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Where are the ethics in ethics committees?

Where Are the Ethics in Ethics Committees?

Where are the ethics in ethics committees? Even a little reflection on the notion of "ethics" committees, or a cursory experience with their deliberations, suggests that the answer to that question is neither trivial nor obvious.

Conflict is the essential element in issues brought before ethics committees. At times, they are asked to advise or comment on specific cases, before or after the fact. At other times they attempt to devise policies for their institutions. I believe that a careful look at ethics committees shows that they are more likely to be successful dealing with cases than with policies--with one broad exception. Defending this claim requires an account of how we make good moral decisions; I can only outline such an account here.

To understand what happens in ethics committees, a rich description of a committee at work would be helpful; fortunately, Ruth Macklin has narrated one such effort--to devise a policy for dealing with transfusion refusals by Jehovah's Witnesses. [1] It is a useful text for understanding the limits and possibilities for "ethics" in ethics committees.

The experience of Macklin's committee shows that there can be plain agreement on one category of cases, but profound disagreement on a closely related one. When the Witness was a competent adult on whom no other being's survival was inescapably dependent, the committee readily agreed that the person's desire to refuse blood transfusions ought to be respected. They agreed as well that if a child's life or health were severely threatened, the hospital should seek court approval of transfusion. For incompetent adults, the problem was to balance the desire to respect their wishes with potential uncertainties about how to discover their genuine beliefs. On these questions, and the problem of what to do in emergencies, the committee reached substantive agreement relatively quickly. One category of persons, though, uncovered serious conceptual and moral disagreement: pregnant women.

When the competent adult Witness who refuses blood is pregnant, we are forced to confront questions about the moral status of the fetus, our obligations (if any) toward that fetus, the relation between moral obligation and public policy, the threat that women may be treated as little more than "reproductive vessels," and a host of other issues. Members of that committee discovered that they held widely disparate views on the meaning and scope of "patient autonomy."

What did the committeehs agreement about competent adults signify? Many considerations could have lead individual committee members to support the competent adulths refusal of blood: a commitment to autonomy as a vital moral principle; a religiously based belief in the sacredness and inviolability of the embodies individual; a conviction that forced bodily intrusions by the state would create grave political consequences; or respect for a legal tradition that attaches great importance to religious liberty.

Each of these reasons supports a policy of respecting competent, adult Witnesses' decisions to refuse blood. For this category of persons, the several reasons are mutually supportive--but not identical. With a slight change in circumstances--say that the competent adult were twenty-eight weeks pregnant--they could as easily take us down divergent paths.

It would be a terrible mistake--a pleasant delusion--to think that, because we can agree on some particular policy issue, we also agree on the precise moral justification for the policy. Stephen Toulmin, describing his experience with the National Commission, observed that as long as the Commissioners stuck to cases, moving from the simpler to the more difficult, they could usually agree. Even when they disagreed, they agreed on the substance of their disagreement. But when they tried to say what principles they were employing, shared language and intelligibility vanished. Toulmin writes: "They could agree; they could agree what they were agreeing about; but, apparently, they could not agree why they agreed about it." [2] Scratch a moral consensus and you may find a chaos of principles.

The National Commission's experience leads me to suspect that ethics committees will have difficulty creating many policies. The exceptions to that generalization will be on matters where there is already a strong consensus, or where a case-centered method can lead to agreement. Policies aimed at respecting the wishes of competent adult patients who refuse treatment may be the easy ones because they reflect a consensus about paradigmatic cases, and because they do not force individuals to confront their differing interpretations of moral principles, or their differing principles.

As we confront hard-case hypotheticals, however, we maximize the likelihood of uncovering areas of moral disagreement.

When committees engage in individual case review, the situation is different. The experience of many suggests that "ethics" per se does not have a primary role in committee discussions of concrete cases. It is commonly said that clarifying the facts and fostering communication comprise upwards of 80 to 90 percent of their work. Is it misleading then to call them "ethics" committees? I think not. But then we must explain how it is that committees incorporate moral considerations into their deliberations.

Ethics committees can and do engage in serious moral deliberation. Should these be seen as "applied moral philosophy" or something more akin to the case reasoning advocated by Jonsen and Toulmin? [3] Applied moral philosophy--deductivism--assumes that the proper way to make moral decisions is to deduce specific judgments from general the oretical principles; conversely, that the way to justify a moral judgment is to subsume it under a general principle or theory. [4] In contrast, a case-centered approach, along the lines of the common law or Halakah, begins with cases that yield unequivocally clear moral judgments, and then proceeds to more problematic ones.

In practice, both approaches, used responsibly, share two characteristics. First, each regards paradigmatic moral judgments--clear instances of right or wrong--as important. Deductivists use such cases to test the plausibility of their theories; case-centered reasoning literally begins with such cases, moving step by step to more difficult ones. Second, when the task is to understand a particular, concrete case, both presume that we must immerse ourselves in its particulars. Otherwise we are likely to miss significant features, and both deductivism and case-centered reasoning will fail to illuminate our moral understanding.

Whether the deductivist, "applied" moral philosophy model, or the case-centered approach, or some amalgam of the two is superior, we cannot now say. It would be intellectually dishonest, though, to pretend that either view of moral decisionmaking is unquestionably valid. Each has its strengths and drawbacks. [5] The ascendancy of the applied philosophy model, and in particular the bioethics triumvirate--autonomy, beneficence, and justice--make it important to remember that there are other honorable means for making moral judgments. Indeed, both deductivism and the case-centered method share complex and unfortunately neglected relationships with our moral traditions.

The most iniquitous fiction that could beset ethics committees would be to pretend that autonomy or some other handy moral principle was a pure deliverance of moral philosophy rather than a shorthand marker for a rich set of complex and even conflicting moral beliefs. Those beliefs--or at least the ones deserving our respect--are hardwon fruits of our individual and collective efforts to make sense out of our moral lives. In part, those efforts are philosophical, whether or not we have formal training in the discipline; but in large measure we must rely on our own, lifelong experience making moral judgments as fairly and consistently as we can. We are not bereft of resources: our various moral traditions, kept alive by our need to navigate the shoals of the moral life, provide a wealth of guidance. Each of us--ethicist or not--to the extent that we are thoughtful and self-critical about our moral judgments and the traditions that guide them, brings valuable experience in practical ethics to the conversations that should take place in ethics committees.

We should not be embarrassed to call upon our moral traditions. Jaroslav Pelikan, eminent scholar of Christian tradition, says it well:

The growth of insight...has not come through progressively sloughing off more and more of tradition, as though insight would be purest and deepest when it has finally freed itself of the dead past. It simply has not worked that way in the history of the tradition, and it does not work that way now. By including the dead in the circle of discourse, we enrich the quality of the conversation.

Ethics committees engaged in conversations about moral problems must draw upon the traditions of moral philosophy and the moral traditions of practical ethics. These traditions are powerful allies in our quest for justice and wisdom.

References

[1] R. Macklin, "The Inner Workings of Ethics Committees: Latest Battle over Jehovah's Witnesses," in this issue.

[2] Stephen Toulmin, "The Tyranny of Principles," Hastings Center Report 11:6 (December 1981), 32-39.

[3] Albert R. Jonsen, "Casuistry and Clinical Ethics," Theoretical Medicine 7 (1986), 65-74.

[4] John D. Arras, "Methodology in Bioethics: Applied Ethics and the New Casuistry." Paper delivered at a conference on Bioethics as an Intellectual Field at the Institute for the Medical Humanities, UTMB, Galveston, Texas, (1986).

[5] Thomas H. Murray, "Medical Ethics, Moral Philosophy, and Moral Tradition," Social Science and Medicine 25:6 (1987), 637-44.

Thomas H. Murray is director of the Center for Biomedical Ethics at Case Western Reserve University in Cleveland.
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Author:Murray, Thomas H.
Publication:The Hastings Center Report
Date:Feb 1, 1988
Words:1535
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