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As the chapters in this collection show, naturalizing bioethics is a dynamic business: it requires us to move continually from theory to practice and back again. Theory is overhauled, adjusted, and fine-tuned in the light of practice and practice in the light of theory, and justification rests on the norms that have been tested and found good in critical and self-reflexive deployments of this process. The essays gathered here offer many examples of how bioethicists might build better theory by understanding individuals in context, attending to the web of relationships in which we all live, appreciating the reality of power, and — a not unimportant point to which we will return — situating themselves within their own work. But what does all this mean for bioethicists in clinical settings? In this epilogue, written specifically for bioethicists working in health care institutions, we set out an agenda for a naturalized bioethics in practice.
The agenda can be thought of as a call for three closely interconnected kinds of change. First, bioethicists will have to alter how they engage in — and teach clinicians to engage in — moral deliberation. Second, because working conditions greatly affect how well health care professionals can exercise their moral agency, bioethicists may need to initiate changes in those conditions. Third, bioethicists will have to change how they understand their own role in the clinical setting. We take up each of these in turn.
“I wonder how many miles I've fallen by this time?” she said aloud. “I must be getting somewhere near the centre of the earth. Let me see: that would be four thousand miles down, I think — ” (for, you see, Alice had learnt several things of this sort in her lessons in the school-room, and though this was not a very good opportunity for showing off her knowledge, as there was no one to listen to her, still it was good practice to say it over).
— Lewis Carroll, Alice's Adventures in Wonderland
When infant patients and their parents tumble into the world of liver transplantation, they are not as lighthearted and curious as Alice — the hospital is not a Wonderland. However, they do discover, as she does, that they are leaving the ordinary life they shared behind. The geography lessons that Alice learned in school have become somewhat pointless; they do not seem to tell her where she is. The same happens with family habits and self-understandings when a child is threatened by disease and the need for liver transplantation. In retrospective interviews with parents about their child's liver transplantation, the time leading up to the transplantation is depicted as a period of transition. Their child's threatening disease has abruptly interrupted their lives, and indeed, many parents indicate that somehow their life stopped in this period: “Your life comes to a halt,” as one of our respondents put it.
Naturalized bioethics represents a revolutionary change in how health care ethics is practised. It calls for bioethicists to give up their dependence on utilitarianism and other ideal moral theories and instead to move toward a self-reflexive, socially inquisitive, politically critical, and inclusive ethics. Wary of idealisations that bypass social realities, the naturalism in ethics that is developed in this volume is empirically nourished and acutely aware that ethical theory is the practice of particular people in particular times, places, cultures, and professional environments. These essays situate the bioethicist within the clinical or research context, take seriously the web of relationships in which all human beings are nested, and explore a number of the different kinds of power relations that inform health care encounters. Naturalized Bioethics aims to help bioethicists, doctors, nurses, allied health professionals, disability studies scholars, medical researchers, and other health professionals address the ethical issues surrounding health care.
Case Analysis in Clinical Ethics is an eclectic review from a team of leading ethicists covering the main methods for analysing ethical problems in modern medicine. Anneke Lucassen, a clinician, begins by presenting an ethically challenging genetics case drawn from her clinical experience. It is then analysed from different theoretical points of view. Each ethicist takes a particular approach, illustrating it in action and giving the reader a basic grounding in its central elements. Each chapter can be read on its own, but comparison between them gives the reader a sense of how far methodology in medical ethics matters, and how different theoretical starting points can lead to different practical conclusions. At the end, Anneke Lucassen gives a clinician's response to the various ethical methods described. Practising clinical ethicists and students on upper level undergraduate and Master's degree courses in medical ethics and applied philosophy will find this invaluable.
Feminist care-ethics makes a difference when analysing and discussing healthcare issues. As a specific moral perspective it frames moral questions in healthcare in terms of responsibilities and is concerned more about the dangers of abandonment than the dangers of interference. The care perspective also invites us to re-examine and re-evaluate current conceptions of autonomy and moral relationships. In this chapter I shall try to show that care-ethics, as a relational ethics, makes a difference in the moral reading of problems arising in the use of genetics. In arguing this, I will start by presenting the main characteristics of care-ethics. I will then go on to discuss the issue of whether care-ethics can be seen as a feminist ethical perspective. In the final part of the chapter I will show how care ethics can make a difference to the discussion of ethical issues in genetics. In particular, I shall concentrate on the tension between responsibility toward others and the value of personal autonomy.
In 1982, Carol Gilligan published In a Different Voice, in which she put forward the thesis that a so-called ethics of justice gives only a partial voice to the moral experiences of men and especially of women. An ethics of justice, needs to be complemented by an ethics of care that is capable of articulating the moral values of nurturing and caring. In developing this care perspective Gilligan challenged the idea that abstract and universalistic moral reasoning was the best way of thinking about moral problems.
Medical ethics has had a rich and complex history over the past 40 years. It has been transformed from a rather clear and straightforward set of rules and attitudes, shaped largely by the medical profession itself, into a major field of academic and social inquiry. Contemporary work in medical ethics can be divided into three parts: ethical analysis and arguments of large-scale issues in science, practice and policy (such as consideration of the ethical issues concerning cloning or resource allocation); theoretical inquiry into the foundations of medical ethics; and practical analysis of particular dilemmas in clinical practice. This last area in medical ethics is normally referred to as clinical ethics, and is in many respects the most important and vibrant part of medical ethics today. It lives through its intimate connection with clinical practice and medical and healthcare education, the ways in which suggestions made by practitioners of clinical ethics are rapidly tested in clinical reality, and the growth of a practical field of work in which ‘ethicists’ support patients, professionals and ethics committees in making good decisions in difficult circumstances.
For all this vibrant growth, there has been some unease with the way clinical ethics has developed. Healthcare professionals are sometimes baffled by the argumentative curlicues of the philosophers; patients and activists are often suspicious that all this ‘ethics’ is just a way of reinforcing existing professional attitudes and authority, and that ethicists are just as blind to patients' concerns as the medical professionals; and philosophers are generally infuriated by the apparent laziness and lack of rigour of their ‘applied’ colleagues.
In the centre of Fedora, that grey stone metropolis, stands a metal building with a crystal globe in every room. Looking into each globe, you see a blue city, a model of a different Fedora. These are the forms the city could have taken if, for one reason or another, it had not become what we see today. In every age someone, looking at Fedora as it was, imagined a way of making it the ideal city, but while he constructed his miniature model, Fedora was already no longer the same as before, and what had until yesterday a possible future became only a toy in a glass globe.
Much writing and thinking in bioethics takes the form of a kind of Calvinesque speculative architecture. Our aim in this book and in the particular way in which it has been created has been to do something different. We wanted, in particular, to encourage the contributors to engage with one another and with the case to a degree unusual in bioethics practice. Behind this intention is something like a commitment to the idea that moral development, the growth of moral understanding and the emergence of moral practice in medicine (and in bioethics) can be facilitated by encouraging moral philosophers and health professionals to engage with one another in a focused and reasonably structured setting. More broadly it is to argue that conversation is a developmental fundamental of human experience (Parker 1995).