As we saw in the previous chapter, the initial encounter between philosophy and interdisciplinary medical ethics in the late 20th Century appeared to lead to some progress in tackling the issues at hand: cases w ere examined, arguments clarified and, in the United States at least, the ideas expressed over the course of various debates passed into both public consciousness and, occasionally, the statute books.
Philosophers had, as Winkler puts it:
contributed to the reduction o f traditional forms o f paternalism in medicine, to a general strengthening o f the rights o f patients and
research subjects, and to improved conceptions o f the appropriate use of medical technology and o f the proper goals o f medicine
and their involvement in bodies such as the President’s Commission had proved a ‘powerful counterpoint to the precious conceit o f the ancien regime that “philosophy boils no cabbages’” Nevertheless, some within the medical profession believed that a focus on theoretical and intellectual matters w as distracting attention away from the realities o f clinical practice, something that (it w as felt) philosophers and other moral theorists did not acknowledge or understand.
On the basis that ‘only the physician is in a position to really understand and address moral problems in medicine’, these critics advocated the adoption of what they termed clinical ethics: ‘dominated by people from the medical scientific community [and] centred in the clinic... informed by the realities o f actual professional practice’2. Certainly it is hard to argue against the view that a knowledge of and appreciation for the realities o f medical practice is o f value to anyone who intends to reflect on moral issues in medicine. Similarly, it is doubtless important for moral theorists to
remember that it is doctors and not theorists themselves who will most often bear responsibility for such moral decisions as are taken in the course of medical practice. On the other hand, we may remember from earlier chapters that ‘the medical scientific community’ had, when entrusted with sole responsibility for deciding on moral
literature produced by the clinical ethics movement tended to differ in language only from work already being done: ‘an increase in clinical data [and] a decrease in philosophical jargon’ nevertheless ended up leading to ‘recommendations...
otherwise indistinguishable from what one would expect’ from their intended targets3. It was not only the medical profession, however, who criticised philosophers’
involvement in medical ethics; by the m id-1980s, dissenting voices could be found amongst lawyers, social scientists, politicians and within the discipline of philosophy itself.
Surveying criticism of his and his colleagues’ work during this period, Gorovitz was able to identify ten main criticisms from a variety o f sources that he grouped into four main strands: those that ‘[reflected] misgivings about... methods and foundations’ (for example, claims that ‘unlike work in the sciences [ethics] consists of assertions without prospect o f verification’)4; those ‘[centred] on pedagogical matters’ (for example, claims that ‘ethics in general can't be taught but is a matter of character that depends on nonacademic influences for its development’)5; those ‘[focused] more generally on utility’ (for example claims that philosophers’ involvement ‘makes practical matters w orse... confuses health care providers, heightens the anxiety of patients, complicates the w ork o f planners and policymakers, and promotes
regulations that impede clinical practice’)6; and those concerned with ‘moral integrity’ (for example claims that philosophers either ‘[promote] unwholesome relativism... or systematically [overemphasise] certain social values, such as liberal individualism’) . Gorovitz allows that ‘each o f these criticisms has some merit, yet each is somewhat misguided’ and, as we shall see over the course o f the following chapter, his
assessment is probably about right. Yet, as he also points out, ‘even criticisms that are untenable as stated may point to prospects for improvement in what they criticize’8; as Lesser has argued with respect to one o f the specific works we will consider below, they are unfair mainly in what they leave out9. For this reason, the following
examination o f several o f these criticisms can be seen to contribute to our understanding o f several important aspects o f philosophical moral thought in medicine.
‘Moral Experts* or ‘Moral Options Brokers*?
The philosophically-trained lawyer Cheryl Noble’s ‘Ethics and Experts’ was penned in 1980, just as proceedings at the President’s Commission were getting underway, and later reprinted in the Hastings Center Report together with responses from a doctor and three philosophers. The article was strongly critical o f what Noble saw as philosophers’ ‘pretensions’ in the field o f applied ethics (including medical ethics and the use o f philosophy in ethical discussions regarding other areas o f public life such as business10) and in particular of what she saw as their claim to ‘a special competence to resolve matters o f right and wrong’1 *. Furthermore, she argued that the pre eminence o f philosophy in interdisciplinary medical ethics was not the result o f its usefulness in addressing the issues at hand but rather o f a mixture of opportunism and historical accident. Whilst allowing that ‘not even philosophy’ could remain
indifferent to the social upheavals o f the late 20th Century, Noble characterises applied ethics chiefly as an attempt by academics to secure students and funding, helped by a social climate ‘fed up with its own scepticism and relativism’ and eager to see ‘moral problems [as] the cause rather than an integral part o f other social conditions’, and the fact that ‘something called ethics has been taught in philosophy departments for as long as philosophy has had a department [my emphasis]’12.
In effect, Noble claims, the practice o f philosophical applied ethics amounts to little more than a confidence trick. Philosophers (on this view) simply dress up
‘conclusions... drawn from a preexisting range o f alternatives’ in technical language that privileges the philosopher over the layperson and gives rise to the idea o f a
‘philosophical expert’ who can be consulted in moral matters ‘just as there are experts to deal with environmental and engineering problems’. Noble argues that, far from contemporary philosophy having been ‘broadened to encompass moral reflection [it had rather] narrowed the field o f moral reflection [in line with the] technician’s
skills’13. Philosophers remain ‘indifferent to history, sociology, and psychology and... inevitably [produce] a kind o f moral criticism that is conventional, comfortable and tame’14; they do not explore, for example, the social context in which something is considered to be moral or otherwise: ‘the ‘facts’ apparently do not extend to an understanding of historical or economic context’15. As examples, she points to two essays by Nagel, one on the morality o f war and one on the justice of income
differentials between ‘professionals’ and ‘blue collar workers’, in which she saw little more than ‘highly abstract descriptions o f norms already embodied in those
practices’16.
When Noble’s article was reprinted in the Hastings Center Report all four respondents flatly rejected her claim that philosophers’ needlessly complicate
everyday moral issues, instead stressing the opposite view that philosophy ‘[clarifies] our thinking about moral issues through the analysis o f important concepts and by organizing and rectifying arguments and points o f view’17. The doctor, Jerry Avom, argued that - far from having taken issues out o f his hands - he was more than happy to be able to turn to philosophers in order to ‘utilise their expertise to sharpen the focus o f [moral] issues’18 (which is o f course quite different to resolving them for him). Beauchamp helped to outline just how philosophy could do this, noting that the critical analysis of language Noble called for with regards to Nagel’s supposedly uncritical use o f the word ‘fight’ in his article on war is in fact typical o f rather than antithetical to philosophy19 (somewhat confusedly, Noble had also criticised Dworkin for offering too many accounts o f what ‘equality’ and ‘justice’ can mean in an article on positive discrimination she dismissed as ‘tedious and complex’20); we may also recall from the previous chapter that philosophers did in fact perform this role with great success in the compilation o f Defining Death. Beauchamp also noted that this analysis could be extended to arguments as a whole, revealing contradictions or unexpected consequences o f commonly-held positions that would call for them to be revised21.
With regards to just what these revisions might be, Singer believed that, given his own views, he should ‘be allowed a chuckle’ at Noble’s claim that philosophers only arrived at conventional conclusions22 (Noble’s own response to this - that they were typical o f any ‘garden variety liberal’23 - scarcely accommodated the examples he gave: ‘[a] defective human being has no more right to life than a dog, or a pig at a
OA
similar mental level’ and ‘[infanticide] is often justifiable’ ). Moreover, philosophers working in interdisciplinary bodies did in fact come to conclusions that proved
unacceptable to their colleagues: the President’s Commission’s ‘essentially conservative’ definition o f death as cessation o f all (rather than higher) brain functions was adopted against the advice o f the philosophers involved25. Noble’s
argument also overlooked two further points. Firstly, as we have argued was the case with Thomson’s ‘A Defense o f Abortion’, a philosophical argument that concludes by lending support to a pre-existing viewpoint can be still be valuable should that
viewpoint have been unfairly marginalised or neglected. Secondly, novelty in moral
theory is not always a recommendation: whilst we should expect that moral philosophy should in some cases be ‘subversive’ (that is, retain the ability to
‘undermine [the] assumptions o f ordinary morality’26) it is more-or-less self-evidently absurd that we should expect it to do so in all cases. Indeed, were a moral theory to suggest that even the majority o f our previous conceptions o f moral conduct were wrong, that would be reason enough to approach said theory with a degree of scepticism.
Beauchamp and Singer also repudiated Noble’s claim that they saw ‘the resolution of moral problems’ as the ‘special province o f philosophy’, and denied that they wanted ‘to have moral problems o f all kinds handed over to them as the appropriate
experts’27. Instead, two o f Beauchamp’s four examples o f the use o f philosophy in medical ethics involve dialogue with members o f other disciplines with regards to policy and case decision (which is not the same as instructing them in what to do) . Noble responded by contending that philosophers still presented themselves in such discussions as ‘the sole professionally competent ethicists’, possessors of special knowledge beyond that o f the layperson29. Yet this criticism could only be sustained were philosophers to claim this ‘special knowledge’ was specifically related to morality (after all, all professionals have special knowledge beyond that o f the
layperson). It is quite clear that the philosophers who responded did not believe this to be the case: with regards to Singer, for example, the ‘advantages that [he believes] philosophers may have over others when it comes to discussing moral problems [my emphases]’30 are concerned with ‘powers o f analysis and clarification [and] skill in... reasoning and argument’ rather than any claim to a specifically moral skill or
knowledge.
As Winkler has pointed out, however, this kind o f rejection o f the notion that
philosophers possess moral expertise is ‘consistent with the possibility that on many, or most, or difficult and complex moral issues, factual understanding together with philosophical analysis and moral argument... can at best only partially reduce the
range o f what survives as defensible or justifiable moral options’31. Indeed, by the early 1980s it was becoming apparent that, despite its undoubted usefulness,
philosophical work in medical ethics seemed in some cases to be coming close to its practical limits. For example, although Deciding to Forego Life-Sustaining Treatment had (by concluding that ‘phrases like “right to die,” “right to life,” “death with
dignity,” “quality o f life,” and “euthanasia” [had] been used in such conflicting ways that their meanings [had] become hopelessly blurred’32) been able to arrive at several definite conclusions regarding ‘resuscitation policy... care o f the permanently
unconscious patient, and the ill newborn’ it was unable to prevent the emergence (contrary to the Commission’s expectations) o f a ‘vigorous, even rancorous, debate over assisted suicide’33. The philosopher was becoming what Winkler has termed the ‘moral options broker’, doing little more than ‘[clarifying] alternative positions and [relating] them to central aspects of moral theory’34: ‘after problematic cases were trotted out, initial positions taken, facts and values clarified, and positions rectified and systematised, everyone tended to wind up with more elaborate versions of the views they had started with’35.
Must Philosophers Claim to be ‘Moral Experts’?
For some, this state o f affairs was in keeping with the proper role o f the philosopher in moral debate. Like Noble, Maclean’s The Elimination o f Morality: Reflections on
Utilitarianism and Bioethics argues that philosophers involved in interdisciplinary
medical ethics have pretended to a moral expertise that they have no right to claim. Similarly, just as Noble saw the involvement o f philosophers in medical ethics as the result o f a mixture o f opportunism and historical accident, so Maclean attributes the late-20th Century growth o f interest in first-order ethical work amongst philosophers, not to the new and perplexing moral challenges offered by (for example) the rapid growth and unprecedented success o f technological and scientific medicine, but to philosophers’ personal weaknesses and socio-economic changes in what was expected from academics and academic institutions. First o f all, she argues, ‘[it] flatters [the philosopher’s] self-esteem to see himself as a moral expert, an authority on moral matters called in to advise and assist important people like the doctor’; secondly, the materialist political climate o f the 1980s had led to a need to show philosophy to be relevant and o f ‘use’ that was at worst greedy and at best somewhat craven36. Unlike
Noble, however, Maclean has a clear conception o f what philosophers might instead contribute to the field.
Perhaps surprisingly, Maclean describes what she thinks philosophers should be doing in terms that recall both the respondents to Noble’s article and (at least part of) our own arguments in the previous chapter. For Maclean, the proper task o f the
philosopher in medical ethics is to help health professionals and others undertake critical analysis o f their own values and moral judgements. First o f all, philosophers should pose questions regarding moral judgements o f particular situations: ‘[why] is it a moral issue at all for us? How does it connect up with other issues? What values does it put at stake?’. Following this, they can further analyse answers to these questions, since the answers, questions, and the situations that prompt the questions tend to be ‘exceedingly complex [and] it is easy to confuse considerations relevant to one o f these issues with considerations relevant to another, or to misunderstand the character o f a particular claim or a particular objection’. In doing so, philosophers can help to identify logical fallacies and confusions between different sorts of issues (for example, empirical and conceptual issues), and analyse concepts (such as ‘quality of life’) that are ‘vague, ambiguous, or even incoherent’37. In summary (Maclean
argues), the philosopher’s task in medical ethics is ‘primarily one of clarification: the clarification o f issues, types o f issue, assumptions, arguments and concepts’38.
For Maclean, however, many philosophers (no matter how much they may protest otherwise) have given into the temptation to go beyond this role and are in fact committed by their methodology to doing so. Despite her title and her focus on utilitarian philosophers Maclean’s book is not, in fact, an attack on consequentialist thinking p er se but ‘on a particular form o f rationalism in ethics, to which she claims these writers subscribe’39. And not only these writers: Maclean defines ‘bioethics’ as ‘medical ethics as conceived and practised by philosophers working in the utilitarian tradition’40, so for her ‘all bioethicists are utilitarians’, albeit ‘invariably of an impure sort’41 (and presumably whether they agree with this judgement or not!). Maclean illustrates the commitment o f philosophers working in medical ethics to this view via the following quotation from Harris:
[Our] interest in all these problems and dilemmas will be an interest in their resolution... just as the proper business of medicine is not merely to understand the nature and cause o f illness but to try to prevent or cure it, so the proper business of medical ethics is not merely to understand the nature of the moral problems raised by medical practice but to try to resolve them42
According to Maclean, this analogy {"if carried far enough [my emphasis]’43) entails the view that it is the task o f the philosopher to discover "the right answers to ... moral questions’ and that these will be like ‘the right answers to certain other sorts of
questions - mathematical questions... or technical questions’44. In other words, it is to find ‘the answers it is rational to give’45: those justified by a ‘reason (or principle) [that] it is demonstrably rational to select’46. This description is, in fact, very close to what Winkler describes as the deductivist “ ‘applied ethics” model of moral
reasoning47’. Under this model, ‘[one] justifies a particular judgement by showing that it falls under a rule’, the rule under a principle, and the principle under ‘the most abstract level o f theory’, with the final aim or ‘Holy Grail’ of moral thinking a ‘single, comprehensive and coherent theory... based in universal, basic principles’48.
We may o f course simply object that this analogy should not be carried as far as Maclean chooses to: it may be that it is not only, as she thinks, a bad analogy for what philosophers can or should do in medical ethics, but a bad analogy for what they
actually do and/or have done. Certainly, as noted in the previous chapter, Hare (who
Maclean criticises at length later in the book49) employed very similar language while still flatly denying that the philosopher could produce answers in this sense (‘pills which the patient can just swallow’). Moreover, far from asserting the philosopher’s special competence to resolve moral problems, we may also recall that Hare’s proposals appeared to presuppose the philosopher working with others as part o f an interdisciplinary effort and that (for example in the case of the President’s
Commission) this was in fact exactly what many philosophers ended up doing. Certainly, as Lesser has noted, with the possible exception of Singer, ‘even utilitarian bioethicists... do not in fact believe [that they are moral experts in this sense]’50 something attested to by the responses to Noble’s criticisms considered above. On the other hand, Maclean advances ‘a plausible argument that logically they should: if you believe that it is possible to discover the basis o f ethics by the correct use of reason,
and also that you are using reason correctly in order to discover this basis, surely you must draw the conclusion that you are now a moral expert!’51.
Lesser has offered three reasons why this argument ‘though plausible, is unsound’. First o f all, even were philosophers to believe that they ‘have reached the truly rational conclusion’ regarding moral matters they are also likely, given the difficulty o f the task and the historical ‘lack o f success [encountered] over many centuries [by] many great minds’ in attempting it, to accept that it is ‘close to certain... that they are partly wrong, and more likely than not they are seriously wrong’. Philosophers are therefore likely to accept that: ‘there are no moral experts... because there is no point at which we can claim immunity from further philosophical scrutiny’52. Secondly, although ‘[attempting] to work toward what is best supported rationally and may at the moment be taken as what is most likely to be true’ is a philosophical exercise, it does not follow that an academic training in philosophy is either necessary or sufficient to undertake it: ‘Socrates and Plato had no [such] training [whilst] Frege, though a brilliant logician, remained a rabid anti-semite’53. Finally, whilst working out fundamental principles o f ethics may be ‘useful’ it is, again, neither necessary nor