bioethics as a discipline daniel callahan

Bioethics as a DisciplineAuthor(s): Daniel CallahanReviewed work(s):Source: The Hastings Center Studies, Vol. 1, No. 1 (1973), pp. 66-73Published by: The Hastings CenterStable URL: http://www.jstor.org/stable/3527474 .Accessed: 27/09/2012 16:42

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THEORETICAL ANALYSIS AND PRACTICAL CASES

Bioethics as a

discipline DANIEL CALLAHAN

NE of the beguil- ing phrases I have picked up from reading scientific and medical journals is "anecdotal evidence." The careful researcher does not claim too much for evidence of that kind; he knows its scientific limitations. I must confess to the perversity of often finding evidence of that sort more suggestive than the solid, well-confirmed kind. It is surely far more interesting to collect. The topic of "bioethics as a discipline" invites a good deal of anecdotal evidence, and I intend to in- dulge fully in the pleasures of retailing my own experiences. For the sake of decency, I will maintain the confidentiality of my clinical records, shielding the names of the innocent and the guilty.

The topic also invites reflection on what I like to think of as "the politics of ethics." By that I mean the problem of taking the probings of professional philosophers and theologians and getting someone other than our lodge brothers and sisters to think that anything is being said at all. Or, in some richer sense of the word "politics," showing that serious ethical thinking has its place in the body politic of medicine and biology.

Finally, the topic invites at least some allusion to the concept of a "discipline," and

particularly the place of disciplines in the academic world. The graduate school catalogue sense of the word denotes specific training, refined methodologies, distinctive approaches and commitments, a long ap- prenticeship, professional expertise. That is a flattering picture. My own connotation, having seen academic disciplines in action, is too often arrogance, insulation, neurosis and narrowness. Can bioethics as a discipline avoid that hazard?

I will begin with three anecdotes. The first was a criticism leveled at a book I had writ- ten on the ethics of abortion. It came from a passionate feminist, strongly pro-abortion, who on the whole liked the book and its conclusions. "But what right have you," she shouted at me, "to press all of your heavy philosophical questions on people who aren't trained philosophers? What arrogance and cruelty! You should be trying to help women, not loading them down with a lot of hard intellectual problems which will just make them suffer all the more. You claim to be interested in ethics. Why don't you practice it!"

The second anecdote comes out of a seminar I once led on ethics and population control. The seminar members were professional sociologists and demographers. On one occasion, after some weeks of discus- sion, I was upbraided by a demographer for not making a precise enough distinction between "birthrates," "crude birthrates," and

BIOETHICS AS A DISCIPLINE 67

"fertility rates." "You philosophers," he gently chided me, "have just got to master the demographic literature and the technical distinctions if you're going to be any help to us." Chastened, I continued my lecture, which that day happened to be on the various philosophical distinctions between act- and rule-utilitarianism. After I had gone on a bit about that, my critic came back at me: "I'm afraid I'm finding this all very boring. You philosophers do nothing but make technical distinctions and split verbal hairs; and all that stuff about the different kinds of utilitarianism is too abstract to be of any use." As a footnote to that story, I might also note that the seminar participants diligently read all of the assigned readings on demography. But, with the exception of one young, un- washed research assistant, they hardly read any of the assigned reading in philosophical ethics; too tedious and irrelevant, they said. Even so, at the end of the seminar, one criticism I received was that I did not give enough time to ethics. "I wish we had been able to get more deeply into the problems," two or three people commented.

My third anecdote is this. Some colleagues and I had spent some months trying to con- vince a group of physicians that a good training in medicine did not necessarily qualify them to make good ethical decisions. They eventually conceded the point. But they conceded it with a twist of the knife. One day they came to us with a particularly agonizing case in hand, requiring a quick black-and-white decision. "What should we do?" they asked. "You're the philosopher, you tell us." The case was appalling, and I mumbled something about not being really qualified to tell them what to do. "But you've been telling us that, as physicians, we have no special qualifications for making ethical decisions. And now you're saying you don't either-even though you have a Ph.D. in philosophy and spend all of your time studying medical ethics. Just who is qualified to decide?"

I have painfully remembered each of these incidents because they well illustrate some of the fundamental problems of bioethics; and each of them illustrates more than one problem.

The first anecdote, involving my feminist critic, suggests three issues to me. The most obvious involves the hazards of pushing diffi-

cult questions on people who would prefer not to think of them; Socrates found out what that leads to. Another issue is the image of the ethicist as someone addicted to raising the philosophical ante, spinning out from one problem ten more, and then ten from each of those ten, the whole process pushing forward into every basic question about the meaning of life and existence; this can be called philosophical overkill. Still another issue is the exasperation ethicists arouse in those already committed to an answer to a specific moral problem, those for whom the intellectual probing is over and dedication to propagating the cause is the only item left on the agenda. The professional diffidence of the ethicist about seeing himself in the role of the advocate (I am less

resisted, with

utter panic, the idea of participating with the physicians in their actual decision. Who me? I much preferred the safety of the profound questions I pushed on them.

certain about the theologian) can only seem an evasion or a failure to take ethics seri- ously enough.

The second anecdote-my experience with the demographers-raises another series of issues. One is the very low tolerance level of most people, however highly educated, for philosophical theories and niceties; their eyes quickly glaze over. "If I had wanted to be a philosopher," one biologist once told me, "I would have gone to graduate school in philosophy." This attitude, however, is quite apt to co-exist with what certainly appears to be a desire on the part of these same critics to wrestle very hard with the issues. It's just that they don't find the char- acteristic way philosophers and theologians approach them very meaningful; which is a

68 HASTINGS CENTER STUDIES

nice way of saying they really think it is mainly hot air. There is another way of put- ting this point. While everyone will agree in principle that there should be reciprocity in the interdisciplinary work of bioethics, it is utterly naive for the philosopher or theologian to think that many scientists and physicians will rush back to Plato, much less G. E. Moore.

The third anecdote pushes us into what is the underlying issue in all three of the stories. Just what is the role of the ethicist in trying to make a contribution to the ethical problems of medicine, biology, or population? I resisted, with utter panic, the idea of participating with the physicians in their actual decision. Who me? I much preferred the safety of the profound questions I pushed on them. But I also realized when faced with an actual case-and this is my excuse-that there was nothing whatever in my philosophical training which had prepared me to make a flat, clear-cut ethical decision at a given hour on a given afternoon. I had been duly trained in that splendid tradition of good scholarship and careful thinking which allows at least a couple thousand years to work through any problem. The Review of Metaphysics ran a contest some years ago, offering a prize to the person coming up with the best answer to the question: "Why can't philosophers make up their minds?" It is still a good question, and of course I haven't been able to make up my mind about the right answer. The propensity of physicians and lawyers to prefer the case-method, and for philosophers and theologians to offer no more than one concrete example every forty pages or so is just another side of the same coin.

Place of the Ethicist

Let me take up the question which I said was underlying my three anecdotes: what is the place of the ethicist in medicine and biology? Does he have anthing to contribute and, if so, what? The answer at this point is that we just do not exactly know. But the fact that we may not know yet with any precision what the contribution can be, provides a splendid opportunity to shape the discipline in a way which might-just might -make an important difference in the long run.

Bioethics is not yet a full discipline. Most of its practitioners have wandered into the field from somewhere else, more or less in- venting it as they go. Its vague and prob- lematic status in philosophy and theology is matched by its even more shaky standing in the life sciences. The lack of general acceptance, disciplinary standards, criteria of ex- cellence and clear pedagogical and evaluative norms provides, however, some unparalleled opportunities. It is a discipline not yet bur- dened by encrusted traditions and domineer- ing figures. Its saving grace is that it is not yet a genuine discipline as that concept is usually understood in the academic and scientific communities. One has always to explain oneself, and that leaves room for creativity and constant re-definition; there are many advantages in being a moving target.

When we ask what the place of bioethics might be, we of course need to know just what the problems are in medicine and biology which raise ethical questions and need ethical answers. I will not retail the whole catalogue of issues here; suffice it to say that they begin with "A" (abortion and amniocentesis) and run all the way to "Z" (the moral significance of zygotes). One evident and first task for the ethicist is simply that of trying to point out and define which problems raise moral issues. A second and no less evident task is providing some systematic means of thinking about, and thinking through, the moral issues which have been discerned. A third, and by far the most difficult, task is that of helping scientists and physicians to make the right decisions; and that requires a willingness to accept the realities of most medical and much scientific life, that is, that at some dis- crete point in time all the talk has to end and a choice must be made, a choice which had best be right rather than wrong.

Not one of these tasks is easy, and one soon learns that all of the smart cracks one can direct at the dear innocent scientist who still thinks there is such a beast as a "value- free methodology" apply equally well to the methodologies of theology and philosophy. Feet will be wet before feet are even in the water. Moreover, one also soon dis- covers that well over half the in-fighting, and three-quarters of all punches to the groin, stem from arguments about whether


such-and-such an issue actually poses any ethical dilemma; or whether what is thought to be the dilemma is actually the dilemma. In the battle of ethics, no less than in other forms of human warfare, the high ground goes to those who succeed in establishing their definitions of the issues-at-stake and their stipulations about what will count as a sound methodology; the rest is mainly a mopping-up operation.

I used above the phrase "the realities of life." Another one of these realities is that the ethical issues of medicine and biology rarely present themselves in a way nicely designed to fit the kinds of categories and processes of thought which philosophers and theologians traditionally feel secure about. They almost always start off on the wrong foot by coming encumbered with the technical jargon of some other discipline. And only in text books is one likely to encounter cases which present a clear occasion, say, for de- ciding on the validity of a deontological or utilitarian ethical solution. The issues come, that is, in a messy, jumbled form, cutting through many disciplines, gumming up all our clean theoretical engines, festooned with odd streamers and complicated knots.

The fact that this is the case immediately invites the temptation of what can be called "disciplinary reductionism." By that I mean a penchant for distilling out of an essentially complex ethical problem one transcendent issue which is promptly labeled the issue. Not coincidentally, this issue usually turns out to be a classic, familiar argument in philosophy or theology. By means of this kind of reductionism, the philosopher or theologian is thus enabled to do what he has been trained to do, deal with those classic disputes in a language and a way he is com- fortable with-in a way which allows him to feel he is being a good "professional." The results of this tendency are doleful. It is one reason why most biologists and physicians find the contributions of the professional ethicist of only slight value. Their problems, very real to them in their language and their frame of reference, are promptly made unreal by being transmuted into someone else's language and reference system, in the process usually stripping the original case of all the complex facticity with which it actually presented itself. The whole business becomes positively pitiable when the phi-

losopher or theologian, rebuffed or ignored because of this reductionism, can only re- spond by charging that his critics are obvious- ly "not serious" about ethics, not interested in "real" ethical thinking.

I stress the problem of "disciplinary reductionism" out of a conviction that if a discipline of bioethics is to be created, it must be created in a way which does not allow this form of evading responsibility, of blaming the students for the faults of the teacher, of changing the nature of the problems to suit the methodologies of professional ethicists.

Toward this end, no subject would seem to me more worthy of investigation than what I will call the "ordinary language of moral thinking and discourse." Most people do not talk about their ethical problems in the language of philosophers. And I have yet to meet one professional ethicist who, when dealing with his own personal moral dilemmas, talks the language of his professional writings; he talks like everyone else, and presumably he is thinking through his own problems in banal everyday language like everyone else. Now of course it might be said that this misses the whole point of a serious professional discipline. Is it not like claiming that there must be nothing to theoretical physics simply because the physi- cist does not talk about the furniture in his house in terms of molecules and electrons? But the analogy does not work, for it is of the essence of moral decision-making to be

have yet to

meet one professional ethicist who, when dealing with his own personal moral dilemmas, talks the language of his professional writings; he talks like

everyone else, and presumably he is

thinking through his own problems in banal everyday language....


couched in ordinary language and dealt with by ordinary, non-professional modes of thinking. The reason for this is apparent. An ethical decision will not be satisfactory to the person whose decision it is unless it is compatible with the way in which the person ordinarily thinks about himself and what he takes his life to be.

My point here is by no means to deny the validity of ethical theory, the value of technical ethical language, or the need for disciplined rigor. Nor am I prepared to grant a narrow scientist or physician the slothful luxury of demanding that the ethicist master his technical distinctions while he himself is dispensed from mastering the ethicist's. The ethicist can make no useful contribution at all unless he is capable, on occasion, of moving more deeply into the issues than others do, of giving them a coherence and clarity which they may lack in the formulations of ordinary language, and of bringing to them a nuanced methodology. I am only trying to make the point that unless, in the process of doing so, he can remain in contact with ordinary language and ordinary thought processes-constantly establishing the con- nections-both his theory and his pedagogy will fail. His theory will fail because it will not bear on psychological reality, and his pedagogy will fail because it will have nothing to do with the way in which the ethical problems actually present themselves. The physician who, in trying to deal with a hard ethical case, keeps in mind his own feelings and thoughts, hospital policy and public policy, the emotions of his patient and his patient's family, trying to be responsible and yet faced with multiple and often conflicting responsibilities-that physician will not be responsive (nor should he) to the ethicist who tells him that, in the end, the real and only issue is, say, utilitarianism.

If I may put the matter in the form of a paradox, the ethicist may be quite correct in his theoretical analysis-perhaps utilitarianism is, say, the largest philosophical issue at stake in many ethical dilemmas. Yet he will be quite clearly wrong if he does not recognize that the issue in particular cases- Mrs. Jones in Ward 5 at 4:10 in the afternoon-must and will involve far more than the status of utilitarian theory.

I want to add an ancillary point. I once knew a distinguished philosopher who said

he had little interest in meeting and talking with other philosophers. After all, he could read their writings and get a far more rigorous, honed version of their views from that source than he could from conversation with them. Perhaps there is something to this when it is a question of one professional trying to understand the views of another professional. But I believe it an absolutely disastrous approach in the case of the ethicist trying to understand the moral thinking of the non-ethicist, particularly that of the scientist or physician. There is often no guarantee whatever that the ethical language used by the physician or scientist has any bearing whatever on the way in which he actually makes ethical decisions. Too often it is perfectly clear, in fact, that the actual principles which are coming into play are quite at variance with the expressed principles. I am not talking about hypocrisy here, nor about garden-variety logical inconsis- tency, but about the far more subtle phenomenon of someone who, because that is the only language he has been equipped with for public discourse, talks one kind of ethical terminology and yet acts in ways which are far more consistent with quite another kind of terminology, which no one has supplied him with. The existence of this phenomenon places a great premium on a good deal of oral exchange and probing, as well as a premium on a certain skepticism toward thinking that what non-ethicists say is actually what they necessarily mean and do.

The Meaning of 'Rigorous'

In trying to create the discipline of bioethics, the underlying question raised by the foregoing remarks bears on what it should mean to be "rigorous" and "serious" about bioethics. I recently talked with a very good philosopher who had spent a year team- teaching a course in ethical problems of biology with a biology professor. He did not want to repeat the experience. He found it impossible, he said, to introduce any real philosophical and ethical rigor into the course, not only because he neither could nor would ever have the time to properly master biology but also because the very process of trying to talk across disciplinary lines seemed inherently inimical to rigorous, methodologically-sound thinking; it was like


mixing apples and avocados, with an inedi- ble result. One can sympathize with his feelings, and it is common enough for ethicists to gather among themselves after some frus- trating interdisciplinary session to mutter about the denseness and inanity of their scientific and medical colleagues.

There are two options open here. One is to continue the muttering, being quite certain that the muttering is being reciprocated back in the scientific lab. That is, one can stick to traditional notions of philosophical and theological rigor, in which case one will rarely if ever encounter it in the interdisciplinary work of bioethics. Or, more wisely, the thought may occur that it is definitions of "rigor" which need adaptation. Not the adaptation of expediency or passivity in the face of careless thinking, but rather a per- ception that the kind of rigor required for bioethics may be of a different sort than that normally required for the traditional philosophical or scientific disciplines.

This is to say no more than that the methodological rigor should be appropriate to the subject matter. I spoke above of three tasks for the bioethicist: definition of issues, methodological strategies, and procedures for decision-making. Each of these tasks requires a different kind of rigor. The first requires what I will paradoxically call the rigor of an unfettered imagination, an ability to see in, through and under the surface appearance of things, to envision alternatives, to get under the skin of people's ethical agonies or ethical insensitivities, to look at things from many perspectives simultaneously.

A different kind of rigor is needed for the development of methodological strategies. Here the traditional methodologies of philosophy and theology are indispensable; there are standards of rigor which can and should come into play, bearing on logic, consistency, careful analysis of terms, and the like. Yet at the same time they have to be adapted to the subject matter at hand, and that subject matter is not normally, in concrete ethical cases of medicine and biology, one which can be stuffed into a too- rigidly structured methodological mold.

I am not about to attempt here a full discourse on what should be the proper and specific methodology of bioethics. Some sketchy, general comments will have to do, mainly in the way of assertions. Tradition-

ally, the methodology of ethics has concerned itself with ethical thinking; how to think straight about ethical problems. However, I believe that the province of the bioethicist can legitimately encompass a concern with three areas of ethical activity: thinking, feel- ing (attitudes), and behavior. The case for including feelings and behavior along with thinking rests on the assumptions (1) that in life both feelings and behavior shape thinking, often helping to explain why defective arguments are nonetheless, for all that, per- suasive and pervasive; and (2) that it is legitimate for an ethicist to worry about what people do and not just what they think and say; a passion for the good is not inap- propriate for ethicists.

If ethics was nothing other than seeing to it that no logical fallacies were committed in the process of ethical argumentation, it would hardly be worthy of anyone's atten- tion. It is the premises of ethical arguments, the visions behind ethical systems, the feelings which fuel ethical (or non-ethical) behavior, which make the real difference for human life. Verbal formulations and arguments are only the tip of the iceberg. An ethicist can restrict himself to that tip; he will be on safe enough professional grounds if he does so. But I see no reason why he can't dare more than that, out of a recogni- tion that the source and importance of his field lie not in the academy but in private and public human life, where what people think, feel, and do make all the difference there is.

Even in individual decision-making, the purely rational part may quite legitimately play only a subordinate role in some cases. Personal or group experience, for one thing, may provide reasonable, though non-articu- latable, principles for conduct. Traditions, for another, may provide still other principles, even though they lie buried well below the surface of consciousness.

To be sure, there will always be the critical task for ethics of asking that reasons and justifications be given for principles derived from experience and traditions. Nonetheless, in the nature of the case, these justifications may not be forthcoming, if only because they may be falsified if pressed into a verbally articulated form. Occasionally, too, we see situations in which behavior is clearly "good," but the reasons given for that be-


havior are weak or non-existent. Only a maniac would want to subvert good behavior on the grounds of the defective arguments used to rationalize the behavior.

Criteria for Methodology

I will only offer one negative and one positive criterion for ethical methodology. The wrong methodology will be used if it is not a methodology which has been specifi- cally developed for ethical problems of medicine and biology. This does not mean it cannot or should not bear many of the traits of general philosophical or theological methodology. But if it bears only those traits one can be assured that it will not deal adequately with specific issues which arise in the life sciences. My positive criterion for a good methodology is this: it must display the fact that bioethics is an interdisciplinary field in which the purely "ethical" dimensions neither can nor should be factored out without remainder from the legal, political, psychological and social dimensions. The critical question, for example, of who should make the ethical decisions in medicine and biology is falsified at the outset if too sharp a distinction is drawn between what, ethical- ly, needs to be decided and who, politically, should be allowed to decide. It is surely important to ethical theory to make this kind of distinction; unfortunately, if pressed too doggedly it may well falsify the reality of the way decisions are and will continue to be made.

The problem of decision-making, which I include as the third task of the bioethicist, cannot be divorced from the methodological question. Actually it makes me realize that I have a second positive criterion to offer as a test of a good bioethical methodology. The methodology ought to be such that it enables those who employ it to reach reasonably specific, clear decisions in those instances which require them-in the case of what is to be done about Mrs. Jones by four o'clock tomorrow afternoon, after which she will either live or die depending upon the decision made. I have already suggested that philosophers are not very good at that sort of thing, and that their weakness in this respect is likely to be altogether vexing to the physician who neither has the right atmosphere nor the time to think through

everything the philosopher usually argues needs to be thought through.

In proposing that a good methodology should make it possible to reach specific conclusions at specific times, I am proposing a utopian goal. The only kinds of ethical systems I know of which make that possible are those of an essentially deductive kind, with well-established primary and secondary principles and a long history of highly refined casuistical thinking. The Roman Catholic scholastic tradition and the Jewish responsa tradition are cases in point. Unfortunately, systems of that kind presuppose a whole variety of cultural conditions and shared world-views which simply do not exist in society at large. In their absence, it has be- come absolutely urgent that the search for a philosophically viable normative ethic, which can presuppose some commonly shared principles, go forward with all haste. Short of finding that, I do not see how ethical methodologies can be developed which will include

he discipline of

bioethics should be so designed, and its practitioners so trained, that it will directly-at whatever cost to

disciplinary elegance-serve those physicians and biologists whose

position demands that they make the practical decisions.

methods for reaching quick and viable solu- tions in specific cases. Instead, we are likely to get only what we now have, a lot of very broad and general thinking, full of vagrant insights, but on the whole of limited use to the practicing physician and scientist.

Much of what I have been saying pre- supposes that a distinction can be drawn between "ethics" understood broadly and ethics understood narrowly. In its narrow sense, to do "ethics" is to be good at doing what well-trained philosophers and theolo-


gians do: analyze concepts, clarify principles, see logical entailments, spot underlying assumptions, and build theoretical systems. There are better and worse ways of doing this kind of thing and that is why philosophers and theologians can spend much of their time arguing with each other. But even the better ways will, I think, not be good enough for the demands of bioethics. That requires understanding "ethics" in a very broad, well-nigh unmanageable sense of the term.

Impossible and Scandalous

My contention is that the discipline of bioethics should be so designed, and its practitioners so trained, that it will directly -at whatever cost to disciplinary elegance-- serve those physicians and biologists whose position demands that they make the practical decisions. This requires, ideally, a number of ingredients as part of the training-which can only be life-long--of the bioethicist: sociological understanding of the medical and biological communities; psychological understanding of the kinds of needs felt by researchers and clinicians, patients and physicians, and the varieties of pressures to which they are subject; histori- cal understanding of the sources of regnant value theories and common practices; requi- site scientific training; awareness of and facility with the usual methods of ethical analysis as understood in the philosophical and theological communities-and no less a full awareness of the limitations of those methods when applied to actual cases; and,

finally, personal exposure to the kinds of ethical problems which arise in medicine and biology.

This is an impossible list of demands, guaranteed in advance to scandalize all of those professionals in whose field one must trespass. The scientist will point out that you are not a trained scientist, the physician that you are lacking both a medical degree and the clinical experience of treating patients, the sociologist that your anecdotal evidence is worth nothing, the philosopher that you are straying from solid philosophical work. Well, so what? That is what the discipline of bioethics requires.

One important test of the acceptance of bioethics as a discipline will be the extent to which it is called upon by scientists and physicians. This means that it should be developed inductively, working at least ini- tially from the kinds of problems scientists and physicians believe they face and need assistance on. As often as not, they will be wrong about the real nature of the issues with which they have to wrestle. But no less often the person trained in philosophy and theology will be equally wrong in his understanding of the real issues. Only a continu- ing, probably tension-ridden dialectic will suffice to bridge the gap, a dialectic which can only be kept alive by a continued exposure to specific cases in all their human dimensions. Many of them will be very un- pleasant cases, the kind which make one long for the security of writing elegant articles for professional journals on such manageable issues as recent distinctions between "rules" and "maxims."

bioethics as a discipline daniel callahan

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