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Practicing ethics: where's the action?

Practicing Ethics: Where's the Action?

When I first joined The Hastings Center twenty years ago, I was a young biochemist working at the National Institutes of Health, researching problems that had solutions, albeit about bacterial physiology. Thanks in part to my involvement with Hastings, I am today a humanist pursuing questions without final answers about human nature and human good, and I can boast only of having at last become old enough to be entitled to my somewhat traditional beliefs and concerns. "Nestor of bioethics," remarked one of my faculty friends when I told him of this speech for this occasion.

Because I want to speak mainly about the present and the future, I will not Nestor you with tales of the good old days. But it would be useful to remind ourselves of a few salient facts. First, the late 1960s were a turbulent time for American society, but a sleepy time for the study of ethics. Academic philosophy busied itself with other things, and no one had ever heard of "ethicists." Second, the effects of the so-called biological revolution were only just beginning to be felt: oral contraceptives and psychedelic drugs were in use and the first heart transplant had just been performed, but legal abortion, fetal tissue implantation, prenatal genetic diagnosis, human in vitro fertilization and embryo transfer, surrogate motherhood, gene synthesis and gene splicing, hospices, and orders not to resuscitate were things of the future, though some of them were already foreseeable. Third, those of us who gathered to found The Hastings Center, though we came from a variety of cultural and professional backgrounds, shared a concern for the human meaning of these and other anticipated new biomedical developments. Some of us inclined toward hope, eager to have the benefits of new technologies, but with protections against error and folly. Others of us inclined toward fear, repelled by certain prospects of biomedical intervention and concerned that even the well-intentioned uses of the new powers over the human body and mind might inadvertently diminish our humanity. But though we were variously moved, moved all of us were by moral (or religious) sentiments and concerns. If I remember correctly, only one of the founding Fellows made his living teaching philosophy, and he would come to meetings only if they did not require that he violate the Sabbath. It goes without saying, but it is important to note, that none of us came into bioethics through either the study or the practice of bioethics as it is now practiced and studied.

That was then. This is now. Today the ethics business is booming. There is ethics action everywhere. Most medical schools offer courses in medical ethics; in colleges and universities undergraduate ethics courses abound; and some philosophy departments offer PhD.s in bioethics. Many hospitals have established ethics committees, mainly but not exclusively for dealing with decisions regarding termination of treatment, while institutional review boards must rule on all sorts of experimentation with human subjects. Courts of law are increasingly asked to settle ethical conflicts, while blue ribbon commissions, national and local, analyze issues and issue guidelines to govern practice. Many other research institutes have followed The Hastings Center into the field, and the literature - professional and popular - grows, it seems, exponentially. And ethicists are in vogue: they get positions in medical schools, are quoted in the daily papers on every hot topic, and appear frequently on television and talk shows.

The Hastings Center has been and remains a major force in these developments. Since its beginning it has led the action on all these fronts, shifting its energies as the times have changed, but being never far from the middle of things. For those who practice ethics - especially biomedical ethics - Hastings, more than anywhere, is where the action is.

In looking toward the future of The Hastings Center, we do well to examine the present. An anniversary is an especially appropriate occasion for taking stock. When a marriage or an institution is strong, it can tolerate critical scrutiny, especially if offered affectionately from loyal friends. This I have taken as my task. Never one to see the value of praising Rome to Romans, even on celebratory occasions, I want instead to have us consider the meaning of our common work, the meaning of "practicing ethics." I want to distinguish two forms of practicing ethics, one of which is flourishing, one of which is not, and I intend to argue for the urgency of redressing the imbalance. My remarks are prompted by reflections not only on our field but also on American society today, and especially on the moral education of the next generation, with whom I am steadily in contact. My sometimes polemical style or sharp comments may give offense; thus, it may be worth pointing out that the criticisms I shall level apply by and large also to my own ways of practicing ethics these past two decades.

Practicing Ethics Today

In the practice of ethics today, not only at Hastings but wherever the action is in the world of biomedical ethics, the action is mostly talk. This is, by itself, not surprising, for to act as a human being often means deliberating and consulting beforehand, in search of what best to do. But the kind of talk ethicists talk is not generally the talk of moral agents faced with the necessity for action. Even when we consider specific cases or actions, our talk is frequently abstract and theoretical. In fact, much of the practice of ethics these days is really meta-ethical. It seeks to analyze and clarify moral argumentation; to establish or criticize grounds for justifying our decisions; to lay down rules and guidelines, principles and procedures, for addressing ethical dilemmas; and, in some cases, to construct comprehensive theories of conduct centering around fundamental norms, called autonomy or utility or duty or equality or benevolence. Faced with all this talk and theory, one may well wonder, "Where's the action?" What, we will later ask, is the connection between this practice of ethical discourse, now vigorously pursued by ethicists and their collaborators, and ethical practice, that is, the deeds of medical practitioners, hospital administrators, public health officials, and the countless citizens who have dealings with them?

Let me describe what seem to me to be some of the dominant fashions in the practice of ethics now flourishing. These generalizations do not apply to all practitioners today, but they seem to me to characterize both the mainstream and its most prominent navigators.

(1) Ethics is seen first and foremost as a field of theorizing. Though ethics is eventually concerned with matters of conduct - with what we do and how we live - most scholars of ethics are theorists, and theorists who do not begin concretely with real actors and deeds but abstractly with theories about action and its proper justifications. Dealing with action is thought to be applying theory to practice, like applied science or engineering.

(2) As theory, ethics today belongs especially to philosophical theorizing. To practice ethics means especially to practice the academic discipline of philosophic ethics. To be sure, the field is home also to people who call themselves religious ethicists, even Christian or Jewish ethicists, but most of these use the terms and play by the rules laid down by academic philosophy. Religious thought - I would hesitate to call it theorizing - has its own and, indeed, profound understanding of the human condition and teachings about the moral life, but the pluralistic premises of American ethical discourse lead the mainstream to view such traditions at least with suspicion, and, in any case, to treat them as hopelessly parochial or sectarian. And religious ethicists - Paul Ramsey was a most notable exception - seem to accept this judgment. Perhaps for the sake of getting a broader hearing, perhaps not to profane sacred teachings or to preserve a separation between the things of Caesar and the things of God, most religious ethicists entering the public practice of ethics leave their special religious insights at the door and talk about "deontological vs. consequentialist," "autonomy vs. paternalism," "justice vs. utility," just like everybody else.

(3) Philosophical ethics today is rationalist, I would say "hyper-rational," and, I would allege, unreasonably so. The dominant mode of American philosophizing today remains analytic. It concerns itself with the analysis of concepts, the evaluation of arguments, and the criticism of justifications, always in search of clarity, consistency, coherence. It spends little time on what genuinely moves people to act - their motives and passions: that is, loves and hates, hopes and fears, pride and prejudice, matters that are sometimes dismissed as nonethical or as irrational because they are not simply reducible to logos. Repugnances and their correlative taboos are also overlooked; since they cannot give incontrovertable logical defenses of themselves, they tend to fall beneath the floor of ethical discourse. As a result, ethical discourse focuses almost exclusively on matters conceptual and logical.

In substance no less than in form, the ethical mainstream tends to be rationalist. Not human beings, as species-specific needy and aspiring embodied souls (or enlivened bodies) enmeshed in formative relations with other human beings, but "personhood" - the independent rational will or the conscious subject - is the supreme focus of moral concern, and becomes the touchstone of our dignity because it is the ground of our autonomy. Reason finds reasons to defend the citadel of rationality alone.

(4) Rationality at work is above all a problem-solver. As in science, so in ethics, rationality's first task is to define and isolate some matter of human concern as a problem demanding or seeking solution. Intelligibility and clarity is purchased at the cost of abstraction, and frequently also of distortion. For example, out of the poignant and complicated human situations surrounding the end of life, filled with the difficulties in facing death and caring for the dying, we isolate as a separate problem "when to pull the plug?" or "Can a physician morally hasten the end of life?" Or, out of the deeply significant relations between parents and children, we isolate as a problem to be solved the legitimacy of contracts for surrogate pregnancy or the ownership of laboratory-preserved human embryos. Or out of the AIDS epidemic, we isolate a problem of privacy versus public safety, or we treat the whole matter as a problem whose solution is a new drug or a better condom, always abstracting from its meaning in relation to human intimacy, trust, fidelity, moderation, and moral and sexual responsibility.

A problem, once it has been abstracted as a problem, is also abstractly analyzed. To be sure, these analyses are often interesting, but because of their rationalistic cast they rarely follow the lines of deliberation of prudent agents faced with the need to act. Choosing the best course of action, in light of the concrete circumstances, is not the same thing as analyzing and solving a formulated problem pulled out of context - not least because the rationalist analysis does not reach to motives and ends, nor to the normative questions of which ends are to be preferred, here and now. (I note in passing a serious danger in ethics seen as rational problem-solving: such ethics does not fill the human void created by technological thinking, nor does it supply the fully human response to the need to act. Rather, rationalistic ethics becomes merely a countervailing technique, the ethicist another technical expert like the ophthalmologist or the cardiologist, in danger of being a specialist without vision and a moralist without heart.)

(5) In its penchant for setting and solving problems, today's approach to ethics abstracts still further from the rich context of our moral life by concentrating mainly on the extreme examples. The implantation of an artificial (or chimpanzee) heart or the Debbie case or Baby M or the definition of death or guidelines for terminating life-sustaining treatment capture most of the attention - not surprisingly - but the morality of ordinary practice is largely ignored. Yet every human encounter is an ethical encounter, an occasion for the practice (and cultivation) of virtue and respect, and, between doctors and patients, for the exercise of responsibility and trust, on both sides. How do physicians speak to patients? Do they respect and protect their privacy and vulnerabilities? Do patients have reasonable expectations of their physicians? How do we, individually and culturally, stand with respect to rearing children, sharing intimacies, revering life, facing death? In the absence of attention to these more fundamental and pervasive moral postures and practices, is it reasonable to expect that an ethics for the extreme cases will be sensibly worked out even in theory, let alone be successful when "applied" to practice?

(6) When rational problem-solving solves its ethical problems, the solutions themselves tend to be purely rational, often taking the form either of rules or ideals; rational rules that should govern conduct, articulable ideals toward which practice should strive. Not addressed are moral sensibilities and affections or habits and customs of moral agents. Moreover, as rational, rules and ideals tend to be enunciated as universals, with no attention paid to the necessary particularity of judgment that all moral action involves.

Sometimes rational problem-solving, mindful of cultural pluralism and personal differences, draws back from offering substantive rules or ideals. Instead, rational procedures for making decisions are devised, without any attempt to specify the content of the decisions that will be duly made. The Hastings Center's much publicized Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying are a highly praised instance of this procedural ingenuity, and there is no question that clarification of relevant considerations is often very helpful, especially where the situation calling for action occurs under conditions of emotional distress. Yet, here too, universalized and abstract procedures are proposed without attention to customary practices or previously existing patterns for seeking advice, making choices, or living with the ambiguity of the choices made. No guidelines can cover all real cases, much less touch the critical nuances that distinguish any one case from another. The methodical rationality of procedure is put in place of the discerning reasonableness of the prudent man-on-the-spot that all real choices demand.

(7) The rationalistic devotion to moral ideals leads moral thought in the direction of ideology, always many steps removed from moral life as lived. Some moral theorists focus largely on solving "systemic problems," rather than, say, on improving moral conduct of individual agents. For example, one recent commentator, complaining about screening employees for illegal drug use, decries "our penchant to focus on individual citizens instead of systemic social problems. We seem to think that by treating citizens like grapes from Chile to be screened for cyanide... that we can solve our problems of poverty, racism, and violence." But do these social evils exempt individuals from the responsibility to be in their right drug-free minds if they are to drive school buses or control air traffic? And how do the "systemic-problem-fixers" expect a society to fight poverty, racism, and violence in the abstract, especially if it is indifferent to the concrete moral well-being and vigor of its particular citizens? Other theorists make an ideology out of "autonomy," without regard to the content of choices freely made, but, curiously, show no concern with the social institutions and communal mores that nurture the growth of self-determining adults and that guide their every choice and deed. These ideals turned into ideologies may effectively dramatize weaknesses and shortcomings in existing practices, but because of their abstractness they are powerless to form new customs and practices. And, as the idealized best is frequently the enemy of the actual good, ideologies, sometimes inadvertently, help dismantle the living and habitual moral fabric of a society that alone can help reform existing conduct.

This crude sketch of the practice of ethics is at best incomplete and suffers from, among other things, my own predilections toward abstraction and generalization. And despite my criticism of this approach to ethics - soon to be made more explicit - I do not underestimate its contributions. Thanks to the work of the last two decades, consciousness has been raised, moral complacency and indifference to moral matters have been partly overcome, issues have been clarified, some thoughtless and unreasonable prejudices have been countered, competing goods have been identified and, to some degree, balanced, and, in general, ethically troublesome situations are faced more deliberately and self-consciously - though, in my view, not obviously with wiser choices or finer deeds or better outcomes. At least until now, the field of medical ethics and bioethics has attracted - if we may say so ourselves - a rather high-minded and principled group of scholars and teachers - no Jimmy Swaggarts and Tammy Bakkers in our parish. The earnestness of many of the practitioners and the sobriety of their speech seem to be promoting a more reflective and reasonable approach, at least among those who participate in the colloquies. And the elaboration of procedures and guidelines and the institution of committee decisionmaking has had perhaps the secondary benefit of promoting community of discourse, again, among those who participate.

Yet, as I have already hinted, this theoretical and rationalistic approach to ethics has grave weaknesses. It speaks little about motives and attitudes, and still less does it concern itself with figuring out how to get people to do what theory says is best. Universalist in conception, it cares little for the variety of human types, some moved by the love of gain, others by the love of honor, some by reverence, others by fear, still others by pleasure. In short, it treats the rational content of speech and argument without regard to the engaged concerns that incite both speech and action. It by and large ignores mores and customs, sentiments and attitudes, and the "small morals" that are the bedrock of ordinary experience and the matrix of all interpersonal relations. It by and large ignores real moral agents and concrete moral situations, preferring the abstraction of the hypostasized "rational decisionmaker" confronting the idealized problem needing to be solved. Because real life is too complicated, it frequently prefers its own far-out cleverly contrived dilemmas - for example, thinking about abortion by conjuring a woman who wakes up to find a world-famous violinist grafted onto her body. Of the rich broth of our social-civil-cultural-spiritual life together, and of the ways in which it seasons us all without our knowing it, we theoreticians know almost nothing. Though originally intended to improve our deeds, the reigning practice of ethics, if truth be told, has, at best, improved our speech.

Theory and Practice:

Speech and Deed

Is this a fair charge? It is difficult to know. We would need to assess comprehensively whether and how the renaissance of the practice of ethics as theory has been beneficial for ethical practice in action. Such an assessment is beyond my powers; but consider these sobering questions. Those of us who entered the field concerned about the road to Brave New World cannot be reassured. Some of the worrisome or repugnant biomedical technologies (for example, extracorporeal conception and surrogate motherhood; sex selection; perfusion of newly dead bodies as "organ farms") have begun to arrive and are being used - to be sure, all with "suitable guidelines," and with the appropriate chorus of earnest concern about possible misuses and moral costs. Bioethicists have by and large behaved as if they could (and should) do no more than give pious blessings to the inevitable. And what about the institutions in which medicine is practiced: do they treat people, humanly speaking, any better than they did twenty years ago? Are hospital staffs more civil and engaged, are nurses and doctors listening and speaking better with patients? Have our required courses and conferences on medical ethics improved the characters and mores of our rising physicians? They may now be prepared to write "Do Not Resuscitate" orders, but are they better at attending the dying before the occasion of cardiac arrest? And what of their general manners and sensibilities? In my family's and my students' own recent experiences with physicians and hospitals the following incidents give pause: emergency-room physicians, one after the next, fail to introduce themselves gynecologists (and their nurses) refer to patients only by first names, and conclude their consultations while women are still lying undressed on the examining tables; a professor of pediatrics displays an intelligent and functioning ten-year-old child with meningo-myelocele, telling the class in the child's presence that had he been conceived today he would have been aborted; a group of (male and female) doctors and medical students stand around the bed discussing its occupant, oblivious to his profound discomfort at being left there stark naked and uncovered (a distressed medical student who later complained to her professor about these last two incidents was told that she was too sensitive for the practice of medicine); an intern greets the ambulance in which I am riding bringing my mother to the hospital by screaming at the paramedics because proper telephone notification had not been given; the attending physician on call for his group practice refuses to accept calls except in an emergency. What sorts of people are being selected for medicine and from whom are they learning what about its ordinary decent and humane practice? More generally, what has ethical theory been able to do for the malpractice crisis, itself a cause and a symptom of a massive breakdown of trust, or for the consequences of the new economic forces operating in medicine? Or again, for all our talk about reproductive ethics, are our families more stable and stronger today? For all our talk about death and dying, are our elderly parents better cared for by us than were their parents by them? Most generally, what about those forces of moral education in the popular culture - music, movies, television? Have they reached a higher standard of decency and moral taste? Will it be said of us that we ethicists fine-tuned our theoretical fiddles while incontinent Rome rocked and rolled its way back to barbarism?

These are, of course, all large and empirical questions, provocatively raised here to hammer home the question about theory and practice. Even if one could prove cultural and professional moral decline or stand-still during our rebirth of theory, that would not necessarily be theory's fault. No one at Hastings or anywhere else in medical ethics promised to work miracles. But our reigning theory can, I think, be faulted for its insufficient and faulty attention precisely to this matter of the relation between moral theory and moral action.

How does one get from theory to practice, from speech to deed, according to current theory? Application is said to be the way, as in "applied ethics." To apply," from the Latin applicare, means to bring into direct contact, to lay upon, to lean against. To apply a theory (or a rule or a rational principle) means bringing it from the outside into direct contact with...with what? Why, with a moral agent, and, presumably with his desires or motives or will, with whatever is the mainspring of his action. But does anybody consider why the motive should care to listen to the applied speech, why appetite should allow itself to be influenced by the applied rules or ideals? As Aristotle noted long ago, thought - or speech or reason - itself moves nothing, especially, one can add, thought merely laid down next to appetite. Thought, to be effective, must be inseparable from appetite.

Thinking (dianoia) moves nothing, but only thinking for the sake of something and practical (praktike); for this is the governing source (arche) also of productive activity (poietike)....Now, regarding the thing done (to prakton) acting-well is the end, and desire (or appetite; orexis) is for this. Therefore, choice (proairesis) - [the source of action] - is either appetitive intellect (orektikos nous) or thoughtful appetite (orexis dianoetike), and a human being (anthropos) is such a principle (or source; arche). (Nicomachean Ethics, 1139a36-b7).

The true source of action is not abstract thought, nor even thought applied to some separate motor or motive force, but rather a concretion, a grown-togetherness, of appetite and mind, so intertwined that one cannot say for sure whether the human principle of action is a species of desire become thoughtful, or an activity of intellection suffused with appetite. How mind and desire become grown together is, of course, a great question, but it is rarely done by applying purely rational doctrines or rules in a passionless way to human agents. On the contrary, the true beginning is rather with the direct but unreflective education of our loves and hates, our pleasures and pains, gained only in practice, through habituation and by means of praise and blame, reward and punishment. Anyone concerned with influencing conduct must be concerned with these in-between powers of the soul, themselves irrational (in the sense of nonreasoning) but fully amenable to reason (in the sense of being formed, to begin with, in accordance with the reasons of one's parents, teachers, and laws, and being open to further refinement through the exercise of one's own powers of deliberation and discernment).

In short, our current theory of the relation of theory to practice has it backwards. Perhaps in ethics, the true route begins with practice, with deeds and doers, and moves only secondarily to reflection on practice. Indeed, even the propensity to care about moral matters requires a certain moral disposition, acquired in practice, before the age of reflection arrives. As Aristotle points out, he who has "the that" can easily get "the why." Moreover, because this sort of philosophical reflection mirrors genuine conduct, ethics would not become wholly or purely abstract, would never reach to what we call ethical theory, because it would retain its connection with the concreteness and complexities of the moral life and the moral agent. This more or less neglected approach to ethics deserves our attention, especially if we mean to make a practical moral difference. We must consider that the real action in practicing ethics will begin when we again see ethics as practice, as the putting-to-work of character and custom, in conduct that both creates and manifests the human agent, thoughtfully-at-work negotiating the many challenges of the human condition.

Habits of Affection and Behavior

The contrast I am suggesting between the two meanings of practicing ethics - ethics as theory with application; ethics as practice with reflection - parallels the contrast between two forms of our moral life described by Michael Oakeshott in a marvelous essay, "The Tower of Babel" (in Michael Oakeshott, Rationalism in Politics [New York: Basic Books, 1962], 59-79). Oakeshott contrasts the moral life as a habit of affection and behavior and the moral life as the self-conscious and reflective application of a moral criterion, and he tries to show the disadvantages we suffer because of our culture's growing emphasis on the latter at the expense of the former. As the second is familiar and in tune with our present preferences, let me speak only about the first, with Oakeshott's help. In the moral life understood through habits of affection and conduct,

[t]he current situations of moral life are met, not by consciously applying to ourselves a rule of behaviour, nor by conduct recognized as the expression of a moral ideal, but by acting in accordance with a certain habit of behaviour. The moral life in this form does not spring from the consciousness of possible alternative ways of behaving and a choice, determined by an opinion, a rule or an ideal, from among these alternatives; conduct is as nearly as possible without reflection. And consequently, most of the current situations of life do not appear as occasions calling for judgment, or as problems requiring solutions; there is no weighing up of alternatives or reflection on consequences, no uncertainty, no battle of scruples. There is, on the occasion, nothing more than the unreflective following of a tradition of conduct in which we have been brought up (61).

Moral life here flows from character - ingrained, concrete, steady, like a second nature. Although the conduct it yields is not the product of reasoning, it is nonetheless (perhaps, therefore) utterly reasonable and fitting. Though (because?) not rationalist, it makes immediate sense.

How is this form of moral life acquired? Not by philosophizing, not by doing "values clarification" or laying out ethical theory, not by applying theory to practice, but from education of a certain sort:

We acquire habits of conduct, not by constructing a way of living upon rules or precepts learned by heart and subsequently practised, but by living with people who habitually behave in a certain manner: we acquire habits of conduct in the same way as we acquire our native language. There is no point in a child's life at which he can be said to begin to learn the language which is habitually spoken in his hearing; and there is no point in his life at which he can be said to begin to learn habits of behaviour from the people constantly about him. No doubt, in both cases, what is learnt (or some of it) can be formulated in rules and precepts; but in neither case do we, in this kind of education, learn by learning rules and precepts....[I]f we have acquired a knowledge of the rules, this sort of command of language and behaviour is impossible until we have forgotten them as rules and are no longer tempted to turn speech and action into the applications of rules to a situation. Further, the education by means of which we acquire habits of affection and behaviour is not only coeval with conscious life, but it is carried on, in practice and observation, without pause in every moment of our waking life, and perhaps even in our dreams; what is begun as imitation continues as selective conformity to a rich variety of customary behaviour. This sort of education is not compulsory; it is inevitable....[I]t is the sort of education which gives the power to act appropriately and without hesitation, doubt or difficulty, but which does not give the ability to explain our actions in abstract terms, or defend them as emanations of moral principles....And a man may be said to have acquired most thoroughly what this kind of moral education can teach him when his moral dispositions are inseverably connected with his amour-propre, when the spring of his conduct is not an attachment to an ideal or a felt duty to obey a rule, but his self-esteem, and when to act wrongly is felt as diminution of his self-esteem (62-63; emphasis added).

Habitual practice informs it source; heart-and-mind are together dyed fast by repeated immersions in the practice of daily living.

Oakeshott's point about amour propre and self-esteem is crucial: practicing ethics in this full sense is nothing less than full self-expression, the manifestation of who one is at one's core. It points to the need for institutions that cultivate self-esteem and, more to the point, give moral content to our self-esteem, that make us believe that acting rightly is not just the other fellow's good but our own true flourishing. Early family life, schools, churches and synagogues, colleges, voluntary associations, and professional societies all have roles to play in such moral education, less by the elaboration of doctrine, more by the encouragement and reward of seemly and decent conduct and sensibilities. And while speech and philosophy have a role to play here, we should not exaggerate their power.

At the end of his Nicomachean Ethics, a deeply reflective work on the active life that indeed tries to show "the why" to those well-brought readers who already have "the that," Aristotle shows why ethics is impotent without politics - without careful attention to law and custom and the ordering of civic life. He makes his turn toward law and politics by remarking on the weakness of speech, including philosophical speech, presumably including also his own.

If speeches [or arguments or discourses on ethics] were sufficient to make men decent, "large fees and many" justly "would they win" (according to Theognis), and to provide such [speeches] would be all that is needed. But it appears that speeches have influence to encourage and stimulate the liberal youth, and given an inborn good character and a true love of the noble, they might make him capable of being possessed by virtue, but they are incapable of stimulating the many toward nobility. For they are not natured to be obedient to reverence [or aweful shame; aidos] but to fear, and to abstain from evil not because of its baseness but on account of the penalties (1179b4-13).

Speeches and arguments are at best influential only with those already well disposed toward the noble or the just; for the many, fear of penalty takes the place of reverence or awe-shame. But, in both cases, the crucial matter for moral education is the ruling passion of peoples' souls. Ethics must concern itself especially with how these passions are formed and addressed.

Where is it that human beings are encouraged in reverence or awe? Where is it that human beings are stretched toward a vision of something better or higher or finer? Could it be that something like piety - familial, civil, and religious - is a crucial ingredient in the most responsive moral souls? And what of the others? Do we not need the development of laws and customs with proper sanctions - logoi with teeth - to help guide those not amenable to persuasion?

These reflections point to the central need for attention to institutions - familial, religious, political. Indeed, one of the most astonishing things to me in the entire field of bioethics is how unpsychological and, especially, unpolitical are its reflections. And yet the character of our regime, the things we honor and reward, deplore and punish, deeply influence - albeit not always in obvious ways - the sorts of moral agents we become as individuals. Ethics will never be efficacious in action until we start attending to these matters.

Where's the Action for Tomorrow?

If my analysis is correct, even partly correct, it points to new arenas for ethical action and new challenges of leadership for The Hastings Center. To be sure, these new challenges will also require careful thought, but thought of a somewhat different kind - let us say "strategic" rather than "theoretic." We need to think less about doctrine and principles and the rules to govern behavior, more about education and institutions - and what sort of people we produce. We need to think about how to encourage and enhance the formation of certain sentiments and attitudes. If there is a greater need for respect, reverence, and gravity, or for trust, sympathy, and tolerance, we need to think about what fosters these things and what undermines them. We need to think about how to strengthen and defend those mediating structures and institutions which cultivate the habits of moral affections and conduct - especially family, the scouts, religious institutions, civic and public-service associations, and the like. It may turn out that changes in divorce law or childcare practices are ethically far more deserving of our attention than arguments about the status of the in vitro embryo or the rights of its biological progenitors. It may turn out that designing programs of compensated national service for our high school graduates deserve as much of our ethical attention as the ethics of various techniques of behavior modification. Such examples could be multiplied at will.

What I am talking about is, of course, nothing less than concern for the moral health of our entire community. We should therefore have no illusions about how much any one organization can contribute, or indeed, about how well the best national effort of the best hearts and minds can succeed. Indeed, I now appreciate a remark made twenty years ago by my cousin when I told him why I was entering the field of medical ethics: "You think you can do something about this? This is work for Mashiyach." (In fact, in a similar mood, I myself once tried to persuade Dan Callahan to prepare a grant request to hasten the coming of the Messiah, but we were both at a loss about where to submit it.)

Yet if we look concretely into our own front yard - medical ethics - there is, it seems to me, much constructive inquiry and action to be taken. We can give special attention to institutions and customs that help shape medical practice and, especially, that shape the attitudes, sensibilities, and habits of medical practitioners as moral agents. We could tackle the question of how prospective physicians, nurses, and hospital administrators are recruited and educated. We could seek to find appropriate studies to deepen their understanding of the meaning of our humanity. Is it from works of dry reason or from works of reasonable feeling - that is, is it from Rawls and Nozick or from the Bible and Tolstoy (not deconstructed) that we best cultivate moral sentiments and sensibilities? What sort and manner of humanistic learning truly humanizes? We could also concern ourselves with questions like the following: What sorts of performances and outlooks are and should be esteemed in the medical admissions process? What is praised and blamed, honored and held shameful, in medical training and medical practice? How can one bring new physicians into more apprentice-like relations with master physicians? What are the criteria for licensure and board certification, and, hence, what sorts of character do they encourage? What is the substructure of hospitals and medical associations, and how do they influence and sanction conduct, sentiments, attitudes? What sort of examples form our culture's perception of medicine? Does it matter whether it comes mainly from Dr. Kildare or from General Hospital? What can be done, institutionally, to foster greater trust and responsiveness between physicians and patients?

These questions about institutions and their effects on character are extremely complicated, and lack the neatness of abstract theory. Yet if we mean to do something about action, if we mean to practice ethics in a way that will yield a more ethical medical practice, we must devote at least some of our energies to these matters.

What to do, specifically, I leave for later brainstorming. We could try to arrange literature seminars for medical educators of the sort once sponsored by the National Endowment for the Humanities. We could convene a major task force involving medical school deans to redesign prerequisites and standards for medical school admissions. We could collaborate with, or help arrange grants for, screenwriters and people in television to promote better fictional portrayals of the practice and human significance of medicine. We will not even know the possibilities here until we try, but try we must.

Coda: Reviving Our Beginning

The present influence of The Hastings Center owes a great deal to the largely careful, fair-minded, and nonpartisan character of its intellectual work. Yet its success in the field of biomedical ethics, I submit, depends decisively also on a moral capital of a different, less reflective sort, harder to specify but I think more fundamental, rooted in that other form of moral life described by Oakeshott. Our rationalistic theoretical activities, for all their clarity, are by their very abstractness incapable of contributing to the increase or renewal of that capital. Indeed, our activities are in danger of undermining it, sometimes explicitly by the condescension shown by self-conscious theory for habitual practice and sentiment, more often by sheer indifference or neglect. We may, in the end, be incapable of stemming the rationalist prejudice, so prevalent in our age, or of restoring those institutions that lay the moral foundations of private and public life. But we would be at fault for not seeing the need to do so.

The Hastings Center, and the field it helped to launch, both now well-founded, face a not atypical problem of perpetuation: how to provide for the kinds of people and moral concerns that got it started. Henry Beecher, Paul Ramsey, Hans Jonas, Robert Morison, Dan Callahan, and Will Gaylin were, I repeat, not brought up on bioethics or moral theory, and no academic training accounts for their vision, courage, and moral passion. They have helped institutionalize a world of ethical discourse that might give the impression that their moral beginnings are no longer necessary. Nothing could be further from the truth. We must return to what animated the enterprise: the fears, the hopes, the repugnances, the moral concern, and, above all, the recognition that beneath the distinctive issues of bioethics lie the deepest matters of our humanity. As we celebrate our present, we must look seriously into the Center's beginnings, to revitalize ourselves for the work of our future.

Leon R. Kass, MD, is professor, The Committee on Social Thought and the College, The University of Chicago, and a founding Fellow and board member of The Hastings Center.
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Title Annotation:bioethics
Author:Kass, Leon R.
Publication:The Hastings Center Report
Date:Jan 1, 1990
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