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2016 Principlism and Casuistry: Different Names for the Same Thing? Sara Kolmes
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COLLEGE OF ARTS AND SCIENCES
PRINCIPLISM AND CASUISTRY: DIFFERENT NAMES FOR THE SAME THING?
By
SARA KOLMES
A Thesis submitted to the Department of Philosophy in partial fulfillment of the requirements for the degree of Master of Arts
2016
Sara Kolmes defended this thesis on April 15, 2016. The members of the supervisory committee were:
David McNaughton Professor Directing Thesis
Piers Rawling Committee Member
Aline Kalbian Committee Member
The Graduate School has verified and approved the above-named committee members, and certifies that the thesis has been approved in accordance with university requirements.
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ACKNOWLEDGMENTS Thank you to my thesis committee for all of their suggestions, patience, and support. I'd like especially to thank my thesis director, David McNaughton, for his invaluable advice and assistance.
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TABLE OF CONTENTS
Abstract ...... v
RIVAL ACCOUNTS ...... 1
META-ETHICAL QUESTIONS...... 5
THE CASE OF ANENCEPHALIC INFANTS ...... 8
CASUIST METHODS...... 15
PRINCIPLIST METHODS ...... 18
JUSTIFICATIONS FOR CASUISTRY ...... 21
JUSTIFICATIONS FOR PRINCIPLISM...... 24
COMPARITIVE LOGIC OF JUSTIFICATION ...... 27
PRINCIPLIST CRITICISMS OF CASUISTRY ...... 31
CASUIST CRITICISMS OF PRINCIPLISM ...... 37
A "DEADLOCK" OF PRINCIPLES ...... 40
References ...... 42
Biographical Sketch ...... 44 iv
ABSTRACT
Tom Beauchamp and James Childress describe a method for analyzing ethically troubling medical situations in their standard work Principles of Biomedical Ethics. Beauchamp and Childress's method is intended to allow those who are not professional philosophers, or who do not share allegiance to the same ethical systems, to have productive debates about what should be done in any specific medical case. "Principlism", as this method is called, is perhaps the most well known method of bioethical case analysis. Shortly after principlism emerged, Albert Jonsen and Stephen Toulmin argued in their book The Abuse of Casuistry that reviving the casuist method of analyzing cases would serve the purposes of bioethical analysis better than principlism. Jonsen and Toulmin argue this is due to casuistry’s superior ability to avoid coming to a “deadlock” of principles, its ability to deal better with concrete cases, and its ability to represent the context of cases more accurately. Jonsen and Toulmin worry that discussions of ethics which are not rooted in cases will not give specific enough advice, may give impractical advice that is obviously unhelpful in the context of real cases, and most importantly may become so caught up with things like exact definitions of terms or principles that they will never be able to give ethical guidance at all. Since then, casuistry and principlism have been characterized as rival accounts of how to conceptualize bioethical debates in the most productive way. In order to clarify what is at stake in selecting one of these two methods to analyze bioethical cases, I will try to pinpoint exactly where the practical differences between the two theories lie. An ideal method for analyzing specific issues that arise in medical contexts would be both theoretically sound (insofar as it succeeds in meeting the theoretical requirements it is inspired by, generally to treat like cases equally) and practical (in order to ensure that it is useable by the medical professionals who will be confronted with these situations and that it can reliably result in consensus solutions). This means that analyzing the theories and practical applications of principlism and casuistry is necessary for comparing the two. The practicality of the two methods of analyzing bioethical cases can be compared by comparing the actual way each method treats moral problems. This can be done both by comparing the actual explicit instructions that principlists and casuists give to those examining medical situations, and by running a model case through each method.
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In order to evaluate methods of bioethical analysis, it is necessary to clarify the theoretical justification for the specific methods suggested. Standardizing the justifications for the two theories will help compare them, as they make use of different intellectual canons and so use terms in ways which are not compatible. The substantive differences between the justifications for the two theories can be made explicit in this way. The final aspect of analyzing the two theories is to look at what proponents of the theories claim are the differences between the methods. This should also include analysis of arguments as to why rival theories are inferior for leaving things out or including unnecessary requirements. This will mainly consist of looking at criticisms of principlism by casuists and vice versa, and determining if the criticisms are apt. If the criticisms are apt, then this will highlight differences between the ways in which principlists and casuists approach cases. If there is no difference between principlism and casuistry on any of these analyses, one of two things is true. Either there is no difference between principlism and casuistry, or the difference between principlism and casuistry is not captured by a practical analysis. The latter suggests that principlist and casuist rejections of meta-ethical or metaphysical concerns is disingenuous if principlists and casuists maintain there is a difference between the two theories. In either case, a shift in debate strategies is necessary. Either principlists and casuists must engage in debate regarding issues beyond practical interpretation of cases, or they must abandon the rhetoric of difference between them.
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RIVAL ACCOUNTS
Tom Beauchamp and James Childress describe a method for facilitating debate about what to do in response to ethically troubling medical situations in their standard work Principles of Biomedical Ethics. This method has been widely referred to as principlism, although Beauchamp and Childress' use of the word "principle" is not related to the meta-ethical position of the same name or the claims that several theory-driven philosophical approaches to ethics make to be based on ethical principles. They developed this method because they believe that the traditional philosophical method for analyzing ethical dilemmas is not helpful for resolving specific cases in medical ethics. They fear that philosophical ethics is focused solely on abstract issues like terminological distinctions, meta-ethical questions, and developing algorithmic ethical analysis methods, and so is not helpful for practical cases even if a perfect philosophical method of ethics were to be constructed.1 They also express concern that this perfect philosophical method of ethics could ever be found, given the entrenched status of seemingly irresolvable disagreements between ethical theories.2 Bioethical cases must often be solved quickly and must always be solved decisively, and Beauchamp and Childress argue that traditional philosophical ethical methods aren't suitable for achieving these goals. Albert Jonsen and Stephen Toulmin explain that their revival of casuistry was motivated by their experiences on the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research in 1974, which led them to have similar concerns about the ability of abstract debate to provide practical solutions to problems. Jonsen and Toulmin point out that the methods with which they were able to reach a consensus seemed to be much closer to traditional case-based ethical methods than those which center on principles. It seemed to them that intractable disagreements arose between members of the commission about abstract principles, but that members of the commission were able to easily come to agreement about what should happen in specific cases. The authors argue that because of this, case based ethics is uniquely suited to reaching a consensus in biomedical ethics in a way that improves on using the
1 Beauchamp, Tom L. , and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York: Oxford University Press, 2009. Print. 2 2 Ibid, 351 1 then-dominant principlism,3 which deals with some abstract principles.4 Jonsen and Toulmin argue this is due to casuistry's superior ability to avoid coming to a “deadlock” of bedrock assumptions, its ability to deal better with concrete cases,5 and its ability to represent the context of cases more accurately.6 Casuistry, originally practiced by Catholic scholars, initially involved balancing the many moral rules set by the Roman Catholic Church with practical concerns in relation to specific moral hard cases. While casuists accepted the necessity for religious moral rules, they also specialized in suggesting practical solutions for parishioners caught between following several mutually exclusive moral dictates in a specific situation or between breaking a supposed rule and causing easily predictable harm. Casuistry was originally developed by focusing on specific situations with a set of stringent moral rules in the background. Jonsen and Toulmin worry that discussions of ethics which are not rooted in cases will not give specific enough advice, may give impractical advice that is unhelpful in the context of real cases, and may become so caught up with things like exact definitions of terms or principles that they will never be able to give ethical guidance at all. Jonsen and Toulmin's resurrection of casuistry replaces a background of fixed religious rules with what they see as equally omnipresent shared moral standards, but still purports to give only advice regarding specific cases rather than generalizing about what should be done in all cases of some specific type. It seems then that the development of principlism and the resurrection of casuistry were motivated by similar concerns: that some methods of ethics may get caught up in debating abstracta and fail to get to the point of providing advice helpful to specific cases. These concerns amounted to pragmatic concerns about what methods would work in the pluralistic context of bioethics, in which the foundational ethical beliefs of interlocutors would not always be the same. The introduction of casuistry prompted a flurry of debate about the relative use of the two methods in actual cases. Since then, casuistry and principlism have been characterized as rival
3 The advocates of a principles-based approach to bioethics do not refer to themselves as principlists with the regularity that their detractors do, but I will use the name because it is a much easier shorthand for the view than the more complex (and probably more accurate) names that philosophers like Beauchamp and Childress use to refer to their ideas. 4 Jonsen, Albert R. "Casuistry: An Alternative or Complement to Principles?“ Kennedy Institute of Ethics Journal 5.3 (1995) : 237-51. Web, 247 5 Strong, Carson. "Specified Principlism: What Is It, and Does It Really Resolve Cases Better than Casuistry?" The Journal of Medicine and Philosophy 25.3 (2000): 323-41. Web, 339 6 Jonsen, Albert R. "Casuistry: An Alternative or Complement to Principles?“ Kennedy Institute of Ethics Journal 5.3 (1995) : 237-51. Web, 248 2 accounts of how to do bioethics, in both the most recent versions of Principles of Biomedical Ethics7 and in most major bioethics textbooks and anthologies.8 The actual performance of the two methods of analyzing bioethical cases can be compared by comparing the way each method deals with hard cases. In order to determine which method better serves bioethicists in providing a system which facilitates pluralistic debate regarding cases, I will first run a model case through each method, and then compare the explicit instructions that principlists and casuists give to those examining medical situations generally. The specific questions asked by principlists and casuists about the same case and the balance of concerns that appears as a result of using each method will be the final piece of evidence regarding what is at stake between principlism and casuistry. Of interest is whether principlist and casuist analyses come to the same conclusion in the same case, but also whether similar concerns are raised by both methods. With the requirements that Beauchamp and Childress and Jonsen and Toulmin each have for the successful examination of bioethical cases, principlism and casuistry can be evaluated on the yardsticks they each advocate. I will then attempt to outlinine exactly what Jonsen and Toulmin mean by casuistry and how they justify it. I will then examine what principlist methods entail and how they are justified by advocates. Standardizing the justifications for the use of two systems of analysis will help compare them, as they make use of different intellectual canons and so use terms in ways which are incompatible. Principlists and casuists both provide a list of requirements for what a bioethical theory must be able to accomplish. The substantive differences between the justifications for how the two theories improve on philosophical ethics will highlight differences in what kind of analyses Beauchamp and Childress and Jonsen and Toulmin were trying to facilitate. By comparing these requirements it can be determined whether the systems of analysis were developed to solve the same problem or whether the justifications of the two merely sound alike. Differences in the characterization of the shortcomings of traditional philosophical ethics
7 Beauchamp, Tom L. , and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York: Oxford University Press, 2009. Print., 400 8 Including Steinbock, Bonnie, Alex John London, and John D. Arras, eds.Ethical Issues in Modern Medicine: Contemporary Readings in Bioethics. 8th ed. Boston: McGraw-Hill, 2012. Print. 39, Fox, Rene, and Judith P. Swazey. Observing Bioethics. Oxford: Oxford UP, 2008. Print., 170, Kuhse, Helga, and Peter Singer, eds. A Companion to Bioethics. 2nd ed. Boston: Wiley- Blackwell, 2009. Print., 117, and Tomlinson, Thomas. Methods in Medical Ethics: Critical Perspectives. Oxford: Oxford UP, 2012. Print.85 3
(which they both dismiss) or in suggestions for how to solve these will help highlight the differences between casuistry and principlism. Significant differences between principlism and casuistry which do not stem from the format of the analyses advocated or the justifications for the analyses may still exist. In order to determine if differences exist between principlism and casuistry which are practical enough to be of concern to bioethicists, I will finally turn to the commentary of the advocates of principlism and casuistry themselves. It is clear that the final way to evaluate the differences between principlism and casuistry is to analyze the ways in which advocates of each claim the other is flawed. These include the principlist claim that principlism in its newest and most careful incarnation involves casuist thinking but does desirable things9 that casuistry cannot, and casuist criticisms that principlism does not successfully avoid intractable and unhelpful debates about abstract principles. I will argue that according to these metrics there is no significant difference between the two ways of doing ethics, only what is emphasized when they are described by their detractors. If this is the case, then those involved in debating which method is superior are not focusing on aspects of the actual process of debating bioethical cases. There are two reasons that this may be taking place. Either casuists and principlists are mistakenly convinced that there are differences in the structure of the debates which will be guided by principlism and casuistry, or principlist and casuists are involved in exactly what the two are intended to avoid: allowing debate to hinge on issues that have no clear implication for the way that bioethical debate unfolds. If it is the first, it is not a good use of time for adherents of either method to criticize each other's analyses of cases for the type of method used alone, because since the differences are simply in emphasis and terminology, nothing practical is at stake. Instead, debates should center on what to do in actual cases. However, if acceptance of principlism or casuistry implicitly hinges on something other than the way that bioethical debate guided by each method plays out, then these issues should be brought to the forefront of the debate so that the difference between the two theories is clear.
9 Various claims about what these are have been made, and I will address them each individually. 4
META-ETHICAL QUESTIONS
An analysis of the worth of principlism and casuistry through the lens of analytic philosophy rather than in terms of their relationships to actual cases would provide answers to a set of very different questions. One large category of these questions, which I will not address in this paper, would touch on meta-ethical issues rather than practical ones. Beauchamp and Childress do not explicitly endorse any meta-ethical positions at all. The project of Principles of Biomedical Ethics is limited to developing a framework for facilitating discussion of bioethical dilemmas which will bypass intractable philosophical debates. Beauchamp and Childress describe meta-ethics as a "non-normative"10 endeavor, because it does not result in specific ethical directives or directly relate to practical questions. Because of this, Beauchamp and Childress explain that they do not want to engage with meta-ethics at all. Jonsen and Toulmin follow this line, arguing that the rise of meta-ethical analysis was motivated by a desire to only deal with rules which can be applied algorithmically to all ethical cases,11 but that rules which provide solutions to ethical problems cannot fulfill this role.12 They reject the goal they see meta- ethicists as pursuing, and so also refuse to engage in meta-ethical debate. While Beauchamp and Childress and Jonsen and Toulmin claim to be doing something fundamentally different from most academic philosophers, this does not necessarily mean that they have divested themselves of the requirement to answer ethical and meta-ethical questions that such philosophers might have. These questions might include investigations into what exactly a principle is, if the differences in terminology between the two theories represent the differences between particularist and principlist ethical philosophies (a debate which both bioethical principlists and casuists would say is not helpful for solving bioethical cases), and what kind of moral theories underpin the two methods of case analysis. Beauchamp and Childress make use of concepts proposed by traditional philosophers such as moral virtue,13 John
10 Beauchamp, Tom L. , and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York: Oxford University Press, 2009. Print.2 11 Jonsen, Albert R. , and Stephen Toulmin. The Abuse of Casuistry: A History of Moral Reasoning. Berkeley: University of California Press, 1988. Print.12 12 Ibid, 297 13 Beauchamp, Tom L. , and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York: Oxford University Press, 2009. Print. 31 5
Rawls' reflective equilibrium,14Kantianism, utilitarianism15 and feminist theory.16 However, while their work is informed by the aspects of these theories that are useable, they maintain that it is better "to trust norms in the common morality more than norms found in general [philosophical] theories",17 using analyses of philosophical theories of morality only as "ways to discover and explicate the common morality".18 Jonsen and Toulmin similarly agree that philosophical theories of morality "give us part of the larger picture we require",19 but they are also only interested in the ways in which philosophy can point out deficiencies in a casuist theory. Arguing that principlism and casuistry cannot be separated from philosophical ethics in the way that principlists and casuists seek would require a different kind of critique of the systems of analysis than I propose. Differences between the ways that the two accounts deal with bioethical cases may in fact be rooted in implicit acceptance of positions in philosophical ethics. If this is the case there must be practical differences in how recommendations for solutions to bioethical dilemmas are developed that my analysis of methodological differences in case analysis will highlight. Explaining whether practical differences between principlism and casuistry are rooted in meta-ethical differences would also be a broader project than I intend here. I will here examine the two methods of bioethical analysis by uncritically accepting that bioethical principlists and casuists are accurate when they say what they are describing is a method for solving specific bioethical problems rather than a holistic theory of how to describe ethical cases, and that metaethics and metaphysics are irrelevant for analyzing either principlism or casuistry. As Beauchamp and Childress and Jonsen and Toulmin have many times claimed that their metrics for success are specific case outcomes, I take it that an analysis of the two methods of analysis in respect to what is useful in bioethical debate is highlighting something
14 Ibid, 283 15 Ibid, 351 16 Ibid, 398 17 Beauchamp, Tom L. , and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York: Oxford University Press, 2009. Print., 424 18 Ibid, 424 19 Jonsen, Albert R. , and Stephen Toulmin. The Abuse of Casuistry: A History of Moral Reasoning. Berkeley: University of California Press, 1988. Print., 293 6 that these authors would find the most relevant, even if further issues exist. Because the intent of this analysis is to highlight the differences between the two methods of bioethical analysis as they relate to analyzing cases,20 questions like those outlined in the previous paragraph are outside of the scope of my analysis. It may be that there are substantive meta-ethical differences between bioethical principlism and casuistry but these meta-ethical differences make no detectable difference at the level of the method of specific case analysis. Given their backgrounds in different intellectual canons, it would be surprising if this were not the case. If this is the case, then this analysis of the differences between casuistry and principlism is only partial and does not capture what is at stake between principlists and casuists. However, if this is the case and differences not captured by a comparison of case analysis procedures are relevant to casuists or principlists, then principlists and casuists must make explicit that they are concerned with meta-ethical, terminological, or otherwise analytically philosophical differences when debate between the methods take place. As proponents both methods denies serious interest in meta-ethical or terminological debates, this would be an important clarification, and would require a shift in the rhetorical strategies of both theories and some explication of what metaphysical, analytically philosophical, or meta-ethical positions are important to casuists and principlists.
20 Partially because this is what proponents of both theories have explicitly said is most important. 7
THE CASE OF ANENCEPHALIC INFANTS
Anencephalic infants are born without significant portions of the brain, scalp, and skull. This means cranial neural tissue is exposed, which is very harmful to the infant's health. Less than 5% of anencephalic infants survive to a week beyond birth, and the longest an anencephalic infant has survived was 14 months. Infants with anencephaly are permanently unconscious due to their lack of a functioning cerebral cortex. However, they may have some brain stem function, although this becomes less likely with more serious cases of anencephaly. Infants with anencephaly do not react to pain stimuli, and so it has been suggested that they do not feel pain. There are clear diagnostic criteria for the condition which, when met, make diagnosis of anencephaly very reliable.21 Anencephaly cannot be cured, and while anencephalic infants can be kept alive, they cannot have brain function restored. Parents and physicians are often unclear if their responsibilities lie with prolonging the lives of or ensuring a dignified death for anencephalic infants. An additional issue is often raised in cases of anencephaly: some non- anencephalic infants require organ transplants upon birth in order to survive. Because their organs are unharmed by the disorder, anencephalic infants are potential organ donors for infants who could survive past infancy, and infant organ donors are otherwise rare. However, this would require ending the life the anencephalic infant even earlier than would happen naturally, and anencephalic infants are incapable of consenting to this. Because of this, when an anenephalic infant is born, the appropriate course of action is often considered an ethically hard question. Principlists and casuists have carefully analyzed this issue and issues like it. I will use Jonsen's recent account of his involvement of some of the original bioethical analyses of cases of seriously ill infants as a guide to how to analyze a case involving an anencephalic infant using casuist methods. In 1972, Jonsen and nineteen other experts, including bioethicists, physicians, lawyers, theologians, and social scientists gathered to discuss intensive care for neonates for the first time.22 The selection of experts the background of the discussion of neonatal intensive care before it even began: pinpointing the issue as at the intersection of medical expertise, moral analysis, and concern about the broader social context that seriously ill
21 "The Infant with Anencephaly." New England Journal of Medicine 322.10 (1990): 669-74. Web. 22 Jonsen, Albert R. "Morality in the Valley of the Moon: The Origins of the Ethics of Neonatal Intensive Care." Theoretical Medicine and Bioethics.33 (2012): 65-74. Web. 69 8 infants are born into. Jonsen suggests that in framing a case in bioethics, medical indications, patient preferences, quality of life issues, and context should be explicitly understood to be important. It seems that this happened in the case of the conference on neonates. The inclusion of physicians indicates an interest in the medical facts of cases surrounding seriously ill neonates. The very lack of access to patient preferences is what makes issues of severely ill neonates uniquely difficult (as compared to the issue of severely ill patients in general), quality of life issues were similarly important in this discussion, as very early in the discussions a vast majority of the experts agreed that there would be times when it would be acceptable to refrain from treating a neonate whose continued life would always be painful.23 Jonsen reports that these discussions led to the interlocutors agreeing on a series of important maxims and principles which should guide discussions of the care of seriously ill neonates. This is the second step of casuist analysis, and can be performed either by looking at specific principles or at classic cases themselves. In analysis of the care of seriously ill neonates, maxims were developed in both ways. Jonsen reports that the discussions resulted in four "basic ethical principles"24: all babies are entitled to medical and social care aimed at their well-being, parents are responsible for the well-being of their infants, physicians have the duty to assist newborns in proportion to the trust the parents put in them, and that the state has an interest in ensuring the newborns are treated fairly. More general principles were also explicitly specified to be relevant to the cases of seriously ill neonates. Doing harm to the patient without proportional benefit was explicitly discussed as unacceptable. This means that painful life preserving treatments could on balance harm infants who will not participate in any aspect of human experience or who will live in immedicable pain, and that quality of life predictions should weigh heavily in decisions regarding live-saving treatment for those who cannot choose for themselves.25 The conference regarding neonatal care itself was inspired by three cases that Jonsen presents as classic cases of inappropriate withholding of treatment from ill neonates, in which infants with Down's syndrome were not treated for intestinal blockages because of assumptions about their reduced quality of life if they survived. Jonsen characterizes these
23 Ibid 24 Ibid 25 Jonsen, Albert R. "Morality in the Valley of the Moon: The Origins of the Ethics of Neonatal Intensive Care." Theoretical Medicine and Bioethics.33 (2012): 65-74. Web. 70 9 assumptions as influenced by a "prejudiced view of quality of life".26 However, the conference participants were presented with a case in which an infant was in severe respiratory distress with clear intracranial hemorrhages, who as a result of complications became blind at 2 months and whose health continued to deteriorate. The infant required constant ventilation to control his carbon dioxide levels.27 The infant would not survive infancy, and the infant's pain was uncontrollable. When asked if it was appropriate for the concerned parents and physician to take the infant off of the ventilator, conference participants unanimously agreed it would be appropriate to allow that infant to die. Only two participants answered that it would be inappropriate to actively end the life of that infant, and Jonsen agreed that ending the life of the infant in both situations was ethically appropriate.28 The final step in casuist analysis is, guided by principles, to compare the case at hand to classic cases and determine if the case at hand is different in relevant ways from cases where the same action is right. In a case involving a seriously ill infant, the case would be compared to situations in which the parents and doctors had a clear responsibility to treat the infant and cases in which there is not enough quality of life to justify such an action. Casuists would begin analyzing a case of an anencephalic infant by studying the medical indications of the case, as described in the beginning of this section. An anencephalic infant has a very specific (and relatively low) quality of life, and is never able to express their preferences. Especially relevant context to the case would be the fact that organs donated from the anencephalic infant could save the lives of several other infants who might live to be able to participate in society and will probably totally recover from the procedure. The case of an infant with anencephaly is similar to the case of the infants with Down's syndrome in that both infants are not actually in pain, and so it is inappropriate to dismiss their lives as without purpose simply because they do not have many of the mental capabilities we value in ourselves. However, it seems more similar to the case of the infant on the ventilator in that anencephalic infants will not survive infancy and will never be able to have any conscious experiences, so potential quality of
26 Ibid, 68 27 Jonsen, A. R., R. H. Phibbs, W. H. Tooley, and M.J. Garland. "Critical Issues in Newborn Intensive Care: A Conference Report and Policy Proposal." Pediatrics 55.6 (1975): 756-68. Print. 758 28 Jonsen, Albert R. "Morality in the Valley of the Moon: The Origins of the Ethics of Neonatal Intensive Care." Theoretical Medicine and Bioethics.33 (2012): 65-74. Web, 69 10 life is at a baseline and the infant's condition will continue to worsen. In addition, the lives that the organs from an anencephalic infant could save have ethical worth just like the lives of the infants with Down's syndrome. In this extremely truncated example of a casuist analysis, the result is that, if the parents and physician agree, the anencephalic infant should be allowed to die and the organs from this infant should be used to save the lives of others. However, a short delay in this is not morally wrong because the infant is not in pain. It may not be required to end the life of the infant if the infant's parents or physician disagree, or if infant's prognosis is somewhat more complicated. A similar case regarding the treatment of seriously ill infants is described in the most recent volume of Principles of Biomedical Ethics. The first step in a principlist analysis is to begin with the common morality and the principles of bioethics. Beauchamp and Childress identify several of these principles as relevant to the case of seriously ill infants. They highlight cases of seriously ill infants as cases which require balancing the principles of nonmaleficence, beneficence, autonomy,29 and justice.30 Beauchamp and Childress then further specify the principles as they apply to cases of seriously ill infants. In the case of an infant who is unable to advocate for themselves, nonmaleficence must focus on quality of life concerns. This is because in infants who (1) will not survive very long, (2) will be in constant pain, and (3) cannot "minimally participate in human experience",31 aggressive treatment intended to prolong life may be harming the patient more than it could possibly benefit them, and so nonmaleficence may require physicians to refrain from treating these infants. Respect for autonomy in the case of seriously ill infants cannot hinge on soliciting input from the infants themselves. Instead, parents and physicians must make judgments based on what the best interests of a normal patient would be in the situation that the infant is in. This will often be based on balancing the quality-of-life judgments made about the infants, the interest that every reasonable patient is taken to have in continuing to live for as long as possible, and the responsibility to respect this interest which
29 Beauchamp, Tom L. , and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York: Oxford University Press, 2009. Print., 174 30 Ibid, 290 31 Ibid, 173 11 stems from beneficence.32 By default, the infant's family should be considered for the role of surrogate decision maker, although this is not always the case and the term 'family' can under- describe the range of people who may care for the infant.33 The principle of justice is relevant to specific infants who require especially scarce treatments, such as extracorporeal membrane oxygenation or organ transplants ( which are especially rare for infants because they must be of a similar size and so from children of a similar age). Infants with a good prognosis should be prioritized over infants with a poor prognosis (either for ability to participate in human society or for survival in general) in situations in which life-saving treatment is rare.34 The guidelines derived from the various principles must then be weighed and balanced. These will be specified to exactly how they apply to the case. If the result is contradictory or seems incommensurable with what is clearly right to do in a similar situation, reflective equilibrium will be engaged to fix the contradiction. Beauchamp and Childress explicitly make clear that it might sometimes be the case that allowing an infant to die is in fact the morally required act.35 In the case of the anencephalic infant, principlists would begin by focusing on concerns related to nonmaleficence, specified in regards to the infant's quality of life. It is clear that an anencephalic infant would be incapable of participating in anything more than minimal human experience however this is defined, and that the infant would not survive for very long. However, the infant is probably in no pain. Because the infant cannot make its own autonomous choices, respect for the infant's autonomy will be based on the parent and physician's opinions (if formed with the wellbeing of the infant in mind) and what a "reasonable" patient would want. We can stipulate that the parents and physician are of the opinion that the infant should be taken off of life support and are indeed acting with the best interests of the infant in mind, as is the case in the casuist analysis. We can also stipulate that the infant's family situation is not complicated, and the two biological parents of the infant are the only parties besides the treating physician with a
32 Beauchamp, Tom L. , and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York: Oxford University Press, 2009. Print. 174 33 Ibid, 190. This may especially be the case in situations in which surrogate parents are involved in a child's conception or serious financial interests are involved for the family of the infant. 34 Ibid, 291 35 Ibid, 173 12 legitimate claim to being the infant's surrogate decision-maker. In this case, the principle of justice requires consideration of the fact that the prognosis of the infants who could benefit from the anencephalic infant's organs is much better than that of the anencephalic infant, but this does not give these other infants a right to the anencephalic infant's organs. The quality-of-life concerns and concerns of justice do not require the infant's organs to be donated, as the infant is not in pain and justice does not require giving up organs. However, quality-of-life concerns seem to more strongly support the anencephalic infant being allowed to die than not. If autonomy concerns, as expressed through the good-faith opinions parents and physicians, are in favor of allowing the infant to die and donating the infant's organs, then the balance of principles would be strongly in favor of this happening. If on the other hand the physician and parents are against the infant's being allowed to die and its organs being donated, the act is probably not morally obligatory, although these principles in this situation might need further specifying because they would conflict in this case. As Beauchamp and Childress are careful to point out, none of these outcomes seems to be clearly against the common morality and so no further investigation into what has gone wrong and how to fix this with reflective equilibrium is needed. It is not surprising that it is possible to get the same ethical result from both casuists and principlists in the same case when the analyses are done by the same author, even when she is guided by the comments Beauchamp, Childress and Jonsen have made on the subject. However, that the same issues and conflicts between intuitions were raised is significant. Both methods examine the infant's prognosis, pain, and ability to participate in human society. In both methods, this last requirement is explicitly very low, and comes with caveats that quality of life must be assessed with care not to discount legitimate value inherent in many different kinds of lives. However, it is clear that a lack of consciousness is in both cases enough to suggest that the infant is lacking a significant aspect of quality of life. In both cases, the lack of pain that an anencephalic infant experiences is reason to be cautious about requiring that life support be removed. Casuists and principlists both place the responsibility of deciding for the infant in the hands of parental figures and physicians, but both caution that this must be done with the infant's best interests in mind and to a reasonable patient standard, and point out that this responsibility might fall to others as well. Both methods of analysis take it to be significant that others could be seriously helped by the donation of the infant's organs. It seems that thinkers with the same 13 intuitions would invariably reach the same suggestions for how to proceed in the case of an anencephalic infant when using either method. No significant differences in analysis seem to result from the choice of method in this case, nor are there any suggestions that a difference in analysis might appear in other cases.
14
CASUIST METHODS
Casuists believe that even conclusions reached from casuist reasoning will be "presumptive", and so subject to falsification based on the situation. Understanding this theoretical basis for casuistry explains why casuist reasoning must unfold in one way: with the specific case informing the ways in which principles are interpreted in the situation. It is not that casuists think that moral principles are not useful in the kind of practical reasoning useful for bioethics. However, casuists point out that the trickiest ethical cases arise when principles conflict (such as "do not lie" and "do not facilitate harm to innocents" in the famous Nazi at the door case) or when it is unclear if an ethical principle applies (there is clearly a requirement to take care of animals in one's care, but has a child done wrong by catching fireflies in a jar, which then die because the child cannot feed them?).36 Casuists believe that while principles are useful, they cannot be used to determine what the ethical thing to do is without reference to cases. Instead, cases must be used to analyze the relationship between the principles as well as to determine which principles are relevant to the type of situation. To emphasize this point it may be useful to resort to metaphor: Jonsen describes ethical principles as a building which is "strangely empty... without the furniture of cases".37 In order to appropriately P-reason about ethics. Jonsen suggests three steps. The first step is to describe the context of the argument: that is, specify what kind of situation you are examining, so that you can use appropriate principles or laws. Arguments in bioethics take place within the structure (or "room") of principles appropriate to bioethics. This structure is a combination of the norms for the situation which distinguishes this kind of situation from other kinds of situations,38 and an accounting of the nature of the various facts of the case. In different fields, different aspects of a case will be problematic. Jonsen suggests that in medical
36 Jonsen, Albert R. , and Stephen Toulmin. The Abuse of Casuistry: A History of Moral Reasoning. Berkeley: University of California Press, 1988. Print. 7 37 Jonsen, Albert R. "Casuistry: An Alternative or Complement to Principles?“ Kennedy Institute of Ethics Journal 5.3 (1995) : 237-51. Web, 238 38 This would be the way to distinguish a bioethical situation from a situation in business ethics. The markers of a bioethical situation might be that a medical problem is at issue or that doctors are being asked to provide information vis a vis their expertise. Jonsen, Albert R. "Casuistical Reasoning in Medical Ethics."Principles of Healthcare Ethics. 2nd ed. Boston: Wiley- Blackwell, 2007. Print, 53 15 ethics, cases have four categories of possibly relevant issues: medical indications, patient preferences, quality of life issues, and contextual features to the case.39 The second step is to describe the particular aspects of the case that might be relevant to the status of the "presumptive" conclusions to be reached (metaphorically, to decorate the interior of the room for later examination). This is done by identifying cases which would clearly be in line with or give reason to discard a conclusion. These are cases in which philosophers "need no proof in themselves...to the conclusions drawn about the case",40 so all philosophers presented with the case would agree on the outcome. These classic cases should provide examples of times when the situation influenced the interpretation of principles of ethics in each direction. These classic examples of what to do in certain situations become maxims which will help guide ethical behavior in the future.41 Jonsen uses the word "principle" to apply to rules which apply to much broader situations than maxims described by classic cases, but which are similarly uncontroversial morally.42 Jonsen says that there must be only "one or several very general principles",43 suggesting that the traditional principles in bioethics are a respect for patient autonomy, a commitment to nonmaleficence, a commitment to beneficence, and a desire for justice.44 The third and final step is determining which kind of standard cases the case at hand resembles most in the relevant respects.45 The last two steps of the casuist method are the most recognizable for case-based ethics and take up most of the actual working out of cases in this manner,46 but it is clear that all three steps are necessary for P-reasoning. Practical reasoning
39 Jonsen, Albert R. "Casuistry: An Alternative or Complement to Principles?“ Kennedy Institute of Ethics Journal 5.3 (1995) : 237-51. Web,, 242, Jonsen, Albert R. "Casuistical Reasoning in Medical Ethics."Principles of Healthcare Ethics. 2nd ed. Boston: Wiley-Blackwell, 2007. Print., 54 40 Jonsen, Albert R. "Casuistical Reasoning in Medical Ethics."Principles of Healthcare Ethics. 2nd ed. Boston: Wiley- Blackwell, 2007. Print. 54 41 Ibid, 55 42 Ibid, 54 43 Ibid 44 Jonsen, Albert R. "Casuistical Reasoning in Medical Ethics."Principles of Healthcare Ethics. 2nd ed. Boston: Wiley- Blackwell, 2007. Print., Jonsen, Albert R. "Casuistry: An Alternative or Complement to Principles?“ Kennedy Institute of Ethics Journal 5.3 (1995) : 237-51. Web,55 45 Jonsen, Albert R. "Casuistry: An Alternative or Complement to Principles?“ Kennedy Institute of Ethics Journal 5.3 (1995) : 237-51. Web,244 46 Jonsen, Albert R. , and Stephen Toulmin. The Abuse of Casuistry: A History of Moral Reasoning. Berkeley: University of California Press, 1988. Print., 196 16 must move from knowledge of principles (which have been determined to be appropriate by earlier examination of the subject matter), to the possibility of principles applying differently to a situation than in the classic manner, and then to examining the actual situation at hand to see if the kind of thing that can cause principles to apply differently has occurred.
17
PRINCIPLIST METHODS
Principlist analysis takes the common morality as its starting point. The common morality consists of the ethical norms which all reasonable people accept. These include the general obligations not to kill, make others suffer, or steal.47 The general morality can provide what Beauchamp and Childress call a "framework of norms"48 which must then be specified in terms of "where, when, why, how, by what means, to whom, or by whom the action is to be done or avoided"49 so that they can become principles useful for specific cases in bioethics. Then, general morality for doctors (and other medical professionals) is examined. Principles derived from this are also specified. This is done using the resources provided by ethical theories, but not in line with any one theory.50 This process should produce a series of descriptions of how to act in specific situations with which everyone would generally agree, perhaps after having the logic of the way the specification was done explained to them. These principles are weighed and balanced against one another in the hard cases in which they conflict, so that they apply to particular situations.51 This is necessary because Beauchamp and Childress argue that no matter how practical a principle is, “each encounter calls for a response not adequately captured by general rules and their specifications”.52 Therefore, weighing and balancing of different values must occur. Beauchamp and Childress argue that balancing treatment options with side effects is an excellent example of this. They point out that "in cases of balancing harms of treatment against the benefits of treatment for incompetent patients, the cases are often so exceptional that it is perilous to generalize a conclusion that would reach out to other cases”.53 This method is presented by the authors with reference to examples of real life cases and they say it will often be done by comparing cases to one another
47 Beauchamp, Tom L. , and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York: Oxford University Press, 2009. Print., 3 48 Ibid,17 49 Ibid 50 Ibid, 19 51 Beauchamp, Tom L. , and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York: Oxford University Press, 2009. Print., 20 52 Ibid, 21 53 Ibid, 22 18 rather than to the specified rules.54 Because the balance of different moral norms is different in every situation, there are situations in which every kind of moral norm will be reasonably overridden.55 No matter how specified principles are and no matter how well cases are described in specific situations, sometimes it will seem that there will be ways in which different principles have been applied that conflict with what seems to be the right thing to do in actual cases. When conflicts arise, the usefulness of different principles must be balanced using a reflective equilibrium (inspired by John Rawls).56 The results of the practical judgments made by using principles are balanced against considered judgments. Considered judgments are specific things that seem morally obvious, like not to be racist or cruel. If a principle which seems to be implied by experience and has been specified to apply to practical situations results in being racist or cruel in some specific situations, it must be rethought. The use of reflective equilibrium advocated by Beauchamp and Childress essentially consists of changing moral principles based on problems these principles face in specific cases.57 Supporters of principlism therefore claim that while the casuist focus on specific cases is useful, casuist methods of analyzing cases are already part of a sufficiently well-developed operationalization of principlism. Principlists point out that the “weighing and balancing” step and use of a reflective equilibrium to fix principles which result in unacceptable recommendations in specific cases allow focus on particular cases rather than principles and that specification of principles means that principlist discourse will focus only on ethical principles as they are relevant to bioethics. Principlists argue that they can use the methods of casuistry satisfactorily because “weighing and balancing” leaves them conceptual room to debate cases within themselves and modify principles as they become inappropriate in specific situations. Principlists use principles informed by their experience of bioethics (which presumably is in terms of cases) when they begin to analyze cases. If casuistry can be subsumed by principlism,
54 Ibid, 23,8, 89 55 Ibid, 15 56 Beauchamp, Tom L. , and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York: Oxford University Press, 2009. Print., 423 57 Beauchamp, Tom L. , and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York: Oxford University Press, 2009. Print., 403 19 then principlist criticism of casuistry must be that casuistry is already being done by principlists, or that principlism does more than casuistry. Examinations of hard cases by principlists and casuists are done very similarly. Both methods begin by describing ethical norms appropriate to the profession. Casuists compare these norms to the walls of the house of ethics which must be populated by classic cases as furniture, while principlists simply call these the principles appropriate for bioethics. Both methods then narrow down the rules prescribed by these norms to more specific situations, but insist that even these narrowed-down rules (which must be informed by specific cases in which the rule is invoked) cannot by themselves provide an easy answer in every real-world situation. For this to occur, many applicable guidelines must be balanced against each other in order to determine what the best course of action is with reference to the specific case and other specific cases which have been resolved satisfactorily in the past. Both methods of analysis admit that sometimes the previously established rules may not fit specific situations, and by this bad fit it will become obvious that the rules must be changed. Principlists explicitly took on board casuist methods in constructing the way that weighing and balancing specified principles and reaching a reflective equilibrium on troublesome principles takes place, so these similarities are not surprising.
20
JUSTIFICATIONS FOR CASUISTRY
Jonsen and Toulmin point out that during the renaissance of high casuistry "no formal 'theory of casuistry' existed".58 This means that those who support a reintroduction of casuistry must seek to define a practice which was originally understood to be self-evident. This in part may be a source of debates as to what casuistry is between advocates of casuistry and its detractors, which I further examine in later sections. Early explanations of casuistry often took the form of examples or metaphors.59 These, while useful for nontechnical illustrative purposes, increase the possibility of misunderstandings arising. A clear explanation of the underlying arguments will make it clear exactly what is at stake when casuistry is advocated as a method for dealing with bioethical cases. I will not here critique the assumptions that Jonsen and Toulmin make when advocating casuistry, although convincing defenses of what they would call the philosophical method of reasoning has been made in many other areas. Instead, I will try to reproduce the justifications of the reintroduction of casuistry into the realm of bioethics in order to compare this to the justifications of the development of principlism. The argument for doing ethical analysis based on interpretation of cases rather than strict application of laws is based on the idea that there are two ways to apply systems of knowledge to the world. The two are expressed as mutually exclusive, and in the realm of ethics they are the only two ways to understand the world.60 In some cases, pure reason is applicable to questions. Geometry is the classic example of this kind of reasoning. In geometry "the starting point [is] a few general statements the meaning of which [is] clear and the truth of which [is] beyond question: from these were derived, by formal deduction, conclusions that were neither obvious nor self-explanatory".61 Jonsen and Toulmin call this brand of reasoning theoretical (or T). T- reasoning is attractive because (granted that the starting theorems are correct) it can get you
58 Jonsen, Albert R. , and Stephen Toulmin. The Abuse of Casuistry: A History of Moral Reasoning. Berkeley: University of California Press, 1988. Print. 250 59 Jonsen, Albert R. "Casuistry: An Alternative or Complement to Principles?“ Kennedy Institute of Ethics Journal 5.3 (1995) : 237-51. Web., 244 60 Jonsen, Albert R. , and Stephen Toulmin. The Abuse of Casuistry: A History of Moral Reasoning. Berkeley: University of California Press, 1988. Print, 2 This is a contentious claim, but it is outside of the scope of my analysis to defend it. Whether or not this is true, the justifications for casuistry assume this, and so it is necessary to include for the purposes of comparing the justifications of casuistry and principlism. 61 Jonsen, Albert R. , and Stephen Toulmin. The Abuse of Casuistry: A History of Moral Reasoning. Berkeley: University of California Press, 1988. Print., 25 21 absolute answers to questions and provide a clear framework within which to determine if a statement is correct. Jonsen and Toulmin say that the defining characteristics of T-reasoning are that it is "idealized, atemporal, and necessary"62(I, A, and N respectively). For example, in Euclidian geometry, the Pythagorean Theorem will apply to all right triangles: a description of other factors surrounding a triangle is not necessary to know if it applies. Jonsen says that philosophical ethics (concerned with principles) meets all of these requirements and so is another clear example of T-reasoning.63 In contrast, the second type of reasoning applies when the subjects of laws are not idealized (~I), the application of laws are temporal (~A), and the application of laws is subject to interference by other situations (~N). This, they refer to as practical (or P) reasoning. This last requirement for P-reasoning, ~N, is according to Jonsen and Toulmin that the reasoning is "presumptive". This means that "the presumptive conclusion is... open to doubt ‘in point of fact’: [even when] no one is denying the initial generalization or questioning the formal validity of the presumptive inference".64 A good example of P-reasoning is diet advice: any diet guideline is subject to situations outside the realm of that specific field or law. The advice that fish should be eaten for health might be inappropriate for vegans or in times of high ocean pollution for reasons entirely unrelated to the nutritional content of the food. Jonsen and Toulmin also list law, medicine, and public administration as areas in which P-reasoning is necessary, highlighting that each of these areas need action-guiding advice to resolve specific issues as a defining feature.65With these terms defined in this way, Jonsen and Toulmin think they can prove that bioethical cases are not the kind of thing for which philosophical ethics is appropriate. They argue that:
1. T iffdf A AND I AND N 2. Bioethical cases = ~A, ~I Therefore
62 Ibid 63 Jonsen, Albert R. "Casuistical Reasoning in Medical Ethics."Principles of Healthcare Ethics. 2nd ed. Boston: Wiley- Blackwell, 2007. Print. 52 64 Jonsen, Albert R. , and Stephen Toulmin. The Abuse of Casuistry: A History of Moral Reasoning. Berkeley: University of California Press, 1988. Print. 28 65 Ibid, 29 22
C1: Bioethical cases ~T
3. Reasoning is T XOR P C1: Bioethical cases ~T Therefore C2: Bioethical cases =P
If we accept 1 and C2, then a third conclusion can be reached.
4. P iffdf ~A AND ~I AND ~N C2: Bioethical cases = P Therefore C3: Bioethical cases = ~N
Finally, accepting Jonsen's assertions about philosophical ethics. 5. Philosophical ethics = T C2: Bioethical cases = P 3. Reasoning is T XOR P Therefore C4: Philosophical ethics cannot be used for bioethics
The third conclusion (C3) is that bioethical cases must be subject to conclusions that are not necessary: that is, that the conclusions reached in bioethics are presumptive. If (C4) philosophical ethics is not appropriate for dealing with bioethical cases, then another form of reasoning must be utilized. This form of reasoning must not only be (~A) rooted in the time that the case takes place in, (~I) and not idealized, as Jonsen had already argued for. Its conclusions must also be (~N) explicitly subject to being canceled out by other facts of the situation. These are the standards to which Jonsen and Toulmin will hold casuistry, and will argue that principlism fails.
23
JUSTIFICATIONS FOR PRINCIPLISM
Beauchamp and Childress were also motivated to develop principle based bioethics by concerns about the usefulness of philosophical ethical analysis. They point out that the debate between classical ethical theories seems endless and that serious flaws seem to be present in each theory (although each theory seems to provide important insights).66 Even if all philosophers were to agree on a single moral theory, Beauchamp and Childress are concerned that "many practical questions would remain unanswered even if a fully satisfactory general ethical theory were available",67 and so even a perfect philosophical ethical theory will not necessarily help with applied ethics. They argue for this by evaluating how well philosophical ethics can solve practical bioethical dilemmas. They first describe the traits they believe a method must have in order to be useful for bioethical analysis. In order to be useful for bioethical cases, a method must be applicable and potentially convincing to all persons regardless of starting assumptions (S),68 be relevant to specific moral situations (R),69 accept that moral dilemmas do exist and that moral change occurs (MC),70 and give advice that is action-guiding (G) (in the sense that unequivocal advice for each case is given as a direct result of using the ethical rules).71 While the requirement to believe MC seems obscure, by moral dilemma they only mean cases in which there is no clear right choice, and by moral change they mean that our moral standards will shift over time (for example, that the majority of people used to think there was a justification for treating women as intellectually inferior to men, and this is no longer the case). Such an approach would be practical for bioethics. In the interest of keeping like terms consistent between the theories, I will call a method of reasoning which meets all of these criteria (P), the letter used to represent a practical method of discussing bioethics by casuists. For the same reason I will refer to a theoretical, or philosophical approach to ethics as (T). According to Beauchamp and Childress,
66 Beauchamp, Tom L. , and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York: Oxford University Press, 2009. Print., 351 67 Ibid, 2 68 Ibid 69 Ibid 3-4 70 Beauchamp, Tom L. , and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York: Oxford University Press, 2009. Print., 11, 412 71 Ibid, 423 24 philosophical theories of ethics primarily aim at producing ethical rules which are logically necessary (L). 72
An ethical rule is L Iffdf the rule always holds no matter the circumstances of any other related facts,73 and arguments justifying or refuting L must proceed from one agreed-upon set of starting premises in order to be valid.74 If ethical rules are L, this rules out moral change occurring (so ~MC), and rules out interlocutors having a discussion if they disagree about starting assumptions (so ~S). This means that
1. P iffdf S AND MC AND R AND G 2. T is L 3. L is ~MC, ~S 4. T is ~MC, ~S Therefore C1: T is ~P
If this is true, then theory-driven approaches to knowledge (including philosophy) cannot be used to solve bioethical problems (C1). Beauchamp and Childress express doubts that T reasoning could be action-guiding (G) or relevant to specific cases (R) as a result of its failure to meet the other requirements, but do not make an argument that this must be the case.75 If P and T reasoning are exhaustive and mutually exclusive, and so could not share traits, then this would necessarily be the case. However, they are not explicit about whether T and P could share traits, or if reasoning could be both P and T. This means that another way to analyze ethical issues must be found. If the problem with philosophical ethical theories is their attempts to be logically necessary, it should be possible to give moral ethical advice in a practical way which abandons this goal and has a chance at actually being useful. Beauchamp and Childress think they can do this by appealing to a
72 Ibid, 412 73 Ibid, 12 74 Ibid, 412 75 Beauchamp, Tom L. , and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York: Oxford University Press, 2009. Print., 412. Some philosophers would argue that they may be somewhat mistaken: individual versions of utilitarianism and orthodox versions of Kant's deontology claim to give specific instructions as to how to determine what action is correct: by measuring pain and pleasure in the former and by applying the categorical imperative in the latter. 25
"common morality"76 as a starting point for ethical reasoning. The common morality consists of the general moral rules shared by everyone who is interested in being moral. Beauchamp and Childress list the responsibilities to keep promises, not to kill, and not to steal as examples of these general moral rules. They point out that "the literature of biomedical ethics virtually never debates the merit or acceptability of these central moral norms, though debates do occur about their precise meaning, scope, weight, and strength".77 Beauchamp and Childress think that the existence of special sets of knowledge and responsibilities for physicians will means that physicians see special aspects of the common morality not accessible to everyone (in the same way that medical knowledge is not accessible to everyone). Like laypeople will not generally understand the steps required to perform open heart surgery, not because they are incapable of learning but because they have never been exposed to the knowledge, laypeople will not generally understand the ethical import of some aspects of medical procedure because they will not be familiar with these medical procedures. This means it is necessary to identify general moral principles specifically for bioethics, which then can be analyzed in terms of things like scope and weight to come to how they determine what should happen in specific situations.78 Beauchamp and Childress believe that two requirements for bioethical argumentation must be met for it to be useful: that it fit the conditions for practical ethics listed in premise one (being S, MC, R, and G) by appealing to the common morality rather than logical axioms as a starting point, and that it deal with aspects of the common morality which are specific to medical ethics. They construct the approach to bioethical analysis which came to be known as principlism (somewhat confusingly, unrelatedly to the philosophical view of the same name) according to these guidelines.
76 Beauchamp, Tom L. , and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York: Oxford University Press, 2009. Print., 2 77 Ibid, 3 78 Ibid, 13,14 26
COMPARATIVE LOGIC OF JUSTIFICATION
In order to compare the grievances that casuists and principlists raise against philosophical ethical theories, I will compare the formalized explanations of why philosophical morality is not useful for solving bioethical dilemmas. This first requires understanding the relationship between the traits of argumentative styles considered in each argument.
Casuists list the following traits as relevant to categorizing reasoning, which they initially use to characterize the kind of reasoning they hope to avoid: I: Idealization A: Atemporality N: Necessity
Principlists have a somewhat different list of relevant traits, which describe traits which they hope to instantiate: S: Convincing regardless of starting premises R: Relevant to specific moral situations MC: Accepting that Moral Change and Moral Dilemmas exist G: Action-guiding L: Logically necessary, which is ~MC and ~S
I will examine the relationships between the premises. Since casuists begin by describing what they hope to avoid and principlists begin by describing what they hope to acheive, it is not surprising that the lists describe traits which are in opposition to one another. (A) Atemporality seems to be expressing the opposite of (MC) accepting that moral change exists. Atemporality of ethical arguments must entail that moral change could not take place (at least in terms of the main ethical rules), because if morals changed then the validity of a moral argument would be temporal. (I) Idealization of moral rules is impossible in cases in which (R) the case is relevant to specific moral situations. The two are opposite strategies regarding the details of a case. (L) Logical necessity and (N) simple necessity seem to be expressing similar goals: logical necessity
27 is part of what it means for something to be simply necessary, because the only way for an argument to be necessarily correct is for it to be logically correct. A claim of simple necessity is stronger than a claim of logical necessity, but it requires the same thing from an ethical rule to eschew having either as a requirement. Simply necessary claims are modally true, that is, it is impossible for them to be untrue. Some of these will be necessary because they are logically necessary (instantiating a law of logic), and some may be necessary for other reasons, such as the fact that they are conceptual truths. However, the reason that an ethical claim is necessary is irrelevant to the effect necessity will have on an ethical claim: whether that claim is simply necessary or logically necessary, the claim cannot be false. (L) Logical necessity requires a set of axioms from which logical reasoning is possible, and so cannot (S) be convincing regardless of the existence of shared starting premises or accomodate (MC) the existence of moral dilemmas and moral change. Only (G) being action-guiding is not transformable from the requirements of principlism to the requirements for casuistry. Both theories use (T) theoretical reasoning to refer to what is done in philosophical ethics, and (P) to refer to the more practical reasoning which they consider themselves to be doing. We now have the following relationships between the traits which principlists and casuists separately raise as important.
I= ~R A= ~MC N = L = ~MC AND ~S = A AND ~S
If these terms do in fact capture the entirety of what is meant by one another, then they can be substituted for one another. With this done, the arguments for principlism and casuistry can be set side-by-side. Using this newly combined terminology, I will compare the definitions and premises that each method uses in order to determine if they characterize philosophical ethics, the ideal method of doing bioethics, or the differences between the two in any different way.
According to casuists:
T iffdf A AND N AND I
P iffdf ~A AND ~N AND ~I 28
2. Bioethical cases = ~A, ~I 3. Reasoning is T XOR P
According to principlists:
T iffdf N AND A.
P iffdf ~A AND ~N AND ~I AND G
Principlists refer to T and P reasoning as though they are entirely different forms of discussing issues, but do not argue that all kinds of reasoning must belong to T XOR P. Beauchamp and Childress list several other modes of reasoning, including a method they refer to as casuistry (although this method is not equivalent to the P reasoning that Jonsen and Toulmin advocate, and so as I argue in later sections that the criticisms of this method are not apt because they mischaracterize casuistry). It is left unstated whether ~I, ~A, and ~N must belong exclusively to P and so cannot belong to T. If this is the case, then principlist T reasoning will also be I, and the two characterizations of P reasoning are identical. The two sets of definitional requirements for P are only different in that principlists require P to be (G) action-guiding by definition. However, Jonsen and Toulmin also say that T reasoning cannot produce action- guiding advice, and that only P reasoning can do this.79 Jonsen and Toulmin see G as an aspect of P which derives from its other characteristics rather than an independent definitional trait, and they would therefore agree with Beauchamp and Childress about all aspects of the definition of P. Similarly, the other premise not contained in the definitions of P and T reasoning in casuist arguments for P reasoning's use is agreed upon by principlists. This is (2) that bioethical reasoning is ~A AND ~I. Principlists would clearly agree with this: P is ~A AND ~I, and bioethical reasoning must be P, so the casuist claim (2) is shared between the theories. Principlists do not provide arguments for why P-reasoning must be the kind of reasoning which is appropriate for bioethics. P is introduced as the only way that bioethical reasoning can take place, with the list of traits which must be involved in P-reasoning serving as an implicit
79 Jonsen, Albert R. , and Stephen Toulmin. The Abuse of Casuistry: A History of Moral Reasoning. Berkeley: University of California Press, 1988. Print., 30 29 argument for their own use. For example, while that a style of reasoning appropriate for bioethics must be G (action-guiding) is asserted, it is not explicitly argued why this is. However, it seems (at least to Beauchamp and Childress, and to most readers) self-evident that this is the case. This highlights a difference in argumentative strategy and standards of rigor between principlists and casuists, but not a difference in what is asserted.
While the argument structures are different between the justification for the primacy of casuistry and principlism over philosophical approaches to ethics, the informational content of the two is the same. The only difference is that principlists are unclear if traits can be shared between P and T reasoning, and casuists are explicit that this is not possible (although neither theory lists any shared traits in the list of traits that identify reasoning as P or T). Principlists and casuists are not just inspired by similar concerns about philosophical ethics. They are inspired by identical concerns about philosophical ethics, and list identical requirements for a practical way of describing bioethical cases. It seems then that a side-by-side comparison of which theory is appropriate for bioethics is easy, because they each claim that bioethical theories should be measured by the same yardstick. There is no "deadlock of principles"80 between the theories in terms of what consists of a useful bioethical heuristic. There is total agreement.
80 Beauchamp, Tom L. , and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York: Oxford University Press, 2009. Print., 43 30
PRINCIPLIST CRITICISMS OF CASUISTRY
Casuistry has long been cast by its proponents as a competitor to principlism, the method of bioethical analysis most famously championed by Beauchamp and Childress.81 Beauchamp has responded to this point directly,82 arguing that while the methods of casuistry are very useful for ethical analysis, principlism can use the methods of case analysis and gain the benefits claimed by casuistry but can also facilitate consideration of issues important in bioethics that case analysis cannot.83 The most common recent response of principlists to casuist attacks has been to claim that casuistry is incorporated into principlism and explain how principlism can improve on it.84 I will accept the principlist claim that they can use casuist methods as part of their attempts to analyze practical cases. In large part, I see this move as reasonable because it is very possible for principlists to begin using casuist methods if they desire to, which they claim to. Instead, I will focus only on the claim that principlism can involve casuist methods and add something valuable to them. Beauchamp has argued that principlism is superior to casuistry because principlism can use casuist methods, making casuistry one of several steps in a principlist analysis of an ethical issue. For this reason he argues principlism has “no flaws that would not for the same reasons impugn casuistry” 85 but “the principles in principlism serve more purposes than guides in case analysis” 86. Beauchamp and Childress argue that casuistry needs “supplementation” 87 for two reasons.88
81 Jonsen, Albert R. "Casuistry: An Alternative or Complement to Principles?“ Kennedy Institute of Ethics Journal 5.3 (1995) : 237-51. Web, 82 He did so directly in articles earlier in the debate, but in the last decade or so has stuck to a relatively unchanging line on casuistry in every new addition of the Principles of Bioethics: presumably he feels he does not need to continue to make the same point over and over again in separate articles. 83 Beauchamp, Tom L. "Reply to Strong on Principlism and Casuistry." The Journal of Medicine and Philosophy 25.3 (2000): 342-47. Web. 344 84 Beauchamp, Tom L. "Principlism and Its Alleged Competitors." Kennedy Institute of Ethics Journal 5.3 (1995): 191, 195 85 Beauchamp, Tom L. "Reply to Strong on Principlism and Casuistry." The Journal of Medicine and Philosophy 25.3 (2000): 342-47. Web. 347 86 Ibid 87 Beauchamp, Tom L. , and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York: Oxford University Press, 2009. Print. 88 Beauchamp and Childress admit that some carefully described accounts of casuistry, such as Strong’s recent account, are free of the problems they point out in casuistry as a whole. They do not further comment on their view of the relationship between their own view and casuistry, or if they see any difference between the two if Strong’s casuistry shares the previously mentioned similarity to principlism as well as the additional benefits they believe principlists have over most casuistry to fix the problems with less well described casuist methods. Ibid, 401 31
Beauchamp and Childress point out that paradigm cases, meant to represent a clear-cut situation where the moral import of a specific act is obvious, must contain both real-world features and clear value judgments. In the case of animal cruelty, the principle would be that it is wrong to be cruel to animals, and the paradigm case would be that it would be wrong to refuse to feed a family pet. The case is a paradigm case because it invokes the principle that it is wrong to be cruel to animals and the real-life factors that the purposely depriving an animal of food is cruel, and that the pet is dependent on your family for food in a way that you have purposefully facilitated. Beauchamp and Childress worry that “casuists have no methodological resource to prevent a biased development of case-based judgment or an ignoring of morally relevant features of cases”. 89 While it is certainly possible for debates over which cases are paradigms of a certain kind of case to arise and for interpretation to be faulty, this initial mistake does not seem to be a problem unique to casuistry. The problem that Beauchamp and Childress highlight stems from people making bad arguments, which is a possibility in any kind of ethics. What Beauchamp and Childress fear is, for example, someone arguing that the paradigm case of responsibilities to animals is your responsibility not to take action against insects infesting your home. If this were accepted it would certainly make it difficult to have reasonable ethical rules regarding treatment of animals. However, it would be just as easy for a philosopher to present a logical argument that because killing things is wrong it is wrong to end insect infestations by killing them. This is not good casuistry or philosophy. Arguments that we have responsibilities to animals infesting our homes and therefore have responsibilities to all animals living in proximity with us90 would not be good arguments because this is clearly not the case. A chain of case-based reasoning which began with a case ill-suited to the claim would soon have to make ludicrous claims about our responsibilities to all animals and by this automatic reductio ad absurdum it would be clear that a bias had emerged, unless casuist analysis fails to have a robust enough system of checks and balances. If casuistry relies too strongly on which initial paradigm cases are selected and it is too difficult to unseat these cases, bad cases might be a serious problem. However, part of casuist debate mediates the possibility that if a morally relevant feature of a case has been ignored by
89 Ibid 90 This would certainly make living near a park a huge moral responsibility, which would be a warning sign about the theory. 32 unskilled casuists it will be pointed out by skilled casuists. The possibility of not noticing a morally relevant feature of a situation exists no matter what method is used to examine cases, and it is clear that casuistry includes methods for unseating cases which are treated as paradigm cases but which are inappropriate for the role. One step in the casuist method is to examine morally relevant features, and so ignoring a morally relevant feature means that something has gone wrong. This seems to be a criticism of bad casuistry, not casuistry taken as charitably as possible. Nothing inherent to the process of casuistry as opposed to other moral examination processes causes these problems Beauchamp and Childress’ example of the risk of misinterpretation of cases makes the point clear. They tell a story of a casuist presenting a paradigm case to a group of physicians in which a patient with amyotrophic lateral sclerosis on a ventilator decides to disconnect the ventilator as a case which exemplifies issues surrounding end-of-life decisions. However, physicians in the audience argued that according to the diagnosis the patient was instead dealing with issues surrounding his disability. They argued that mismanagement of the patient’s treatment ought to be corrected by making the patient comfortable and helping him come to terms with his new form of life so that the patient’s disability could be dealt with rather than the patient being subject to the overwhelming feeling of hopelessness associated with end of life cases.91 However, the problem here was not with the method of casuistry per se. It was a matter of how each party interpreted the case. The casuist did not fully understand the practical facts of the case: she missed the patient’s prognosis and the ways in which a change in treatment might make the patient less hopeless. The physicians in the audience clarified the case for her, and in doing so they made the moral issues more obvious. This is casuistry at its best, allowing the possibility of corrections to an under-informed ethicist. In the same vein, in other cases an ethicist could illuminate a part of the case (such as unmet patient need or a lack of autonomy allowed to the patient) that the physician doesn't notice, improving medical treatment. Both of these are examples of good casuistry. The problem was in understanding the patient’s situation rather than a misfire of theoretical models. This is why casuists argue that communicating with patients and understanding the locus of their exact complaints is an integral part of bioethics.
91 Beauchamp, Tom L. , and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York: Oxford University Press, 2009. Print, 402 33
The second criticism that Beauchamp and Childress raise, which continues to be raised in the literature,92 comes from the same root as the first. They explain that there seems to be no way for casuistry to have the theoretical distance from cultural biases necessary to critique them.93 There is a risk of this, but the risk is again of bad casuistry without a sufficiently strong method for self-correction. For example, a very racist society might accept individual cases of white and black patients being treated differently, but would have problems justifying why race was the defining characteristic between the two cases. The racists would certainly notice that many cases were determined along the lines of race, but no coherent principle for why this is the case would be determinable.94 The cases racists accept might suggest the form of such a principle and casuists might try to describe a racial principle, but once they have moved from noticing it in the cases to describing the principle itself the project of constructing an ethical principle centered around race will fail and the method of casuist debate will result in other casuists pointing this out. If casuistry is done well, it will involve the first step that Jonsen and Toulmin describe. This step is determining and describing or working out the principles relevant to ethical cases. If race (or any other illegitimate category) is to be a relevant principle for an area of ethics, this must be justified to oneself and to other casuists. A casuist cannot justify race being a morally relevant category any better than a philosophical ethicist can, and perhaps casuist debate is better equipped to catch subtle racism by comparing cases in which nothing is clearly explicitly done wrong but which have been done differently in cases of different races, whereas philosophers who only focus on one case at a time may not notice that race has been taken into account. Again, the case of racists is simply a case of people doing casuistry badly, not casuistry itself being wrong. Paul Cudney also believes that Beauchamp has not accurately described the difference between casuistry and principlism. He says that “as it stands proponents and critics of these two views are often talking past each other because the terms of the debate are ambiguous” .95 It is
92 Including in Tomlinson, Thomas. Methods in Medical Ethics: Critical Perspectives. Oxford: Oxford UP, 2012. Print, 2 and Kuhse, Helga, and Peter Singer. A Companion to Bioethics. 2nd ed. Oxford, UK: Blackwell, 2010. Print., 122 93 Beauchamp, Tom L. , and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York: Oxford University Press, 2009. Print., 403 94 Unless racism were logically justifiable. I feel I can uncontroversially say it is not. 95 Cudney, Paul. "What Really Separates Casuistry from Principlism in Medical Ethics?" Theoretical Medicine and Bioethics 35.3 (2014): 205-29. Web, 207 34 easy to ignore that casuistry involves principles even if those principles are exemplified and analyzed through cases, so it is easy to make criticisms of casuistry that do not fit the actual method. He says that if casuistry is going to be criticized by the principlist, it must be in virtue of differences in the practical application of epistemological commitments. This difference between the two methods of analysis is epistemological, but this is not a purely theoretical difference: it hinges on how ethical principles for use in practical cases are developed. According to Cudney, while the principles in both theories can operate in the same way the difference is that for a casuist the principles are developed with reference to the cases which make the need for them clear and then these principles are applied to further cases, while for a principlist the already justified principles are simply applied to cases.96 This means that if Cudney is correct, differences in opinion between casuists and principlists boil down to debates about which grounding for moral facts is epistemologically prior, and how moral judgments can therefore relate to cases. Cudney is claiming that casuists begin with a set of principles which are appropriate to the subject as determined by previous cases and then begin to deal with these principles. He thinks that when determining what principles are appropriate to apply, principlists would point to facts about the common morality as reflected in the principles themselves and casuists would point to how a principle fits in with other cases for justification. This would certainly have the potential to result in very different recommendations coming from the two methods if casuists took principles which seem to stem from cases uncritically and simply applied them to cases, allowing argument only regarding specific cases with the principles set in stone. However, there is room for casuists to debate principles stemming from cases in a field in terms of other cases and principles stemming from other cases in addition to debating cases simpliciter. An example will make this labyrinthine claim clearer. Let’s say that some bioethical cases seem to point to some sort of a principle or rule that claims that paternalism is appropriate for analyzing ethical cases. It seems that often people do things that are against their best interests, out of ignorance or stubbornness. These cases make a principle of justified paternalism attractive. This principle is allowed to become one of the “walls” of the room of bioethics, a principle of the field. So, according to the method described
96 Cudney, Paul. "What Really Separates Casuistry from Principlism in Medical Ethics?" Theoretical Medicine and Bioethics 35.3 (2014): 205-29. Web, 224 35 in section III, the first step is to look at cases to determine if they require paternalism as an appropriate response. In the second step, clear cases that seem to point to paternalism being appropriate are selected for reference. Then in the third step, relevant “hard” cases are examined. If cases arise in which invoking paternalism is destructive even when the cases are similar in the relevant respects to the paradigm “good paternalism” cases (and such cases will certainly arise if paternalism is wrong), this means that paradigm cases of paternalism and the appropriateness of it being a common or standard practice must be re-evaluated. If cases in which paternalism is invoked often result in decisions that seem wrong, casuists would re-evaluate if it is paternalism or another value that underpins the cases making paternalism attractive. This would determine if they should continue to compare hard cases to cases in which “paternalism” is clearly necessary in order to determine if this is appropriate or if other comparisons (perhaps to cases in which beneficence is clearly required) are more helpful. It is possible at this conceptual level to abandon the use of paternalism as a guide even if the kind of situations which used to justify paternalism continue to appear in cases. We will simply have decided that the cases of what seemed to be justified paternalism may be cases of other values instead, perhaps beneficence for the non-autonomous due to disease or youth. These cases will have been re-contextualized because of a re-interpretation of the principle. This is a more complex situation than simply analyzing paternalism and then throwing it out like Cudney suggests principlists would advocate, but the result is the same. It seems that in determining which principles to use, casuistry simply starts a step later than Cudney believes principlism does in determining principles epistemologically but will go through the same cycle of steps and so ultimately go through all the same steps. Even at this abstract level, claims that principlism somehow has more to offer than casuistry seem to be groundless when confronted with a nuanced and charitable view of casuistry. If the difference between principlism and casuistry is the epistemological grounding of morality, it is not the kind of difference which will result in differences in the methods for justifying ethical suggestions in relation to bioethical cases.
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CASUIST CRITICISMS OF PRINCIPLISM
Jonsen has explained that the reason that he and Toulmin began to argue for a return to casuistry for moral analysis was that, while he agrees that principlism provides structures with which to analyze cases, it does not seem to him to give specific enough assistance in real-life situations to be useful. In a move that mirrors Beauchamp and Childress' comments about principlism being necessary to make casuist analyses of ethical cases more complete, Jonsen says that casuistry serves as a necessary supplement to principlism, because without it principlism is unhelpful for specific advice related to each case.97 While this may have been an apt criticism at the time, since this paper was written in 1995 it seems that Beauchamp and Childress have taken Jonsen's criticisms to heart. As expressed earlier, more recent versions of principlism have included two steps in the process of evaluating ethical cases which requires dealing with practical situations and allow for changing principles which are not useful in practical situations. Since principlists have argued that they now do use casuist methods, there may be no debate on this point any longer. Jonsen originally argued that principlists should begin using his methods, and they agreed. It seems that Jonsen agrees that principlists have taken his criticism on board in an acceptable manner: in 2001 he published a defense of the general field of bioethics in which he cited Principles of Biomedical Ethics as an example of a triumph of the combination of armchair analytical analyses and practical concerns which "provides a reasonable way of making ethical arguments in a public policy setting".98 While he makes clear he still has problems with arguments made by some bioethicists (it would be incredible if he did not disagree with some thinkers in his field), the concerns he cites are with the arguments and conclusions themselves rather than the type of method with which they were reached.99 Jonsen remains an advocate of the incorporation of casuist methods into modern bioethics, but he no longer characterizes this method as providing something missing from modern principlism. Instead, his advocacy is for increased use of and the continuing appropriateness of casuist methods within bioethics.100
97 Jonsen, Albert R. "Casuistry: An Alternative or Complement to Principles?“ Kennedy Institute of Ethics Journal 5.3 (1995) : 237-51. Web, 249 98 Jonsen, Albert. "Beating Up Bioethics." Hastings Center Report . 31.5 (2001): 40-46. Web. 42 99 Jonsen, Albert. "Beating Up Bioethics." Hastings Center Report . 31.5 (2001): 40-46. Web. 42 100 Jecker, Nancy Ann Silbergeld., Albert R. Jonsen, and Robert A. Pearlman.Bioethics an Introduction to the History, Methods, and Practice. 3rd ed. Boston: Jones and Bartlett, 2011. Print., 179 37
To Jonsen's general approval,101 Carson Strong analyzed the early attempts at integration of casuist methods into principlism as a way to answer casuist criticisms.102 Strong argues that while principlists claim to have changed their methods of ethical analysis to make them more appropriate for use on specific cases (and in some cases simply claim to have begun using casuist methods), this has not succeeded. He points out that at the time he is writing no principlists have proven that their revised methods were successful by providing an example of analysis of a specific case which successfully reaches an uncontroversial and specific course of action necessitated by only the principlist reasoning.103 What he means by this is not that no one has attempted to analyze ethical cases using principlist methods, but that using principlism on a specific case results in many possible arguments for different courses of action along the same lines, which means to him that principlism has not been useful in the case.104 Of course this failure to come to a conclusion is a possibility, but debate about the right way to analyze a standard case’s applicability to the issue at hand is possible in casuistry, so the same problem can plague both kinds of ethical theorists. Many casuist ethicists could just as easily take different reasoning paths based on different standard cases and end up suggesting different courses of action. Because modern principlism involves engaging in balancing the different principles applicable to a case, the debate about which course of action is appropriate could take place within the bounds of principlism, and so principlism does not fail to provide a method for providing specific answers. What Strong seems to be asking for is that principlist methods provide a calculus that leads to one certain result in each case, but neither principlism nor casuistry promise this result. In fact, both principlists and casuists argue that the kind of reasoning which can lead seamlessly from first principles to one definite answer to a question is not the kind of reasoning which is appropriate for ethics. This kind of reasoning is what casuists call T-reasoning and what principlists call the reasoning done by traditional ethicists. It seems that principlism has in fact answered casuist criticisms, which may be why have been less
101 Jonsen, Albert R. "Strong on Specification." The Journal of Medicine and Philosophy 25.3 (2000): 348-60. Web. 102 Strong, Carson. "Specified Principlism: What Is It, and Does It Really Resolve Cases Better than Casuistry?" The Journal of Medicine and Philosophy 25.3 (2000): 323-41. Web. 324 103 Ibid 326 104 Ibid 329 38 articles written criticizing principlism more recently from a casuist perspective (although characterization of the two as rival accounts has continued to be prevalent105).
105 For example, in "Bioethics" by John-Stewart Gordon, The Internet Encyclopedia of Philosophy, ISSN 2161- 0002, http://www.iep.utm.edu/, 12/5/2014, Arras, John, "Theory and Bioethics", The Stanford Encyclopedia of Philosophy (Summer 2013 Edition), Edward N. Zalta (ed.), URL =
A "DEADLOCK" OF PRINCIPLES
Beauchamp and Childress caution that in ethical analysis it isn’t helpful to stop disagreeing about substantive issues and get caught up in disparaging another method of ethical reason for reasons not directly explicable as practical concerns. This is part of what is unhelpful in traditional ethical theories.106 Jonsen and Toulmin are similarly concerned about coming to a “deadlock of principles" and being unable to move on when arguments take place at a theoretical level rather than about specific cases.107 If differences between casuistry and principlism have no substantive effect on how ethical analysis can take place, then the difference between casuistry and principlism is not a difference between heuristics for ethical analysis but is the difference between theories about ethics generally. It does not seem that casuistry and principlism suggest different methods of analysis, as principlists have adopted casuist changes to their methods. Criticisms of both principlism and casuistry seem to be criticisms of mistakes in practical ethical reasoning rather than the structure of the reasoning itself inherent to either theory, and attempts to point out differences between the two in the literature have so far failed. The two also seek to solve the same problems. If they are justified and operationalized in the same way, it does not seem that practical differences exist between casuistry and principlism. It may be that criticism of principlism by casuists or casuistry by principlists is actually criticism of existing badly done ethical reasoning, which is certainly justified. However, in order to productively move towards pointing out the problems with badly done ethical reasoning, it is important to be able to pinpoint where mistakes were made. There are two things that this could mean. The first is that principlism and casuistry advocate the same method of ethical analysis. If principlism and casuistry are essentially the same, then bad reasoning is not done badly because it is done using the wrong method, and more care in pointing out where mistakes were made is required. Debating which method is better should be abandoned in favor of dealing with actual cases on the essentially complete common ground which the two ethical theories have. The second possibility is that if there remain
106 Beauchamp, Tom L. , and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York: Oxford University Press, 2009. Print. 25 107 Strong, Carson. "Specified Principlism: What Is It, and Does It Really Resolve Cases Better than Casuistry?" The Journal of Medicine and Philosophy25.3 (2000): 323-41. Web, 339 40 differences between principlism and casuistry despite the fact that they guide ethical analysis in the same ways, then the differences must be theoretical. If this is the case, and principlists and casuists insist that there is a relevant difference, then proponents of the two methods of case analysis must allow the focus of debate to include some meta-ethical issues. While differences in the use of terminology between the two methods of analysis (such as principlists acceptance of the term "principle" and casuists squeamishness to invoke it, and the different names that proponents of the two theories use to refer to the meta-ethical debates that many philosophers engage in) suggest some meta-ethical differences, if these differences are important then it is important for principlists and casuists to make their positions explicit and to identify which meta- ethical issues they consider important. This would not require the development of a whole philosophical system on the part of principlists or casuists, and so the difference between principlism and casuistry and traditional philosophical ethics could remain intact. At stake in whether principlists and casuists engage in debates about anything beyond the way that case analysis in bioethics unfolds is not whether the two methods of analysis remain separate from philosophy: it is whether the two methods of analysis remain separate from one another.
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REFERENCES "Bioethics" by John-Stewart Gordon, The Internet Encyclopedia of Philosophy, ISSN 2161- 0002, http://www.iep.utm.edu/, 12/5/2014
"Casuistry: An Alternative or Complement to Principles?“ Kennedy Institute of Ethics Journal 5.3 (1995) : 237-51. Web.
"The Infant with Anencephaly." New England Journal of Medicine 322.10 (1990): 669-74. Web. Arras, John, "Theory and Bioethics", The Stanford Encyclopedia of Philosophy (Summer 2013 Edition) Edward N. Zalta (ed.), URL =
Beauchamp, Tom L. "Reply to Strong on Principlism and Casuistry." The Journal of Medicine and Philosophy 25.3 (2000): 342-47. Web.
Beauchamp, Tom L. , and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York: Oxford University Press, 2009. Print.
Cudney, Paul. "What Really Separates Casuistry from Principlism in Medical Ethics?" Theoretical Medicine and Bioethics 35.3 (2014): 205-29. Print.
Fox, Rene, and Judith P. Swazey. Observing Bioethics. Oxford: Oxford UP, 2008. Print.
Jecker, Nancy Ann Silbergeld., Albert R. Jonsen, and Robert A. Pearlman.Bioethics an Introduction to the History, Methods, and Practice. 3rd ed. Boston: Jones and Bartlett, 2011. Print.
Jonsen, A. R., R. H. Phibbs, W. H. Tooley, and M.J. Garland. "Critical Issues in Newborn Intensive Care: A Conference Report and Policy Proposal." Pediatrics 55.6 (1975): 756-68. Print. Jonsen, Albert R. "Casuistical Reasoning in Medical Ethics."Principles of Healthcare Ethics. 2nd ed. Boston: Wiley-Blackwell, 2007. Print.
Jonsen, Albert R. "Casuistry: An Alternative or Complement to Principles?“ Kennedy Institute of Ethics Journal 5.3 (1995) : 237-51. Web.
Jonsen, Albert R. "Morality in the Valley of the Moon: The Origins of the Ethics of Neonatal Intensive Care." Theoretical Medicine and Bioethics.33 (2012): 65-74. Web.
Jonsen, Albert R. , and Stephen Toulmin. The Abuse of Casuistry: A History of Moral Reasoning. Berkeley: University of California Press, 1988. Print.
Jonsen, Albert. "Beating Up Bioethics." Hastings Center Report . 31.5 (2001): 40-46. Web.
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Kuhse, Helga, and Peter Singer, eds. A Companion to Bioethics. 2nd ed. Boston: Wiley- Blackwell, 2009. Print.
Kuhse, Helga, and Peter Singer. A Companion to Bioethics. 2nd ed. Oxford, UK: Blackwell, 2010. Print.
Singer, Peter A., and A. M. Viens. The Cambridge Textbook of Bioethics. Cambridge: Cambridge UP, 2008. Print.
Steinbock, Bonnie, Alex John London, and John D. Arras, eds.Ethical Issues in Modern Medicine: Contemporary Readings in Bioethics. 8th ed. Boston: McGraw-Hill, 2012. Print.
Strong, Carson. "Specified Principlism: What Is It, and Does It Really Resolve Cases Better than Casuistry?" The Journal of Medicine and Philosophy 25.3 (2000): 323-41. Web.
Tomlinson, Thomas. Methods in Medical Ethics: Critical Perspectives. Oxford: Oxford UP, 2012. Print. Tomlinson, Thomas. Methods in Medical Ethics: Critical Perspectives. Oxford: Oxford UP, 2012. Print
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BIOGRAPHICAL SKETCH
Curriculum Vitae
Sara Kolmes
EDUCATION
Ph.D.
Florida State University, in progress
MA
Florida State University
Advisor: Michael Ruse
BA
Gonzaga University, May 2013
Primary Major: Philosophy Secondary Major: Political Science
PUBLICATIONS
Kolmes, Sara, Rev. of The Human Microbiome: Ethical, Legal, and Social Concerns, ed. Rosamond Rhodes, Nada Gligorov and Abraham Paul Schwab. The Quarterly Review of Biology Sept. 2014: 376. Print.
Kolmes, Sara, Rev. of The Human Microbiome: Ethical, Legal, and Social Concerns, ed. Rosamond Rhodes, Nada Gligorov and Abraham Paul Schwab. The Quarterly Review of Biology Sept. 2014: 376. Print.
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TEACHING EXPERIENCE
Graduate Teaching Assistant: Department of Philosophy, Florida State University
08/2013- Present
Bioethics- Instructor Tracie Mahaffey Fall 2015
Bioethics Online- Instructor Tracie Mahaffey Summer 2015
Screening Science- Instructor Jeff O’Connell Spring 2015
Screening Science- Instructor Jeff O’Connell Fall 2014
Ethical Issues and Life Choices- Professor Michael Robinson, Spring 2014
Ethical Issues and Life Choices- Professor Angela Schwenkler, Fall 2013
RESEARCH ASSISTANTSHIP
Research Assistant to Dr. Michael Nair-Collins, Florida State University School of Medicine, Social Sciences Office. Fall 2014-Spring 2015
Research Assistant to Dr. Randy Clarke, Florida State University Department of Philosophy. Summer 2014
CONFERENCE PRESENTATIONS
Simple Points against Pointy Simples
Florida Philosophical Association, Saint Augustine, FL, November 2015
A Goal-Oriented Approach to Intrinsic Value in Environmental Ethics
International Society for Environmental Ethics Conference, Kiel Germany, July 2015
Ego Depletion and Organ Donation
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International Society for the History Philosophy and Social Study of Biology, June 2015
Ego Depletion and Organ Donation
Southern Society of Philosophy and Psychology Conference, April 2015
Anxiety and Well-Being
South Carolina Philosophical Society Conference, March 2015
Ego Depletion and Organ Donation
North Carolina Philosophical Society Conference, February 28 2015
Do Environmental Science Advisors Represent the Risk of a Technocracy?
Conference on Science and the Public Domain, University College of London, July 2014
A Goal-Oriented Approach to Intrinsic Value in Environmental Ethics
Society for Women's Advancement in Philosophy Conference, Florida State University, March 2014
DEPARTMENT INVOLVEMENT
Philosophy Graduate Student Association, President
National Undergraduate Bioethics Conference Organization, Graduate Student Liaison and Invited Speaker
Philosophy Graduate Student Association, Vice President
Undergraduate Bioethics Bowl Team, Coach
Society for Women's Advancement in Philosophy, Member
ACADEMIC DISTINCTION
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Ermine B. Owenby Jr. Fund for Excellence Travel Grant Recipient
National Merit Presidential Scholarship Recipient
National Merit Scholarship from Gonzaga University
Trustee Scholarship from Gonzaga University
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