Part Two HOW TO DO BIOETHICS? Veikko Launis - 9789042027404 Downloaded from Brill.com09/30/2021 04:09:34AM via free access Veikko Launis - 9789042027404 Downloaded from Brill.com09/30/2021 04:09:34AM via free access Four THE UNBEARABLE LIGHTNESS OF BIOETHICAL PRINCIPLES Veikko Launis If there is such a thing as the truth about the subject matter of ethics—the truth, we might say, about the ethical—why is there any expectation that it should be simple? In particular, why should it be conceptually simple, using only one or two ethical concepts, such as duty or good state of af- fairs, rather than many? Perhaps we need as many concepts to describe it as we find we need, and no fewer.1 1. Introduction: Metaphysical and Normative Lightness In the past two decades or so, a mode of theorizing commonly known as “prin- ciplism” or a “principle-based approach” has been the dominant approach in bioethics. As Donald C. Ainslie points out, the label “principlism” was origi- nally meant to be derogatory, but became embraced by its defenders.2 In the form it has come to be known, principlism is usually characterized by adopting a limited number of prima facie binding bioethical principles which are then individually specified and balanced against each other when a specific moral problem is discussed. The derivation of the principles, the number of princi- ples, and the specification and balancing methods differ depending on the in- terpretation.3 Though there are different principlist theories, principlism is most com- monly characterized by citing four so-called “midlevel” principles—respect for autonomy (the obligation to respect and promote the decision-making ca- pacities of autonomous individuals), nonmaleficence (the obligation to avoid the causation of harm), beneficence (the obligation to provide benefits and bal- ance benefits against risks), and justice (obligations of fairness and non- discrimination in the distribution of benefits and risks). The principles are called “midlevel principles,” since they are located below moral theories and above moral rules, the general idea being that principles follow from moral theories and, in turn, generate more specific rules that are then used to make moral judgments concerning particular cases.4 The idea is that these principles Veikko Launis - 9789042027404 Downloaded from Brill.com09/30/2021 04:09:34AM via free access 42 VEIKKO LAUNIS can (one way or another) provide the proper justificatory framework for bio- ethics and be used as a method for resolving bioethical issues. It is not surprising that principlism has so often been attacked by aca- demic philosophers and professional (clinical) bioethicists, because the term “midlevel” already in itself suggests a compromise between two key spheres of ethics—theory and practice. However, as Allen Buchanan, Dan Brock, Nor- man Daniels and Daniel Wikler have remarked, to a large extent the critics of principlism have been attacking a view “that is at worst a strawman and at best a vulgarization of the framework for analysis advanced most prominently by James Childress and Tom L. Beauchamp in various editions of their influential book Principles of Biomedical Ethics.”5 In this chapter, I will attempt to show that, if taken seriously, principlism can provide a defensible normative frame- work in bioethics. Because there is at present considerable controversy about the proper theory and methodology for bioethics, it would be unrealistic to hope to resolve these complex issues here.6 My modest aim is to raise certain philosophical questions about the (metaphysical and normative) adequacy and sufficiency of the principle-based approach. 2. The Varieties of Bioethical Problems The extent to which a bioethical issue can usefully be discussed by reference to midlevel principles depends, of course, on the kind of issue it is. For the pur- poses of the present discussion, four kinds of issues may be distinguished.7 Firstly, some issues are, or turn out to be, controversial largely because relevant empirical facts are in dispute. These may be called empirical ethical problems. A possible example of this category of issues is the question whether the development and cultivation of genetically modified crops should be permitted because of the risk they pose to the environment and people’s health. It should be no surprise that the contribution of moral philosophers to discussions of these issues is often very limited. Secondly, there are issues that may be characterized as conflicts between principles. A classic example would be the question as to whether a woman’s right to autonomy and self-protection overrides her unborn child’s (assumed) right to life in the case of abortion. Issues of this kind are genuine ethical prob- lems in the sense that the moral conflict may remain even when the empirical facts are clear and accepted by all parties involved in the disagreement. Thirdly, there are issues that are most properly called relevance or inter- pretation problems. These are characteristically raised by novel technologies and new scientific inventions. We may speak of a relevance problem when we are confronted with a new situation in which our traditional principles do not seem to apply very well and we are unable to see what features of the situation are relevant to its moral appraisal. To give an example, whether experiments in human reproductive cloning techniques should be permitted is largely a rele- Veikko Launis - 9789042027404 Downloaded from Brill.com09/30/2021 04:09:34AM via free access The Unbearable Lightness of Bioethical Principles 43 vance problem, because we do not know what is morally speaking involved in the development of such techniques. Finally, there are issues that may be characterized as demand-for-reason problems. There is a demand-for-reason problem when we consider a certain practice to be morally acceptable (for instance, using genetically modified mice as cancer models) or unacceptable (for instance, waiving the informed consent rule in the context biobanks) but are unable to specify on what morally relevant grounds it may be considered so, even though there is a morally justi- fiable demand for providing such a ground. These four categories are, of course, interconnected and may occur either simultaneously or in succession. To take an example, experiments in human reproductive cloning techniques may be seen to constitute a demand-for-reason problem as well, because such experiments are prohibited by common consent without there being any well-articulated moral ground for such a prohibition.8 As soon as such grounds can be articulated, objections to them will be raised and human cloning techniques are likely to constitute new empirical ethical problems as well as new conflicts between principles. 3. The Method How, then, can such problems be resolved? The above discussion suggests that there is no one thing we can do that is always central to solving an ethical problem for there is no one paradigmatic ethical problem.9 Nevertheless, something more constructive and more general needs to be said. The central methodological assumption here is that the coherentist view of moral justifica- tion offers the best guidance for bioethical issues. (There are also other meth- ods of moral justification within the principle-based approach.10) By coher- entism I mean the process of working back and forth between our considered moral judgments about particular situations and general moral rights and prin- ciples that cover these situations and help to explain our intuitive beliefs about them. (Considered moral judgments are judgments which we affirm with great confidence and without hesitation. Some such judgments are very specific, whereas others are more general. No matter how general, considered judg- ments are not to be seen as self-evident nor necessary truths, but as open to revision—and sometimes even rejection—in the process of reflection. Consid- ered moral judgments have some modest degree of epistemic priority simply because some sources of error and distortion, such as the agent’s being upset or frightened, have been eliminated from the deliberation process.) The key idea underlying this method is that “we test various parts of our system of moral beliefs against other parts of our general system of beliefs, seeking co- herence among the widest set of moral and nonmoral beliefs by revising and refining them at all levels.”11 For example, we might test the appropriateness of the informed consent doctrine in the context of human biobanks by asking Veikko Launis - 9789042027404 Downloaded from Brill.com09/30/2021 04:09:34AM via free access 44 VEIKKO LAUNIS whether we can accept its implications in this particular context and whether it accounts for the particular cases discussed within this context better than alter- native principles. Our considered moral judgments and beliefs about particular cases count in this process. Such judgments have justificatory weight for at least two rea- sons. Firstly, they can be referred to when applying more specific bioethical methods, such as reasoning by analogy and slippery slope arguments.12 Sec- ondly, they provide what Norman Daniels has called “provisional fixed points,” which makes them usable not only in the process of “testing” and re- formulating midlevel principles but also in attempts to resolve conflicts be- tween such principles. I take general philosophical reasoning (including metaphysics, philoso- phy of mind, rational decision-making, etc.) to be an elementary part of this method. Such reasoning is needed for example when we address the largely discussed question as to whether there is something morally special about ge- netic medical information as compared with non-genetic medical information. One answer to this question is the (partly) metaphysical claim that genetic in- formation is morally exceptional because genetic (disease) characteristics are more important to our “essential core identity” than non-genetic (disease) characteristics.13 The principle-based approach, according to the method sketched above, is not simply a list of midlevel principles, as the principlist caricature would have it.