Published online by Cambridge University Press: 13 April 2010
Applied ethics is at a watershed. In all its domains a gulf between the theory of applied ethics and the practice of applied ethics is now being recognized. In medical ethics, for example, it has been observed that “practicing clinicians often feel let down by bioethics.” The disappointment of clinicians is attributed in part to their own unrealistic expectations but is also said to be a function of
the extent to which bioethics as a discipline doesn't seem to be in possession of the realities of practice. Bioethicists tend to leave the “facts” of clinical medicine to the doctors; their task is then to apply elegant and compelling arguments drawn from first principles of ethics … to these undisputed and indisputable facts. Unfortunately, when the relationship between clinical medicine and bioethics is conceived … [in this way], the result is a very sterile discourse.
4 Hargrove, Eugene C., review of Roderick Frazier Nash, The Rights of Nature: A History of Environmental Ethics, Canadian Philosophical Reviews, 9 (November 1989): 457.Google Scholar
7 Engelhardt, for instance, says: “At some point in the not-too-distant future, there will be enough individuals who will recognize the essential precariousness of most applied philosophy so that the very endeavor of applied philosophy and of social philosophy will need to be rethought” (Engelhardt, H. Tristram Jr., “Applied Philosophy in the Post-Modern Age: An Augury,” Journal of Social Philosophy, 20 : 45).CrossRefGoogle Scholar
8 See, for example, Jonsen, Albert R. and Toulmin, Stephen, The Abuse of Casuistry (Berkeley: University of California Press, 1988)Google Scholar, and Zaner, Richard M., Ethics and the Clinical Encounter (Englewood Cliffs, NJ: Prentice-Hall, 1988)Google Scholar. For an excellent critical assessment of the casuistical alternative, see Arras, John D., “Getting Down to Cases: The Revival of Casuistry in Bioethics,” Journal of Medicine and Philosophy, 16 (1990): 29–51.CrossRefGoogle Scholar
9 The philosophical preoccupation with systematization probably can be traced back at least to Descartes. The earliest and clearest statement I have found so far is Whewell's insistence in 1846 that there be a “System of Morality,” which he repeatedly defines as, “A Body of Moral Truths, definitely expressed, and arranged according to their rational connection.” See Whewell, William, Lectures on Systematic Morality (London: John W. Parker, 1846)Google Scholar. The systematization of morality probably reaches its apotheosis with Henry Sidgwick, however. See, for example, Book III, Chapter XI of The Methods of Ethics, 7th ed. (1907), where Sidgwick talks about “throw[ing] the Morality of Common Sense into a scientific form,” searching for moral propositions that must be “clear and precise” and that have “the highest degree of certainty attainable,” as well as the “mutual consistency” of “self-evident” moral propositions. The main failing of ordinary morality, for Sidgwick, is that it lacks the definiteness and self-evidence of science, but this ostensibly can be rectified by the construction of a moral system.
10 The example comes from Whewell, Lectures on Systematic Morality, p. 31. Whewell says that a moral system “must contain a provision for this developement [sic] of new truths, out of those already familiar, and for the application of such truths to the new relations of society, and the enlarged capacity of man, if his capacities of morality should be enlarged. In this capability of educing new truths out of a system of established truth, there is surely nothing which is not perfectly in harmony with the most familiar characters of a system of truths” (ibid., p. 63).
11 This is the moral analogue of classical legal positivism in the vein of Austin or Kelsen.
12 Morality, in this view, becomes merely technical. The technical emphasis of applied ethics is captured nicely by Caplan's description of it as an “engineering model.” See Caplan, Arthur L., “Ethical Engineers Need Not Apply: The State of Applied Ethics Today,” Science, Technology, and Human Values, 6 (1980): 24–32CrossRefGoogle Scholar; Caplan, Arthur L., “Mechanics on Duty: The Limitations of a Technical Definition of Moral Expertise for Work in Applied Ethics,” Canadian Journal of Philosophy, Supp. Vol. 8 (1982): 1–18CrossRefGoogle Scholar; Caplan, Arthur, “Applying Morality to Advances in Biomedicine: Can and Should This Be Done?” in New Knowledge in the Biomedical Sciences, edited by Bondeson, William B. et al. (Dordrecht, Holland: D. Reidel, 1982), p. 155–68CrossRefGoogle Scholar; and Caplan, Arthur L., “Can Applied Ethics Be Effective in Health Care and Should It Strive to Be?” Ethics, 93 (1983): 311–19CrossRefGoogle ScholarPubMed.
14 Beauchamp, Tom L. and Childress, James F., Principles of Biomedical Ethics, 2nd ed. (New York: Oxford University Press, 1983)Google Scholar. In support of this point, Arras says that the “‘new casuistry’ has emerged as a definite alternative to the hegemony of the so-called ‘applied ethics’ method of moral analysis that has dominated most bioethical scholarship and teaching since the early 1970s [and he cites Beauchamp and Childress]. In stark contrast to the methods that begin from ‘on high’ with the working out of a moral theory — from which are derived various principles and maxims — and culminate in the deductivistic application of these norms to particular factual situations, this new casuistry works from the ‘bottom up,’ emphasizing practical problem-solving by means of nuanced interpretations of individual cases” (Arras, “Getting Down to Cases,” p. 30). Indeed, the influence of Beauchamp and Childress's view of what medical ethics is has been so great that those working in the field now talk about “the applied ethics mantra,” i.e., the reverential intoning of their four principles — autonomy, beneficence, nonmaleficence, justice. See Arras, ibid., p. 47.
16 Beauchamp and Childress, Principles of Biomedical Ethics, p. 8.
20 I have heard Beauchamp say that this shift becomes even more pronounced in the forthcoming fourth edition. This move away from the orthodox model of applied ethics is, as one might expect, causing some consternation. See, e.g., the review of the third edition by Becky Cox White in the APA Newsletter on Philosophy and Medicine, 89, 3 (Spring 1990): 104–7.
21 The summary and points in this section and the next are culled from five papers by Lippman-Hand, Abby and Fraser, F. Clarke that report the results of their research: “Genetic Counseling: Parents' Responses to Uncertainty,” Birth Defects: Original Article Series, 15, 5C (1979): 325–39Google ScholarPubMed; “Genetic Counseling: Provision and Reception of Information,” American Journal of Medical Genetics, 3 (1979): 113–27CrossRefGoogle Scholar; “Genetic Counseling — The Postcounseling Period: I. Parents' Perceptions of Uncertainty,” American Journal of Medical Genetics, 4 (1979): 51–71CrossRefGoogle Scholar; “Genetic Counseling — The Postcounseling Period: II. Making Reproductive Choices,” American Journal of Medical Genetics, 4 (1979): 73–87CrossRefGoogle Scholar; “Communication and Decision Making in Genetic Counseling,” in Human Genetics, Part B: Medical Aspects, edited by Bonne-Tamir, Batsheva (New York: Alan R. Liss, 1982), p. 511–19.Google Scholar
22 “The marked tendency of parents to view their chances in binary form occurred irrespective of the quantitative value of the rate, the qualitative impression of risk, or the specific condition to which these applied. Rates were secondary; that something could happen at all, primary” (Lippman-Hand and Fraser, “Parents' Perceptions of Uncertainty,” p. 57).
23 Lippman and Fraser talk about the ‘ambiguity’ of the women's situations. Although “ambiguous” can mean “obscure,” it can also mean “having two senses,” and it is the latter construal that is likely to be misleading. For this reason I prefer the word “amorphous.”
24 I recently heard a philosopher reply to a question about the moral relevance of the social roles a person can occupy by denying any relevance whatsoever to these roles. According to this philosopher, morality is a matter of doing what one ought to do as a person, not as a teacher, a lawyer, a spouse, a parent, a citizen, or whatever. This view is, I think, gravely mistaken. It remains attractive to philosophers, I suspect, because a formal (and therefore empty) conception of persons fits nicely with a formal notion of rationality.
25 The reproductive issue for which a decision-theoretic approach has been most strongly advocated and most thoroughly elaborated is amniocentesis. See Pauker, Susan P. and Pauker, Stephen G., “The Amniocentesis Decision: An Explicit Guide for Parents,” Birth Defects: Original Article Series, 15, 5C (1979): 289–324.Google ScholarPubMed Pauker and Pauker concede, however, that “the actual choices [of those being counselled] bear no relation to the choice suggested by the model. These data suggest that couples may not be reaching logical decisions after classic genetic counseling” (p. 317). The problem, in my view, is not with the couples but with the model for the reasons set out here. For additional discussions of their approach, see Pauker, Susan P. and Pauker, Stephen G., “The Amniocentesis Decision: Ten Years of Decision Analytic Experience,” Birth Defects: Original Article Series, 23, 2 (1987): 151–69Google ScholarPubMed, and Pauker, Stephen G. and Pauker, Susan P., “Prescriptive Models to Support Decision Making in Genetics,” Birth Defects: Original Article Series, 23, 2 (1987): 279–96.Google ScholarPubMed
26 Baxandall, Michael, Patterns of Intention (New Haven: Yale University Press, 1985), p. 13.Google Scholar
27 It would be foolish to suggest that decision theory could never become elaborate and sophisticated enough to model the decision-making of these women. But were a model that could handle risk and dynamic utilities and that could take account of real situations to be developed, the notion of optimizing it would embody would be non-formal and non-standard.
28 “The parents' uncertainty that a particular event will occur (Will a subsequent child be born abnormal?) and the ambiguity surrounding the outcomes that may stem from this event (How serious will it be? How long will he suffer? Will I be able to handle the situation?) are so thoroughly intertwined as to make distinctions between risk and consequences more theoretical than real” (Lippman-Hand and Fraser, “Provision and Reception of Information,” p. 124).
29 “[T]his interaction of risk and consequences becomes an important determinant of how their reproductive decisions are made…. This orientation differs from the more traditional one which suggests that the independent effects of risk and burden determine what alternatives are chosen. The constant interaction of risk and consequences in the parents’ remarks suggests that this is an irreducible complex to be processed in subsequent reproductive decision-making and supports the need for a model of such decision-making that involves the heuristic processing of complex information rather than one that assumes a traditional cost-benefit (risk-burden) approach. The latter may be more amenable to formal decision analysis; the former seems more characteristic of what really happens …” (ibid., [emphasis in original; references deleted]).
30 In a discussion of choosing a rational “life plan,” Fried says: “Now I do wish to suggest that there may be considerable ad lib creativeness in respect to life plans, and that to the extent that we can be said to choose a life plan we can be said also to choose ourselves, to choose who we are” (Fried, Charles, An Anatomy of Values [Cambridge, MA: Harvard University Press, 1970], p. 100).CrossRefGoogle Scholar
32 Lippman and Fraser seem to appreciate this when they comment that “their [the women's] behavior and their ways of formulating the other issues relevant to childbearing do follow logically when viewed as an attempt to limit or neutralize this uncertainty” (Lippman-Hand and Fraser, “Parents' Responses to Uncertainty,” p. 333).
33 Fried, e.g., says, “The capacity to impose rational order on ends is necessary to morality …” (Fried, Anatomy of Values, p. 100).
34 Another problem with orthodox moral theory is that it seems unable to account for this phenomenological aspect of the situation. If moral decision-making is understood as maximizing utility, for example, the difficulty of a decision is a function solely of its technical complexity. Given this approach, a decision about whether to donate $1,000 to cancer research or to cystic fibrosis research could be more difficult than a decision about whether to withdraw a feeding tube from an elderly patient in a persistent vegetative state. Yet the latter would be experienced as more agonizing.
35 Rawls, John, A Theory of Justice (Cambridge, MA: Harvard University Press, 1971), p. 421.Google Scholar
37 The phrase comes from Yeats:
Turning and turning in the widening gyre
The falcon cannot hear the falconer;
Things fall apart; the centre cannot hold;
Mere anarchy is loosed upon the world …
(Yeats, W. B., “The Second Coming,” in The Collected Poems of W. B. Yeats [London: Macmillan, 1933], p. 210–11Google Scholar).
38 One could, as Rawls suggests, talk about maximizing “the expected net balance of satisfaction” or adopting “that course most likely to realize one's most important aims,” but, as Rawls recognizes, any such “formal” principle “fails to provide us with an explicit procedure for making up our minds. It is clearly left to the agent himself to decide what it is that he most wants and to judge the comparative importance of his several ends” (Rawls, Theory of Justice, p. 416).
39 Fried, Anatomy of Values, p. 96.
40 Rawls, Theory of Justice, p. 422, gender of pronouns changed.
41 Rawls says, “the principle of responsibility to self resembles a principle of right: the claims of the self at different times are to be so adjusted that the self at each time can affirm the plan that has been and is being followed. The person at one time, so to speak, must not be able to complain about actions of the person at another time” (ibid., p. 423).
42 Rawls recognizes the limited help that rationality can provide: “while rational principles can focus our judgments and set up guidelines for reflection, we must finally choose for ourselves in the sense that the choice often rests on our direct self-knowledge not only of what things we want but also of how much we want them” (ibid., p. 416). See also Fried, Anatomy of Values, p. 100 and 177.
43 Recognizing that moral decision-making is a function of one's life experiences has important implications for the nature of moral education, but they cannot be pursued here.
44 Dancy, Jonathan, “Ethical Particularism and Morally Relevant Properties,” Mind, 92 (1983), p. 546Google Scholar, emphasis in original.
45 I would like to thank Françoise Baylis, Cliff Hooker, Abby Lippman and Michael Yeo for their detailed and helpful criticisms of a draft of this paper. I also benefited from the criticisms of three anonymous referees for Dialogue. An early version was read to the Department of Philosophy at McMaster University. I am grateful for both the invitation and the ensuing discussion.