ABSTRACT Title of dissertation: JUSTIFYING BIOETHICAL CASE DECISIONS: REFLECTIVE EQUILIBRIUM AND MID-LEVEL MORAL PRINCIPLES Nancy Stowe Kader, Doctor of Philosophy, 2005 Dissertation directed by: Professor Judith Lichtenberg Department of Philosophy Bioethics is a practical enterprise intended to produce morally acceptable so- lutions to clinical case problems. Although answers can be derived from deductivist or principle-driven methods of deliberation, these solutions may be too abstract to be accepted as appropriate to the circumstances, clinically effective, or suitable to those stakeholders affected by the decision. Furthermore, it has proven difficult to identify the best moral principle to apply to each case, because of the variation in detail and nuance impacting each situation. In this dissertation, I exemplify the difficulty in practical bioethics delibera- tions by presenting in detail the activities of a practicing ethics committee, working at the clinical level of private medical practice in the field of assisted reproductive medicine. In descriptions of over forty cases, I show the difficulty this committee faced in solving routine cases and even more when attempting to solve the novel cases that arise with some frequency in this unique field. This research leads me to recommend a more procedural approach, based on the process of reflective equilibrium described by John Rawls, but supplemented by the contractualist version put forth by T. M. Scanlon. In this deliberative process, a wide variety of factors are considered: moral theory, particular details, paradigm cases, information from policy boards or professional organizations, diverse points of view, and public input. From this style of reasoning, useful mid-level principles can emerge, providing justification for bioethical solutions and encouraging consen- sus, which can also play a legitimizing role in decision-making. I conclude that this inclusive kind of deliberation is more likely to occur at the level of the professional organization or the national commission, where broad diversity in participation and information, as well as public input, can take place. Decisions or principles achieved from this wider level of discourse will be more le- gitimate and can then be used to guide ethics committee members functioning at the private level. JUSTIFYING BIOETHICAL CASE DECISIONS: REFLECTIVE EQUILIBRIUM AND MID-LEVEL MORAL PRINCIPLES by Nancy Stowe Kader Dissertation submitted to the Faculty of the Graduate School of the University of Maryland, College Park in partial fulfillment of the requirements for the degree of Doctor of Philosophy 2005 Advisory Committee: Professor Judith Lichtenberg, Chair Mr. David Wasserman, Esq. Dr. Robert Wachbroit Professor Samuel J. Kerstein Professor Karol Soltan ©Copyright by Nancy Stowe Kader 2005 To Aishe Kader, Mildred Stowe Anderson, and my supporters, Omar, Tarik, Gabriel, Aron, and Jacob ii Table of Contents List of Tables ....................................................................................................................v Introduction.......................................................................................................................1 Part One Problems in Deriving Mid-level Principles.....................................................................10 Chapter One: The Range of Bioethical Methods ...........................................................11 Deductivism ..............................................................................................................12 Casuistry....................................................................................................................17 Principlism ................................................................................................................22 Specification of norms ..............................................................................................29 Chapter Two: Coherentism ............................................................................................33 Reflective Equilibrium..............................................................................................39 Critique of Reflective Equilibrium............................................................................43 Chapter Three: Locating Mid-level Principles...............................................................53 Chapter Four: Case Solving in the Clinical Setting .......................................................63 Part Two Identifying Method and Mid-level Principles in the Clinical Ethics Setting..................87 Chapter Five: Ethics Decisions at a Clinic for Assisted Reproductive Medicine..........88 Chapter Six: Risk and Consent ......................................................................................99 Age-Related Issues in Donors and Surrogate..........................................................106 Frequency of Attempts............................................................................................111 Consanguinity .........................................................................................................113 Doing the Medicine First: Concomitant Illness ......................................................114 HIV Cases ...............................................................................................................119 Medicine First as a Method.....................................................................................121 Chapter Seven: Relationship Issues .............................................................................131 Homosexual Parenting ............................................................................................134 Donor Egg/Donor Sperm ........................................................................................139 Known Donors ........................................................................................................142 Mixing.....................................................................................................................148 Splitting...................................................................................................................153 Transgenerational Relationships .............................................................................156 Child Replacement – Child as Treatment ...............................................................160 iii Chapter Eight: Kass and the Argument From Repugnance .........................................164 Part Three Locating Principles Through Public Reflective Equilibrium........................................186 Chapter Nine: Background Assumptions.....................................................................187 Background Clinical Assumptions..........................................................................192 Methodological Assumptions .................................................................................194 A Theoretical Position ............................................................................................200 Chapter Ten: Saving Reflective Equilibrium...............................................................208 Bibliography..................................................................................................................233 iv LIST OF TABLES Ethics Cases Over Four Years at ARM Clinic Table 1. Category: Risk and Consent.......................................................................... 96 Table 2. Category: Relationship.................................................................................. 97 Table 3. Category: General Issues .............................................................................. 98 v INTRODUCTION Bioethics is more than an abstract investigation of the moral problems arising in medicine and health care; it is also a practical enterprise intended to offer solutions to real cases, and to provide a guide to action in particular situations. Health care profes- sionals, their patients, and those associated with their cases must make considered and acceptable decisions about medical treatments and options in practice settings where value-laden conflicts are involved. Some conflicts can be easily resolved while others may be so difficult as to require legal adjudication, but to be credible each case resolu- tion must be backed up by moral reasoning. It is the duty of bioethicists to offer valida- tion for their decisions and to defend their actions by providing ethical justification. However, identifying a specific theory, a method, a principle, or a process by which to justify specific bioethical decisions has proven difficult. Some bioethical problems are rare but urgent; that is, they arise out of active circumstances in which the decision-makers must act without taking time for consultation or reflection. Other problems are novel; that is, they present themselves to decision-makers without prece- dent. Disagreement about the best approach for problem-solving abounds, although it is generally agreed that examining cases through the lens of traditional moral theories has not proven satisfactory, since they often produce conflicting solutions. Over the past twenty-five years, the literature in the field exposes increasing interest in generat- ing and selecting appropriate methods for confronting bioethical decision-making. The proponent of each new method hopes to show that its use might work to better deliver more consistent, thoughtful, supportable and morally acceptable