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Contemporary research and teaching in medical ethics is unduly influenced by the imagery of stability, order and uniformity. Many commentators presume the existence of a placid social order and pay little regard to differences in understandings of birth, illness, suffering, death and the nature of healing. Moral philosophers such as John Rawls and Norman Daniels, for example, argue that with the existence of an ‘overlapping consensus,’ morality is in a state of ‘side reflective equilibrium’1. Tom Beauchamp and James Childress, two of the earliest proponents of the ‘principlist’ approach to bioethics, take this view2, as do advocates of case-based moral reasoning (casuistry) such as Albert Jonsen and Stephen Toulmin3. Notwithstanding methodological differences in the manner these philosophers address practical ethical issues in medicine and healthcare, all of them presume the existence of a stable, settled moral order. ‘Society’ is discussed in monolithic terms, and both principlists and casuists pay remarkably little attention to the role of religion and culture or ethnicity in shaping understandings of such topics as abortion, physician-assisted suicide, prenatal genetic testing, stem-cell research or the withdrawal of treatment in end-of-life care. Relying upon philosphical approaches that presume the existence of shared principles and moral paradigms, contemporary ethicists commonly neglect to address important differences in the moral understandings of particular religious communities and ethnic groups4. The notion of ‘common morality’ tends to obfuscate the complex realities of providing medical care in multicultural, multifaith societies5. In pluralistic settings, different interpretive communities can exist, with distinctive understandings of what constitutes moral conduct, forms of evidence and reasoned arguments6. In short, commentators on the ethics of medicine and healthcare greatly over-simplify their task by presuming widespread social support for norms and practices that are in reality subject to vigorous dispute.
Let us consider the position of a physician or nurse in London, New York, Sydney or Toronto, where patients come from diverse cultural and religious backgrounds. Some patients wish to receive detailed information about their diagnosis, prognosis, and treatment options. Other patients follow a different cultural script, expecting family members to make important health-related decisions and shield them from ‘bad news’. Some patients, fearful that they will become captive to sophisticated medical technologies, prepare advance directives refusing various possible medical interventions. Others, perhaps because of deep religious belief, want ‘everything done’, and insist on cardiopulmonary resuscitation even in circumstances deemed medically futile by healthcare providers. Some families seek to practise their religious traditions by asking physicians to circumcise their male children—an act that other groups see as child abuse and a violation of human rights. Members of some right-to-die organizations insist that compassionate healthcare providers and legislators would permit physician-assisted suicide, whereas members of many Jewish, Muslim and Christian religious communities declare that legalization of physician-assisted suicide would seriously devalue human life. To contribute usefully to contemporary debates, ethicists need to better address the multiethnic, multifaith character of contemporary social settings7. They need to recognize the existence of a plurality of ‘communities of interpretation’ and ‘local moral worlds’8.
In the field's early years—at least in the North American context—the imagery of the layer cake model of moral reasoning permeated discussions of medical ethics. This model was most persuasively articulated in successive versions of Beauchamp and Childress' Principles of Biomedical Ethics, which popularized the notion that from moral theories can be derived moral principles and rules that can then be utilized at progressively more refined levels of specification9. Working in a deductive manner, the ethicist proceeds down the layer cake from moral theories to mid-level principles that are applied to cases of various sorts. While Beauchamp and Childress never presented the layer cake as the sole model for the process of moral reasoning, this deductivist approach came to serve as a major tool of bioethicists. But the layer cake is now yielding to a different image—that of the ‘web’ of wide reflective equilibrium or common morality10. The image of the web reflects the notion that no singular theory or principle can serve as an adequate foundation for moral reasoning in all instances.
The increased predominance of the web model of moral reasoning reflects the détente now being established between principlists and casuists. The decade following publication of Albert Jonsen and Stephen Toulmin's The Abuse of Casuistry witnessed a lengthy debate between the supposedly deductivist claims of principlists and the more inductivist case-oriented approach3. However, the differences separating these approaches have seemed ever less important. Contemporary casuists and principlists emphasize the extent to which the exploration of moral issues in medicine and healthcare requires attentiveness to common morality.
According to casuists and principlists, common morality encompasses a shared body of rules, rights, maxims, obligations and mores that constitute the fabric of everyday moral life. Eschewing universalistic foundations for moral reasoning in favour of a historically informed understanding of basic paradigms, the common-morality approach assumes the existence of a stable, shared, comprehensive moral order. Whether such a model of wide reflective equilibrium existed in particular times—for example in regions of medieval Europe or in the USA of the 1950s—is a matter of dispute11. Certainly, the contemporary multiethnic, multifaith scene to be found in most of the major urban centres of the world is not to be characterized by images of order, stability and uniformity12. In the clinical setting, some of the relevant differences concern sexual relations and kinship patterns, perceptions of modes of healing, dietary preferences and moral norms. The notion of a single web of moral reasoning fails to capture the different understandings of morality and medicine.
In turning from images of the layer cake to the rhetoric of the web, philosophers have paid too little attention to multiplicity and variability13. For example, in the latest edition of Beauchamp and Childress' Principles of Biomedical Ethics2 ‘mid-level’ principles are deemed to encapsulate the common sense wisdom of a host of alternative moral visions and theories. Common morality resides at the convergence of diverse theories, norms and moral traditions. However, despite their articulation of a common-morality model incorporating mid-level principles, Beauchamp and Childress still do not fully acknowledge the multiple ways in which particular principles can be understood and applied within different settings. For example, ‘autonomy,’ as both a word and a substantive principle, can assume quite different meanings. Antonella Surbone, an Italian medical oncologist, writes, ‘In the Italian culture, autonomy (autonomia) is often synonymous for isolation (isolamento)... Protecting the ill family member from painful information is seen as essential for keeping the family together and not allowing the ill member to suffer alone’14. Likewise, questions of what constitutes beneficence, non-maleficence and justice can be addressed in quite divergent manners, depending upon the manner in which moral reasoning is informed by religious and cultural norms15.
The diversity of moral tongues can be recognized even within what is often termed the western intellectual tradition. A philosophical and religious tradition that includes not just Plato, Augustine, Aristotle, Aquinas, Descartes, Kant, Bentham, Mill, Rawls, Nussbaum and Habermas, but also Seneca, Vico, Herder, Nietszche, James and Berlin, is scarcely a seamless garment of common sense or common morality. It is more of a patchwork quilt.
The motley character of this patchwork quilt or tangle of webs becomes even more evident when one recognizes that the western philosophical tradition is not the only starting-point for normative analyses. Many contemporary bioethics textbooks assume that the most decisive moral battles are between different schools of western moral philosophy. Students are given potted summaries of Aristotle, Mill and Kant as though moral reflection in various communities is completely uninformed by Hindu, Jewish, Roman Catholic, Protestant, Muslim, Buddhist, Confucian, Shinto and Taoist interpretive traditions.
Unfortunately, a host of simplifying labels obscure the complexities of the various cultural and religious traditions that shape moral reflection in various settings. Terms such as Judaeo-Christian ethics or eastern and western thought conceal far more than they reveal with their massive generalizations. Just as it is one thing to be born in Pocatello, Idaho, and quite another experience to be raised in Barcelona, Cape Town, Kyoto or Reykjavik, there is good reason to differentiate between the ‘local moral worlds’ found within such regions as Thailand, South Korea, North Korea, Singapore, Japan and China8.
While differences within and amongst cultural and religious traditions need to be recognized, we must not fall into the trap of fostering ‘frozen’ accounts of discrete, highly bounded moral traditions. Take for example the city of Los Angeles—a key site for the observation of globalization and the transnational flow of communities, where individuals from different religious traditions and ethnic groups grapple with different understandings of moral practice. Of course, these individuals do not just transplant their ‘culture’ to Southern California or leave their salient religious and cultural traditions behind when they immigrate to the USA. Rather, ethnic traditions and religious practices are commonly transformed in the new setting, just as the new locale is shaped by the cultural traditions and mores of its immigrant communities. There is a process of mutual influence and transformation. Innovative social and familial arrangements, courtship patterns, culinary dishes, musical forms and dances begin to emerge. Over time, these groups blend and blur, so that the citizens of Los Angeles are not just multiethnic in the sense that individuals from many different ethnic groups inhabit Los Angeles, but in the sense that particular individuals live at the intersection of multiple strands of human community, language and history.
Through cultural exchange, dispersion and globalization urban centres such as Paris, San Diego and Vancouver illustrate the growing porousness of cultures and nations16. Increasingly, it will not make sense to think of culture as a sharply demarcated body of knowledge or sets of practices expressed by the members of discrete, isolated social groups17. Rather, recognition of the varieties of common sense and ways of worldmaking will require attentiveness to flux, diversity and heterogeneity18. Increasingly, it will make little sense to think in terms of eastern and western religions and philosophical traditions, or of ‘national’ culture. In an era of rapid globalization, boundaries and borders begin to blur19. In such a setting, it is misleading to think of ‘society’ existing in a state of reflective equilibrium. Rather, we live in a time when competing narratives bring different standards of reasoning, argumentation and evidence to topics ranging from male circumcision to the definition of death.
Anthropological and sociological approaches to social analysis can avoid the most egregious weaknesses of approaches to bioethics that presume the existence of a common morality. These more ethnographically attuned studies of moral orders will not necessarily disavow all claims to a common morality—or to minimal standards necessary for shared social institutions and legal frameworks20. While the introduction of tools and approaches from anthropology, sociology and ethnic studies into medical ethics risks accusations of ‘ethical relativism,’ the current complacent emphasis upon the existence of a common morality seems more appropriate to Enlightenment Scotland than to the realities of contemporary multiethnic, multifaith, multicultural regions. ‘Commonsense’ moral philosophies of medical ethics must recognize the multiplicity of modes of practical moral reasoning. The existing models of moral reasoning in bioethics simply do not face the challenges that exist in highly pluralistic social settings. Bioethics as a discipline will take an important step when it stops presuming the existence of a stable, settled, order and begins to acknowledge the multiplicity of moral worlds.