Book Review

Medicine and Moral Reasoning

N Engl J Med 1995; 332:1177-1178April 27, 1995

Article

Medicine and Moral Reasoning
Edited by K.W.M. Fulford, Grant R. Gillett, and Janet Martin Soskice. 207 pp. New York, Cambridge University Press, 1994. $59.95 (cloth); $19.95 (paper). ISBN: 0-521-45325-9 (cloth); 0-521-45946-X (paper).

If there is an unacknowledged tension lurking behind much recent work in bioethics, it is over the place of philosophy and philosophers. Certainly, the origins of contemporary bioethics owe much to philosophy and its subfield of ethics. Whether it was the rigors of logic and careful analysis of concepts or the advantage of the objectivity of outsiders regarding the accepted practices of the medical subculture, philosophers such as Robert Veatch, Tom Beauchamp, Dan Callahan, Al Johnson, and Leon Kass were seminal contributors to the developing new field in the late 1960s and early 1970s.

Recently the call has gone out to make medical ethics more practical, more clinical — to bring it to the bedside. This has been done. The past decade has seen the growth of clinical applications of bioethics, its inclusion in the curriculum of undergraduate and graduate medical education, and its presence in hospital ethics-consultation services. Most textbooks now include many cases for discussion — not just one-dimensional examples, but complex true-to-life situations involving conflicting interests. Furthermore, textbooks for specialized audiences have appeared in psychiatry, neurology, pediatrics, obstetrics and gynecology, intensive care, and anesthesiology and for medical students and residents. In clinical settings the relative strengths and weaknesses of philosophical and clinical training tend to balance out, and much teaching and consulting is now done by physicians (and nurses) with training in bioethics.

This subtle shift is also apparent in research and publications in the field, which place more emphasis on empirical studies, often of a sociological or poll-taking nature. Institutional forces often enhance these tendencies with pressure to bill for consultation services (which is considered by many philosophers to be ethically questionable) and to conduct the type of research that is funded by outside sources (i.e., research in social science rather than philosophy). The result is a dimming of the influence of philosophy in bioethics.

This collection of 15 essays aims to remedy the situation by having clinicians deal with ethical problems and by having philosophers deal with medical problems, at a theoretical level, thereby trying to demonstrate again the value of using logic and conceptual analysis to illuminate some of the remaining knotty controversies of medical ethics. This is a most worthwhile goal. As might be expected, the essays are uneven in quality. I will comment on only a few of them.

Those who are naive about the field of ethics — and in the United States this includes many scientists and physicians because of the structure of our educational system — often think it is a simple subject, confusing personal opinions with self-evident truths. Among college students this yields relativism (the belief that everyone's opinion is equally good), but physicians may be more likely to see the need for ethics to have a solid foundation and to seek it in evolutionary theory. The opening essay by the keen philosopher Mary Midgley, on Darwinism and ethics, is thus a good start. “Is does not imply ought,” as David Hume long ago put it, so a good scientific theory about how the world is can contribute to, but not settle, ethical questions about how it ought to be. Equally important, Midgley argues that to ascribe selfishness to genes in this day and age flies in the face of considerable scientific evidence and is probably best understood as the projection of a preferred political ideology (such as Ayn Rand's or Milton Friedman's).

In contrast to Midgley with her purely secular approach, typical of philosophers, Janet Martin Soskice defends the potential value of theology (specifically, Christian theology) for medical ethics. Although the primary contribution of religious representatives on ethics committees is often thought to be as pastoral counselors (who become more useful as psychiatry becomes more medicalized) and not as theologians, Soskice argues the reverse. Taking the utilitarian philosophers Helga Kuhse and Peter Singer as her adversaries, she argues that their defense of infanticide for severely handicapped infants proves the failure of secular ethics. But some neonatologists appreciate that Kuhse and Singer are airing a topic others fear to discuss, and they believe it is a useful tonic to the aggressive treatment required by Baby Doe regulations against the wishes of parents and the best interests (if any) of infants. Furthermore, the views of Kuhse and Singer are rebutted as often by other philosophers, especially those who reject utilitarianism, as by theologians. Without a more reasoned discussion of why Soskice rejects the theory, this essay lacks philosophical substance and is only, so to speak, anecdotal.

Most books about bioethics are careful to present the two major modern theories of ethics: utilitarianism (usually represented by John Stuart Mill) and deontology (usually represented by Immanuel Kant). Three essays in this collection, by philosophers Thomas H. Murray, Grant R. Gillett, and James O. Urmson, discuss some of the other theories philosophers have offered and focus especially on a cluster of three important approaches that have only recently received due recognition in the bioethics literature: casuistry, the Aristotelian theory of virtues, and the theory that sympathy and other natural emotions are the basis of ethics (first brilliantly argued by David Hume in the 18th century and recently revived by feminist philosophers).

If medical ethics is not to become just clinicians talking among themselves, codifying the consensus, and solidifying the status quo, it must keep two other groups in the conversation: patients, whose authority derives from their personal, subjective experience of medicine; and philosophers, whose authority derives from their rational arguments and an objectivity that is preserved by their status as outsiders. This is not a book for practitioners seeking guidance, but rather for the few who seek to contribute to the literature of medical ethics. For them, some of these essays will provide helpful examples of how to think and write clearly about ethics. To quote Urmson:

I have heard medical men reproach moral philosophers with not providing a solution to the problems, but this is a misunderstanding of what moral philosophers can do. Certainly they have no special moral insight not found in other men. They can attempt to state accurately and clearly the relevant facts known to them, they can attempt to argue dispassionately and rigorously, they can make distinctions that might be overlooked, but they cannot pontificate, or, rather, when they do they are exceeding their authority. . . . Philosophers cannot answer the moral questions concerned with birth and respect for human life, but they can help to show more clearly what the questions involve and that they require human invention, not divination.

Jeffrey Spike, Ph.D.
University of Rochester Medical Center, Rochester, NY 14642