If I Were a Rich Man Could I Buy a Pancreas?

IF I WERE A RICH MAN COULD I BUY A PANCREAS?

Arthur L. Caplan

Indiana University Press, $29.95, 348 pp.

Newborn intensive care units struggle to keep premature, drug-ravaged babies alive while healthy fetuses are being aborted down the hall. Doctors and nurses labor to honor a dying man's request to keep him alive by all possible means at the same time as 15 percent of the U.S. population lacks any form of health insurance.

Morality--normative codes of moral behavior-is of little use in these circumstances; the Ten Commandments and the magisterium are mum about who should receive a bone marrow transplant. In this situation, caregivers turn to applied ethics in order to analyze which principles are at stake and which should govern the outcome.

But basic principles must be agreed upon if they are to be applied. In our culture, religious pluralism, Enlightenment values, and an anti-authoritarian ethos have enshrined reason and individual autonomy. Each person is free to choose for him or herself among an array of possible goods, and reason is the primary tool in evaluating those goods. Given the ultimately subjective nature of this view, the ethics industry spends a lot of time trying to construct an elaborate groundwork that will logically prove the superiority of one principle over another. This is thin gruel for those who have to control the ethical fires that rage in a health-care system fueled by a consumer-oriented, individualistic, technologically driven culture.

Given this scenario, can ethics really help people make tough decisions? Arthur Caplan says yes.

Caplan, a philosopher and director of the Center for Biomedical Ethics at the University of Minnesota, writes from the perspective of the health-care practitioner for whom moral conflicts are too pressing to wait upon elegant ethical arguments. And in this collection of nineteen essays he takes up a variety of moral conflicts--from human and animal experimentation, reproduction and genetics, transplants and rehabilitation, to money and medicine--trying to justify the usefulness of applied bioethics against critics who argue that without a foundational theory, applied ethics is all leaves and no roots.

Mundane decisions are the stuff of patient care and they can have a central ethical importance. An astute and relentless observer of the quotidian in health care, Caplan rightly asserts that here ethics can be of real value. But in spite of lucid and accessible writing and some provocative thinking, the book is something less than the sum of its parts.

Through all of the essays, Caplan tries to negotiate among the shoals of "engineering ethics" (in which moral plumbers apply their analytical tools to the problem at hand); of foundationalism (the search for unifying ethical theories); and of teleological ethics (which holds that there are intrinsic goods and evils that can be located along a range of better and worse choices). But navigating among them. Caplan risks missing the port altogether, for nothing he writes about leaves the reader any better equipped to address ethical conflicts.

As I suggested at the beginning, Caplan is not alone in this problem. Absent an articulated and ordered set of principles, ethicists doing applied work are much like the teen-age mechanic who is considerably more proficient in taking things apart than putting them back together. The dilemma they face--along with all medical decision makers--is all too real: How can ethics be made accessible and applicable in a culture where we cannot assume a common understanding of a moral order and where reason-based ethical theory falls apart once it leaves the classroom? Moral theologians and other teleological ethicists face the same problem: reasoning based on the Imago Dei and Christ's redemptive suffering hold little sway in a tertiary medical-care center.

Caplan's frustration with foundationalism and engineering ethics is shared by many health-care practitioners, but he offers nothing in their stead. Neither these paradigms nor Caplan's own effort truly recognize the relational and fragmentary nature of applied ethics, especially in a medical-care setting. There ethics involves groups of people trying to discover the right thing to do. Ethicists participate in this process with a collection of resources. As a physician carefully works with patients to allow them to choose their care, so must an ethicist step gingerly with patients. With experience and reflection, tradition and reason, a sense of the good can emerge from these discussions and relations. At the collective level that dialog is called politics and policy making.

Caplan inches toward this notion of relationality when he tries to set a value on wisdom--the collected, reflective experience of the older person in ethical decision making. But his "just do it" methodology leads him to adopt and then discard such values in an ad hoc manner: autonomy here, wisdom there, and a preference in the extreme for the quotidian.

Enshrining reason and autonomy resuits in making comprehensiveness and consistency the evaluative criteria in ethical decision making. Caplan implicitly forsakes these criteria when he forsakes foundationalism. But there has to be a middle ground between his "just do it" spirit and more philosophically systematic approaches. No doubt, he has a limited bag of principles that describe most human conditions and values. When these conflict he has a reasonable suspicion about which to honor. It is the reader's loss that he cannot present them even in a fragmentary fashion, because at least part of what informs ethics is what individuals value--what Caplan values--and those beliefs encompass much more than reason.