Modern applied bioethicists generally use a casuistic (case-based) approach to identify practical solutions to real world ethical dilemmas in medicine. Although a purely casuistic approach does not require it, practitioners of American standard bioethics frequently rely on a shared set of accepted bioethical principles including autonomy, beneficence, nonmaleficence, and justice
Critical care: why there is no global bioethics [Ethical, legal and organizational issues in the intensive care unit] Engelhardt, H Tristram Jr Department of Philosophy, Rice University, Houston, Texas, USA Correspondence to H. Tristram Engelhardt Jr, Department of Philosophy, MS-14, Rice University, 6100 Main St., Houston, TX 77005, USA Tel: 713 348 2491; e-mail: firstname.lastname@example.org Abstract Purpose of review: The possibility of content-full, universal, bioethical norms is assessed. The literature brings into question a global bioethics. A salient moral and bioethical pluralism undermines the plausibility of imposing of uniform bioethical norms on critical care. Addressing the tension between the aspiration to a global bioethics and the presence of moral pluralism is timely, given the United Nations Educational, Scientific and Cultural Organization’s development of universal, bioethical norms. The practice of critical care in the 21st century will be influenced by the tension between bioethical pluralism and counter-assertions on behalf of a global bioethics. Recent findings: A growing literature reflects a bioethical pluralism with significant implications for critical care. Much of the literature supporting pluralism is rooted in a reaction in the Pacific Rim against North American and Western European moral and philosophical commitments. These voices of moral dissent join an already salient moral diversity in the West regarding issues ranging from abortion to end-of-life decision-making, physician-assisted suicide, and euthanasia, as well as conflicting understandings of the bioethics of appropriate approaches to the allocation of scarce medical resources. This literature acknowledging bioethical diversity contrasts with announcements of universal bioethical norms. Summary: Clinicians need to appreciate the sources of moral controversy that divide them from their patients and from their colleagues and to recognize that moral and economic differences may lead to different standards of care. Taking bioethical diversity seriously supports focusing on procedural moral approaches that allow peaceable collaboration in the face of substantive moral disagreement. ——————————————————————————– Abbreviation UNESCO United Nations Educational, Scientific and Cultural Organization Introduction The literature of bioethics shows the presence of announcements of universal norms and of global bioethics, while at the same time demonstrating the presence of a robust moral pluralism, which not only is persistent but also for theoretical reasons may remain intractable. A new literature supporting bioethical pluralism is developing in the Pacific Rim. In this article, I outline sources of the inclination to deny moral and bioethical diversity with the consequent failure to focus on procedures for peaceable collaboration in the face of substantive moral disagreement. Appreciating moral pluralism: the challenge for the 21st century Although much of the technology associated with critical care may be constant throughout the world, critical care itself is embedded in different moral and economic environments. The implications of the diversity of these environments are often under-assessed. My goal in this article is to introduce the disparate moral assumptions underlying different views of bioethics that make different critical-care decisions more or less plausible. There is an under-appreciation of the bioethical implications of moral diversity. It is remarkable that in a world rent by violent expressions of moral difference, the existence of universal, secular, moral, and bioethical norms would be announced, rather than the possibilities of living peaceably in the face of foundational moral disagreement explored. An important expression of the failure to confront the challenges of moral diversity is found in the United Nations Educational, Scientific and Cultural Organization’s (UNESCO) Declaration on Universal Norms of Bioethics, which has been taking shape since 2002 . Nowhere in the document is there recognition of the challenges of substantive moral diversity, or an appreciation of the need to find procedural strategies for collaboration in the face of real moral disagreement. Core to the Declaration are such very general principles as Human dignity, human rights and fundamental freedoms are to be fully respected (Article 3) and The fundamental equality of all human beings in dignity and rights is to be respected so that they are treated justly and equitably (Article 10). Contemporary bitter disputes regarding the morality of abortion depend on when humans are understood to be human persons and therefore bearers of rights. So, too, disputes regarding physician-assisted suicide and euthanasia turn on disagreements as to whether autonomously choosing death nevertheless affronts human dignity. The decisions that confront intensivists are clothed in particular moral assumptions. As developed countries face the challenge of providing ever more health care through social systems supported by ever fewer younger workers, the sustainable meaning of equity becomes a major issue of philosophical and political concern. The result has been a lack of easy access outside the United States to a range of morbidity- and mortality-reducing technologies, thus illustrating the difficulties in maintaining equality of health care in low-resource health care systems . As populations age, it will become ever more difficult to put high-cost, low-yield health care interventions at the disposal of all of the aged. The development of different levels of basic care will appear ever more plausible to many policy-makers. In developing countries such as China, whose populations in different areas have starkly different resources and levels of health care at their disposal, it will be impossible to maintain the same access for all to high-technology medicine [3,4]. For such societies, a secure development into a high-technology society requires living with different standards of medical care in different geographical areas and between different economic groups [5,6,7]. Such countries, it should be noted, are also looking increasingly to non-Western models for their health care systems, such as that in Singapore, which through its medical savings accounts has kept 70% of health care expenditures in private hands while delivering quality health care . There is in addition a commitment on the part of many scholars in the Pacific Rim to develop an understanding of morality that would foundationally reconfigure the established discourse on human rights and human dignity. Edward Woo, for example, argues different societies must adopt different criteria when human rights are discussed. To impose arbitrarily the same standard for all governments and societies is against nature and will inevitably turn out to be a failure . On the crest of the resurgence of indigenous moral understandings, a bioethics is emerging that is not rooted in Western philosophical and moral commitments [10,11,12,13]. Varieties of this bioethics, for example, will find it acceptable to stop treatment when family resources are expended. Despite the obvious presence of moral and bioethical disagreement, the UNESCO document radically discounts the deep moral and metaphysical divisions at the root of contemporary bioethical controversies. It states, for example, that The importance of cultural diversity and pluralism should be given due regard. However, such considerations are not to be invoked to infringe upon human dignity, human rights and fundamental freedoms, nor upon the principles set out in this Declaration, nor to limit their scope (Article 12). The challenge of the 21st century will be to frame public policy and practices for clinical medicine in the context of robust moral controversy and substantive bioethical disagreement [14,1516]. Moral pluralism: strident and ubiquitous From the United States to Iraq, nations are divided by substantively incompatible moral and metaphysical understandings of the human condition. As Alasdair MacIntyre has observed, a characteristic feature of contemporary culture is that it is marked by persistent and foundational moral disputes . The substance of the culture wars [18,19] involves ongoing and often strident disagreements about the proper allocation of scarce medical resources, the moral significance of homosexual acts and marriages, the appropriateness of capital punishment, the moral significance of abortion, the permissibility of human cloning, the pursuit of human embryonic stem-cell research, and the acceptability of physician-assisted suicide and euthanasia, to name only a few points of ongoing, frequently impassioned debate. The controversies mark not only the United States but Europe as well . Moral controversies drive political debates across the world. Many of the parties to the disputes find themselves embedded in morally and metaphysically incongruent understandings of proper human deportment, the significance of human life, and the nature of human flourishing. This moral diversity will have divergent implications regarding end-of-life decision-making and the use of high-cost, low-yield medical interventions. The disputes that engender the battles that move the culture wars not only involve serious moral concerns, they are in addition persistent. In many cases, contemporary controversies have a history that reaches back centuries, if not millennia, as for example, with abortion, physician-assisted suicide, and euthanasia . Moreover, the controversies separating disputants are often nested within incompatible understandings of the meaning of appropriate moral conduct, as in the contrast between thoroughgoing consequentialists, who hold that the meaning of all right- and wrong-making conditions can be reduced to concerns with the good (i.e. consequences), and those deontologists that hold there to be right- and wrong-making conditions independent of consequences. Those involved in disputes are also frequently separated by foundationally different metaphysical understandings of the human condition, as in the case of the gulf separating theists and atheists. The antiquity of many of these controversies provides robust testimony of their persistence. These background moral and metaphysical commitments make more or less acceptable different forms of limiting treatment and intentionally bringing about an earlier death. Not only are the disputes foundational and persistent, there are also good grounds for holding that the disputes cannot be resolved by sound rational argument: many of the participants in moral controversies are committed to disparate basic premises and rules of inference . Consequently, those engaged in substantive moral controversies will assess what is at stake separated by incommensurable moral-metaphysical frameworks. Attempts to resolve such controversies by sound rational argument will always crucially beg the question, argue in a circle, or engage in infinite regress. There is no common morality; therefore, there is no common bioethics If having a morality in common with others involves a common ranking of right-making conditions and important human goods, so as to share a common understanding of the morality of sexuality, reproduction, property rights, suffering, dying, and death, then humans do not share one common morality. Humans, because of the character of human embodiment, may nevertheless have in common concerns regarding sexuality, reproduction, the use of resources, truth-telling, suffering, dying, and death, even when the character of their concerns will be different. Even if all moralities are concerned with such matters as the taking of human life, they will be distinguished by the circumstances under which it is considered obligatory or forbidden to take life. Disagreements regarding the morality of withdrawing treatment, withholding treatment, aiding suicide, and providing active euthanasia frequently also reflect deep disagreements about the ultimate meaning of human life. Even if the building blocks of human morality were all the same, different views of how moral concerns should be assembled into a moral framework would produce different moral ways of life, as well as different systematic clusters of settled moral judgment about proper conduct. It is because humans, nested within different moralities, have different views about when to tell the truth and when to lie , when to take human life and when to protect it, that their bioethics differ as well. The incompatibility of background moralities and the settled judgments they sustain support incompatible bioethical claims regarding truth telling in medicine, the role of individuals or families as decision-makers, physician-assisted suicide, and euthanasia. Many physicians, patients, and families, who have incompatible views as to when and under what circumstances one may or may not act or refrain with the intention to bring about an earlier death, will find themselves separated by different moralities. In the face of such disagreements, the strategies in bioethics that succeed most widely are those that do not depend on substantive agreement but instead involve procedures that allow limited collaboration in the presence of disagreement. It is for this reason that one finds the salience of procedural mechanisms such as free and informed consent, documents that allow the withdrawal of authorization for treatment (e.g. advance directives), market solutions, and limited democracies . Even when one cannot discover the correct thing to do, one can still create procedures that allow limited, peaceable cooperation in the face of substantive disagreement. Both areas of substantive disagreement and possibilities for collaboration underscore the existence of a plurality of incompatible moralities and a diversity of bioethics. Why despite moral pluralism, there are claims of moral consensus Given the stridently obvious presence of moral pluralism, the question is why many bioethicists not only deny its presence but also claim a substantive moral consensus that would warrant the official establishment of a secular global bioethics . Indeed, there is a considerable literature that focuses on the importance of consensus, though it fails to give an adequate account of how much of an agreement is morally significant in what ways and why moral agreement on a particular point would indicate moral truth [26,27,28,29]. The passion for consensus may, in part, reflect a response to a misunderstanding of the significance of recognizing moral pluralism that construes the acknowledgment of pluralism as the equivalent of endorsing moral relativism. Claims of consensus may thus represent attempts to assert the existence of morality in the face of perceived threats from moral relativism. It is therefore important to note that it does not follow from intractable moral diversity that there is no moral truth. At most, a moral-epistemological skepticism is warranted: discursive reflection (i.e. philosophical reflection) has proven unable to secure by sound rational argument a single, substantive account of moral truth as morally canonical. However, a metaphysical-moral skepticism, a skepticism with regard to the existence of moral truth itself, is unwarranted. At most, one can conclude that philosophical reflection has failed through sound rational argument to establish a particular substantive (i.e. content-full), moral viewpoint as normative. The strong interest in claiming, contrary to fact, the existence of a moral consensus is likely rooted in at least three other associated phenomena. Consensus as false consciousness The creation of the impression that rational persons agree with regard to a particular moral view can be used as a means for circumventing democratic political discussion regarding matters of moral dispute. If one can convince others, contrary to fact, that rational persons must endorse a particular moral view, then one can enhance the likelihood of the broad acceptance of the particular moral and bioethical views to which one is committed. In a democracy, the assertion of a particular account of basic human rights can thus serve to take certain issues outside of ordinary, open public discussion, for insofar as one succeeds in enshrining certain issues as essential to the moral view, it will appear unseemly to seek seriously to qualify those claims. The intellectual establishment can thus advance a particular moral view as normative, even when the grounds for its normativity are not widely accepted. This approach has deep roots in such Enlightenment accounts as those of Immanuel Kant (1727-1804), who argued that morality and rational action are coincident, and that all belong implicitly to one secular moral community defined by his account of rationality, which then provides the authority for coercive state action. Consensus as realpolitik The impression that all rational persons concur regarding most substantive moral and bioethical issues is enhanced by the logic of the function of national commissions and bioethics committees. Were such commissions and committees honestly to reflect the diversity of most societies, they would produce interminable debates and would fail to forward the recommendations sought. As a result, those who impanel commissions and committees will seek individuals with broadly similar ideological commitments so as to deliver the desired recommendations. Impaneling the right members of commissions and committees is thus integral to the effective realization of one’s political ends, by providing the moral foundations for the laws, public policies, and recommendations one hopes to establish. One might think of the different conclusions reached by bioethics commissions impaneled by Bill Clinton versus George Bush [30-32,33]. A so-called consensus report may amount to nothing more than a thoughtful set of recommendations by a group of well-regarded individuals [34,35]. Consensus as observer bias The impression that all rational persons concur regarding most substantive moral and bioethical issues is enhanced by the sociology of moral discourse and association. Insofar as persons tend not to have sustained moral discussions with those with whom they are separated by fundamental moral disagreements, then when persons reflect on how to integrate their various moral intuitions, understandings of moral principle, and habits of action, they will experience a commonality that can establish a working consensus. The difficulty is that one often fails to note that a similar phenomenon is experienced by those who share a moral perspective foundationally different from one’s own. The result is that, in the face of foundational moral and bioethical disagreement, there is nevertheless the assertion of moral consensus. Moved by moral, political, and psychological reasons, the robust differences lying at the root of moral and bioethical controversies are discounted. The result is that one often under-appreciates the moral differences that separate colleagues from colleagues, and physicians from patients and their families. Taking moral diversity seriously: some implications for clinical practice Given the presence of substantive and often strident moral disagreement, it will be important to find procedural means for peaceable collaboration that do not require stakeholders to abandon their moral commitments or compromise their moral integrity. At the international level, this will require accepting different defeasible assumptions, as for example whether patients should be regarded as independent decision-makers or as decision-makers lodged within families. In most Western countries, persons will be presumed to wish to be treated as autonomous, independent agents until they indicate otherwise (e.g. by patients indicating that their spouses should decide on their behalf). In some other countries, persons will be presumed to wish to be treated as members of families until they indicate otherwise [36,37]. Where resources are more than moderately limited, it will be necessary to consider the establishment of different standards of basic and critical care, both within and across geographical regions. It will be impossible under many circumstances to defend a single standard for the appropriate quality of intensive care. Even in North America and Western Europe, there is sufficient moral heterogeneity to require taking the reciprocal nature of free and informed consent seriously so as to allow not only patients to refuse to receive treatments they find unacceptable but also physicians to refuse to be involved in the provision of treatments they find unacceptable. Most conscience clauses require physicians who have moral scruples to provide a particular treatment to refer, nevertheless, to those who will provide the treatment. If one takes seriously the objection of some physicians to physician-assisted suicide and euthanasia, it will not be enough to preserve moral integrity to allow them to refuse directly to be involved, on the condition that they must refer patients to those who will provide the services considered morally inappropriate. Requiring physicians with moral objections to refer is analogous to allowing physicians opposed to capital punishment to avoid involvement only on the condition that they refer to other physicians willing to provide the service. An adequate recognition of the concerns of both sides of moral controversies will require, for example, allowing those who wish to exempt themselves from involvement in physician-assisted suicide and euthanasia to announce in advance that they will provide neither treatment nor information about how to acquire such treatment. Attention will need to turn to developing procedures that allow for peaceable cooperation, while recognizing the moral disparities that are at the heart of our culture wars. Conclusion If matters are as they appear, namely, that bioethical diversity is real, persistent, and intractable, then assertions of a content-full, global bioethics are brought into question, and energies should instead be invested in exploring the nature of bioethical diversity and the possibilities for peaceable interaction in the face of moral disagreement. Intensivists will need to be able critically to assess the intellectual force of claims to consensus and the character of bioethical pluralism.
Ethics of physician gifts from industry (Ann Emerg Med 2006;48:513)
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