Pragmatic Bioethics.

Second edition Edited by Glenn Mc Gee A Bradford Book, The MIT Press, Cambridge, Massachusitts; London, England, 2003 pp. 293, paperback, ISBN 0-26263272-1 $26.95 U.S.

From the mid-nineteenth century on, with the rise of atheism and materialism, continental Europe and the English-speaking world progressively abandoned belief in God. Natural law ethics and the moral teaching of the Catholic Church were increasingly rejected, and a purely secular morality began to take their place. Among the wellsprings of Western secular morality were the philosophies of Charles S. Peirce, William James, and John Dewey. The book Pragmatic Bioethics gives a good account of the theoretical basis and practical reasoning of this new morality as it applies to medical and bioethical matters. The contributors are seven academics in philosophy, bioethics, and medical ethics.

Belmont Report, 1978

Modern bioethics was confected by congressional mandate in 1978 in the U.S., when a commission produced the Belmont Report. This report identified three ethical principles: respect for persons (now referred to as 'autonomy'), justice (now referred to as 'fairness'), and beneficence. The Belmont ethics was known as 'principalism', and was a totally new way for defining right and wrong. It is still used extensively in the official journals and other publications of the medical and surgical professions. Its principles also pervaded business, engineering, the legal profession, and the media. However, it gradually broke down, and it is now admitted that principalism did not work because there was no way simultaneously to reconcile the values of all three principles. As a result, Belmont ethics has become obsolete and is being replaced by pragmatic ethics.

Pragmatic bioethics

Pragmatic bioethics is predominantly an American affair. In essence, it holds that in order to solve moral problems, one must ascertain the outcome most desirable to the parties involved and also construct a means for its realization. It puts great emphasis on the duty of influencing the community in order to solve social problems. At the same rime (and this is adverted to repeatedly in this book) it stresses the contention that there are no absolute fixed moral norms and that one should follow no principle or philosophy, natural law, or God's law. Instead, one is counseled to use these resources as tools to achieve a "reflective equilibrium," resulting in a balance of moral theories, principles, and intuitions, in order to produce a consensus about the best outcomes.

Pragmatism defines the good (or best outcomes) as being the result of a compromise among the parties of a debate in regard to their desires. If an agreement is not reached in a debate about a moral problem, and conflict persists about how to act, then it should be resolved by deliberation. If this also fails, the parties to the dispute might be subjected to the influence of ethics committees and, if necessary, even to judicial intervention.

Pragmatists insist that they greatly respect the moral autonomy of the person, but they also emphasize that their philosophy also has as a primary goal the power to influence the public. In the last analysis, they seek to guarantee that their notion of the best outcome, or public good, and their notion of how it is best achieved, will trump the good sought by any party with whom they disagree. The individual is expected to create and be committed to a "life plan" requiring a "practical wisdom", both of which must be consistent with pragmatic ethical principles.

Pragmatists are willing, using the influence of the elites in society, and using the power of the judiciary where necessary, to compel others to do their will in many matters which are morally disputed. As a justification of this 'will to power' it necessarily follows that the assumed to act on the basis of a knowledge of the truth about the good (or at least of how to arrive at that truth) with a certainty that others either deny or do not possess. This is ironic, since one of the fundamental tenets of pragmatism is the assertion that objectively true moral laws do not exist.

Euthanasia

Such an approach to morality results, as various authors in this book have shown, in attempts to justify euthanasia. William Gavin holds that it is morally permissible to kill in order to relieve pain. Dr. Micah Hester tells us that we are ethically obligated to help persons in their wish to end their lives. He advises those who want to commit suicide to do so if they see it as giving meaning to their lives.

In the chapter on embryonic stem cell research, the authors state that "he who makes the definitions wins the debate" and, later, "the public debate must be shepherded and fostered by an elite that is prepared to seize rhetorical primacy, and to mold existing institutions, or create new ones, for that purpose." They also include scientifically incorrect statements in regard to hybrid formation, nuclear transfer cloning, and the scientific study of the human embryo. They state that the definition of embryonic stem cells is a "sociomoral exercise."

This would appear to be a telling example of making "definitions in order to win the debate." The truth is that only human embryological science can define the scientific nature of human stem cells. The single-cell human zygote is scientifically already a member of the human species, a human being. This fact can be obscured by sociopolitical, sociomoral, or other such exercises which argue about "personhood", or use such non-scientific terms as "pre-embryo" when referring to the human being before implantation has occurred.

Another contributor

Martin Benjamin suggests that perhaps a human being could be regarded as dead if deemed to have lost "personhood." This is a sociopsychological conception of human life in which one is alive but no longer a "person" who possesses human rights when one has lost the ability to think and choose to act, or to experience pleasure or pain. He also suggests that this concept of personhood "may lead to plausible and coherent resolutions of ... a wide range of bioethical issues--from abortion and embryo research ... to euthanasia and assisted suicide."

Catholic teaching dismissed

Throughout this book the teaching of the Catholic Church is singled out for comment which is dismissive if not derogatory. However, there are some parts of the text with which one can readily agree. Beth Singer makes a convincing case for a method of establishing a patient's competence which includes an assessment of his or her capacity to discuss the information that has been given. She also rightly states that a patient may have to be committed for reasons less drastic than those usually used by physicians, such as attempting or threatening suicide. A patient's refusal to take medication may not cause death but may cause serious harm to him or her or to those close to them.

Jacquelyn Kegley bases her paradigm for patient care on the thinking of Josiah Royce, the virtue ethicist, who was deeply committed to a theology of human moral imperfection, struggle, and hope for spiritual redemption through divine grace. Kegley speaks of the important role of an interpreter," a role that can be played by physicians, nurses, patients, or hospital administrators. The interpreter builds bridges between those involved in the solution of medical, ethical, and bioethical problems. This role is difficult, she says. It involves, indeed, one of the struggles referred to by Royce. Kegley lists the virtues used by the interpreter as humility, hope, courage, tolerance, patience, compassion, and loyalty. These are all made possible in the greatest perfection, as Royce witnessed to, by divine grace.

Pragmatic Bioethics is a significant work. It describes the ethical theory which dominates the secular western world today. Pragmatism has replaced principalism, and also, to a large extent, Catholic moral teaching, in the minds of many in the Western world's universities, medical facilities, and courts of law. A serious flaw in this ethical theory is that the fundamental principle and the modus operandi at its root are incoherent. Pragmatism defines the good simply as a project, desired and achieved by a consensus of the persons involved, working as a group. It holds that there are no fixed moral principles by which to justify a means of resolving a moral problem. Nonetheless, it insists on the validity of its own principle of how to determine the highest good. It holds also that knowledge is not of objective reality, or being, but of experience, and that means to an end are not to be considered right or wrong, but morally acceptable, only if agreed upon by consensus.

For Aquinas, the good is just another way of thinking about being. Aquinas' natural law tells us that natural reason, when presented with various instances of the good, sees that we are not just free, but also morally obliged. Pope John Paul Il in Fides et Ratio (par.98) has taught: "In order to fulfill its mission, a moral theology must turn to a philosophical ethics which looks to the truth of the good, to an ethics which is neither subjectivist nor utilitarian. Such an ethics implies, and presupposes a philosophical anthropology and a metaphysics of the good."

It is of paramount importance for Catholics who take seriously their vocation to the apostolate, and who are involved professionally in patient care, politics, the law, theology, or philosophy, to be aware of this kind of moral thinking and of its influence. I therefore highly recommend that all involved in these professions obtain this book and study it carefully.