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PubMed1990

A critique of principlism.

The authors use the term "principlism" to refer to the practice of using "principles" to replace both moral theory and particular moral rules and ideals in dealing with the moral problems that arise in medical practice. The authors argue that these "principles" do not function as claimed, and that their use is misleading both practically and theoretically. The "principles" are in fact not guides to action, but rather they are merely names for a collection of sometimes superficially related matters for consideration when dealing with a moral problem. The "principles" lack any systematic relationship to each other, and they often conflict with each other. These conflicts are unresolvable, since there is no unified moral theory from which they are all derived. For comparison the authors sketch the advantages of using a unified moral theory.

Beneficence↗
PubMed1990

Zygotes, souls, substances, and persons.

The thesis that the human zygote is essentially identical with the person into which it can develop is difficult to maintain, because the zygote can become several persons. In addition, the thesis depends upon ambiguities in the notions of human being, human individual, human body, and soul. A human being may be individual in the sense of either a biologically integrated unity or a psychologically integrated unity. A person is a psychologically integrated unity, because it must unify its experiences in morally imputable actions. To say that the zygote is a person requires one to assert that the zygote has the same principle of psychological integration, i.e., a rational soul, as one who can obviously manifest psychological integration. The assertion is incapable of being justified in empirical (e.g., non-religious) terms.

Beginning of Human Life↗
PubMed1991

Getting down to cases: the revival of casuistry in bioethics.

This article examines the emergence of casuistical case analysis as a methodological alternative to more theory-driven approaches in bioethics research and education. Focusing on The Abuse of Casuistry by A. Jonsen and S. Toulmin, the article articulates the most characteristic features of this modern-day casuistry (e.g., the priority allotted to case interpretation and analogical reasoning over abstract theory, the resemblance of casuistry to common law traditions, the 'open texture' of its principles, etc.) and discusses some problems with casuistry as an 'anti-theoretical' method. It is argued that casuistry so defined is 'theory modest' rather than 'theory free' and that ethical theory can still play a significant role in casuistical analysis; that casuistical analyses will encounter conflicting 'deep' interpretations of our social practices and institutions, and are therefore unlikely sources of increased social consensus on controversial bioethical questions; that its conventionalism raises questions about casuistry's ability to criticize norms embedded in the societal consensus; and that casuistry's emphasis upon analogical reasoning may tend to reinforce the individualistic nature of much bioethical writing. It is concluded that, not-withstanding these problems, casuistry represents a promising alternative to the regnant model of 'applied ethics' (i.e., to the ritualistic invocation of the so-called 'principles of bioethics'). The pedagogical implications of casuistry are addressed throughout the paper and include the following recommendations: (1) use real cases, (2) make them long, richly detailed and comprehensive, (3) present complex sequences of cases, (4) stress the problem of 'moral diagnosis', and (5) be ever mindful of the limits of casuistical analysis.

Bioethical Issues↗
PubMed1991

The irreducibly clinical character of bioethics.

Current bioethics scholarship and pedagogy suffers from an insufficient correlation with the realities and variables of clinical medicine, particularly in its dominant paradigm of patient autonomy. Reference to various basic clinical factors will be made here toward proposing certain conceptual, tactical and pedagogical modifications to this paradigm.

Beneficence↗
PubMed1991

Clinical judgment and bioethics: the decision making link.

The literature on bioethics is diverse and confusing in its treatment of appropriate components for decision making. As a result, the literature on teaching bioethics is also confusing, even contradictory, in presenting an 'appropriate' framework within which learners may come to understand the nature and process of bioethics. The article sets out five decision components which are seen as common to all decision making. These components are then shown to have a significant influence both on bioethics decision making and on bioethics teaching. They are also shown to play a role in breaking down the separatism evidenced in contemporary bioethics literature aimed at individual professions.

Beneficence↗
PubMed1991

Integrity and compromise in nursing ethics.

Nurses are often caught in the middle of what appear to be intractable moral conflicts. For such times, the function and limits of moral compromise need to be explored. Compromise is compatible with moral integrity if a number of conditions are met. Among these are the sharing of a moral language, mutual respect on the part of those who differ, acknowledgement of factual and moral complexities, and recognition of limits to compromise. Nurses are in a position uniquely suited to leadership in fostering an environment that makes compromise with integrity possible.

Attitude of Health Personnel↗
PubMed1991

Possibilities of consensus: toward democratic moral discourse.

The concept of consensus is often appealed to in discussions of biomedical ethics and applied ethics, and it plays an important role in many influential ethical theories. Consensus is an especially influential notion among theorists who reject ethical realism and who frame ethics as a practice of discourse rather than a body of objective knowledge. It is also a practically important notion when moral decision making is subject to bureaucratic organization and oversight, as is increasingly becoming the case in medicine. Two models of consensus are examined and criticized: pluralistic consensus and overlapping consensus. As an alternative to these models, the paper argues that consensus refers to the dialogic aspects of a broader normative conception of democratic moral agency. When the preconditions for that dialogic democratic practice are met, consensus has a justificatory role in ethics; when they are not, consensus, as distinct from mere agreement, does not emerge and can have no moral authority.

Bioethical Issues↗
PubMed1991

The theoretical tenability of the doctrine of double effect.

The doctrine of double effect shows that for which the moral agent is responsible, by explicating the relationship between the act directly intended and the consequences of that act. I contend that this doctrine is necessary not only for natural law absolutism, but also for Donagan's Kantianism and for Quinn's revised construal of the doctrine, and even for consequentialism, as bioethical implications of the doctrine make clear. For those who do not accept this necessity, I contend that it is necessary metatheoretically, in order to deal with those moral agents with irreconcilably different notions of the morally good.

Double Effect Principle↗
PubMed1991

Moral absolutism and the double-effect exception: reflections on Joseph Boyle's Who is entitled to double effect?

Joseph Boyle raises important questions about the place of the double-effect exception in absolutist moral theories. His own absolutist theory (held by many, but not all, Catholic moralists), which derives from the principles that fundamental human goods may not be intentionally violated, cannot dispense with such exceptions, although he rightly rejects some widely held views about what they are. By contrast, Kantian absolutist theory, which derives from the principle that lawful freedom must not be violated, has a corollary--that it is a duty, where possible, to coerce those who try to violate lawful freedom--which makes superfluous many of the double-effect exceptions Boyle allows. Other implications of the two theories are contrasted. Inter alia, it is argued that, in Boyle's theory, that a violation of a fundamental human good can be viewed as a cost proportionate to a benefit obtained, cannot yield a double-effect exception to the prohibition of intentionally violating that good, because paying a cost cannot be unintentional.

Bioethical Issues↗
PubMed1991

Reply to Boyle's "Who is entitled to double effect?

I have only minor quibbles with Boyle's presentation of my version of the Doctrine of Double Effect (DDE) (Boyle, 1991). On my view, the extra morally problematic element in cases of direct intention is the subordination of a victim to purposes that he or she either rightfully rejects or (and this is something that I should now wish to add in light of Boyle's criticisms) cannot rightfully accept. In cases of indirect intention the victim is incidentally affected by an agent's strategy, but in cases of direct intention the victim is made part of the strategy. Boyle suggests at one point that this amounts to using the person.... But I do not think the "using" metaphor is always apt in these cases, although it is perhaps helpful in pointing to the objectionable element in direct intention, which in its perfectly general form can be put only more abstractly.... My only other concern with Boyle's exposition of my view involves his use of the expression "intentionally harming"....The discussion there tends to suggest, in contrast to what Boyle has said earlier, that I represent DDE as discriminating between cases of incidental and intentional harming. But this is precisely what I tried to avoid....

Bioethical Issues↗
PubMed1991

Conceptions of morality and the doctrine of double effect.

Whether one should accept a principle like DDE cannot be settled independent of one's more general moral theory. In this, I take it, I agree with Professor Boyle, though I do not think he has shown that DDE has a role only in his particular form of absolutism. Still, since his theory does require DDE, an important question is what the alternatives are--whether we must choose between this absolutism and either utilitarianism or intuitionism. A form of contractualism, the requirements of which derive to a large extent from institutionally or conventionally established rights, is sketched here as an attractive alternative. It does not lead, so far as I can see, to DDE.

Bioethical Issues↗
PubMed1991

Further thoughts on double effect: some preliminary responses.

Since the papers in this issue by Alan Donagan, Don Marquis, William Nelson and Warren Quinn raise complex and challenging questions about almost every aspect of my "Who is Entitled to Double Effect", I cannot, in the present context, provide more than preliminary responses to some of the more important issues they raise in the hope that this might contribute to further clarification of the doctrine of double effect (DDE).

Bioethical Issues↗
PubMed1991

The doctrine of double effect: reflections on theoretical and practical issues.

The Doctrine of Double Effect and the Principle of Do No Harm raise important theoretical and practical issues, some of which are discussed by Boyle, Donagan, and Quinn. I argue that neither principle is correct, and some revisionist, and probably nonabsolutist, analysis of constraints on action and omission is necessary. In making these points, I examine several approaches to deflection of threat cases, discuss an argument for the permissibility of voluntary euthanasia, and present arguments relevant to medical contexts which justify intentionally harming some to aid others, with and without the consent of those harmed.

Bioethical Issues↗
PubMed1992

Moving forward in bioethical theory: theories, cases, and specified principlism.

The field of bioethics has deployed different models of justification for particular moral judgments. The best known models are those of deductivism, casuistry, and principlism (under one, rather limited interpretation). Each of these models, however, has significant difficulties that are explored in this essay. An alternative model, suggested by the work of Henry Richardson, is presented. It is argued that specified principlism is the most promising model of justification in bioethics.

Casuistry↗
PubMed1994

Observations on the epistemological status of bioethics.

Different definitions of bioethics in American and Italian literature are reported. It is argued that they refer to three different conceptions of the epistemological status of bioethics: the first conceives of it as an application of moral principles to biomedical problems, the second as a methodology for the working out of clinical judgement, the third as a broader and interdisciplinary public inquiry. It is suggested that each approach grasps a part of the truth, for each singles out one level of the bioethical work. Bioethics is in fact a complex, three-level form of knowledge. The misunderstanding of this complexity has led to some confusion and to conflicts of attribution among those who are concerned with it.

Beneficence↗