This book is about the ethical issues that clinicians encounter as they care for patients and is written to assist those who serve on hospital ethics committees as they deliberate about appropriate action in difficult ethical cases.

This long-awaited book sets out the implications of Habermas's theory of communicative action for moral theory. "Discourse ethics" attempts to reconstruct a moral point of view from which normative claims can be impartially judged. The theory of justice it develops replaces Kant's categorical imperative with a procedure of justification based on reasoned agreement among participants in practical discourse.Habermas connects communicative ethics to the theory of social action via an examination of research in the social psychology of moral and interpersonal development. (...) He aims to show that our basic moral intuitions spring from something deeper and more universal than contingent features of our tradition, namely from normative presuppositions of social interaction that belong to the repertoire of competent agents in any society. Jürgen Habermas is Professor of Philosophy at the University of Frankfurt. (shrink)

During the last thirty years different methods have been proposed in order to manage and resolve ethical quandaries, specially in the clinical setting. Some of these methodologies are based on the principles of Decision-making theory. Others looked to other philosophical traditions, like Principlism, Hermeneutics, Narrativism, Casuistry, Pragmatism, etc. This paper defends the view that deliberation is the cornerstone of any adequate methodology. This is due to the fact that moral decisions must take into account not only principles and ideas, but (...) also emotions, values and beliefs. Deliberation is the process in which everyone concerned by the decision is considered a valid moral agent, obliged to give reasons for their own points of view, and to listen to the reasons of others. The goal of this process is not the reaching of a consensus but the enrichment of one's own point of view with that of the others, increasing in this way the maturity of one's own decision, in order to make it more wise or prudent. In many cases the members of a group of deliberation will differ in the final solution of the case, but the confrontation of their reasons will modify the perception of the problem of everyone. This is the profit of the process. Our moral decisions cannot be completely rational, due to the fact that they are influenced by feelings, values, beliefs, etc., but they must be reasonable, that is, wise and prudent. Deliberation is the main procedure to reach this goal. It obliges us to take others into account, respecting their different beliefs and values and prompting them to give reasons for their own points of view. This method has been traditional in Western clinical medicine all over its history, and it should be also the main procedure for clinical ethics. (shrink)

Over the course of its first seven editions, Principles of Biomedical Ethics has proved to be, globally, the most widely used, authored work in biomedical ethics. It is unique in being a book in bioethics used in numerous disciplines for purposes of instruction in bioethics. Its framework of moral principles is authoritative for many professional associations and biomedical institutions-for instruction in both clinical ethics and research ethics. It has been widely used in several disciplines for purposes of teaching in the (...) classroom, during conferences, etc. (shrink)

Can we legitimately speak of ethicsexperts? Recent literature in philosophy and medical ethics addresses this important question but does not offer a satisfactory answer. Part of the problem is the absence of an examination of what it means to be an expert in general. I therefore begin by reviewing my analysis of expertise which appeared earlier in this journal. We speak of two kinds of experts: persons whose expertise is in virtue of what theyknow (epistemic expertise), or what theydo (performative (...) expertise). Applying this analysis to the domain of ethics, I argue that we may speak of ethical expertise in three epistemic senses: a) expertise indescriptive ethics, b) expertise inmetaethics, c) expertise innormative ethics, and in a performative sense: d) expertise inliving a good life. I conclude with a brief description of some social roles of ethics experts. (shrink)

: This paper presents a method of moral problem solving in clinical practice that is inspired by the philosophy of John Dewey. This method, called "clinical pragmatism," integrates clinical and ethical decision making. Clinical pragmatism focuses on the interpersonal processes of assessment and consensus formation as well as the ethical analysis of relevant moral considerations. The steps in this method are delineated and then illustrated through a detailed case study. The implications of clinical pragmatism for the use of principles in (...) moral problem solving are discussed. (shrink)

We assume that acting ethically is a skill. We then use a phenomenological description of five stages of skill acquisition to argue that an ethics based on principles corresponds to a beginner’s reliance on rules and so is developmentally inferior to an ethics based on expert response that claims that, after long experience, the ethical expert learns to respond appropriately to each unique situation. The skills model thus supports an ethics of situated involvement such as that of Aristotle, John Dewey, (...) and Carol Gilligan against the detached, rationalist ethics of Kant, John Rawls, Lawrence Kohlberg, and Jürgen Habermas. (shrink)

As everybody knows, advances in medicine and medical technology have brought enormous benefits to, and created vexing choices for, us all – choices that can, and occasionally do, test the very limits of thinking itself. As everyone also knows, we live in the age of consultants, i.e., of professional experts who are ready, willing, and able to give us advice on any and every conceivable question. One such consultant is the medical ethics consultant, or the medical ethicist who consults.Medical ethics (...) consultants involve themselves in just about every aspect of health care decision making. They help legislators and judges determine law, hospitals formulate policies, medical schools develop curricula, etc. In addition to educating physicians, nurses, and lawyers, amongst others, including medical, nursing, and law students, they participate in clinical decision making at the bedside. (shrink)

The phenomenon of expertise produces two problems for liberal democratic theory: the first is whether it creates inequalities that undermine citizen rule or make it a sham; the second is whether the state can preserve its neutrality in liberal ’government by discussion’ while subsidizing, depending on, and giving special status to, the opinions of experts and scientists. A standard Foucauldian critique suggests that neutrality is impossible, expert power and state power are inseparable, and that expert power is the source of (...) the oppressive, inegalitarian effects of present regimes. Habermas argues that expert cultures make democratic discussion impossible. Analogous problems arise with ’cognitive authority’, understood in Mertonian terms. Cognitive authority, as Merton sees it, allows us to ask about the democratic legitimacy of this authority, which appears to solve the problem (or part of the problem) because it returns ultimate ’authority’ to the people, who reject or accept the experts’ claims. And many claims to expertise in fact do fail to gain acceptance. Through an examination of the type of expert that appears to evade the demands of legitimation, it is shown that expertise and liberal democracy can in principle co-exist, contrary to the claims of the critics. (shrink)

Whether ethics is too important to be left to the experts or so important that it must be is an age-old question. The emergence of clinical ethicists raises it again, as a question about professionalism. What role clinical ethicists should play in healthcare decision making – teacher, mediator, or consultant – is a question that has generated considerable debate but no consensus.

The notion that it is useful to specify norms progressively in order to resolve doubts about what to do, which I developed initially in a 1990 article, has been only partly assimilated by the bioethics literature. The thought is not just that it is helpful to work with relatively specific norms. It is more than that: specification can replace deductive subsumption and balancing. Here I argue against two versions of reliance on balancing that are prominent in recent bioethical discussions. Without (...) meaning to address the substance or the overall merits of either view I criticize, I attack Gert, Culver and Clouser's implicit reliance on some overall dimension of balancing as a basis of resolving conflicts among norms and Beauchamp and Childress's residual acceptance of 'justified balancing'. The former authors' description of resolving conflicts depends upon a type of value commensurability that (as they otherwise seem to admit) does not obtain, while the latter authors' role for justified balancing would be better served by continued specification. (shrink)

: The increasing reliance upon, and perhaps the growing public and professional skepticism about, the special expertise of bioethicists suggests the need to consider the limits of moral expertise. For all the talk about method in bioethics, we, bioethicists, are still rather far off the mark in understanding what we are doing, even when we may be going about what we are doing fairly well. Quite often, what is most fundamentally at stake, but equally often insufficiently acknowledged, are inherently political, (...) essentially contested visions of the most compelling and attractive forms of life for individuals and social organization. The current situation in bioethics parallels similar debates in eighteenth-century jurisprudence, especially Jeremy Bentham's withering critique of the prevalent forms of judicial argument and his own, equally unsuccessful, attempt to develop a decision-making procedure in ethics that would operate on a plane above politics. The risk, both then and now, is that we will fail to appreciate the wide range of reasonable disagreement that will remain past the point of extended reflection and discussion. (shrink)

This paper sets out to examine the integrity and professional standing of “Bioethics.” It argues that professions have certain responsibilities that start with setting criteria for and credentialing those that have met the criteria and goes on to ultimately have social responsibilities to the community. As it now stands we claim that Bioethics—while it certainly has achieved some progress in the way medicine has developed—has failed to become a profession and has to a large extent failed in its social responsibility. (...) We feel that Bioethics has to define itself, set criteria for membership in the profession, police itself and—above all—meet its social responsibility to become a profession meriting that name. (shrink)

Using the bench trial of Colorado’s Amendment 2 as an example, this article focuses on the more general question of expert testimony in moral philosophy. It argues that there is indeed expertise in moral philosophy but argues against admitting such expert testimony in cases dealing with what John Rawls terms “constitutional essentials” and ‘matters of basic justice.” Developing the idea of public reason inherent in the Rawlsian concept of political liberalism, the article argues that philosophers can and should speak out (...) on public issues, if they do so with due respect for certain restrictions, but that they should not serve as expert witnesses on core constitutional questions, since doing so suggests that they claim a type of authority that would require fellow citizens to defer to their views. Such claims to authority in basic ethical matters threaten the mutual respect for divergent comprehensive doctrines that lies at the core of political liberalism. Philosophers have a duty to serve the public good, and they perform this service in fruitful ways. But they should refuse a public role that appears incompatible with equal respect for the committed ethical searching of their fellow citizens. (shrink)

A decade ago, we reviewed the field of clinical ethics; assessed its progress in research, education, and ethics committees and consultation; and made predictions about the future of the field. In this article, we revisit clinical ethics to examine our earlier observations, highlight key developments, and discuss remaining challenges for clinical ethics, including the need to develop a global perspective on clinical ethics problems.

There seem to be two clearly-defined camps in the debate over the problem of moral expertise. On the one hand are the “Professionals”, who reject the possibility entirely, usually because of the intractable diversity of ethical beliefs. On the other hand are the “Ethicists”, who criticise the Professionals for merely stipulating science as the most appropriate paradigm for discussions of expertise. While the subject matter and methodology of good ethical thinking is certainly different from that of good clinical thinking, they (...) argue, this is no reason for rejecting the possibility of a distinctive kind of expertise in ethics, usually based on the idea of good justification. I want to argue that both are incorrect, partly because of the reasons given by one group against the other, but more importantly because both neglect what is most distinctive about ethics: that it is personal in a very specific way, without collapsing into relativism. (shrink)

Services of ethics committees are nowadays commonly used in such various spheres of life as health care, public administration, business, law, engineering, and scientific research. It is taken that as their members have expertise in ethics, these committees can have valuable contributions to make in solving practical moral problems. It has, however, also been maintained that it is simply absurd to claim that one has some special knowledge and skills in moral matters; in connection with moral questions there is no (...) expertise to be had. In this paper, I assess this criticism of the use of ethics committees and ethics consultants. I argue that there is no sufficient reason to reject the possibility of ethical expertise. (shrink)

A decade ago, we reviewed the field of clinical ethics; assessed its progress in research, education, and ethics committees and consultation; and made predictions about the future of the field. In this article, we revisit clinical ethics to examine our earlier observations, highlight key developments, and discuss remaining challenges for clinical ethics, including the need to develop a global perspective on clinical ethics problems.

The objective of this article is to analyse and compare four methods of ethical case deliberation. These include Clinical Pragmatism, The Nijmegen Method of ethical case deliberation, Hermeneutic dialogue, and Socratic dialogue. The origin of each method will be briefly sketched. Furthermore, the methods as well as the related protocols will be presented. Each method will then be evaluated against the background of those situations in which it is being used. The article aims to show that there is not one (...) ideal method of ethical case deliberation, which fits to all possible kinds of moral problems. Rather, as each of the methods highlights a limited number of morally relevant aspects, each method has its strengths and weaknesses as well. These strengths and weaknesses should be evaluated in relation to different types of situations, for instance moral problems in treatment decisions, moral uneasiness and residue, and the like. The suggestion arrived at on the basis of the findings of this paper is a reasonable methodological plurality. This means that a method can be chosen depending on the type of moral problem to be deliberated upon. At the same time it means, that by means of a method, deliberation should be facilitated. (shrink)

Some ethical issues facing contemporary medicine cannot be fully understood without addressing medicine's internal morality. Medicine as a profession is characterized by certain moral goals and morally acceptable means for achieving those goals. The list of appropriate goals and means allows some medical actions to be classified as clear violations of the internal morality, and others as borderline or controversial cases. Replies are available for common objections, including the superfluity of internal morality for ethical analysis, the argument that internal morality (...) is merely an apology for medicine's traditional power and authority, and the claim that there is no single, "core" internal morality. The value of addressing the internal morality of medicine may be illustrated by a detailed investigation of ethical issues posed by managed care. Managed care poses some fundamental challenges for medicine's internal morality, but also calls for thoughtful reflection and reconsideration of some traditionally held moral views on patient fidelity in particular. (shrink)

In this paper a plea is made for an unprincipled approach to biomedical ethics, unprincipled of course just in the sense that the four principles are neither the start nor the end of the process of ethical reflection. While the four principles constitute a useful “checklist” approach to bioethics for those new to the field, and possibly for ethics committees without substantial ethical expertise approaching new problems, it is an approach which if followed by the bioethics community as a whole (...) would, the author believes, lead to sterility and uniformity of approach of a quite mindbogglingly boring kind. Moreover, much of bioethics is not concerned with identifying the principles or values appropriate to a particular issue, but rather involves analysing the arguments that are so often already in play and which present themselves as offering solutions in one direction or another. Here, as I try to show in discussion of these four scenarios, the principles allow massive scope in interpretation and are, frankly, not wonderful as a means of detecting errors and inconsistencies in argument. (shrink)

Chapter 1 Who this book is for and who it is not for1 There are already too many books offering solutions to the problems of the health service. ...

Experts play an important role in society, but there has been little investigation about the nature of expertise. I argue that there are two kinds of experts: those whose expertise is a function of what theyknow (epistemic expertise), or what theydo (performative expertise). Epistemic expertise is the capacity to provide strong justifications for a range of propositions in a domain, while performative expertise is the capacity to perform a skill well according to the rules and virtues of a practice. Both (...) epistemic and performative experts may legitimately disagree with one another, and the two senses are conceptually and logically distinct. (shrink)

This paper sets out to examine the integrity and professional standing of “Bioethics.” It argues that professions have certain responsibilities that start with setting criteria for and credentialing those that have met the criteria and goes on to ultimately have social responsibilities to the community. As it now stands we claim that Bioethics—while it certainly has achieved some progress in the way medicine has developed—has failed to become a profession and has to a large extent failed in its social responsibility. (...) We feel that Bioethics has to define itself, set criteria for membership in the profession, police itself and—above all—meet its social responsibility to become a profession meriting that name. (shrink)

Philosophers, particularly moral philosophers, are increasingly being involved in public decision‐making in areas which are seen to raise ethical issues. For example, Dame Mary Warnock chaired the ‘Committee of Inquiry into Human Fertilization and Embryology’ in the UK in 1982–4; the Philosophy Department at Auckland was commissioned by the Auckland Regional Authority to report on the ethical aspects of fluoridating the public water supply in 1990; and many of us are serving on ethics committees of various sorts. Not only are (...) philosophers actually being called on or consulted, but many of us would argue that a philosophical contribution in such areas is essential.The involvement of moral philosophers in public policy decisions raises a question of professional ethics, viz, what role should a philosopher's own moral perspective or judgements play in the advice s/he gives, or contribution s/he makes, to public decision‐making on ethical issues. Like most problems in professional ethics, this prompts reflection on the nature of the profession, and in particular on the expertise we take moral philosophy to offer. It also prompts reflection on how processes of public decision making in ethically problematic areas should be understood. I explore these issues in this paper. (shrink)

In 1986, philosopher-bioethicist Samuel Gorovitz published an essay entitled “Baiting Bioethics,” in which he reported on various criticisms of bioethics that were “in print, or voiced in and around … the field” at that time, and set forth his assessment of their legitimacy. He gave detailed attention to what he judged to be the particularly fierce and “irresponsible attacks” on “the moral integrity” and soundness of bioethics contained in two papers: “Getting Ethics” by philosopher William Bennett and “Medical Morality Is (...) Not Bioethics,” coauthored by us. Gorovitz attributed some of the criticisms that bioethics was eliciting to the fact that this new, rapidly rising, and increasingly visible field had brought “scholars and practitioners together who otherwise would have little exposure to one another's disciplines. Their interactions are mutually enriching at times,” he declared, “but mutually baffling and even infuriating at other times.” In this latter regard, he suggested that “perhaps” Fox and Swazey's characterization of bioethics in the article he dissected “reflects a general revulsion at endeavors they see as inadequately like the social sciences or insufficiently respectful of them.” He went on to say that despite his objections to our “complaints” about bioethics—especially to our claim that “autonomy [had] been an unduly emphasized value” in the field—he had “a lingering sense” that there might be “a grain of truth” in them. Gorovitz ended his essay with an affirmation about the “benefit” that bioethics can derive from “responsible” and even from “irresponsible” criticism. “The unexamined discipline invites the philosopher's critical scrutiny no less than the unexamined life,” he aphoristically concluded. a. (shrink)