Simulación y comprobación del método propuesto

Conventionally, philosophy is normative. Its definitive tools are those of theories of morality, practical rationality, analyses of moral concepts and so on. Much sociological research, on the other hand, is empirical, providing the ‘facts that healthcare ethics grinds in its normative mill’ (Nelson, 2000, pl2). However, the distinction is not that clear. To be sure philosophical approaches to ethics are inclined to be normative, whilst those of social science are more empirical. However, some sociologists working in areas relevant to medical ethics have ‘disavowed any interest in the application of their researches to procedures and policy-making. They prefer to stress their implications for such abstruse matters as the sociology of the professions,

"theories” of organisations, or the social organisation of cognition’ (Zussman, 2000, p7).

A necessary condition for any research on empirical ethics is that it employs the 'combined philosophical and sociological approach' of the title of this dissertation. In such an approach these disciplines have a two-way relationship not unlike that between theory and experiment in the natural sciences. Empirical ethics draws primarily upon applied sociological research methods to test a number of questions raised by the ethics literature and brings in specific sociological theorising in discussing the implications of the findings for practice. Philosophy can, in turn.

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enrich the form and content of the empirical study and research findings by providing a set of theories and skills which help frame the questions to be asked, especially where, as in this case, these involve high-level concepts such as beliefs or values.

Philosophy also guides analysis of the results, the findings of the empirical study informing and contributing to the development of the philosophical theory.

Working simultaneously in both philosophy and applied sociology reveals that the difference between these disciplines is more subtle than it might initially seem.

Perhaps because they believe that it is enough to know that a phenomenon exists, regardless of those characteristics such as distribution and social trends which interest sociologists, philosophers tend to be less systematic in dealing with empirical matters. The former, on the other hand, can says Zussman (2000) sometimes appear incapable of making more than a limited range of normative claims. Deontological arguments about moral judgements are, this author suggests, remarkable for their absence in sociological thought.

Whilst significant, such differences do not imply a deep and totally insuperable

’incomprehensibility' between philosophical and applied sociological approaches to healthcare ethics. Rather, they imply that degree of complementarity described by Fulford et al. (2002, p 12) and which this study, in which applied sociological research informs substantive philosophical discussion of the ethical issues involved in the care of the mentally disordered, aims to demonstrate.

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It could, therefore, be considered surprising, even disappointing, that applied sociology has not so far made a valuable contribution to medical ethics. This is incongruous given that the questions being examined in this, such as informed consent, managed care, and so on. hinge to a very large extent on empirical considerations, whilst tending to be based on consequeniialist arguments.

The fact is that at present a good deal of healthcare ethics - the QALYS15 system would be a good example - is based upon consequentialist claims which sociologists, with tools such as quantitative and qualitative analysis at their disposal, are particularly well-equipped to assess. If an ethical claim is based on the belief that a practice or arrangement is ethically either desirable or questionable because it results in a particular outcome, then that claim - as this research will show - is empirically testable. It is, though, most unusual for philosophers specialising in healthcare ethics to perform such tests themselves. They often prefer the more conventional philosophical tool of the “thought experiment” (see footnote 16 for an example).

However, sociologists can very effectively carry them out. for regardless of whether the issue in question is informed consent, violence, managed care or the withdrawal of rights, ethical arguments depend to a great extent on empirical propositions. There are many kinds of ethical issue about which an empirical study of mental health care practice might ask questions. In this study these questions are raised, and the findings which emerge from fieldwork are analysed and discussed.

15 QALYS are quality-adjusted life years and are used to evaluate the number of "quality" years, which a user would be likely to live, compared to another, in prioritising treatments. Implicit in their use is 'the idea that the only objective of health services is health maximisation' (Beauchamp and Childress, p3l I)

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According to Beauchamp and Childress (1994), good moral reasoning involves the following:

1. Accurate empirical beliefs 2. Defensible moral values 3. Clarity about relevant concepts 4. Formally valid argumentation.

The first of these is an area in which applied sociology would naturally operate. As far as Beauchamp’s and Childress's second point is concerned moral philosophy, theology and other disciplines all serve to inform the articulating and defence of moral values. Finally, philosophy, as the 'guardian of conceptual analysis' (Nelson.

2000. p i 3) and logic informs both point three, conceptual clarity, and point four, the formal validity of the arguments.

However. Beauchamp's and Childress's four-step approach to moral reasoning might, not unreasonably, be considered by the sociologist to be a gross oversimplification of the moral, conceptual and empirical relationship. Sceptics of this so-called 'linear' view might, for example, ask how the normative effect upon fact-finding is to be recognised without undermining the moral arguments that draw upon the facts.

Nonetheless, it could equally be argued that the values inherent in applied sociological research do not necessarily distort the healthcare ethicist's access to the factual world at all. but to the contrary, deepen and enrich the normative understandings on which those moral concepts and beliefs employed in analysis are based.

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Clarifying the workings of values in empirical disciplines seems, in itself, to be an empirical task. As such this process is potentially subject to undermining by distortions caused by the personal scale of values which the researcher inevitably brings to enterprises such as that under consideration. Whilst this kind of scepticism may be common, it is not necessarily plausible and might even be considered paradoxical in that: ‘It makes ambitious knowledge claims itself, concerning what knowledge is and what's wrong with all efforts to establish any’ (Nelson, 2000. p 14).

The fact that empirical enquiry incorporates values does not necessarily imply that it is self-defeating. In reaching a better understanding of the norms inherent to factual accounts, as Nelson points out, healthcare ethicists can also deepen their understanding of values. In addition to providing the latter with facts, sociologists may act as “catalysts”, causing ethicists to investigate and challenge their particular notions of what is worth studying and, more importantly, whose interests are worth serving. This appears to be the result of the research process described here.

Can sociology really embody normative traditions? Sociologists, as human beings with all the defects and weaknesses inherent in this condition are, as Nelson says:

‘hardly likely to be distinguished from philosophers with regard to political and ethical affiliations consistently enough to see their fields as sources of distinct moral views on features of medicine or any other aspect of society’ ( p i4). They do not present a ‘morally united front’ (ibid.). However, given their particular interest in group dynamics, sociologists may be able to indicate normatively significant features of human life which are virtually overlooked by disciplines such as applied ethics,

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which is explicitly concerned and inextricably linked with moral values. Epistemic and ethical values can perhaps inform one another in the sense that what sociologists consider effective ways in which to study people scientifically can influence what ethicists consider to be good ways to think about people morally. Healthcare ethics can benefit from using the investigative procedures and engaging with the heuristic interests characteristic of applied sociology. This would provide a new and different

"gaze" and consequent understanding of the ethical inferences to be made from the study of individuals, communities, relationships and responsibilities.

Something which originally interested philosophers working in healthcare ethics was the notion, held by some, although not all, that 'reflecting on developments in health care provided ... a very good way of doing philosophy’ (Op. cit. p i 7). However, the success of healthcare ethics in informing clinical practice has been relatively minor and in some areas, including mental health practice, has arguably proved frustrating.

Ethics cannot merely give advice. It must improve understanding of morally relevant ideas and promote deeper understanding of those aspects of these which can be, as the research findings reveal, at best confusing and at worst counterproductive, in both clinical and research contexts.

If this is so. philosophical and sociological collaboration is essential insolar as the normative understandings which attend sociological practice must come to he regarded as significant to ethics generally. This is beginning to happen and healthcare ethicists are seeking and creating approaches to ethics which rely quite heavily upon empirically demonstrated understandings of social life. Indeed, a recent editorial in the Journal o f Medical Ethics (Gillon, 1996) described the publication of empirical

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studies as a healthy development in what it termed the ‘maturing’ subject of medical ethics.

Theoretical tenets of various kinds - ideological, metaphysical and value-based - underlie the prescriptions of present mental health ethics, but the resolution of many ethical dilemmas within practice demands appeal to sociological theory. Theoretical assumptions which raise and affect concerns about mental health practice can also be identified. Is it. for example, true that most female health workers care instinctively, whilst the majority of their male colleagues tend to exercise paternalistic power? Or is this a socially constructed ‘myth' which research, informed by sociological theorising on emotional labour, may prove to have little foundation in fact? This is important, for if men are revealed as ‘carers' in the feminist sense, or if caring proves to be a form of emotional labour, then an ‘ethic of care’ cannot be described as uniquely ‘feminine’, in spite of Noddings’ title and the credence given to her views by many feminists. (Although it could be argued that this might be the case if this was construed as a gender orientation in biologically sexed men/males10).

The conventional contrast between normative philosophical approaches and empirical sociological perspectives draws upon excessively clear-cut distinctions. If, as has been claimed, different theoretical tenets underlie the prescriptions of mental health ethics, any empirical study of these must consequently be informed by philosophical and sociological theory and analysis. Theories may be the roots of the tree upon which informed knowledge and understanding of social reality grow, but they cannot

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be based upon simple observation of society. Whilst social and medical research are essentially about 'humans investigating humans' (Shipman. 1997, p3), this involves philosophical and empirical issues. Empirical research aims to ascertain and clarify facts, making arguments based on these more substantive. However, although facts may thus discipline reason this is: 'the advance guard in any field of learning’.

‘Empirical projects must have implications for theoretical constructions', (Wright Mills. 1959. p205).

From a philosophical point of view, the epistemic strategy described by Deutseh (1966) allows for a reflexive dimension, which understands itself as the theory's social and historical embeddedness, to be incorporated into this. The Deutschian notion of science as the process whereby our world knowledge is acquired is represented in the following reflexive cycle (Fig. 1). This shows how early theoretical consensus on basic assumptions and methods is followed by a period of empirical research, producing data which in turn lead to further philosophical questions.

Figure 1.

PHILOSOPHY ^ OBSERVATION

T

I

H A T A C O L L E C T I O N

PROBLEMS AND ANALYSIS

As Deutsch says:

‘Philosophic stages in the development of a particular science are concerned with strategy; they select the targets and the main lines of attack. Empirical stages are concerned with tactics', they Thanks are due to Dr. Simon Williams for pointing this out to me.

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attain the targets, or they accumulate experience indicating that the targets cannot be taken in this manner.

(Deutsch, 1966, pp 3-4) For sociologists who study healthcare ethics, the normative implications of their task are unavoidable, although it might be the philosopher who clarifies these. Applied sociological research can. on the other hand, effectively inform any philosophical discussion of the ethical issues involved in patient-centred practice. Analytic ethics is ethically neutral and therefore arguably "needs” the input which only applied sociological research methods can provide ’... content must be added to form, data to concept, if conclusions bearing on a concrete issue are to be drawn’ (Fulford, 2002, p 162). Combining philosophical ethics and social scientific empirical fieldwork in researching mental health ethics would, therefore, seem to make good sense.

The relevance of applied sociology to empirical ethics also lies in the fact that: 'moral theory begins in practice’ (Hoffmaster, 1992. p 1421). This author points out that moral decision making is essentially the search for an adequate response to a particular situation and more a question of finding creative solutions than applying philosophical formulae17. First, how moral dilemmas are perceived and constructed is investigated. Second, how each individual confronts such problems is recorded.

Third, these attempted resolutions are analysed. Research such as that undertaken for this dissertation will reveal the forms of moral rationality in mental health practice, provisionally indicating and defining the strengths and limitations ot each form of resolving ethical dilemmas. 11

11 This has a certain resonance with Jonsen and Toulmin (1988). See section 2.2.1.

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What Hoffmaster suggests is a style of ethical theory that, like grounded theory, works from the (research) ground up and is based on a real and detailed knowledge of the situation in question. His argument constitutes what has been described as a 'virtual manifesto’ (Zussman, 2000. plO) of healthcare ethics for sociology and must consequently merit close consideration. If Hoffmaster’s views were taken seriously, a radical change could occur in these, the present boundaries between sociology and philosophy, between normative and empirical, eventually disappearing. Applied sociology’s most important contribution to healthcare ethics could be bringing into the practice setting a set of ethical standards which are 'not native to the occupational and organisational cultures' (Zussman. plO), such as those pertaining to the professional organisations of mental health practitioners of all disciplines.

Hoffmaster also asks how ethical issues are generated. In one form, he claims, the medical ethicist merely reacts to issues raised by practitioners. In another (which this study seeks to emulate) the former is a Socratic “gadfly”, reading, thinking and then researching the potentially awkward questions and situations which serve to make users, practitioners and policy-makers question what may be the previously unquestioned status quo.

It might be claimed that healthcare ethics has adequately survived without the “help”

of applied sociology, but the empirical ethicist would claim that being informed by this discipline brings a more pragmatic and "practical” dimension to the occasionally

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ludicrous flights of imagination which characterise some works in healthcare ethics18.

Whilst few sociologists are trained in moral reasoning and analysis, disavowing normative concerns will not help sociology, either. Social sciences, sometimes thought to provide ‘just the facts’ (Nelson, 2000), may leave attending to moral values, clarifying concepts and constructing formally valid arguments to philosophy.

However, all disciplines are informed by epistemic values, and healthcare ethicists are increasingly aware that sociological practices and normative understandings of what is relevant to human flourishing are important to ethics generally.