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The limits of moral objectivity.

The Limits of Moral Objectivity

It is commonly agreed that life-sustaining treatment decisions should be oriented by the voice of the patient. But when that voice falls silent and is nowhere recorded, from what direction and source should medical care take its moral bearings? In the years ahead, when the decision of a surrogate for an incompetent patient is challenged, it may increasingly fall to ethics committees to answer this question, the hardest one of all.

Across the country, ethics committees are poised to embark on a search for clear standards of institutional review and assessment of surrogate decisions. Behind the search for standards lies a deeper quest for moral objectivity upon which to ground the surrogate's authority within the framework of a liberal ethic of individual autonomy and self-determination.

I suggest that this quest is philosophically misguided. The attempt to base the legitimacy of surrogate decisionmaking on the objectivity of the surrogate's judgment cannot succeed. It grows out of, but at the same time is precluded by, the philosophical foundations upon which our conventional wisdom in bioethics rests--in particular, by underlying notions of moral pluralism, subjectivism, and skepticism. These notions are characteristics of the liberal roots of our current mainstream bioethic of autonomy.

These are big terms to throw around in a small essay. What I have in mind can be made clear by focusing on three aspects of liberalism that are especially significant. The first is the notion that the good for persons consists in a certain sense of autonomy or freedom: namely, the freedom to define and to pursue one's own good in one's own way, subject to constraints imposed by others' equal freedom to do the same.

The second tenet of liberalism is a corollary of the first: no one should be allowed to impose her sense of the good on anyone else. The state should protect individuals from this kind of imposition, by others and by society at large (or the state itself).

Finally, there is a sense of moral skepticism or, at any rate, moral subjectivism underlying the entire liberal outlook. If there were a universal pattern of life that constituted the good for persons, and if that pattern could be known rationally and objectively, then the moral tilt toward autonomy and neutrality would certainly be less appealing and harder to defend. It is precisely because no one can definitively say which pattern of life constitutes the good that everyone should be free to define and pursue a good subjectively. This will not be the good, but it will at least be their good, and not that of someone else who happens to have more power or more wealth, but not (we assume) greater moral wisdom.

Now these ideas are certainly not the whole of liberalism, but they are characteristically liberal concepts. And they have a particularly compelling resonance in the care of the dying. As a society, we no longer believe that we can define a "good death" for particular individuals. That ultimate determination is up to each one of us, a last meaningful act in a life of making meaning.

When it comes to the moral freedom and authority of competent patients in terminal care situations, unless harm to others is involved, the ethical message of liberal pluralism and subjectivism holds sway. Very often, I suspect, the main function of ethics committees is to give clear voice to this message when it is not being heard, and to defend it when necessary.

When the patient is no longer able to function as a subject defining his or her own good, however, this liberal framework does not provide an ethics committee with a clear mission, and it may arguably saddle the surrogate with an impossible task. As we move from patient decisionmaking to surrogate decisionmaking, pluralism and subjectivism are transformed from liberal ideals into liberal nightmares.

In terms of ethical standards this means that we perform an awkward volta face: from an almost complete lack of moral (or legal) constraint placed on the subjective definition of the good by a competent patient, we turn to very strict constraints on the exercise of a surrogate's subjective judgment. We demand that the surrogate win through to an extraordinary form of objectivity in making a substantive judgment about what course of medical treatment would be in the patient's good or "best interests." Most often the desired conception of objectivity is couched in the notion of rationality or in metaphors about taking on the perspective of the hypothetical "reasonable person."

The liberal motivation for making these moves is clear enough. The great evil to be avoided is the imposition of one person's (the surrogate's) subjective conception of the good on another (the patient). If the surrogate's decision is to have any liberal ligitimacy, then we must be assured that this kind of intersubjective domination is not taking place. But since some decision has to be made by someone in these cases, the liberal concern about domination would seem to force us back to some notion of moral objectivity about the good. And, if an individual surrogate is to decide, then the standards of "reasonable person" and "best interests" would seem to demand that the surrogate completely efface her own subjectivity, bracket her own personal experience and local knowledge, and step outside her own time, place, and skin to adopt the detached perspective that Thomas Nagel has aptly called "the view from nowhere."

Note that this is not objectivity in the sense of knowable moral truth or certainty, for liberalism does not believe that there is such a thing to be had. Instead, the kind of objectivity that many proposed standards for surrogate decisionmaking seem to call for is the end result of a winnowing-out process, a radical imaginative act of self-emptying. This is to be performed within the mind of the deliberating surrogate; and then, one supposes, again in the minds of ethics committee members, guardians ad litem, or judges if they review a surrogate's treatment decision.

We need to ponder, much more deeply than has been done in the literature so far, just how demanding--and perhaps psychologically unobtainable--this legitimation requirement is. In the end we may simply come to recognize that surrogate medical-ethical judgments, like all human judgments, are going to be made with imperfect objectivity by situated persons--somebodies with a view from somewhere.

With this recognition will come, or should come, a new purchase on the problem that surrogate decisionmaking poses for ethics committees. The issue is not whether a surrogate lives up to some regulative standard of selfless reasonableness or objectivity. The issue is whether the surrogate's imposition of a subjective conception of the good constitutes in a given case the kind of domination and depersonalization that should not be allowed.

For this kind of assessment, abstracting away from the concrete situatedness of the surrogate is precisely the opposite of what should be done. The committee needs to encounter the surrogate as a concrete person, not the shadow figure of the hypothetical reasonable person within the surrogate. The problem surrogacy poses for ethics commitees, I believe, is really not a problem of objectivity at all. It's a problem of trust.
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Title Annotation:Ethics Committees
Author:Jennings, Bruce
Publication:The Hastings Center Report
Date:Jan 1, 1989
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