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Theory and Practice in Medical Ethics.

Theory and Practice in Medical Ethics. By Glenn C. Graber and David C. Thomasma (New York: Continuum Press, 1989), 229 pp. $24.95 cloth.

The reappearance of the first of these books and the appearance of the second and third provides an occasion to comment on a currently vexed issue in bioethics, namely, the relationship between theory and practice. This review will notice the books briefly and discuss the issue more at length. This reviewer's reaction to the three books can be summarily stated: the first volume is welcome, the second is disappointing, and the third is confusing.

Principles of Biomedical Ethics is a young classic. When it first appeared in 1979 the literature of bioethics was made up largely of essays and articles and the anthologies that collected and commented on them. These essays usually discussed the current perplexing cases and issues (in those days usually called "paradoxes" or "dilemmas"), but only rarely offered much in the way of methodology. The first decade of bioethics was dominated by one book-length treatment, Paul Ramsey's Patient as Person, but its methodology was idiosyncratic and arcane: many readers could quote Ramsey's conclusions without understanding his arguments. It was time for a book that would link the currently interesting ethical questions of biomedicine to the currently accepted approaches of moral philosophy. Principles of Biomedical Ethics did this and so provided the emerging field of bioethics with a methodology that could be readily taught and employed by practitioners, both of clinical medicine and of what was coming to be known as "clinical ethics."

That method consisted of an exposition of the two major "ethical theories," deontology and teleology, and a treatment of four principles, autonomy, nonmaleficence, beneficence, and justice, in the light of those theories. The four principles have become the mantra of bioethics, invoked constantly in discussions of cases and analyses of issues. The third edition of Principles retains this method. The authors, however, have expanded almost every important discussion of theory and principle, and in so doing, have brought much greater clarity and precision to their text. They add new material, reflecting the new problems that medicine and health care face in the 1980s (AIDS is a prominent example). This third edition is essentially a new book, far better in style and content than its already satisfactory predecessors. It is, then, welcome.

At the same time, its appearance stimulates a question: Is the relationship between ethical theory and moral distinctions as clear as Beauchamp and Childress seem to suggest? Although they maintain the original approach, namely, that "particular judgments are justified by moral rules, which in turn are justified by principles, which are defended by an ethical theory" (p. 7), some inklings of doubt about the adequacy of this approach appear. One slight change of phraseology suggests this doubt. In the first edition, the authors, before setting out the tests for the adequacy of an ethical theory, write, "Although it is possible that no ethical theory will satisfactorily meet all these tests..." (12) The second edition modifies this to "It is possible that no ethical theory..." (12), and the third edition leaps to "Even if no ethical theory satisfied all of these tests-and we think no currently available theory does-we can legitimately appeal to them... " (14). This is a bold admission for two authors who are committed to theory, and who in fact do not let their doubt much affect their actual discussion of the principles and cases in the rest of the text.

It can be asked whether doubt about the adequacy of theory arises because the authors have been reflecting on the philosophical literature of the last few years in which critics such as Rorty, MacIntyre, and Williams have challenged the place of theory in ethics or because, being in touch with the activities of clinical ethics, they have seen theory so little used and so unprofitable in practice. Doubtless, both have influenced Beauchamp and Childress, and both are having an effect on the way in which the methodology of the field of bioethics is conceived. The second and third books noticed in this review bear witness to this effect.

Moral Theory and Moral Judgments in Medical Ethics collects the contributions to another of the Engelhardt and Spicker Conferences in Philosophy and Medicine. Like most of these collections, the essays are of variable quality, but I found this volume as a whole quite disappointing, Editor Baruch Brody opens with a critique of the mantra of bioethics. The principles of autonomy, nonmaleficence, beneficence, and justice are often in conflict in particular cases. He then states, "Which is the best solution to this problem of conflicting principles of bioethics? We need a moral theory to answer that question ... how can we appeal to moral theory to help deal with that problem?" (3) The contributors then suggest answers from several traditions: utilitarianism, natural rights, marxism, and Christian ethics. Ironically, the overall impression from these contributions is that the theoretical doctrine under discussion will not do much to answer Brody's question. While ironic, this is not surprising, since within each of these traditions there are rending debates about the internal consistency and applicability of theory. Most honest adherents to one or another of the major traditions are bound to admit this when asked "Can your tradition offer a theory that can reconcile conflicting principles?"

Only one contribution directly challenges Brody's question itself. Carson Strong (almost the only contributor to this conference who is deeply engaged in clinical ethics) comments, after criticizing each of the major theories,

It remains an open question as to whether a defensible higher-order theory can be found from which the middle-level principles can be derived. However, one need not answer this question about ultimate foundations in order to arrive at justifiable conclusions about what ought to be done in specific cases (208).

Strong describes an approach to clinical problems that he calls the case comparison method and which is a version of the casuistic method described by Stephen Toulmin and myself in The Abuse of Casuistry. (Although several of the essays in Brody's volume have "casuistry" in the title, none except Strong's sets out the method of practical ethics that the term "casuistry" designates.) Thus, in my opinion, the promise of this book is not realized: it does not get much further than demonstrating that the classical theories do not seem to provide what the editor asks of them, namely, a grounding for the judgments and principles of bioethics. In the long run, the editor acknowledges this: "Until these internal problems (of specification and of theory to concrete judgment) are resolved ... we will not have to worry about which of the theories to employ" (9). What, then, is the use of theory?

The third book, Theory and Practice in Medical Ethics, does little to clarify this question. Written by two persons adept at clinical ethics, Glenn Graber and David Thomasma, the book reflects a sensitivity to the concrete and complex features of clinical situations. It insists that "the clinical focus of medical ethics requires greater stress on the context than the more general theories provide" (174). Yet it goes about this shifting of stress in a cumbersome manner. Six chapters delineate six models of the relationship between ethical theory and practice and a final chapter outlines the authors' own "unitary theory of clinical ethics." The models are descriptions of the various moves that various ethicists make as they go about analyzing various problems. Some of these are predominately deductive, others are inductive. The authors critique each model and construct their own "unitary theory" out of what they consider the better features of each, counting better" those that seem to "fit" the nature of the clinical encounter and the practical situation.

I am deeply sympathetic to this position, but I found the authors' approach cumbersome and confusing. It is never entirely clear what the "models" are supposed to represent; each is constructed out of bits and pieces of the reasoning of a variety of authors. Whether each amounts to a schematic for practical reasoning that any one of the quoted authors would recognize as "their" approach is unclear. If individuals would not acknowledge their approach in these models, what do they stand for? But more problematic is the vagueness that suffuses the notion of theory. Defined in the opening pages as "the embodiment of general and abstract ethical thinking," the idea of theory never gets much clearer. When the authors finally propose a "unitary theory' (which they compare to the Unified Field Theory of physics!), they dignify with the title theory what seemed to me little more than a collection of reflections about practical reasoning.

These three recent contributions to the literature of bioethics reflect a widespread concern in moral philosophy and in bioethics about practical reasoning. In each of them, one finds the presumption that in some sense practical reasoning "hangs together" loosely or tightly with theoretical reasoning. Since the history of philosophy reveals this presumption from the Platonic dialogues up to today, we should not be surprised. However, the association between practical and theoretical has not had a consistent form during that long history and in its more recent formulation, say since the late nineteenth century, it deserves particular scrutiny. I doubt that it can be affirmed that the term "theory," as used in moral philosophy, has anything like a univocal meaning. Thus, when contemporary authors employ it, either to embrace or to reject theory, it is often quite unclear what they refer to.

The term "ethical theory" became a familiar phrase in moral philosophy only after C.D. Broad's Five Types of Ethical Theory (1929), who used it much as Sidgwick had used the term "methods," namely, "any type of general theory which claims to unify our various ethical judgments into a coherent system on some principle which is claimed to be self-evident." (Broad, 148). Any such theory, Broad believed, must address certain "main problems," namely, the nature of ethical characteristics, such as "good," "wrong," "duty," epistemological questions about the relative roles of reason and emotion in ethical judgment, questions about volition and motive, including the question of free choice, questions about the role of sentiment and finally, the question about whether and to what extent ethics can be reduced to a system. He simplifies this final question into the problem of the relation between two prominent ethical characteristics, obligation and value, and, in the context of this discussion, suggests that those doctrines that see obligation as fundamental be called "deontological" and that those that place value as fundamental be called "teleological." This terminology, broached in the last few pages of Broad's book, has become canonical in undergraduate courses and textbooks. Frankena's popular text Ethics (1963) promoted its canonization.

Despite the canonical standing of this distinction, and the widespread presumption that theory is an inseparable companion to practice, the role, function, and meaning of ethical theory remains rather fuzzy. The distinction between metaethical theory and normative theory, popular a decade ago, has become unfashionable, possibly because its users began to recognize that commitments in metaethical theory had little or no effect on normative theory. Contemporary authors appear to use the concept of normative theory itself in quite different ways; some, such as Brandt, to refer to tightly unified deductive systems, others, such as Rawls, as general "guiding frameworks" within which one can identify and test particular moral judgments. Sometimes theory is justificatory; sometimes explanatory. Some theory is heavily epistemological; other theory attempts to lay metaphysical foundations. And, as most authors admit (but rarely explain) "ethical theory" is a quite different creature than scientific theory.

In light of the diversity of views about the meaning and role of ethical theory in moral philosophy, we need not be surprised at the confusion in that branch of moral philosophy called "Practical" or (with a bias toward one view of theory) "applied ethics." We might be surprised, however, if it were suggested that theory is not at all necessary or useful in practical ethics. Yet the surprise at such an audacious statement might be mitigated by a look at the resolution of cases in those authors who do espouse a place for theory. It has been noted more than once that case resolutions seem to have a life of their own, apart from theoretical considerations. Authors who begin their works with erudite expositions of teleology and deontology hardly mention them again when they plunge into a case. Indeed, Beauchamp, who espouses rule utilitarianism, and Childress, who favors deontological theory, admit that "for both of us the most satisfactory theory is only slightly preferable" and that the distinction between the theories "can be and has been overestimated." They are almost always in agreement about the resolution of cases.

It is this that the clinical ethicists notice and that leads some of them to answer the theory-practice question by wondering whether it is the right question and whether the connection between these classic antonyms is not just loose or tight, but even possible or relevant. Strong does this in the Brody book; Graber and Thomasma teeter on the brink of it in their book. Beauchamp and Childress discreetly skirt it but hint, in uncautious moments, at their discomfort.

It is impossible in this short review to expand on this matter. Stephen Toulmin and I have done so at length in our Abuse of Casuistry and much more commentary on the question of theory and practice can be expected in the next few years. A debate is in the offing, similar to the deconstructionist debate in literary studies and to the critical legal studies argument in jurisprudence, between the "philosophers" and the "casuists." The former look upon ethics as an intellectual problem of consistency and coherence and seek to formulate theory that might be applied systematically to practice. The latter wrestle with cases of conscience and find theory a clumsy and rather otiose obstacle in the way of the prudential resolution of cases. The prototype of this debate was between Socrates (or his ghost-writer, Plato) and the sophists (the intellectual ancestors of the casuists). Despite his fame and their disrepute, it is still not clear that Socrates won that debate or that the sophists were entirely wrong.
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Author:Jonsen, Albert R.
Publication:The Hastings Center Report
Article Type:Book Review
Date:Jul 1, 1990
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