Is bioethics an American plot?
I have chosen a rather provocative title for the closing paper of our conference because there is much talk of "Asian values" and "Western values" around these days in bioethics. Many people now question whether the universalist aspirations of traditional ethics can stand up to historical, sociological and philosophical scrutiny, and assert that more culturally specific mores are the only legitimate ones. If this is true it has serious implications not just for healthcare practice and bio-lawmaking, but for the formation in professional ethics offered in our higher education institutions.
Following the Second World War the World Medical Association published a code of ethics for all medical practitioners and declarations on various matters such as human experimentation. Some secular academics now doubt the usefulness of such universal codes. Some are similarly sceptical about the universalist claims of papal encyclicals such as Veritatis Splendor, Evangelium Vitæ and Fides et ratio or of Church documents such as the Catechism of the Catholic Church and the Vatican Charter for Health Care Professionals.
Even if we agree that some global bioethic is possible, there are rival claimants as to which it should be and there may be a suspicion that a kind of "values imperialism" is going on, with one group colonizing the mores of the other. By far the most influential bioethic in the world today is Principlism. Following the exposure of a number of horrific biomedical experiments before, during and after World War Two, the National Research Act 1974 directed the Secretary of the US Health Department to appoint a commission to "identify the basic ethical principles" that the federal government should use in funding and regulating medical research and practice. The 1979 Belmont Report identified respect for persons, justice and beneficence as the (only) three basic principles of bioethics over which there was a general consensus. The attempt to reduce ethics to just a few basic principles reflected the simplification and secularisation of the much richer Hippocratic tradition of medical decorum and the more religious "Medico-Moral" tradition that had reigned in healthcare well into the twentieth century.
Following the Belmont Report a version of "Principlism" was popularised by Thomas Beauchamp and James Childress of Georgetown University in Washington DC in their classic text. With the explosion of the bioethics industry this approach spread like a virus through the world, transmitted by a textbook now in its sixth edition and by thousands of students returning from quick courses in Georgetown and elsewhere, ready to put up their shingle as a "bioethicist". What many people found attractive about this approach was the way it eschews commitment to any one culture, religion or moral theory or to any particular set of metaphysical or moral foundations. It also avoids prescribing any detailed moral norms, while proposing some (supposedly) common ground on "middle order principles". The globalisation of ideas has meant that products like these are readily exported to almost everywhere in the world and very widely consumed, so that I hear Principlism parroted as often in Asia and the Pacific as I do in the United States, Britain or Europe.
Principlism seeks to reduce bioethics to four basic "principles": beneficence, non-maleficence, autonomy and justice. This is commonly called "the Georgetown Mantra" because after learning to rattle off those four words, some people think they've got bioethics.
Yet as many critics have noted, the four principles are not really moral principles at all. They are so "neutral", "thin" or "empty" as to invite many interpretations and to allow their users to rationalize almost any practice. To the extent that have any stable content at all, they tend to presume -- and subtly impose -- a (Northeastern establishment) American value set. This commonly includes a dogmatic secularism and a radical individualism that proves empowering for the already powerful but disempowering or even lethal for many unborn babies, handicapped neonates, persons living with disabilities, the frail elderly, the unconscious or demented, the poor and the dying.
The supposed "neutrality" of Principlism, then, is naïve at best, disingenuous at worst. It is this last complaint that is the basis of my question about bioethics, not as it could or should be, but as it is actually practised today: is it really an American plot? I am not suggesting, of course, that there is any mastermind behind the export of the Georgetown product, though that university has famously had many links with the CIA over the years! However, this consumer product has proven so successful in penetrating the world "market of ideas" that I think it is worthy of consideration and critique in Catholic centres of higher learning.
Before we can adopt or critique Principlism we must understand what it is proposing. What sense might we make of these very popular four principles and where might this point us from here? Bioethics should be rational reflection upon what people should be and do in the spheres of life, death, health and healthcare. It should start with the human person, the traditions and experience of action in those particular arenas, the general principles of morality and the dilemmas of contemporary practice. Catholics -- and the followers of some other religions and philosophies -- believe that a sound ethic can be recognised by anyone following reason's guidance, undeflected by distracting emotion, prejudice or convention.
However, practical reasoning will take us only so far and most people will not follow it even that far. Our human predicament and opportunities include some realities only fully and reliably revealed by the life and teachings of Jesus Christ and through the Church's Scriptures and living tradition. So bioethics is a matter not only for moral philosophy (and history, sociology, anthropology…) but also for moral theology, not only for the secular academy but also for Catholic centres of higher education. Like all Catholic morality, it should offer people a guide to a life that befits their human nature, responds to their divine calling and prepares them for eternal life in God's family. It should educate conscience, shape virtues and make possible wise decisions in particular cases. Making sense of principlism: four foundations for a global bioethic? So what is it reasonable to do? What choices "make sense", are "good" or "right"? Moral philosophy begins its answer with three basic features of human persons: (1) that we are responsible, (2) that we each want to be happy and (3) that we want to be happy together. To say that we are "responsible" is to say that we are free to make choices and can deliberate rationally about our options. Human beings are choosing beings. What's more, our choices are self-making and self-telling, they shape our character and express our identity. Autonomy or self-rule is not so much a bioethical principle as a fact of human nature and action.
Why we choose what we do is a complex matter, but at its most basic it is that we each want to be happy rather than unhappy. Most people, if they've had the chance to reflect upon these things, recognize that that is about more than maximising pleasurable experiences and avoiding unpleasant ones. It is about harmony, wholeness, flourishing. Human beings are fulfilment-seeking beings. Some things contribute to that fulfilment: we call them good or "beneficent". Other things do not: we call them bad or "maleficent". At the heart of the moral life, then, is striving to do what is good and avoid what is evil. "Beneficence" and "non-maleficence" are not particular moral principles so much as the fundamental grounding of all we do (and what such doing does to us). Beneficence-non-maleficence is, if you like, the principle before all principles.
Of course none of us is the only or the most important being in the world, however much some people behave as if they thought they were. We are social beings and much of our good is a shared or good-in-common with others. Happiness for us includes achieving the good for others and those others being happy by achieving the good. The state of not just me getting my due, but all of us getting our due, we call "justice". Once again, justice is not so much a principle as an ideal state of affairs and a human disposition to bring that about (a "virtue"). There are, of course, many principles of justice, such as respect for the dignity and rights of persons, solidarity with others (especially the needy), subsidiarity in decision-making, and so on. The Catholic Church offers the world a comprehensive social doctrine, of which Pope Benedict XVI's recent encyclical, Caritas in veritate, is just the latest contribution in a long line of reflection.
My attempt so far to make some sense of the four principles -- by showing that they are not really moral principles at all but something more foundational -- suggests that authentic morality is not mere personal preference or social convention, but rather the very logic of choices made in the pursuit of happiness for ourselves and others. Read together and in this favourable light, they are the four elements of the most general and foundational principle of all morality, not just bioethics: that one should will (ie, exercise one's autonomy with respect to) those possibilities whose willing is compatible with happiness (beneficence) for one and all (justice) and only those possibilities (non-maleficence). Some have called this ideal "integral human fulfilment".
Of course there is more to morality that that: these four elements of the fundamental principle of morality are only starting points. They tell us what it means to be moral at all. But we still need to articulate a serious morality, including a bioethic, one that more fully explores the nature of the human person and choice, basic human goods such as life and health that explain why we do healthcare, and what are the reasonable ways of achieving such goods. The principlists would prefer to avoid being prescriptive in these matters. However, if this leaves them unable to say that choices shaped by egoism or partiality are wrong, that directly attacking human life or health or using evil means to achieve even good goals is unethical, then they are not doing bio-ethics at all. Four competing bioethical teams? So one way of reading the four principles is not as principles at all, but as ethical equivalents of the four elements of fire, water, earth and air in traditional physics. They are the stuff of which every ethic is made, in any and every culture. They are the stuff, too, of a truly global bioethic, if one is possible, as opposed to a merely globalised American bioethic. But what they will not, by themselves, yield is answers to questions such as whether and how we should tell the terminally ill that they are dying or whether and how we should help that dying along. When the principlists claim to pull answers out of hats on those questions, there is a distinct sense of sleight of hand, and that is because they are relying upon various other hidden biases, norms and pre-conclusions.
I want now to suggest an alternative way that we might read the four "principles". Once again, I will suggest that they are not four principles at all; but neither are they foundational. Rather, they might be seen as the catchcries for four different bioethical football teams -- or perhaps for some in this audience I should say four basketball teams. We might say that there is not one Georgetown mantra but four, the war-cries for four rival cultural-ethical perspectives. This may help to explain the intractability of bioethical debates and the unlikelihood of one global bioethic emerging any time soon. It serves to highlight different poles of the ethical compass by which different individuals and cultures set their course. The Autonomy Team The most common feature of American bioethics, that has been increasingly globalised in recent years, has been "individualism" or what we might call in the present context the autonomy team. Its players come from diverse backgrounds such as egoism, subjectivism, libertarianism and situation ethics. They include followers of Adam Smith, John Stuart Mill's On Liberty, Jean-Paul Satre, Ayn Rand, Robert Nozick and Alan Gewirth; from contemporary philosophy the "neocons" and free-market liberals such as the recently deceased Michael Novak; and from bioethics and theology players as Max Charlesworth, Charles Curran, Tristram Engelhardt and Joseph Fletcher. The catchcry of this team is that getting you own way is what matters. Thus when Americans such as Beauchamp and Childress do bioethics, "autonomy" -- though supposedly one principle amongst many -- usually "trumps all". On this account individual rights are much more important than concern for others.
Advocates of such approaches to bioethics emphasize independence and taking responsibility and deplore the paternalism they find in traditional medicine. They insist that decision-making in life, death, health and healthcare should be made by the individuals most immediately concerned, taking into account their own particular values and circumstances. In healthcare this spotlights respect for patients, informed consent, privacy and confidentiality. The chief (and arguably only) constraint on "getting one's own way" in this model of bioethics is allowing a similar freedom to others.
Take the issue of whether we should tell those with a terminal condition that they are dying. According to this perspective they should certainly be told: only the patient can make appropriate decisions about what healthcare she should have and how healthcare fits into the bigger picture of her goals and values. Only she can properly make the decision about whether to continue treatment, and which treatment, and where, and she can only do this if she is told her diagnosis, prognosis and treatment options. Whether she wishes to share this information and discuss her options with family members or others is up to her. But what is clear here is that the terminally ill should be told. This very Western, one might say very American, perspective on end-of-life care is highly contested in Asian cultures.
Consider another contemporary bioethical controversy: euthanasia. Who should decide? Those who chant the autonomy mantra would say: the patient and anyone she chooses to involve in her care. The Church, law, profession and other busy-bodies should "get out of people's faces" on such matters and leave it to the individual to decide for themselves. If I want euthanasia I should be free to decide when, by what method and on what conditions. If you are against it because of your religious beliefs or your Hippocratic ethics, you are free to choose otherwise. The law and professions should remain neutral or, indeed, promote choice. As long as it is truly voluntary, it should be permitted, even assisted. Once again, more traditional cultures that place a high value upon respect for elders, resignation in suffering, the support of extended family and so on, are a long way away from this very individualistic response to care at the end of life.
Part of the attraction of autonomy-oriented approaches is that they ostensibly recognize the dignity and rights of each person as a free agent and no one's slave or pawn. They avoid grand moral theories that may not do justice to the complexity of individual situations and to pluralism of opinion. The downside of such approaches is that they can reduce conscience to a private internal voice or intuition beyond external criticism, with authority to decide what to do without much regard for objective truth or tradition. Autonomy-based approaches to morality also offer little or no basis for scrutinizing personal prejudices and give puzzled individuals no help in making decisions. They allow people to compromise basic values such as reverence for life and compassion for the suffering, and can easily become anti-social or adversarial with respect to others. Thus Pope John Paul II in Veritatis Splendor criticized moral theories that separate freedom from truth and truth from authority and tradition. One function of Catholic colleges and universities must be to form graduates who will look beyond the self to the common good. The Justice Team Many commentators have suggested that the biggest difference between American (or Western) ethics and Asian (or Eastern and Southern) ethics is that for the latter the kinship group, village, people, class, gender and/or nation rather than the individual is the locus and end of decision-making. Despite the globalisation of Anglo-American individualism, many people and cultures remain more group-focused or other-focused. The community or Justice Team might include members of "traditional" cultures, followers of the great Eastern philosophies, as well as Marxists, feminists and other radical social critics, proponents of culture-specific ethics and recent writers in justice such as the disciples of John Rawls. Players from contemporary philosophy might include Annette Baier, Carol Gilligan, Alasdair MacIntyre and Charles Taylor and from bioethics, (the later) Daniel Callahan, Norman Daniels, Ezekiel Emanuel, Renee Fox and Verena Tschudin. Their mantra is: getting on with others is what matters.
Followers of such approaches to bioethics emphasize interconnectedness, dependence and interdependence, compassion, authority and loyalty, culture, tradition and profession, and deplore the wilfulness and injustices they see inherent in individualist-capitalist medicine. They insist that decision-making in life, death, health and healthcare should be made by the communities most directly concerned, or by individuals with an eye to the interests of that community, taking into account the group's values and needs. In healthcare this spotlights the codes and customs of the profession, the fair allocation of health opportunities and resources, the cares of extended families and other groups.
Take our example of the person diagnosed with a terminal condition. Followers of this more community-focused approach may well hold that the patient's spouse or children should be told, and that they should make any decisions in conjunction with the health professionals. Whether the dying person will be told would depend upon local custom and the judgment of those others about the usefulness of telling the patient. It might, after all, only frighten her and cause her to lose hope. She should be freed at this time from the burden of such hope-robbing information and such difficult decision-making. In Asia, unlike America, she may very well not be told.
Or consider our other contemporary bioethical controversy: euthanasia. People at this pole might say the community must decide whether such a practice in general, or in this particular case, is appropriate. Respect for elders and the need to protect the weak, including the frail, handicapped and dying, from their own despair or from the pressures of others who would rather not continue their care, would militate strongly against euthanasia. The law would generally exclude it. The push for euthanasia is, unsurprisingly, nowhere near as strong in Asia as it is in America, Britain and Europe.
Part of the attraction of such community or justice perspectives is that they recognize the reality that, far from being independent atoms, every human person is part of a web of relationships and forms and expresses their values in company with others. Even recognition of individual rights requires a rich view of the common good and joint effort with others to promote the flourishing of all. At least as important as rights are ties to family, community, tradition. Such approaches avoid the asocial individualism of the capital- and technology-driven West and encourage people to take responsibility not only for their own health but for that of others.
The downside of such theories is that they can discourage personal initiative and promote the dream of some corporatist utopia. As the 20th century demonstrated repeatedly, the vain attempt to achieve such dreams usually comes at a great cost to individual freedom and even life. Community or justice-oriented approaches to ethics commonly fail to allow space for individual differences and can incline their followers to a blind obedience to the group that reduces to a cultural relativism. As Pope Benedict XVI has argued repeatedly, cultural relativism can be tyrannical. One of the functions of Catholic colleges and universities must be to identify and critique such relativism that is as corrosive of sound ethics as is subjectivism. The Beneficence Team We might disagree about what is good or what are the best or permissible ways of achieving it or for whom: but wherever you are from in the world, ethics requires that you try to do the good. However, a feature of Anglo-American and some European ethics, perhaps more commonly than ethics in other parts of the world, has been notion that acts gets their meaning from the results they produce and that the right action is always the one than achieves the most net good. We might call those who take this view the Beneficence Team. They include various consequentialists, including the utilitarians who until recently dominated the academies of Anglo-America and its allies and the proportionalists who until recently held many seminaries and theology faculties captive.
On this team are followers of classical pragmatism and utilitarianism, as well as contemporary bioethicists such as Peter Singer, Michael Tooley and Julian Savelescu. Players from moral theology include Josef Fuchs, Richard McCormick and Jack Mahoney, to name a few. The war-cry of this team is that results are what count. Intentions, motives, inherent values and duties are less important: agents must consider all the likely consequences of each option before them and pick the one that maximizes net sum of good consequences over bad.
To return to our example of the person diagnosed with a terminal condition: followers of this results-focused approach will not accept any absolute norm of telling the truth to patients, nor of leaving it to the children and others to decide. They may have some rules of thumb, but in each case they will decide what is likely to produce the best result. Directly lying to the patient or to the relatives, involving or excluding others from the decision-making without the patient's consent may well be in order. What matters it what gets the best result.
Most consequentialists favour euthanasia. One clear way of reducing the amount of suffering in the world is to reduce the people who are suffering. Singers of the beneficence mantra say "they shoot horses, don't they?" and insist that human beings deserve a similar "mercy". Consequentialists will agree with individualists on a pro-euthanasia position, but will be less particular about all euthanasia being voluntary. After all, children, the handicapped, the demented and unconscious might all be rated as better off dead and their deaths might also benefit those around them.
Others have identified and critiqued the strong consequentialist tendencies of much contemporary bioethics. The attraction remains, however, because such approaches appeal to the benevolence and "can do" mentality of many in "the helping professions". Many health professionals have little time for rules that constrain advances and prefer a scientific mindset focussed on effectiveness and efficiency. The problem is: what is a good result? What counts as a benefit and a loss, how are we to predict, measure, aggregate and compare all the "apples and oranges" involved, how are we to make rational comparisons across individuals and communities? Does anything go, as long as the best result is achieved?
The beneficence mantra allows, indeed requires, its devotees to compromise justice, the sanctity of life, human rights, truth-telling and promise-keeping when this serves "the greater good" however defined. As Pope John Paul II pointed out in Veritatis Splendor and Evangelium Vitæ, the moral calculus required by these approaches is philosophically incoherent, socially dangerous and contrary to the Christian precept that one can never do evil to achieve good. Catholic colleges and universities must form for us leaders, professionals and citizens who will resist the contemporary tendency to a death-dealing pragmatism. The Non-maleficence Team A last ethical tendency -- one that possibly influences some Eastern or Asian ethics more than Anglo-American ethics -- emphasizes the intrinsic value of certain acts and thus duties to self and others, honour, keeping face and obedience to authority. The adherents of this approach are the Non-maleficence Team. They say there are some things health professionals and others just never do, some harms they should never entertain bringing about. Amongst the ethical approaches that coalesce here are many faith or tradition-based ethics, as well as deontological or Kantian ethics.
This team includes many adherents of the great monotheistic religions, philosophers within the Kantian tradition such as Alan Donagan and Martha Nussbaum, and health professionals who follow the great codes from Hippocrates, Maimonides, Nightingale, the World Medical Association and the International Council of Nurses. Recent "players" on this team include Paul Ramsay, Leon Kass, Benedict Ashley and Gilbert Meilaender. This team sing doing your duty is what counts: we must consider our duty or debt to the moral law-giver, whether that is God and his representatives, the extended family and community, the profession with its ethical codes, or to right reason and honour; we must obey rules that oblige because of the authority of that law giver, whatever the results.
Followers of these approaches to bioethics may exercise prudence as to when and how they tell a dying person of their condition, but they will never lie to them, as direct lying is an attack on truth, disrespectful of the victim of the lie and degrading to the liar him/herself. Likewise most deontologists oppose euthanasia, as it is a direct attack upon the good of life, is lethal for the victim and renders the agent a killer. According to most religions, lying and killing are also against God's law.
Amongst the attractions of such non-maleficence approaches to bioethics is that they tend to offer a clear, principled approach to healthcare dilemmas, enable formation of conscience in duty and obedience and provide a basis for criticism of personal and social prejudices. Primum non nocere -- the first principle of Hippocratic medicine -- opposes any exterminative kind of medicine that seeks to "solve" sickness (or some other problem) by killing the sick, and any exploitative kind of medicine that uses people (such as very early human lives) destructively. Faith and reason require the pursuit of integral human fulfilment in all its aspects, and refuse to compromise basic human goods and principles of morality even for the best of results.
Opponents of this bioethical football team deny the alleged self-evidence of the authority or norms it proposes. They complain that such approaches yield moral absolutes that are arbitrary, legalistic, inflexible and often irreconcilable. As even the Catechism of the Catholic Church insists, the commandments are not a law unto themselves, they do not serve themselves: rather, they are there to serve human beings, they are the reliable ways to love God and neighbour, to live life to the full and to attain eternal, blessed life. Catholic colleges and universities must demonstrate to their students that Christian life is the dynamic endeavour of persons to become fully the beings God wills and enables them to be, rather than just a computer program for moral robots. Conclusion Some people today dream of a "value-free" bioethic, liberated from the "moralizing", "judgmental" interference of churches and professions and serving instead the self-validating agenda of scientific "progress" or personal fulfilment. In fact healthcare and medical research are as value-laden as any other human activity and our contemporary scientific and market mindsets have their own moral limitations. Catholic institutions of higher education can offer our region and our world some explicit basis by which to judge some science as uplifting for the human person and genuine progress for the human community, and other technologies as degrading the person and regressive for the community.
In the first part of my paper today I attempted to make some sense of and critique the Principlist bioethic that has been globalised by the American bioethics industry. One way of reading the four principles is not as bioethical principles at all, but as the underlying assumptions for any sound ethics. Moral principles tend to lose their meaning and rational warrant if just announced (as principlists do) as if plucked out of the air or just the rules of a club to be applied, compromised or "balanced". A bioethic with such oracular "foundations" overlooks the true basis for a rational and Christian ethic. I have suggested that Catholic colleges and universities in South East Asia share in the mission of a Church that runs the oldest and largest healthcare system in the world, as well as the oldest and largest education system in the world, a Church that is an "expert in humanity" and guided by the Holy Spirit not just in her practice in these areas, but in reflecting upon that practice. The triplet encyclicals Veritatis Splendor, Evangelium Vitæ and Fides et ratio, for instance, propose a much richer basis for a contemporary bioethic than a thinned down Principlism ever could.
In the second part of my paper I presented the four principles as the competing discourses, catchcries or mantras of four teams, rivals for players and audience. I did so in very broad brush-strokes. Of course, few people sit neatly at one pole of the moral compass or support one ethical team only, all the time; people who are most often concerned for themselves will sometimes be concerned also for others; people who mostly follow a fairly pragmatic policy will say there are some lines they will never cross; and so on. Individuals may find themselves more at one pole or quadrant or another much of the time, but there will be other times when they act more from another place on the compass.
Nor does everyone in a particular culture follow the same moral lights. Nonetheless, if I may be permitted two very broad generalisations, I would suggest, first, that most Asians tend to place themselves in the South-East of my moral compass and that most Anglo-Americans, at least in the academy, incline to the North-West. To the extent that this represents cultural conditioning, it must make us wary of the globalisation of the Georgetown bioethic. Secondly, while the Catholic moral tradition is far too "Catholic" to support any one "team" and far too respectful to chant any one "mantra", I do think that it is more often to be found teaching in the South-East of this moral compass than the North-West. Veritatis Splendor, Evangelium Vitæ and Fides et ratio said far more about moral absolutes and the common good than they did about preferences and results. The tradition of which those documents form part gives us the tools to critique any approach that takes just one bit of ethics and tries to make of it the whole.
Catholic colleges and universities have the privilege of forming many of our future healthcare professionals, managers and patients, as well as many of the leaders, professionals and citizens of the surrounding community, in sound principles, critical thinking and virtue. They also evangelize the culture by their published research and by entering into public discourse on the great questions of the day. We can be confident that our region has something important to offer the Church universal and that the Church universal has something to offer our region by way of a wisdom worthy of the healthcare professions and of every human person, the basis for building a culture of life and love. Anthony Fisher OP is Catholic Auxiliary Bishop of Sydney. This article is based on a speech he gave at the University of Notre Dame Australia, Sydney.
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