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Theory in Biomedical Ethics THEORY IN BIOMEDICAL ETHICS: THE COMPATIBILITY of PRINCIPLISM and CARE ETHICS by LARISSA L. McWHINNEY B.A., The University of Toronto, 1993 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES Department of Philosophy We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA August 1995 0 Larissa L. McWhinney, 1995 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department The University of British Columbia Vancouver, Canada DE-6 (2/88) 11 ABSTRACT The subject of this thesis is the relationship between "principlism," a dominant trend in the theory of biomedical ethics, and a recently articulated alternative account of ethics known as "care ethics." I will argue that, rather than being competing or mutually exclusive approaches to moral theory, these two perspectives are compatible and that their partnership is mutually beneficial. I will situate my arguments within the larger philosophical debate between theorists and anti-theorists. I will contend that principlism has evolved to a position more closely allied with anti-theory than with theory. Due to the fact that care ethics has been nurtured by anti-theoretical roots, principlism's current philosophical orientation predicts the compatibility of the two perspectives in biomedical ethics. By clarifying terminology and providing reasons for promoting care ethics, I will elucidate some of the causes for the assumption that care ethics and principlism are unsuited to each other. By demonstrating how care ethics can inform the principles of principlism without offending their structure, I will indicate how the two approaches to biomedical ethics are actually well matched. To further dispel scepticism, I will address the criticism that care ethics does not display the necessary methodological requirements for moral theory. I will contend not only that care ethics can meet the standards for a legitimate philosophical school of thought and that it does not fall into the disarray of situationalism, but also that the methodological characteristics it possesses should be adopted by conventional moral theory. Using these strategies, I intend to argue that the contributions from care ethics to biomedical ethics are abundant, and that the partnership between principlism and care ethics is not only possible but that it should be encouraged and promoted. Ill TABLE OF CONTENTS ABSTRACT ii TABLE OF CONTENTS iii ACKNOWLEDGEMENTS y INTRODUCTION 1 CHAPTER I: Modern History and Theoretical Evolution of Biomedical Ethics Introduction 9 The Renaissance of Biomedical Ethics 11 A Shift in Theoretical Perspective: Beneficence to Autonomy 13 The Urgency of Justice 14 The Emergence of Principles of Biomedical Ethics 16 An Alternative Historical Account 17 Conclusion 24 CHAPTER II: The Principles of Biomedical Ethics and the Grand-Theorists Introduction 26 The Basic Principles 26 Challenging Principlism: The Proponents of Grand-Theory 31 Conclusion 38 CHAPTER III: Anti-Theory and Beauchamp and Childress' Principlism Introduction 40 A European Deontological Criticism of the Principles of Biomedical Ethics 41 A Buddhist Critique of the Principles of Biomedical Ethics 49 Phenomenology and Biomedical Ethics 53 Virtue Theory and Biomedical Ethics 55 Conclusion 58 iv CHAPTER IV: The Evolution of Care Ethics Introduction 60 The Kohlberg/Gilligan Disparity 61 Care Ethics and Nursing: Professionalism Vs. Philosophy 64 The Evolution of the Term "Care" as an Ethic Vs. as a Feeling 66 Conclusion 72 CHAPTER V: Care Ethics and Principlism: Constitutive of Derivative Introduction 74 Care Ethics and Principlism 74 Care and Autonomy 75 Care and Beneficence 80 Conclusion 88 CHAPTER VI: Care in Personal Vs. Impersonal Relationships: Professional Ethics Introduction 90 Care in Private Vs. Public Morality 91 Care and Health Care Professionals 98 Conclusion 104 CHAPTER VII: Care Ethics Vs. Justice, Universalism and Equality Introduction 106 Care Ethics and Contextual Analysis 107 The Primacy of Care or Universalism 113 Conclusion 118 CONCLUSION 120 BIBLIOGRAPHY 123 V ACKNOWLEDGEMENTS This thesis is imbued with the good will and care of many individuals who contributed simultaneously to its completion and to the well-being of its author. Most meritorious of praise and gratitude is my friend Francis Dupuis-Deri, whose quick mind kept me intellectually merry and whose supportive kindness kept me psychically healthy. I am very indebted to the philosopher-fireman, Ward Whitehead, whose meticulous editing and perceptive questioning kept my thoughts nimble and quick. My mother, Jane McWhinney, deserves my appreciation for her general support, for her occasional worries and for the benefits bestowed on me by her keen intellect. To my supervisor, Dr. Michael McDonald, I extend my thanks for his time, for his valuable comments and suggestions, and for his course on Biomedical Ethics in which I was initially exposed indirectly to the subject of care ethics. Paddy Rodney and Rosalie Starzomsky must be acknowledged for introducing me to care ethics and are to be held responsible for the romance I have had with it for the past two years. I am obliged to my friend Andrew Hare, the quintessential Green College scholar, whose art of conversation often coaxed my thoughts out of hiding and rendered this thesis more eloquent. I offer my gratitude to my boyfriend, Olivier Tardif, who endured a woman on Pre Thesis-Completion Syndrome for a year, and who nurtured me through Two- Broken Arm Illness for a summer. Appearing like guardian angels in times of need, kindred spirits Karen Murray, Peter Gainsford and Geoff Moran made my life joyful and fun in times of hardship and blues. My heartfelt gratitude and thanks to you all. I INTRODUCTION In the past two decades, the subject of biomedical ethics has enjoyed considerable attention from academics, professionals and lay people. Initially, the emergence of this field was accompanied by innovative theorizing; however, more recently, conventional methods of analyzing and discussing the ethical issues which arise in the arena of health care have become accepted as the status quo. Almost invariably, these methods employ four common reference points, composed of the principles of 1) autonomy, 2) beneficence, 3) non-maleficence and 4) justice. As K. Danner Clouser and Bernard Gert explain, these principles have become the "mantra of biomedical ethics" (Clouser & Gert, 1990:219). Many of the general textbooks, as well as the academic work (Gillon, 1994; Baylis, Downie, Freedman, Hoffmaster & Sherwin, 1995) which is currently being done in this area, tend to take these principles for granted (Hoffmaster, 1992). Books on biomedical ethics are often issue-oriented (Mappes & Zembaty, 1991; Pence, 1995), as opposed to being focused on the fundamental tenets which underlie the ethical perspectives which they adopt. The editors of such texts usually identify a number of crisis topics such as abortion, euthanasia, the distribution of health care dollars in times of scarcity, etc. These areas are then dealt with using the familiar principles enumerated above. For instance, abortion is repeatedly addressed, either defended by the principle of a pregnant woman's autonomy (Warren, 1984), or refuted by the principle of beneficence - or at least non-maleficence - towards the fetus (Noonan, 1970). In recent years, there has been a resurgence of interest in the fundamental characteristics of the generic optic which is employed to find solutions to ethical dilemmas. Some authors suggest that this perspective is myopic, or astigmatic. What is needed is a corrective lens which can help us more clearly address the issues which arise in biomedical ethics. New optics in the literature of ethics in general, and of health care ethics in particular, attempt to both diagnose and find the right prescription for the current state of biomedical ethics. Among these new approaches is a perspective known as "care ethics."1 1 In order to contrast the tenets of care ethics with those of conventional philosophies, I will refer to the latter as "justice ethics," using the terminology which Carol Gilligan coined when she originally observed the distinctive characteristics of care ethics (Gilligan, 1982). 2 Laura Purdy corroborates this account in her explanation that [i]n the last few years, we have been venturing into more theoretical territory, and there has been an extraordinary explosion of imaginative new ideas. Among them are persuasive criticisms of widely accepted assumptions and new models of human interaction (Purdy, 1994:9). One of the "widely accepted assumptions" to which Purdy refers, and which I assess in light of the premises of care ethics, is the belief that ethical discussion in the field of medicine can be adequately encompassed by the quartet of principles which constitute the "mantra" of biomedical ethics. According to my analysis of the care ethics literature, proponents of care ethics also challenge assumptions in the following areas: 1) epistemological
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