters Advanced Tools Contact Support SEP Support the SEP PDFs for SEP Friends Make a Donation SEPIA for Libraries Entry Navigation Entry Contents Bibliography Academic Tools Friends PDF Preview Author and Citation Info Back to Top Theory and Bioethics First published Wed Nov 25, 2020 The relation between bioethics and moral theory is a complicated one. To start, we have philosophers as major contributors to the field of bioethics, and to many philosophers, their discipline is almost by definition a theoretical one. So when asked to consider the role of moral theorizing in bioethics, a natural position of such philosophers is that moral theory has a crucial, if not indispensable, role. At the same time, there are those who call into question the “applied ethics” model of bioethics. Roughly, on this model, one moral theory or other (e.g., utilitarianism, Kantian deontology, virtue theory) is imposed upon the applied ethics problem at hand, in the hopes of producing a resolution. Such a model, according to its detractors, overplays the separation of the theoretical from the applied. Still further, there are those such as Will Kymlicka (1993 [1996]) who hold that moral theory should not have a place in the making of public policy on bioethical issues.[1] This entry starts by addressing the complexities surrounding the very notions of bioethics and moral theory. From there, we explore the question of what doing applied ethics amounts to. Moving on, the discussion centers upon the main methodological movements in bioethics’ relatively short history: its appeal to high moral theory, the emergence of mid-level approaches to bioethics, and approaches to bioethics that attribute a lesser role to theoretical tools, or no role at all. Feminist approaches to bioethics are treated next, followed by a look at the significance of moral theory to clinical bioethics. 1. What is Moral Theory? What is Bioethics? 1.1 Varying Accounts of Moral Theory 1.2 The Pursuits of Bioethics 2. What is the Nature of Applied Ethics? 2.1 Problems with the “Applied Model” of Applied Ethics 2.2 Applied Ethics and Disagreement on Theory 2.3 Applied Ethics and Rule Application 2.4 Toulmin on the Tyranny of Principles 3. Bioethics and High Moral Theory 3.1 The Attractions of High Theory 3.2 Problems with Bioethics Conceived as An Appeal to High Moral Theory 4. The Move to Mid-Level Theorizing: a Principles-Centered Approach 4.1 A Move Away from Deduction, and Reflective Equilibrium 4.2 The Common Morality 4.3 Criticisms of the Principles-Centered Approach 5. Other Methods of Bioethics 5.1 Casuistry 5.1.1 Advantages of casuistry 5.1.2 Criticisms of casuistry 5.2 Narrative Ethics 5.2.1 Criticisms of Narrative Ethics 6. Feminist Theory and Bioethics 7. Moral Theory and Clinical Bioethics 7.1 Models of Clinical Ethics Consultation 7.2 Clinical Ethics and Moral Theory 8. Conclusion Bibliography Academic Tools Other Internet Resources Related Entries 1. What is Moral Theory? What is Bioethics? The question of the relation between moral theory and bioethics is made difficult by a number of factors, not the least of which is the absence of any one account of what constitutes philosophical theory. There are, of course, the standard moral theories of introduction to moral philosophy—consequentialism, deontology, and virtue ethics. And we also speak of mid-level theories, such as moral principlism and casuistry, though the extent to which such approaches are strictly speaking theoretical is somewhat unsettled. What do we mean by moral theory? What characterizes an approach to moral philosophy and bioethics as theoretical? Add to such questions the fact that bioethics itself is not a monolithic discipline, and our topic is complicated right from the start. 1.1 Varying Accounts of Moral Theory On some accounts, a theoretical approach to a philosophical issue or problem is defined by intellectual tendencies toward some combination of generalization, universality, systemization, abstraction, explicitness, and the capability to generate recommendations. For instance, Martha Nussbaum holds that there are certain necessary and sufficient criteria for ethical theory (Nussbaum 2000: 234–236). On her view, ethical theory: Gives recommendations about practical problems; Shows how to test correctness of beliefs, rules, and principles; Systematizes and extends beliefs; Has some degree of abstractness and generality; Is universalizable; Is explicit. Generalization, universality, and abstraction are also taken by others to be hallmarks of moral theory (Arras 1997: 74; 2003; Louden 1990). Even so, some philosophical approaches to moral and bioethical questions that do not satisfy all or even any of the criteria set out above are referred to as theories. For instance, moral particularism, which aspires neither to the formulation of generalizations nor to systemization [2] is sometimes referred to as a moral theory.[3] Further still, one might even hold that beyond the criteria listed above, moral theory employs a certain argumentative mode, with a certain tone and style (Louden 1992: 156; Nussbaum 2000: 239). There is more one could say here on agreement and disagreement on what counts as theoretical within philosophy, including something about what might qualify as an anti-theoretical approach to morality and bioethics (Clarke 1987; Clarke & Simpson 1989; Fotion 2014; Louden 1990). But our main point for the moment is that what counts as moral theory is not perfectly clear, which complicates the question of the relation between moral theory and bioethics. We need not here stipulate one definition of what we shall count as a theoretical approach to bioethical problems moving forward. Suffice it to say that the question of the relation between theory and bioethics will be approached by canvassing various methodological approaches to treating problems and questions in bioethics. 1.2 The Pursuits of Bioethics Turning now to what counts as bioethics, the label does not indicate a unitary pursuit, what with bioethics’ academic, policy-oriented, and clinical instantiations (McMillan 2018: 11–16; Battin 2013: 2). When it comes to bioethics as an academic or scholarly pursuit, the practical constraints of clinical decision making, and the timelines imposed by commissions, are non-existent, freeing the bioethicist of the need to reach closure on a decision or to resolve a complex issue. As it has been put, for the academic bioethicist and her students, it does not matter if you end the seminar more confused than when you started it. It is within this academic domain that the relationship between bioethics and moral theory will be most explicit, the role of moral theory most intently debated, and moral theory probably most welcome. Looking at policy-oriented bioethics, here the bioethicist assists in the development of policies affecting large numbers of people on issues of bioethical relevance (such as the rationing of kidney dialysis services, or the availability of medical assistance in dying). There are challenges upfront with the bioethicist’s invoking moral theory of any sort in tackling policy challenges as a member of a national commission, say, or as a member of her regional health authority’s ethics committee, or as a member of any other sort of policy-oriented working group. For starters, there is the fact that she is likely to be in the vast minority as a group member with philosophical training. But that aside, there is the further challenge of the unlikelihood of agreement amongst working group members on which moral theory should rule the day or govern the decision at stake.[4] There is the third category of clinical ethics, a pursuit taking place as health care is practiced on the ground. As we will see in more detail shortly, the relevance of moral theory to clinical ethics turns heavily on the operative conception of clinical ethics. In particular, it relies upon our conception of the goals of the clinical ethics consultation (the main activity of clinical bioethics), and upon our conception of the role of the clinical ethics consultant. What constitutes what we call applied ethics is just as fraught a question as the one of the relationship between theory and bioethics, and it implicates our take on that relationship. We now turn to that question. 2. What is the Nature of Applied Ethics? We have briefly reviewed the variety of tasks and problems to which bioethics addresses itself. But we should also briefly examine the ways in which bioethics, and its broader cousin applied ethics, is and has been conceptualized. Such an examination is important within the context of this entry in that questions about the nature of applied ethics are often implicitly questions about the relation between the theoretical and the applied, or between “theory” and “practice”. The very term applied ethics suggests that the discipline involves an application of some sort or other moral theory to the practical problem or question at hand. Arthur Caplan writes that many contributors to the field of bioethics take applied ethics to involve the application of existing theories and principles to moral problem in medicine (Caplan 1980: 25–26). But what does it mean to apply an existing theory to a practical problem? How easily can the distinction between applied ethics and ethical theory be sustained? As it turns out, many say that the field of applied ethics cannot be what the name would lead us to suppose it is. 2.1 Problems with the “Applied Model” of Applied Ethics Caplan argues that there are problems with such a model of applied ethics (which many call “the applied model”). To start, many moral problems arise within medicine for which moral theories have no answers. The applied model of applied ethics also presumes that those involved in the analysis and solution of a moral problem take it that the nature and description of the problem or quandary is not in dispute, where in reality it is often not clear exactly what is the moral issue at stake (Caplan 1980: 28; 1989; Agich 2001; and Magelssen, Pedersen, & Førde 2016). This model also implicitly involves a naïve suggestion, argues Caplan, namely that by dint of expertise in moral theory, the well-trained philosopher can almost immediately solve moral dilemmas in the intensive care unit or the emergency department (Caplan 1980: 27). Moreover, adherence to such a model of applied ethics forecloses the opportunity for medical ethics (or other fields of applied ethics) to inform theory construction, as the direction of influence on that model moves only from theory to the practical. 2.2 Applied Ethics and Disagreement on Theory Further disruption of the application model came shortly afterwards from both Tom Beauchamp and Alasdair MacIntyre.[5] Beauchamp challenges the application model of applied ethics, defined largely as above: ethical theory develops general and fundamental principles, virtues, rules, and the like, and applied ethics treats particular contexts through less general, derived principles, virtues, and so on. In a 1984 issue of The Monist dedicated to “Ethics and the Modern World”, Beauchamp and MacIntyre each probe the relation between moral theory and applied ethics. Beauchamp argues for the elimination of the distinction between the two, citing the lack of significant difference between them in terms of philosophical activity or method. Philosophers doing applied ethics do what philosophers have always done, says Beauchamp—they analyze concepts, for instance, and submit to critical scrutiny various strategies that are used to justify beliefs, policies, and actions. The application model also problematically presumes a unilateral direction to the flow of ethical knowledge, from moral theory to practical cases and problems. But in fact, says Beauchamp, moral theory has much to learn from practical contexts (Beauchamp 1984). 2.3 Applied Ethics and Rule Application MacIntyre tells us that applied ethics cannot be the sort of activity it is commonly supposed to be. He turns our attention to the complexities surrounding the notion of what it would mean to apply a moral rule. If applied ethics is in fact an application to cases of the rules of morality, we should expect to find that disagreements over moral rules reproduce themselves within debates on matters of practical ethics. But in a high proportion of cases these theoretical disagreements, of which there are plenty, are not in fact replicated. Large disagreement on what are the rules of morality turn out to be compatible with large agreement within the domain of applied ethics. Noting how common such situations are (situations in which clear disagreement exists on what are the rules of morality, while fairly easy agreement can be reached on concrete moral issues), MacIntyre holds that it cannot be the case that we first and independently comprehend the rules of morality and then secondly enquire as to their application under particular circumstances. As MacIntyre has it, no rule exists apart from its application (and he admits that his argument entails the rejection of any conception of moral principles or rules as timeless and ahistorical). Often times, he suggests, it appears as though agreements among a group of decision makers is being reached through rational argumentation, but in fact often group members are reopening debates about perennial philosophical questions. This is particularly so in medical ethics, MacIntyre tells us. Our common conception of applied ethics does indeed rest on a mistake (MacIntyre 1984). 2.4 Toulmin on the Tyranny of Principles Stephen Toulmin, in his well-known paper “The Tyranny of Principles”, recounts his experience on the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (Toulmin 1981). Agreement amongst members of the commission was relatively easy to reach even on difficult cases, even in the face of thoroughgoing moral theoretical disagreement amongst members. His main point in the paper is not to directly address the nature of applied ethics, but to argue for a regaining of what he calls the “ethics of discretion”, calling into question the role of moral principles. En route, though, he undermines the application model of applied ethics, through his discussion of how much agreement on practical problems there can be among theorists of radically different stripes. According to Toulmin, this shows us that applied ethics is not a matter of applying a theory to a problem, in that there can be agreement on how to resolve a practical issue amongst those who strongly disagree on which moral theory ought to prevail. Again, we have an emphasis upon a lack of reproduction of theoretical disagreement in dealing with issues in practical ethics. One might question whether such agreement on particular cases paired with theoretical disagreement shows that the applied model ought to be abandoned. Nevertheless, Toulmin’s experience prompted him to wonder what final appeals to principles really achieved. One final point for the moment on the disruption of the distinction between ethical theory and applied ethics: as will be discussed in more detail in section 4, many would say there recently has been widespread adoption of reflective equilibrium as the method of justification in bioethics (Arras 2007). One important implication of this adoption is a blurring of the distinction between moral theory and applied ethics, what with the fact that on reflective equilibrium, our responses to real cases inform our theorizing as much as our theories inform our handling of cases. We have just seen reasons to think that we cannot neatly separate moral theory and applied ethics. Even so, moral theory in some form plays a crucial if not indispensable role in bioethics. We will now look at the relevance of high theory. 3. Bioethics and High Moral Theory As the discipline we now call bioethics emerged in the early 1970s, moral philosophers and political theorists were primed to contribute to debates on any number of practical issues in areas such as law, economics, the environment, business, research on human beings, and medical practice. These academics were understandably hopeful both that their knowledge of moral theory would prepare them to apply their theoretical understanding to real-world problems, and that their skills in critical analysis would be appreciated. Even today, such confidence in the usefulness of moral theory to the solving of practical problems is manifest in the introductions to bioethics textbooks, many of which include discussions of at least the basics of consequentialism, virtue theory, deontology, and so on. 3.1 The Attractions of High Theory The attractions of high theory were, and are, significant, and indeed, such moral theories have provided the groundwork for many an approach to bioethical issues. Examples here include Alan Donagan’s Kantian-inspired work on informed consent (Donagan 1977), Tristram Engelhardt’s libertarian critique of redistribution in health care (Engelhardt 1986 [1996]), and Joseph Fletcher’s utilitarian approach to a broad range of issues in bioethics (Fletcher 1974). What might explain such recourse to high moral theory? What are the attractions of high moral theory for the bioethicist? Let us consider three important possibilities. First, in bioethics as in everyday life, our routine moral coping skills work often enough. When they do not, though, we need recourse to more structured and systematic moral guidance. On these occasions, high moral theory, such as consequentialism and deontology, looks helpful and attractive. Besides offering guidance, such theory provides the resources for moral justification, especially helpful when we are pressed to explain our bioethical or everyday moral decisions. Second, when we appeal to mid-level principles (such as the principle of justice or the principle of beneficence), we sometimes need help in weighing, balancing, and adjudicating between those principles. High moral theory could well provide such help, by providing a form of moral standard. Recall Sidgwick’s argument in support of utilitarianism, that it could provide guidance in resolving conflicts among ordinary duties that everyday (non-theoretical) moral thinking cannot resolve on its own (Sidgwick 1874). In a similar vein, Martha Nussbaum defends the need for moral theory in part by emphasizing what she takes to be its power in helping us weigh various rules against each other in varying circumstances through its setting of a normative standard (Nussbaum 2000). Third, high moral theory can help us achieve consistency in our moral lives, as well as a systematic perspective. There is benefit, the thought goes, to bringing moral theory to bear upon various facets of our ordinary and bioethical lives, because of the systematicity and coherence it can provide. Bernard Gert is one for whom such systematization, at least within bioethics, takes priority (Gert, Culver, & Clauser 2006). 3.2 Problems with Bioethics Conceived as An Appeal to High Moral Theory The days of bioethics conceived of as high theory were short lived, however, and the reasons plentiful. For starters, there is the question of which moral theory should prevail. Even if one has no problem choosing a moral theory in the first place, one is bound to have difficulty in successfully defending that choice of theory against its alternatives (Magelssen, Pedersen, & Førde 2016: 27). The intractability of the debates between utilitarians and deontologists, say, should give anyone pause when staking out her positions on bioethical matters with the guidance of her preferred moral theory. This is one thing for the academic bioethicist. But it is quite another for the clinical ethicist (for instance) to attempt to settle the moral matter at hand through recourse to (say) Kant’s categorical imperative. Not only is she likely to be surrounded by non-philosophers (where recourse to the intricacies of such high flying moral theory is liable to fall flat), but we must ask why the public to whom she might be accountable should be subject to her preference for Kantianism. The same would hold true for the bioethicist working in the public policy arena. Second, that challenge aside, there are disagreements within the ranks of any given theory. Consider rule versus act utilitarianism, for instance, or disagreement amongst Rawlsians. Third, some cite tensions between some versions of high theory and democracy. Publicity, many hold, ought to be a fundamental norm governing policy making in a democratic society (Rawls 1971). Requiring such publicity would preclude justifications that no one outside an elite class of philosophers can understand. One need not be a theory sceptic, then, in order to demote the place of high theory within bioethics; one need only recognize the tension between doing bioethics in a democracy, and rarefied moral theory (Bertram 1997; London 2001). Fourth, and this is focused on the usefulness or lack thereof of high moral theory within the clinical ethics context, using theories in the prescribed way may be very demanding for the clinical ethicist without high level philosophical training. Furthermore, the comprehensiveness of the justifications promised by high moral theory may be unnecessary within that context (Magelssen,, Pedersen, & Førde 2016: 27). Fifth, and reminiscent of Caplan’s problems with the applied model of applied ethics earlier discussed, it is doubtful that any high-level philosophical theory can generate straightforward answers to complicated applied problems. Norman Daniels, whose work on justice and access to health care was inspired by Rawls’ theory of justice, came to admit that philosophical theory is insufficiently fine-grained for actual policy making, and that it needs to be complemented by justly structured political deliberation (Daniels 1996: 144–175; 2007: ch. 4). The general thought here is that high philosophical theory is ill-equipped to deal with practical decision making on the concrete level (Gutmann & Thompson 1998). After all, one’s preferred moral theory could well, for instance, endorse several possible policy options, leaving decision makers wanting for further guidance. In sum, bioethics as conceived of as an appeal to high moral theory has been found to have significant limitations, despite its initial promise. We now to what appears to be a more promising approach. 4. The Move to Mid-Level Theorizing: a Principles-Centered Approach The move to what is often referred to as mid-level theorizing was (partly) a result of the challenges with high theory just discussed, and manifested most prominently by the 1979 publication of Tom Beauchamp and James Childress’ influential Principles of Biomedical Ethics (PBE). The approach set out in that book, and its revised versions appearing in the book’s subsequent editions, feature mid-level moral norms, which take the form of four moral principles.[6] Beauchamp and Childress’ four principles are: the principle of autonomy (the value of self-direction regarding one’s life and choices), the principle of beneficence (the value of enhancing the welfare of others), the principle of nonmaleficence (the value of avoiding imposing harm on others), and the principle of justice (the value of according each person her due) (Beauchamp & Childress 2019a; Arras 2017: 5). Coming on the heels of Joseph Fletcher and Paul Ramsey’s early work in what we now call bioethics—both Fletcher and Ramsey were moral theologians, whose work, while very different from one another’s, was based on Christian moral theology—Beauchamp and Childress offered the promise of a moral framework that could appeal to a pluralist and secular society.[7] Beauchamp and Childress have different theoretical starting points, with Beauchamp describing himself as a rule-utilitarian, and Childress a Christian deontologist (Arras 2017: 3; Beauchamp & Childress 1979: 40: 2019b: 9). This underlines the approach as one that refrains from promoting a single theory over all others, and as one that requires no underlying theoretical or metaphysical commitments for its uptake. 4.1 A Move Away from Deduction, and Reflective Equilibrium Beauchamp and Childress’ approach has evolved since the book’s first edition, and one important aspect of this evolution is the move away from deductive reasoning, or (in other words) away from a “top down” application of principles to cases. Their initial take on the relation between moral theory, principles and cases was that theory justified principles, that principles justified moral rules, and that rules justified moral judgments in particular cases. (Arras 2017: 11) This, at least, was the impression given by a diagram appearing in the first edition of the book (Beauchamp & Childress 1979: 5), which many took to endorse such a top down model. The approach was met with resistance, with those in favor of case-based reasoning (also known as casuistry) objecting to what at least appeared to be a unidirectional movement from principles to cases. Intuitive, case-based judgments seemed to be left out of the picture, and the possibility of a dialectical relationship between principles and our responses to cases ignored. In fact, and as a result of an evolution of their approach, Beauchamp and Childress now fully ascribe to this position on the reciprocal relationship between our responses to cases and moral principles. This is evidenced by their current commitment to reflective equilibrium as the methodology of bioethics. Briefly, reflective equilibrium is a process by which our considered responses to actual cases influence our moral principles, and those improved-upon principles then provide enhanced guidance for our response to further cases. This is a way of doing moral philosophy originally formulated by Rawls (Rawls 1971: 48–51; Daniels 1979; Arras 2007: 47). Cases and principles work in tandem, then, as opposed to moral principles being applied deductively to cases. A distinction is made between narrow and wide reflective equilibrium. Narrow reflective equilibrium involves interplay between our responses (or intuitions) about cases and the moral principles used to structure such intuitions, as explained above, where wide reflective equilibrium brings in additional moral and social theories. Beauchamp and Childress endorse wide reflective equilibrium (Arras 2017: 182). That Beauchamp and Childress take (wide) reflective equilibrium to be such a crucial component of their approach is an important aspect of their approach as it currently stands. As their view has evolved over subsequent editions of PBE, reflective equilibrium has grown to have a more and more prominent role. An important result of this embrace of reflective equilibrium is that, paired with Beauchamp and Childress’ appeal to the common morality, we have a hybrid approach to justification, hybrid in the sense of embracing both coherentism and foundationalism. Reflective equilibrium is the source of coherentism, with the appeal to the common morality meant to provide a foundation. Before moving on to a closer look at the notion of the common morality, we should note that this hybrid approach differs from accounts of reflective equilibrium we might find in political theory, for example, and in other areas of practical ethics. Those more standard accounts involve achieving moral justification by bringing the various elements of our moral reflection into contact with one another, with none of these elements regarded as foundational and all of them regarded as open to revision. By contrast, Beauchamp and Childress accord foundational status to the common morality, and it is the common morality that underwrites their four principles. 4.2 The Common Morality Since the third edition of PBE, the source of the four principles has been not high theory but the common morality. For Beauchamp and Childress, the common morality is what they take to be a universal morality, one to which all morally serious persons are committed (Beauchamp & Childress 2019b). The content of the common morality is dictated by the primary objectives of morality, which include, for example, the amelioration of human misery. It encompasses certain rules of obligation (tell the truth, keep promises), and endorses certain standards of moral character, such as honesty and integrity (Arras 2017: 21–3). Importantly, this common morality is historicist, in that its authority is established historically, through the success of its related norms in advancing human flourishing across time and place. However, unlike many historicist accounts, the common morality is not relativist, as its norms are to be applied universally. Beauchamp and Childress accord the common morality a special place within their approach, a place shielded from the jostling involved in the quest for coherence through wide reflective equilibrium. The common morality is thus the foundationalist aspect of their account. Moral conclusions, then, are justified through both coherence (via the method of reflective equilibrium), and through foundationalism, being connected to the principles of the common morality (Arras 2017: 23; Beauchamp & Childress 2019b: 11). 4.3 Criticisms of the Principles-Centered Approach There is a pluralistic element to Beauchamp and Childress’ approach, which is manifested, in part, by the fact that the approach avoids a single overarching principle in favor of the short list of four moral principles. This has lead some to criticize Beauchamp and Childress’ approach for an alleged lack of systematicity—a fatal flaw, according to some, in any philosophical theory (Gert, Culver, & Clauser 2006). Such critics claim that without a clear prioritizing of principles, Beauchamp and Childress’ principles-centered approach lacks rigor and leaves too much room for intuitive judgments in cases where principles conflict. Beauchamp and Childress respond, first, by rejecting the very idea that they are offering a philosophical theory, rather than a framework or practical guide. But perhaps more importantly, they doubt that any priority ranking of their principles would stand the test of time (Arras 2017: 6–9). A fairly recent criticism comes from John McMillan, according to whom Beauchamp and Childress’ approach stifles careful reflection about real issues. McMillan claims that principle-centered methods cannot lead to the formulation of what he calls “reasoned convictions about moral problems”, and writes that the four principles approach hinders bringing moral reason to bear upon practical questions. This is because, as McMillan has it, newcomers to bioethics will subsume whatever issues are under consideration under one of the four principles, and then rule that the principle of autonomy should trump the other three principles. While recognizing that such a method is not what Beauchamp and Childress intended, McMillan writes that it is in fact the way the four principles approach is typically employed (McMillan 2018: 51–53). Two interesting criticisms of Beauchamp and Childress’ latest moves come from the late John Arras. Arras questions the plausibility of Beauchamp and Childress’ hybrid account, specifically the account’s reliance upon the common morality as a foundation. Arras asks why Beauchamp and Childress distinguish the norms of the common morality from (what John Rawls called) our considered moral judgments, which are themselves revisable. Arras recognizes that Beauchamp and Childress might motivate their appeal to a foundation on the ground that coherence alone cannot secure moral truth. In that case, though, Arras wonders how much additional justificatory advantage is leveraged by appealing to the foundational common morality, as reflective equilibrium itself is maximally inclusive of all pieces of the moral picture (including, presumably, the common morality’s norms). The problem, as Arras has it, is the conception of the common morality as being in its own moral sphere, removed from reflective equilibrium’s dialectic. Arras is skeptical that the common morality is in fact untouched by the vicissitudes of time and the dialectics of reflective equilibrium (Arras 2017: 24–26). A second criticism from Arras deals with Beauchamp and Childress’ embrace of wide reflective equilibrium. According to Arras, it is difficult to comprehend how moral principles can retain their priority in conceptual analysis in the face of this endorsement of wide reflective equilibrium (Arras 2017: 182–3). Arras asks us to recall that within wide reflective equilibrium, no single cluster of moral considerations (e.g., considered case judgments, background theories, moral principles) is privileged. What matters in reflective equilibrium’s revising process, in fact, is our level of commitment to those considerations, rather than the form of the commitments themselves (Scanlon 1992; DePaul 1993: 57). Thus, our beliefs about principles, just like our beliefs in background theories and considered case judgments, are always subject to revision. The principles-centered approach seems to have sacrificed its methodological distinctiveness, so Arras’ criticism goes, given how principles appear to have been robbed of their conceptual priority. Finally, Beauchamp and Childress themselves recently acknowledge two misunderstandings of their four principles framework. The first misunderstanding is that the framework represents American individualism, with the principle of autonomy taking priority. Their response is, first, to contest any connection between American individualism and a respect for autonomy. Further, they emphasize that their framework’s principles are all only prima facie binding. The second misunderstanding is that the framework downplays the virtues. It has been argued that medical ethics should be underwritten by virtue-based ethics rather than by principle-based ethics, and that that approach has a better chance of restoring humanity to health care (de Zulueta 2015). Here, Beauchamp and Childress point to various discussions of virtue theory and moral character appearing in various editions of PBE, including a discussion in the eighth edition of how virtues and principles might work together in certain practical scenarios (Beauchamp & Childress 2019b: 11). 5. Other Methods of Bioethics 5.1 Casuistry There are other approaches to bioethics that embody alternatives to high theory. The first, casuistry, can in some sense be understood as a critical response to early versions of Beauchamp and Childress’ four principles approach. Recall a certain response to at least early versions of Beauchamp and Childress’ approach, namely that that approach was too abstract and that its alleged deductivism was objectionable. Advocates of casuistry, or case-based reasoning, objected to what they at least took to be the unidirectional “downward” movement from principles to cases (Arras 2017: 11). Instead, they argued for a more “bottom up” approach, which would see actual cases, rather than any one moral theory, as the starting point, and would conceive of moral principles as in fact emerging from our consideration of cases. We often speak of casuistry full-stop, and when we do we generally have in mind an approach to ethics that emphasizes analogical reasoning with concrete actual cases (the one before us, and relevantly similar past cases). When one encounters a case, one harkens back to a relevantly similar case from the past, recalls how one responded in that case, and “applies” that reasoning to the case before one. We should, however, recognize the distinction between two versions of the approach. To start, there is casuistry understood simply as the practice of addressing particular cases, treating them through the application of (abstract) principles. Understood as such, casuistry would seem to be rightly viewed as a logical complement to approaches to bioethics that take moral principles to be morally binding (Arras 2017: 46). Casuists here hold that principles can have an action-guiding or normative force that is not reducible to our responses to cases, and that the moral knowledge represented by such principles is not reducible to responses to cases (Jonsen 1995). Note that when defined in this way, differences between this moderate version of casuistry and a more traditional top-down application of moral principles to cases might be difficult to pinpoint. A more radical interpretation of casuistry, though, has a different story to tell about the derivation of moral principles. Where on the moderate version we approach cases with our moral principles already established, on this more radical version, principles develop through our analysis of actual cases (Arras 2017: 47). So the two different versions adopt different pictures of the source of our moral knowledge. On the radical version, it is at the level of the concrete case, rather than at the level of theory, where we find the greatest confidence in our moral judgments. The claim here is that moral principles are, at base, merely formalizations of our intuitive responses to cases, without independent normative force (Toulmin 1981). 5.1.1 Advantages of casuistry According to its proponents, casuistry as an approach to bioethics has specific advantages. One is its potential to offer chances of reaching agreement amongst those of different theoretical commitments, rendering it particularly well-suited for decision making in a pluralistic society (Sunstein 1996). Turning to the more applied medical context, casuistry is well-suited to use by health care workers, whose orientation is already case-focused, and whose time for and interest in moral theory is likely quite limited. When it comes to teaching bioethics, casuistry would call for the use of richly detailed case studies, which many whose teaching responsibilities include teaching those in health care would count as a strength (Arras 2017: 55–57). 5.1.2 Criticisms of casuistry Despite these sorts of advantages, casuistry has been met with criticism. One is that the approach seems to assume a straightforwardness when it comes to deciding what counts as a case. However, as some would have it, deciding what counts as a case (or not) might well be underwritten by the bioethicist’s picture of the sorts of problems worthy (or unworthy) of appearance on the moral agenda (O’Neill 1988). It has been argued that that agenda is overly narrow and sculpted by the interests of, for example, the medical profession, and a male outlook (Carse 1991). A related but distinct point concerns what counts as an adequate description of the issues at play in a case. Casuistry, to its detriment, seems silent on this matter. Some argue that a strike against the radical version of casuistry is its recourse to analogical reasoning. Such recourse, so the thought goes, fails to properly recognize that such reasoning is not self-standing. Analogical reasoning would seem to need pre-established principles to give it direction, and radical casuistry rejects such principles. Moderate casuistry, which does use principles or generalizations to provide some structure in identifying what is morally relevant to a case and across cases (Jonsen 1995) would not be subject to this criticism. Another concern is that given its disregard for theoretically-derived principles, radical casuistry may amount to no more than a refinement of our intuitive responses to cases. It might be thought to be morally conservative, ill-equipped for social critique, with the casuist as mere expositor of pre-ordained moral norms (Arras 2017: 60–67). Finally, the approach seems to require pre-established agreement on fundamental values in order to reach conclusions, agreement that may well be lacking in pluralistic modern society. 5.2 Narrative Ethics A further alternative approach to ethics in general and bioethics in particular is
— Abortion, embryo-destructive research, assisted reproductive technologies, artificial wombs, genetically modified babies, physician-assisted suicide and euthanasia. These are just a small sampling of the bioethical questions our country will have to address in the coming years. Lying beneath these questions are competing visions of what it means to be a human being and how human beings flourish. Join an academic all-star panel as they discuss the ethics, policies, and philosophies at the core of today's debates. All three scholars served in various capacities on The President's Council on Bioethics, and have written extensively on these issues, including a new Harvard University Press book by Carter Snead, What It Means To Be Human: The Case for the Body in Public Bioethics. Still haven’t subscribed to The Heritage Foundation on YouTube? Click here ► https://bit.ly/2otKliy Follow The Heritage Foundation on Facebook: https://www.facebook.com/heritagefoundation/ Follow The Heritage Foundation on Twitter: https://twitter.com/Heritage Follow The Heritage Foundation on Instagram: https://www.instagram.com/heritagefoundation/?hl=en