Bioethics - A Systematic Approach 2nd ed - B. Gert, et al., (Oxford, 2006) WW

372 Pages·2006·3.19 MB·English

Bioethics:
A Systematic Approach,
Second Edition

BERNARD GERT, PH.D.
CHARLES M. CULVER, MD., PH.D.
K. DANNER CLOUSER, B.D., PH.D.

OXFORD UNIVERSITY PRESSS

Bioethics

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Bioethics:
A Systematic Approach

Second Edition

BERNARD GERT, PH.D.
Stone Professor of
Intellectual and Moral Philosophy
Dartmouth College
Adjunct Professor of Psychiatry
Dartmouth Medical School

CHARLES M. CULVER, MD., PH.D.
Professor of Medical Education
Barry University

K. DANNER CLOUSER, B.D., PH.D.
University Professor of Humanities
Pennsylvania State University College of Medicine

2006
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Library of Congress Cataloging-in-Publication Data

Gert, Bernard, 1934–
Bioethics : a systematic approach / Bernard Gert, Charles M. Culver,
K. Danner Clouser.—2nd ed.
p. cm.
Includes bibliographical references and index.
ISBN-13 978-0-19-515906-6
ISBN 0-19-515906-3
1. Medical ethics.
I. Culver, Charles M.
II. Clouser, K. Danner.
III. Title.
R724.G46 2006
174.2—dc22
2005050871

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Printed in the United States of America
on acid-free paper

Preface

This book is an extensive revision of Bioethics: A Return to Fundamentals. We
have changed the subtitle to A Systematic Approach, in order to emphasize that
what distinguishes our approach to bioethics from almost all others is that it is
systematic. We provide a systematic account of our common morality as a public
system; we do not merely accept our thoughtful moral decisions and judgments,
but show how all of these decisions and judgments can be explained in terms of a
common moral system. We then apply this common moral system to the moral
problems that arise in the practice of medicine. We do not make ad hoc judgments
about particular cases and policies, but show that all of these judgments about
cases and policies are related to and justified by this common moral system. We
also show, in a systematic way, that the concept of rationality that is used to justify
morality is the same concept that is used to define the critical bioethical concept of
malady or disease. Further, we offer an account of the concept of death and
provide an account of euthanasia that fits within the systematic account of mo-
rality and rationality that we have provided. We even show that this systematic
account explains the controversy about the morality of abortion. Our approach to
bioethics is fundamentally at odds with most of the current approaches to bio-
ethics.
Our subtitle, A Systematic Approach, thus both describes the content of this
book and speaks to a concern. The content consists of concepts, information, lines
of reasoning, and theory that are basic to medical ethics. Our concern is provoked
by numerous observations of the state of the field, chief among which is the

tendency on the part of many to regard each area of applied ethics as an entity unto
itself, that is, as independent of a general account of morality. Few, if any, sys-
tematic attempts are made to relate a general account of morality to any applied
field, including the field of bioethics. Correspondingly, there is a tendency for
professionals coming into the field to be trained in the culture of medical ethics, in
its classic cases and standard resolutions, but with no real understanding of com-
mon morality or of its relation to the various branches of applied ethics.
Witness the spate of medical ethics anthologies being published. In the req-
uisite sections of the books (always in the introductory or first chapter) dealing
with theory, there is typically a gathering of various approaches to ethics, or moral
theories, with a brief description and, sometimes, a critique of each one. But there
is no systematic investigation of the different approaches or moral theories, no
attempt to discover or validate the foundations of these moral theories, and no
effort to attempt to relate these moral theories to the systematic solving of medical
ethical problems. Indeed, typically, theory is never mentioned again in the rest of
the book. Of course, knowledge of medical practices and of the realistic alter-
natives is essential for dealing with actual problems, but without the framework
provided by a systematic account of morality, moral decisions tend to be made
ad hoc.
We acknowledge that medical ethical problems often can be satisfactorily re-
solved on the fly, citing ad hoc rules, cases, principles, or traditions, as they come
to mind. In these instances, ordinary moral understanding provides those involved
with an acceptable agreed upon resolution to the problem and the citing of
‘‘proofs’’ or ‘‘principles’’ is generally nothing more than academic window dress-
ing. However, ordinary moral understanding is often not sufficient to understand
more complex and difficult cases. Whenever a case provokes disagreement among
different participants, something beyond implicitly shared moral intuitions is
necessary, especially when the disagreement cannot be resolved, e.g., the moral
acceptability of abortion. Contrary to the standard assumptions, a systematic
account of morality provides an explanation and justification of why there is often
more than one morally acceptable alternative to controversial moral problems.
Understanding this can promote more civil and fruitful discussion of these con-
troversial moral problems.
Thus, in addition to its theoretical value, we believe that there is considerable
practical value in discovering and validating the foundations of those moral be-
liefs that guide decisions and actions, and in systematically relating them to
fundamental concepts and problems in medical ethics. This explains our subtitle A
Systematic Approach. Indeed, we believe our exposition of the linkage between
morality in general and its expression in medical ethics in particular is clear
enough to be of conceptual help to all areas of applied ethics. It explains both why
most medical decisions are uncontroversial and thus do not provoke any moral
discussion, and why some moral issues in medicine are so controversial. Only an

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PREFACE

appreciation of the systematic character of moral thinking allows for some un-
resolvable moral disagreement without degenerating into relativism.
Most of the themes and concepts in this book were developed to some extent in
our previous book Bioethics: A Return to Fundamentals, but we have made some
significant changes in some of these topics, and have introduced some completely
new topics. For example, this current book contains chapters on abortion and on
‘‘what doctors must know,’’ subjects that were not addressed at all or only tangen-
tially in the previous book. Also, significant changes, additions, and improve-
ments have been made in our treatment of the concepts of consent and malady,
and we have devoted an entire chapter to the concept of mental maladies. We also
develop our arguments against principlism and show how the authors of prin-
ciplism misunderstand our view, which undermines their criticisms of us. In the
chapter on ‘‘what doctors must know,’’ we discuss the pervasiveness of proba-
bilistic phenomena in medicine. We give examples of several measures derived
from clinical epidemiology and discuss the implications of these measures for the
consent process. The chapters on death and euthanasia have been updated; the
former by considering advances in technology, the latter by taking into account
the Supreme Court decision concerning physician-assisted suicide. Most signif-
icant, this current book integrates all of these themes and concepts, grounding
them in a systematic account of rationality and morality. The connections among
bioethics, morality, rationality, and values are clearly explored, made explicit,
and shown to be systematic.
To be systematic requires considering the implications that each part of the
account of morality has for every other part. There must be consistency through-
out the moral system. If a feature is judged to be morally relevant in one case, that
same feature must be judged to be morally relevant in every other case of the same
kind. Not only must there be consistency within the moral system but there must
also be consistency in applying the rules, ideals, and lines of reasoning to different
persons. If a violation of a moral rule is justified in one case, it must be justified in
all cases with the same morally relevant features. The emphasis on consistency
and coherence is in direct opposition to the ad hoc approach characteristic of much
of bioethics.
We are aware that talk of a ‘‘systematic account’’ may connote something
monolithic and presumptuous. That is unfortunate since misunderstanding of this
matter has had a considerable negative impact on bioethics. Our systematic ac-
count of ethics is not monolithic; it does not claim that there is a unique right
answer to every moral question. On the contrary, one of its virtues is that it pro-
vides an explanation of why some moral disagreement is unresolvable. Nor is our
approach presumptuous, for it includes as morally acceptable all positions on
controversial topics that have been accepted by any significant number of people.
We do not reject as unacceptable any position that any impartial rational person
might put forward.

PREFACE
vii

Our systematic approach is distinct from all of the standard moral theories.
Unlike Kantian views, we recognize the importance of consequences. Unlike
consequentialist views, we emphasize that morality is a public system. For ex-
ample, in considering whether a moral rule violation is justified, the decisive
consideration is not the consequences of the particular violation in question, but
the consequences of everyone knowing that this kind of violation is allowed.
Breaking a moral rule in circumstances when one would not be willing for ev-
eryone to know that such violations are allowed is contrary to the impartiality
required when considering violating a moral rule. That morality is a public system
that applies to all rational persons explains why everyone knows what morality
forbids, requires, discourages, encourages, and allows. Our recognition of this is
why our account of morality does not lead to the kinds of counterexamples that
have led so many in bioethics and in other areas of applied ethics to consider
themselves anti–moral theory or, in what amounts to the same thing, to adopt the
anthology approach to ethical theory, that is, to advocate different theories for
different problems.
The appropriateness of the descriptive name ‘‘common morality’’ for our ac-
count of ethics will become clearer as the reader progresses through the book.
Meanwhile, in this context, we wish to point out that the description of our ac-
count as ‘‘impartial rule theory’’ is extremely misleading. Although rules are an
important aspect of our account of morality, we continually emphasize that these
rules can be properly understood only as they function within the moral system.
Other essential components of the moral system include moral ideals, specifica-
tion of the ‘‘morally relevant features’’ of situations that help focus the search for
the relevant facts, and an explicit two-step procedure for dealing with conflicts
among rules and between rules and ideals. These features are all implicit in our
ordinary moral decisions and judgments, and leaving out any of them distorts our
common understanding of morality. Thus we regard ‘‘common morality’’ as the
appropriate name for our approach.
We wish to acknowledge the help that we have received from many sources in
the writing of this book. Bernard Gert continues to acknowledge the value of
working with challenging Dartmouth College students, and the research envi-
ronment and support offered by Dartmouth College. He also wishes to thank
the Centre for Applied Philosophy and Public Ethics (an Australian Research
Council–funded Special Research Centre at Charles Sturt University) for the
stimulating environment at the Australian National University where he spent
the summer of 2004 working on the chapter on moral disagreement. An earlier
version of that chapter was published in their journal, the Australian Journal of
Professional and Applied Ethics.
Charles Culver wishes to thank, for their encouragement and support of his
scholarly efforts, Dr. Chester Evans and Dr. Doreen Parkhurst of the Barry
University School of Graduate Medical Sciences. He also wishes to thank the

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PREFACE

physician assistant students of that school for their perceptive and stimulating
reactions to many elements of the material contained in this book.
We wish to explicitly thank Jeffrey House of Oxford University Press for his
encouragement and wise counsel during our preparation of this book. This is the
third OUP book for which Jeff has served as our editorial mentor and we are
enormously grateful both for his general support and his many specific sugges-
tions about how to clarify our writing.
Unfortunately, this revision of Bioethics: A Return to Fundamentals has not
had the benefit of one of the authors of that book. K. Danner Clouser died on
August 14, 2000, at Mary Hitchcock Memorial Hospital in Lebanon, New
Hampshire, at the age of seventy, almost five years after first being diagnosed with
pancreatic cancer. We continue to list him as an author of this book, because much
of what he wrote for that first book has remained in this one. Though that alone is
not the reason for his inclusion, since both of us have learned so much from Dan
that his influence on this book continues to be significant. We feel privileged to
have had him as our colleague for so many years and we wish to dedicate this book
to him.

PREFACE
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