Moral Theory and Moral Judgments in Medical Ethics

224 Pages·1988·13.555 MB·English

by  Baruch A. Brody (auth.), Baruch A. Brody (eds.)

MORAL THEORY AND MORAL JUDGMENTS IN MEDICAL ETHICS
PHILOSOPHY AND MEDIClNE
Edi/ors:
H. TRIS1RAM ENGELHARDT, JR.
Cenler for E/hics, Medicine, and Public lssues,
Baylor College ofM edicine, Hous/on, Texas, U.SA.
STUART F. SPICKER
School of Medicine, Universi/y ofConnec/icu/ Heallh Cenler,
Farming/on, Connec/icu/, U.SA.
VOLUME 32
MORAL THEORY AND
MORAL JUDGMENTS
IN MEDICAL ETHICS
Edited by
BARUCH A. BRODY
Center for Ethics, Medicine, and Public Issues, Houston, Texas, V.S.A.
KLUWER ACADEMIC PUBLISHERS
DORDRECHT / BOSTON / LONDON
Library of Congress Cataloging·in·Publication Data
Moral theory and moral judgments in medical ethics.
(Philosophy and medicine ; 32)
Includes index.
1. Medical ethics. 2. Bioethics. 3. Judgment
(Ethics) 1. Brody, Baruch A. II. Baylor Col lege of
Medicine. III. Institute of Religion (Houston, Tex.)
IV. Rice University. V. Series: Philosophy and
medicine ; v. 32. [DNLM: 1. Ethics, Medical.
2. Judgment. 3. Morals. W3 PH609 v.32 / WSO M8277]
R724.M824 1988 174'.2 88-4684
iSBN-13: 978-94-010-7723-1 e-ISBN-13: 978-94-009-2715-5
DOI: 10.1007/978-94-009-2715-5
Published by Kluwer Academic Publishers,
P.O. Box 17,3300 AA Dordrecht, The Nether1ands
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AlI Rights Reserved
@ 1988 by Kluwer Academic PubIishers
Softcover reprint of the hardcover 1s t edition 1988
No part of the material protected by this copyright notice may be reproduced or
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TABLE OF CONTENTS
BARUCH A. BRODY / Introduction - Moral Theory and Moral
Judgments in Biomedical Ethics 1
SECTION I / DERIVING
UTILITA RIAN CONSEQUENCES
L. W. SUMNER/Utilitarian Goals and Kantian Constraints (or:
Always True 10 You, Darling, in my Fashion) 15
WILLIAM RUDDICK / Utilitarians Among the Optimists 33
JEFFREY REIMAN / Utilitarianism and the Informed Consent
Requirement (or: Should Utilitarians be Allowed on Medical
Research Ethical Review Boards?) 41
L. W. SUMNER / Reply to Ruddick and Reiman 53
SECTION In NATURAL RIGHT CASUISTRY
ERIC MACK / Moral Rights and Causal Casuistry 57
BART K. GRUZALSKI / Death by Omission 75
MICHAEL P. LEVINE / Coffee and Casuistry: It Doesn't Matter Who
Caused What 87
SECTION III / MARX'S THEORY:
DERIVING MORAL IMPLICATIONS
ALLEN BUCHANAN / Marxism and Moral Judgment 101
MARY B. MAHOWA LD / Marx:, Moral Judgment, and Medical
Ethics: Commentary on Buchanan 119
vi TABLE OF CONTENTS
SECTION IV / CHRISTIAN CASUISTRY
STA NLEY HAUERWA S / Reconciling the Practice of Reason:
Casuistry in a Christian Context 135
LAURENCE THOMAS / Christianity in a Social Context: Practical
Reasoning and Forgiveness 157
SECTION V / FROM THEORY TO PRAXIS
ALAN DONAGAN / The Relation of Moral Theory to Moral Judg-
ments: A Kantian View 171
CARSON STRONG / Justification in Ethics 193
PHILIP E. DEVINE / Theory and Practice in Ethics 213
NOTES ON CONTRIBUTORS 225
INDEX 227
BARUCH A. BRODY
INTRODUCTION - MORAL THEORY AND MORAL JUDGMENTS
IN BIOMEDICAL ETHICS
THE NEED FOR MORAL THEORY
Bioethicists regularly make moral judgments about the appropriateness or
inappropriateness of particular actions. They may judge that it is morally
appropriate to withhold therapy from a particular patient because that patient
has refused to receive that therapy. They may judge that it is morally
appropriate to warn a third party about a thrcat posed by a patient even if the
patient demands confidentiality. They may judge that a particular patient in
an ICU should be dischargcd from the ICU to the floor bccause demands of
justice require that a place be made for a patient with a greater nccd for the
ICU bed. That bioethicists make such judgments about particular actions
should come as no surprise. One of the major reasons for the emergence of
bioethics is just that such judgments regularly need to be made in the world
of high technology medicine.
Bioethicists regularly make moral judgments about the moral appropriate
ness of particular social policies. They may judge that it is morally ap
propriate to allocate additional funds to better prenatal care rather than to
additional beds in neonatal ICUs. They may judge that it is morally ap
propriate to weaken some of the restrictions on involuntary civil commitment
so as to aid some segments of the homeless population efficiently. They may
judge that it is morally appropriatc to allocate scarce organs without reference
to the 'social worth' of the rccipient. That bioethicists make such judgments
about particular social policies should come as no surprise. One of the main
rcasons for the emergence of bioethics is just that such judgments regularly
need to be made in the world of limited resources.
What is the basis for such judgments? How are they to be justified? How
can they be defended against those who would make different judgments?
Questions such as these explore the epistemological basis for bioethics.
Epistemology is, after ali, the study of knowledge. It is the study of how we
know that various judgments are true or false. Questions such as these force
bioethicists to develop an epistemology for their discipline.
If one looks at standard practice in bioethics, one would be tcmpted to
answer these questions in the following fashion: there are a variety of
1
Baruch A. Brody (ed.), Moral Theory and Moral Judgmenls in Medical Elhics, 1-12.
el 1988 by Kluwer Academic Publishers.
2 BARUCH A. BRODY
principles that constitute the foundation of aU bioethical judgments. These
include such principles as beneficence, non-maleficence, autonomy, the right
to life, justice, and confidentiality. Bioethicists justify their judgments about
particular actions or particular policies by reference to these principles. They
constitute the basis of bioethical knowledge.
There is no doubt that bioethicists oft en proceed in this fashion. Neverthe
less, there are good reasons for thinking that these principles are not the true
foundations of justified judgments in bioethics. There are good reasons for
believing that we must go beyond them if we are to find the appropriate
epistemological foundations for bioethics. After aU, these principles often
conflict with each other, their scope and implications are unclear, they are
themselves open to challenge, and they cannot explain how bioethics fits into
a complete picture of the morallife. These problems can be resolved only if
the principles of bioethics are integrated into some larger theoretical
framework. We need moral theories and notjust bioethical principles.
What is the problem of conflicting bioethical principles and how can an
appeal to moral theory help deal with this problem? It is a truism that the
above-mentioned principles of bioethics can lead to conflicting judgments
about particular actions or social policies. Beneficence may tell us to treat a
patient in a certain way because that form of treatment will produce the best
results for that patient Uudged by the patient's own values and goals), while
autonomy may teU us to eschew that form of treatment because the patient,
for one reason or another, is refusing that form of therapy. Confidentiality
may call on us to keep information about a patient secret, while non
maleficence may call on us to reveal that information so that others may not
be harmed. The right to life may demand that a particular patient should be
allowed to keep for a long time his or her place in the ICU because it offers
the best chance for life, while justice may suggest that the bed should be
reallocated to several others, each of whom has a better chance of benefiting
from the reallocation of that place in the ICU. The problem of conflicting
principles is the problem of what to do when the principles of bioethics lead
to different conclusions about particular cases. One solution to this problem
is to develop a lexical ordering of the principles of bioethics. Adopting this
solution means ordering the principles so that there is one whose implications
are followed in alI relevant cases, a second whose implications are followed
when the first is irrelevant, a third whose implications are followed when the
first and second are irrelevant, etc. Such a solution is attractive because of its
simplicity, but it might not be acceptable because it is not easy to think of a
principle that takes precedence in alI cases over alI combinations of opposing
INTRODUCTION 3
principles. A second solution to this problem is to develop a scale for
weighing the significance of the conflicting principles in a given case and for
concluding which action should be adopted because it is supported by the
weightier considerations in that case. Such a solution seems more realistic
than the lexical ordering approach, but the development of such a scale is a
problematic task. Still other, more complex solutions are possible. Which is
the best solution to this problem of conflicting principles of bioethics? We
need a moral theory to answer that question. This is the first reason for
concluding that the principles of bioethics are not the true foundations of
justified judgment in bioethics.
What is the problem of the unclear scope and implications of the principles
of bioethics and how can an appeal to moral theory help deal with that
problem? The scope of a bioethical principle is the range of cases in which it
applies. The implications of a bioethical principle are the conclusions to be
derived from that principle in those cases in which it applies. It is clear from
a review of the discussions in bioethics that there are major unclarities about
the scope and implications of each of the principles. Consider, for example,
the principle of autonomy. Does it apply to fourteen-year-olds, and if it does,
does it apply to them with as much force as it applies to adults? Does it apply
to very depressed patients, and if it does, does it apply to them with as much
force as it applies to others? Consider, as a second example, the principle of
the right to life. Does it apply to fetuses and/or to newbom children, and if it
does, does it apply to them with as much force as it applies to adults? Does it
apply to severely demented patients and/or to persistent vegetative patients,
and if it does, does it apply to them with as much force as it applies to those
with fulIer cognitive capacities? These questions are illustrative of the many
crucial questions about the scope of the principles of bioethics. Consider, as a
third example, the principle of beneficence. Does it require doing what is best
for the patient regardless of what that means to others, or does it involve
taking into account the results for others? If the Iauer, which others should be
considered? The family? The health care providers? The rest of society? How
should the interests of these many parties be balanced? Consider, as a final
example, the principle of justice. Does it mean treating everyone equally?
Does it just mean insuring that everyone has equal access to some basic
minimum of health care, and if so, how do we determine what is that basic
minimum? These questions are illustrative of the many crucial questions
about the implications of the principles of bioethics. How shall we deal with
this problem of the unclear scope and implications of the principles of
bioethics? It seems that we need a moral theory to help us deal with this
4 BARUCH A. BRODY
problem. That is the second reason for conc1uding that the principles of
bioethics are not the true foundations of justified judgment in bioethics.
What is the problem of the challenge ta bioethical principles and how can
an appeal to moral theory help deal with that problem? Bioethicists tend ta
assume that everyone accepts the validity of the standard principles of
bioethics. Even if that is so, we need to be sensitive to the possibility that this
is an unjustified consensus. More realistica11y, however, we need to recognize
that there are real challenges to the validity of these principles. The principle
of autanomy is a simple example of this. It is c1ear that the literature of
bioethics assumes that everyone accepts its validity, even if there are
disagreements about its scope and implications. Discussions with clinicians
make it equally c1ear that many are dubious about its validity. They want ta
do what is best for their patients, and that, they believe, sometimes means
disregarding patients' expressed wishes. How can one respond ta this oft en
felt but not oft en articulated challenge ta the principle of autonomy? I see no
choice but to argue for the principle of autanomy by appealing to some more
fundamental moral theory. The principle of justice presents an even better,
although more complex example of this need for moral theory. In truth, there
is no single principle of justice. There are libertarian principles of justice in
health care, egalitarian principles of justice in health care, social-contrac
tarian principles of justice in health care, etc. For any particular principle of
justice in health care, there are many who would challenge its validity. How
can one respond ta such challenges? I see no choice but to argue for some
principle of justice in health care by appealing ta some more fundamental
moral and political theory. In short, there are challenges to the validity of the
principles of bioethics, and it seems that we will need a moral theory to help
us deal with these challenges. This is the third reason for conc1uding that the
principles of bioethics are not the true foundations of justified judgments in
bioethics.
What is the problem of how bioethics fits ioto a complete picture of the
moral life and how can an appeal ta moral theory help deal with that
problem? Bioethical principles are normally understood as principles
goveming the relation between health care providers (aH providers, not just
doctors) and health care recipients (aH recipients, not just patients in offices
and hospitals). Sometimes - and this is an improvement - they are under
stood as principles goveming the relation between providers, recipients, and
other affected individuals. We oft en forget, however, that nobody is just a
health care provider or a health care recipient. Providers and recipients are
human beings who play many other roles and who have many other relations,