|Bioethics and Medical
Synthetic Model of Bioethical Inquiry
Michele A. Carter
ABSTRACT: Bioethics, viewed as both a form of reflective practice and a developing discipline, is concerned with the moral aspects of health care practice and research. With its steady maturation in the domain of moral discourse, bioethics has presided over a number of questions about the nature of human illness and how problems imposed by illness can be understood in an age marked not only by progress, but also by the concomitant fear that such progress will outstrip our humanity and our dignity as persons. I discuss some of the current tensions and ambiguities inherent in the field of bioethics as it continues to mature. In particular I focus on the present tendency in bioethics to bifurcate ethical theory and practice. I analyze some of the dichotomies resulting from such bifurcation. Finally, I call for an approach to bioethical discourse defined by the rigor of systematic and critical thinking characteristic of ethical theory, the disciplined eloquence and persuasive power of rhetoric, and the principles of Renaissance humanism. A new model of bioethics is proposed, one that synthesizes the analytic functions of moral theory with the practical and therapeutic functions of rhetorical humanism; such a model bridges the divide between theory and practice. This synthetic model of bioethical inquiry emerges from both ancient and contemporary debates about the possibility and nature of moral knowledge as well as from the moral teachings of humanists and rhetoricians throughout the history of ideas.
The bioethics field has had an impressive impact on public, professional, and personal life in the last twenty five years. Bioethics, viewed as both a form of reflective practice and a developing discipline, is concerned with the moral aspects of health care practice and research. With its steady maturation in the domain of moral discourse, the field of bioethics has presided over a number of questions about the nature of human illness and how the problems imposed by illness can be understood in an age marked not only by progress, but by the concomitant fear that such progress will outstrip our humanity and our dignity as persons. This paper attempts to sort out some of the current tensions and ambiguities inherent in the field of bioethics as it continues to mature. In particular it focuses on the present tendency in bioethics to bifurcate ethical theory and practice and analyzes some of the dichotomies which result from it. Finally, the paper calls for an approach to bioethical discourse which engages the rigor of systematic and critical thinking in ethical theory, the disciplined eloquence and persuasive power of rhetoric, and the principles of Renaissance humanism.
A new model of bioethics is proposed, one which synthesizes the analytic functions of moral theory with the practical and therapeutic functions of rhetorical humanism, thus bridging the divide between theory and practice. This synthetic model of bioethical inquiry emerges from both ancient and contemporary debates about the possibility and nature of moral knowledge as well as from the moral teachings of humanists and rhetoricians throughout the history of ideas. There are two contexts for this discussion: 1) the sheer breadth and enormity of the social transformations within American life and culture; and 2) the changing nature of bioethics itself as it both mirrors these transformations and responds to the ageless question about what constitutes a good life. As co-inhabitants and co-conspirators of the forms of life in which these changes will manifest themselves, bioethicists must ask what methods of analysis will connect the diverse ways of seeing the world, of knowing the good, of doing what is fair. Will the old bioethics, grounded in the discipline of moral philosophy and its focus on abstract theories of morality, goodness, character, and justice be sufficient? Will the Platonic quest for moral knowledge that is certain, genuine, transcendent, and permanent give way to the aggrandizement of personal opinion and emotion that is the mark of a culture heavily mired in Protagorasian pluralism? Will bioethicists, persistently concerned about issues of professional authority and identity, continue to draw a false dichotomy between theory and practice, as if one or the other would yield the understanding of humanity we seek? Will currently popular methods of analysis in bioethics be sufficient to serve the needs of humanity in the years to come, or should they be transformed? In short, does bioethics, and philosophy for that matter, need a more humanistic mission?
Scholarship in bioethics continues to expand, gradually shaped by the cultural traditions of moral philosophy, science, medicine, and the humanities. At the same time, bioethics is constantly responding to new knowledge, new ideas, and emerging questions. What, for instance, is the morally permissible scope of our ever-present curiosity about human life? How and when ought human life be sustained, manipulated, cloned, or extinguished? Is knowing one's genetic future always for the best or might it bring about evil and become a harmful burden one need not take on? (1) And as the second millennium stretches out before us, what ideas of human flourishing will find their rightful birth in the minds and hearts of our children?
This question of bioethics' intellectual parentage continues to surface in discussions of bioethics and accounts for a palpable tension between those who believe that the correct method for bioethical analysis is drawn from moral philosophy, and those who argue that the "philosophical method" is unsuitable for the work currently being done in bioethics. In general, contemporary advocates of the former view are representatives of the discipline of philosophy, alleged by their opponents to be staunch defenders of abstract theories of morality, goodness, justice, and character. Advocates of the latter, who represent other disciplines in the humanities, social sciences and clinical medicine, reveal their own disciplinary prejudices and temperaments, and conceptual loyalties. These representatives tend to focus on describing and analyzing the concrete particulars of human culture and experience. In place of moral theory and the application of universal principles of moral action or agency, methods of bioethical inquiry from these perspectives include narrative and interpretation, case study and casuistry, and procedural decision-making by consensus, as occurs in many bioethics committees and commissions.
These polar perspectives join a series of similar dichotomies that have been expressed throughout the history of ideas: the friction between the universal and particular, the abstract and concrete, the objective and subjective, the a priori and a posteriori, the philosophical and rhetorical, and the descriptive and normative. Much of the current debate about the ethos, authority, and methodologies of bioethics echoes these tensions. In part, they reveal the self-conscious search for intellectual identity and authority that has occupied the field of bioethics from its earliest beginnings. Disagreements about the disciplinary status of bioethics thus expose not only the diversity of the questions the field comprises, but also the persistent anxiety over what forms or methods should characterize the intellectual work bioethics claims to do.
It is important to note that these tensions are not confined to the field of bioethics, but illustrate historical changes occurring within philosophy itself. Philosophy, once believed to be both the queen of all the sciences and the patriarch of ethical thought, is undergoing rigorous examination and questioning directed at its very foundations and identity. Additionally, transformations within the field of moral philosophy have been occurring for much of the twentieth century, exacerbating already contentious debates about the epistemic status of claims of truth, reason, intuition, and morality.
In an increasingly pluralistic society and postmodern culture, the objective authority of reason to discover, explain, and justify moral truths is heavily disputed by philosophers themselves. The resulting perception that reason cannot provide an objective foundation for morality has encouraged some to claim there are no absolute moral values by which we can resolve our moral disagreements. Moral claims are thus said to be relativistic, subjective, arbitrary, or contingent. Although it is beyond the scope of this paper to critique the problems associated with the standard account of moral objectivity and debates in moral realism, it will suffice to make two remarks. First, even if reason does not or never did provide irreducible first premises for moral discourse, it does not follow that all moral judgments are epistemically powerless. Moral justification relies upon reason, but moral knowledge is also embedded in other forms of inquiry and belief such as moral intuition, conscience, grace, and narrative. Second, if objectivity is considered critical to the epistemic power of moral knowledge, then its particular semantic role must be articulated. Crispin Wright argues that three different conceptions of "objectivity" must be demarcated. They are 1) a belief in the objectivity of truth. This holds that a class of statements may be fully intelligible to us although resolving the truth value these statements represent may defeat our cognitive powers. Truth is 'not of our making' because it defies our powers of rational appraisal. Since truth values cannot be settled unilaterally, Wright argues they are perhaps a function of the meanings ascribed to them. This leads to 2), the belief in objectivity of meaning. This implies that the meaning of a statement is a real constraint to which we are bound, that is, the truth values of a particular statement may hold independent of our particular, considered opinions about the matter; and 3) the belief in the objectivity of judgment, which is the kind f objectivity that statements in ethics might have. (2) Objectivity in ethical discourse would thus amount to a realism about the existence of certain reasons, principles, or ethical values which we can discover through a process of ethical inquiry and about which we can come to have some moral knowledge, and justification. In this process, moral theories might help explain our common moral experience and help to elucidate the epistemic etiology of our moral disagreements. On this view, ethical principles may be said to have a certain degree of objectivity in that they are connected to a type of practice in which particular norms operate.
Richard Rorty, on the other hand, argues that the patterns of normal moral discourse do not require ultimate justification in terms of Reality, Truth, Objectivity, or Reason. On his account, ethical values exist as part of shared practices and are capable of being verified by the methods of pragmatism, infused with cultural and social conventions. His project is to continue the 'conversation with mankind' (3) about moral matters rather than attempting to discover ultimate moral truth. For Rorty, there is no other way to justify truth claims than by appealing to the social and linguistic practices which have been hammered out in the course of human history. There is no false separation between the individual self and the social milieu which one inhabits. For him, objectivity and cognition should never be "anything more than an expression of the presence of, and hope for, agreement among inquirers." For Rorty, moral choice is not some Platonic project "ticking off the objective truths." (4) Instead of the quest for Truth, he regards the most important task to be the search for new methods of creative inquiry. Freed from the metaphysical burden to discover ultimate foundations or final justification of moral truths, his aim is for the conversation to continue, and 'to let a hundred flowers bloom.' (5)
Although searching inquiry, disagreement and criticism have always been the hallmarks of philosophy, the perceived erosion of the assumed authority of such inquiry in the domain of normative ethical theories is also apparent in the thinking of many of its most influential writers. For instance, Bernard Williams is skeptical about philosophical ethics in general and of the view that philosophy can determine how we should think in ethics. He explains:
William's argument is based on the assumption that morality, whatever real or objective existence it may have, operates in the practical realm in which we live and relate to others.
Other contemporary moral philosophers likewise eschew the unnecessary abstraction of formalistic ethical theories. Annette Baier rejects an overly intellectualized and theory-driven approach to ethical discourse. She is interested in the morality of relationships where there is an asymmetry of power and unavoidable inequality, and she claims that these relationships make up much of our lives. These relationships, "as much as our relations to our equals, determine the state of moral health or corruption in which we are content to live." (7) Such relations include not only those between parent and child or professional and client, but also the relations among institutions, nations, and societies. Her overall project is to generate a moral theory which is responsive to the needs of those who are vulnerable due in part to inequalities of power, autonomy, or knowledge. According to Baier, moral reflection about problems in bioethics should yield moral judgments which are social, interpersonal, and interdisciplinary. Bioethicists should reflect carefully on the ordinary experiences of people, the way they act, and the customs and practices they follow. (8) Following Hume, she notes that bioethicists should be developing approaches to moral reasoning about actions and choices that include practical, cooperative, and reflective judgments. The questions she wants bioethicists to consider are "questions of the heart as well as the mind, and questions of social organization, not just the marshaling of arguments." (9) Clearly, these accounts demonstrate the need on the part of philosophy to address more particular, concrete, and contextualized aspects of the moral life as experienced by actual individuals who are in relationships with others. However, criticism that moral theories as a whole do not attend to the concrete particulars of individual moral lives would be unfounded. Many ethical theories in fact do just this. Hume, for instance, clearly stated that moral judgments are concerned with actions, values,motives, and feelings rather than with the rules of reason. Of the utility of ethical theory he asks: "What theory of morals can ever serve any useful purpose, unless it can show, by a particular detail, that all the duties which it recommends, are also the true interest of each individual?" (10) Clearly, Hume envisioned an approach to ethics that is not grounded in abstract principles of reason alone, but one which incorporates judgments about human sympathy and passion. This insight finds its current expression in discourse among bioethicists interested in theories of care, narrative and interpretative ethics, and phenomenology.
Moral theory in bioethics
Ethical theories support a set of beliefs about human nature and the moral universe upon which they base suggested courses of action. They attempt to explain the force of our moral judgments of actions by making explicit certain features of moral discourse and other kinds of social behavior. Ethical theories embody insights about what is right or best to do or be, and set forth generalizable statements or ideal standards of moral choice, action, and decision. Most ethical theories have the following characteristics: 1) They provide a comprehensive account of the moral life; 2) They provide a foundation for morality, whether that be in the form of duty, rights, virtues, consequences, or rules; and 3) They explain, defend, and justify particular classes of evaluative judgments regarding human action, choice, and decision.
Although ethical theories can be descriptive, normative, or prescriptive in structure, their application to specific problems in bioethics is limited to providing theoretical guidance regarding the moral claims embedded in particular contexts. Ethical theories should not be reduced to methods of decision making or viewed as mandating a particular resolution to a particular case. They illustrate specified aspects of moral discourse and theoretical concepts by which a deeper understanding of moral obligation can be discovered. The purpose of theory in applied ethics is thus not to ground morality in some ultimate principle or rule but rather to articulate an account of what morality requires of us in terms of our values, actions, choices, and decisions. Moral theory enlightens practical reasoning in ethical matters and articulates those shared assumptions which allow us to debate, deliberate, and arrive at justifiable decisions. Moreover, as Nussbaum notes in her analysis of Aristotle's ethical arguments, moral theory aims not only at theoretical understanding, but at improving a particular instance of moral practice. (11)
In my view, dichotomization of theory and practice, so evident in many contemporary discussions of bioethics, is misguided. Bioethics, and especially clinical ethics, is a form of professional practice that deals directly with concrete lives and the decisions of people struggling to realize value or meaning. Bioethicists are not concerned with how to locate the supreme principle of morality for humanity, or in discovering moral goodness in some suprasensible, transcendent world. Rather, they are concerned with the humanity of those whose lives they are invited to enter as moral inquirers. As Terrence Ackerman notes, moral inquiry in the health care setting is evoked by situations of moral obscurity and ambiguity. The purpose of moral inquiry in bioethics is set by the social and practical context which generates moral predicaments; its function is "to identify plans of action for resolving moral dilemmas which are socially endorsable because . . . they effectively and impartially realize the values which people cherish." (12) Although good moral philosophy is necessary to articulate and justify a vision of human flourishing, justice, and moral excellence, what really matters to us morally is how these visions reproduce themselves in the concrete lives of others. The sharp division between theory and practice is counter productive for bioethics because it dilutes and diminishes the moral uniqueness and dignity of the person, it denies the possibility for the "reflective equilibrium" of our practical and theoretical judgments about what is morally right or good to do, and the therapeutic goal to make human life better. Furthermore, while knowledge of ethical theory and principles helps to correct an over emphasis on emotive judgment and flagrant subjectivity, an overly rigorous application of theory-driven principles seems to ignore the moral spaces between health, healing, wholeness, and humanism. That is, the human problems associated with living, choosing, valuing, creating, suffering, maturin, wasting, flourishing, and dying raise moral enigmas that cannot be answered by appeal to theory and principles alone. Even skillful application of moral theory and principles cannot do the kind of work required to capture the distinctly personal and individual aspects of our moral selves. As individuals, whether sick or well, we are never purely rational; we have wills which are far from holy and fears that cannot be willed away for the sake of some peaceable kingdom. When we confront clearly and distinctly the range of differences that matter morally in our individual lives, the sheer openness and plasticity of knowledge and value is revealed. No moral theory, nor any other theory for that matter, has the power "to fill humanity's absolute and open spaces" with disciplined thought about one's own question of what constitutes the moral life. (13) Bioethics is neither theory nor practice, but a bridging of both. It is a form of inquiry that connects various approaches to knowing, experiencing, and understanding moral life. And, as has been argued cogently by Charles E. Larmore, notions of the good and the right, as well as the concept of moral judgment, are far too complex to be accounted for by universal notions of moral order, under which moral philosophers, both ancient and modern, have operated. For Larmore, and I would argue for bioethics too, the sources of moral value are not one, but many. (14)
Toward a humanist-rhetorical bioethics
Contemporary bioethics embodies certain tensions and dichotomies between science and humanism, thought and action, and theory and practice that have evolved from a diverse set of traditions and beliefs. By combining contemporary discussions of the role of theory in bioethics, the ancient discipline of rhetoric, and the tradition of humanism which developed in the Renaissance, a new approach to bioethics is offered. Whereas the disciplined study of philosophy conceived by the ancient philosophers to be the pursuit of theoretical wisdom was both opposed and subordinated by many Sophists interested in the practical usefulness of knowledge, the model proposed here aims to synthesize the methods of philosophy and rhetorical humanism. Humanists, both of the ancient period and the Renaissance, placed special importance on the power of speech to persuade the intellect and to move the heart. The discipline of rhetoric aims at the possibility of rendering best judgments in particular cases through a process of negotiation that takes into account the diversity of human context and value. In this humanistic-rhetorical model, the pursuit of knowledge regarding the different spheres of moral life is a dialogic process, directed inward toward the development of a sincere and authentic self, and outward, toward the cultivation of civic responsibility in the public arena. It captures a fundamental tenet of humanist thought, which is the integration of humane feeling with knowledge, intellect and character. It also incorporates a number of core values usually associated with the humanist tradition. (15) Among these are the attempts to harmonize the public and private aspects of the human self, to integrate the passions and the intellect, and to accept the contradictions and paradoxes revealed by the complexities of the human condition.
As an analytic tool, rhetorical discourse uncovers and reveals the value commitments embedded both in theory and in practice. The focus on rhetoric as a way to facilitate dialogue and practical judgment is an important aspect of the work of many bioethicists engaging in clinical ethics consultation. The critical task of deliberative rhetoric is to achieve contextual, contingent understanding of human problems and their proposed solutions as opposed to acquiring objective, universal knowledge of ultimate truths or realities. In its deliberative form, rhetoric can help participants discover their own voice and moral truths, to understand their moral attachments and passions, to foster knowledge which is both personal and shared, and to cultivate an honest engagement between reason and experience. Therefore, instead of relegating the discipline of rhetoric to the shelves of history, I suggest that it be employed by bioethicists as a way to enhance knowledge through open, spirited and public discourse as well as to deepen our understanding of ourselves and others.
This humanist rhetorical model of bioethics has two essential functions, which together successfully resolve the theory-practice dichotomy: 1) moral theory occupies an analytical role and, 2) rhetorial humanism occupies a more practical or therapeutic role. In its analytical function, bioethical inquiry would retain the intellectual methods of moral philosophy. In analyzing conflicts regarding duty, obligation, rights, and virtues, the intellectual traditions of moral thought should remain instructive, critical tools of moral reflection, explanation, and justification. Knowledge of moral philosophy illuminates certain conceptual, semantic, epistemological, and axiological issues that have bearing on theories of ethics, but which also impact theoretical issues in the life sciences, technology, and the humanities. In an open, diverse, and changing world of ideas, theories of ethics provide necessary guideposts to the analysis and justification of moral claims.
In its practical or therapeutic role, bioethical inquiry involves the application of the knowledge, skills, and abilities derived from philosophy, the life sciences, social sciences, and humanities to actual events in the lives of particular individuals. Bioethicists enter into conversation with these individuals and share in the resolution of human problems and conflicts. Practical competencies of the reflective practitioner include skillful dialogue about personal value and meaning, understanding, persuasiveness, responding, listening, and witnessing. These skills incorporate moral knowledge and critical thinking, but they often involve a way of knowing that is also spontaneous and intuitive. As argued by Donald Schn in The Reflective Practitioner, (16) the bioethicist as a reflective inquirer would not "simply draw on knowledge that is 'inside'" ( p. 296) as an expert. Rather, he tries to discover the limits of his expertise through reflective conversation with others. In its practical role, bioethics must attend to the uniqueness of each situation, employing knowledge of moral theories where appropriate, but 'enlarging the self '' (17) through the use of moral imagination, intuitive knowing, and pragmatic problem solving.
In sum, bioethics is a discipline which tries to reconcile the conflicts between our insatiable hunger for knowledge and technology and our moral concern over its appropriate application in human life and culture. Bioethics explores the moral spaces wherein we talk about our lives, deliberate about moral problems, and seek answers to questions about our moral and mortal selves. A humanistic-rhetorical model in bioethical discourse shapes and integrates human experience and patterns of reasoning about moral choices in medicine in ways that autonomy or justice-driven paradigms can not accomplish. On the model, bioethics would occupy a more synergistic role, uniting pathe, logos, and ethos and by doing so synthesizing patterns of human thought, personal experience, and moral reflection. It confronts the angoisse of freedom and the sometimes unutterable fears that concern all human beings.
Approaching bioethics discursively and contextually has the advantage of enlarging the terms of its discourse. A humanist-rhetorical approach, viewed not as a replacement for moral philosophy but rather as a means of enriching it, would shift the focus of bioethics from "case consultation" and "ethical decision-making" to the practice of reflection and transdisciplinary analysis. Driving the development of a humanist-rhetorical approach to the moral problems revealed by bioethics is the search for practical wisdom about these problems and the particularized solutions we might be able to design. (18) Practical wisdom is concerned with human affairs about which deliberation is possible (NE, 1141b, 7-10). As a virtue or excellence in itself, practical wisdom is a "truthful rational characteristic of acting in matters involving what is good for man." (NE, 1140b, 20-23). The Aristotelean concept of phronesis applied to bioethics would thus yield judgments aimed at the best possible decisions or adaptations to the predicaments of human life. These judgments incorporate moral knowledge and ethical therories but extend beyond them to the unique moral experiences of those whose good we are aiming to realize.
This approach to reasoning would incorporate the intellectual products of both theoretical and experiential knowledge in a way that transcends a too narrow focus on either principles or cases. It is informed by theoretical concepts which help shape our understanding of various ethical responsibilities, virtues, and commitments. Additionally, it enables bioethicists to engage in a deliberative process of intellectual and practical discernment that takes into account other ways of acquiring moral knowledge, including insight, intuition, and moral imagination. These forms of "knowing" include intellectual and clinical judgments, as well as capacities of moral insight and imagination, derived from the health professions, law, social sciences, and the humanities. The tensions between detachment and engagement, theory and practice, rhetoric and philosophy are embraced through a process of inquiry that deepens our understanding and appreciation of our moral selves. The result is practical wisdom, using knowledge, experience, and understanding for the realization of moral value in each human life. Finally, this approach enables us to elaborate those shared, coherent meanings of what constitutes the fundamental questions of humanity: how to live, what to live for, whom to be, what to care about, and why morality should matter to us at all.
NOTES(1) Michele A. Carter. "Patient-Provider Relationship in the Context of Genetic Testing for Hereditary Cancers." Monographs, Journal of the National Cancer Institute, no. 17 ( 1995): 119-21
(2) Crispin Wright, Realism, Meaning and Truth (New York: Basil Blackwell, 1987).
(3) Richard Rorty, Consequences of Pragmatism (Minneapolis: University of Minnesota Press, 1992).
(5) Richard Rorty, Philosophy and the Mirror of Nature (Princeton: Princeton University Press, 1979).
(6) Bernard Williams, Ethics and the Limits of Philosophy (Cambridge, MA: Harvard University Press, 1985), 93.
(7) Annette Baier, "What Do Women Want in a Moral Theory?", Nous, XIX, no. 1 (March, 1985) 53-63.
(8) Annette Baier, "Doing Without Moral Theory?", in Postures of the Mind (Minneapolis: University of Minnesota Press, 1985), 233.
(9) Annette Baier, "Alternative Offerings to Asclepius?", Medical Humanities Review, 6, no. 1 (January, 1992) 9-19.
(10) David Hume, An Inquiry Concerning Human Understanding 1749, cited in L.A. Selby-Bigge, ed. (Oxford, 1988) 25.
(11) Martha Nussbaum, The Therapy of Desire (Princeton, NJ: Princeton University Press, 1994), 72-73.
(12) Terrence F. Ackerman, et al., eds., Clinical Medical Ethics (University Press of America, Inc., 1987), 146. See also: Terrence F. Ackerman, , et al., "Moral Problems, Moral Inquiry, and Consultation in Clinical Ethics," in Clinical Ethics: Theory and Practice (Clifton, NJ: Humana Press, 1989), 141-160.
(13) David D. Karnes and Robert G. Shoemaker, eds., Falling in Love Wisdom: American Philosophers Talks About Their Calling (Oxford: Oxford University Press, 19......).
(14) Larmore, Charles E, Patterns of Moral Complexity (New York: Cambridge University Press, Press Syndicate of the University of Cambridge, 1987), 151.
(15) William J. Bouwsma, The Culture of Renaissance Humanism (Richmond: William Byrd Press, 1959), 6.
(16) Donald Schn, The Reflective Practitioner: How Professionals Think in Action, Temple Smith, 1983.
(17) Bertrand Russell, The Problems of Philosophy (New York: Oxford University Press, 1969), 153-61.
(18) Richard McKeon, ed. The Basic Works of Aristotle Book VI, chapters 5, 7 (New York: Random House, Inc., 1941) 12