Academic Approaches

Any academic discipline in the social sciences and the humanities can claim to have an approach to bioethics—the relevant problems can be studied historically, economically, sociologically, psychologically, anthropologically, or from the viewpoint of political, art, literature, gender, or disability studies. Philosophers were among the first to join bioethical debates with physicians, theologians, and lawyers in the mid-twentieth century, when the intricacies of abortion, euthanasia, doctor-patient relationships, resource allocation, and research ethics began to be publicly discussed. I return to the specific question of philosophical bioethics in the second part of this article.

Pragmatic Approaches

Nonacademic approaches to bioethics claim direct practical usefulness. Professional self-regulation endeavors to show how things can be done properly by physicians, nurses, and scientists. Vocational and professional associations, unions, and interest groups are dedicated to this mission. Legal work attempts to regulate practices in and around healthcare, research, and social and environmental matters, as well as in many other associated fields. This task is taken on by legislators and their adjacent public officials, including members of courts. And activities that are related to (but are not quite) law can make similar claims of practical impact: social policies aim at anticipating potential problems; governance is set to promote good practices; and advocacy of “causes” can aspire to promote equality, justice, and ecological sustainability.

Political Approaches

Political awareness and commitments can also give rise to other, content-driven sets of pragmatic lines. These can be ideological in a very general sense, and a distinction can be made between, say, conservative, moderate, liberal, and radical approaches. They can also lean toward desired forms of political interaction and can give rise to branches of bioethics with the epithets “democratic,” “deliberative,” or “communicative.” Other logical possibilities in this context would include totalitarian, dictatorial, and despotic moral codes and considerations, but these have not been much advertised by professionals in the field. An emphasis on political emancipation produces tactics like feminist, Marxist, black, and postcolonial bioethics.

Another emancipatory approach would be to stress disabilities, poverty, or a combination of the two. Some work has been done in this direction, but most disability scholars and political scientists studying poverty seem to believe that bioethics is somehow inexorably based on premises that rule out such emancipatory styles. This phenomenon is further commented on subsequently under the rubric of epistemological schemes.

Yet another approach draws on African, Asian, European, and Latin American bioethics, and efforts have been made to publicize Central European, Chinese, Indian, Japanese, and many other regional viewpoints. The striking feature here is that North American and Anglo-American bioethics have seldom been studied or practiced as the geographic and linguistic peculiarity that they are. Academics from other regions have seen the idiosyncrasy of these approaches in comparing their own ways of thinking with the North American, English, and Australian ethos; but bioethicists in the native-English-speaking world tend to consider their own patterns of thought normal—as opposed to the strange ponderings of other cultures.^{Footnote 3}

Theological Approaches

Religious studies as part of the humanities can use the full scale of academic methods—anthropology, sociology, psychology, philosophy, history, and so on—to seek knowledge and gain understanding of practices in medicine, healthcare, and scientific research. Apart from these theoretical efforts, however, religions can have, and often do have, their own approaches to ethics. During the last few decades, Christian bioethics has been influential in its many forms, Roman Catholicism often being globally the most visible and audible. Gradually, other Middle Eastern religions—Judaism and Islam—have also become more active in bioethics. And at least Buddhist, Hindu, Shinto, Confucian, Taoist, and Wiccan approaches to bioethics have been outlined or hinted at in the literature.

Epistemological Approaches

Epistemology, or the theory of how we can know about things, provides yet another way of drawing a distinction among approaches to bioethics. Styles can be divided into the positional and the antipositional; a constellation in which members of the first group represent the challengers and the second group the challenged defenders of the status quo.

Positional approaches claim that certain issues can be ethically understood only, or best, by the disenfranchised individuals or groups who are affected by them. Ova sales for research and in vitro fertilization affect women, so it can be argued that the feminist approach should rule supreme in this matter. The pharmaceutical trials of multinational corporations in countries where people are poor and regulations scanty have a marked impact on the citizens of these self-same countries, and because those nations are mainly former colonies of European powers, the postcolonial approach is the best. This logic can be extended, in theory, to any regional, religious, or other discernible lines, and eventually the argument can be made that only Panamanian people have a sufficient understanding of the ethical issues concerning the Panama Canal.

Antipositional approaches claim, or at least arguably have to claim, that knowledge is fundamentally the same for all rational persons regardless of their specific characteristics. It is irrelevant what the individual’s gender or physical ability or disability is, or what the person’s ethnicity, nationality, social class, religion, ideology, and political views are. All rational people see the world in the same way and think alike when it comes to ethical matters. This is why, for instance, a libertarian academic bioethicist of an elite university in the United States can competently assess what the economically struggling farmer in India should think when faced by a choice either to continue traditional farming or to go to work in a factory with minimal pay and inadequate health and safety regimes.

Positionalists believe that neutral knowledge is impossible in important ethical and political matters, and that antipositionalists assume, whether or not they realize it, a stance that is definitely male and able-bodied; almost invariably white, Western, and middle class; and probably Christian, oppressive, and right wing.

To return to our earlier question about emphasizing poverty and disabilities, academics who want to see poverty and disability studies as intrinsically distinct from bioethics seem to assume that bioethics cannot be genuinely positional. They may ultimately be right, although religious and regional variety in the field, as well as the thriving subdiscipline of feminist bioethics, seems to testify otherwise. There may be dimensions of positionality and partiality that ethics as it is usually conceived, perhaps due to its tendency to be universal and impartial, simply cannot reach. But even this needs to be carefully studied before judgment can be passed on the matter.

Your Choice

Approaches to bioethics are, and must be, chosen. The most basic choice is between the practical and the theoretical. Anyone primarily inclined toward the practical direction would be best served by selecting as her or his field of interest and activity professional ethics, law, politics, governance, advocacy, ideology, regionality, or religion. The second part of this article should interest these individuals only tangentially, as it is intended for those who (at least might) in their primary work prefer theoretical understanding to practical impacts. For the members of the theoretical group, other choices present themselves. Which discipline should they select? History, sociology, anthropology, philosophy, and all the other disciplines mentioned previously provide equally fruitful starting points. Which epistemological perspective should they assume? A choice has to be made between nonpositionality (universality, impartiality) on the one hand and positionality (point of view, epistemic empowerment) on the other. In case of the latter, one must pick a particular viewpoint. Similar qualifications need to be made in all theoretical approaches. Philosophers, for instance, must initially pin themselves down to one level of human interaction—individuals, communities, societies, or official political units—to gain clarity on the issues that they study, although these categories of moral, social, and political philosophy may become blurred in more advanced work.

To summarize the first part of this article, there are many approaches to bioethics, all of them legitimate unless proven otherwise, some of them overlapping, and some of them mutually contradictory. Choices have to be made among these, and there is no higher authority to guide us in this task than our interests, views, and opinions. Some approaches can be truly bizarre, and they can be abandoned after balanced assessment, but many remain, and at least reason alone cannot dictate which one of them should rule over others.^{Footnote 4}

Studying Views, Theories, and Approaches

In philosophical work, the tasks of defining concepts and divisions, reconstructing views, and clarifying judgments standardly proceed in three stages, namely, description, interpretation, and assessment.

At the descriptive stage, philosophers examine ideas presented or implied by people (including themselves) and try to figure out what exactly has been said. The principle of charity requires that people’s ideas be scrutinized in the best possible light. This entails always making the initial assumption that what has been expressed is interesting instead of trivial or boring, sensible instead of nonsensical, meaningful instead of meaningless, rational instead of irrational, reasonable instead of unreasonable, and comprehensible instead of unintelligible. If, for instance, someone says that cloning human beings is playing God, it is unhelpful to respond that because God does not exist, or is not one to all, the claim is silly. The speaker may not have that kind of God in mind, or we may better understand the statement by supposing that he or she does not. An accurate description that observes the principle of charity neatly paves the way to the next stage of the analysis and partly prefaces it.

Because not all notions, views, and verdicts are, even if expressed without ambiguity, immediately clear to everyone, interpretation is needed. Interpretation, or reconstruction, sets the raw description into a more familiar framework in an attempt to convey the meaning of what has been said. There are two main ways of doing this. Historical reconstruction aims to tell us what the idea means or has meant to those who have expressed it. Playing God, for instance, has in the past quite literally meant stepping outside the boundaries of what you are supposed and allowed to do, and thereby exposing yourself to divine punishment. Prometheus, of the ancient Greek myth, played God by stealing fire from the Olympian deities and giving it to humankind, for which he was promptly sentenced to eternal torment. This nugget of information about the history of literature, of course, may or may not be of interest to us, so other ways of construing what playing God might mean are also needed. Rational reconstruction attempts to tell what we, as rational human beings, can learn from an idea or train of thought that we do not comprehend in its original form. In this vein, it has been suggested that arguments from playing God remind us of our human limitations and warn us against hubris, or excessive ambition.^{Footnote 5} There are activities, like the creation of life, that are conceivably safe when they are in the hands of all-knowing and all-powerful forces (God or nature) that can anticipate problems and fix things if they go wrong. But because human beings do not have these qualities, it would be unsafe for them to engage in such activities.

Description and interpretation are, in full analyses, followed by evaluation. This is the stage at which the validity and soundness of the best possible readings of the distinctions, views, and verdicts are tested. The test of validity is internal and aims to ascertain that what is expressed is coherent and consistent within the framework set up by the charitable interpretation. The test of soundness is external, and it focuses on whether or not the premises of the constructed argument are true.

The Limits of Evaluation

The distinction between internal and external testing can be illustrated by two simple syllogisms.

First, consider this valid and, as most would agree, unsound argument:

• • If the moon is cheese, then I am a good person.

• • The moon is cheese.

• • Therefore I am a good person.

The inference is valid, which in philosophical thinking means that the concepts used are unambiguous and the conclusion logically follows from the premises. But it is unsound, on at least two grounds. There are no good theories linking the material composition of the moon to human virtue, so the first premise does not make much sense, no matter how charitably we look at it. And because most of us firmly believe that the moon is mostly made of inanimate argon, helium, sodium, potassium, hydrogen, and radon, the claim that it consists of cheese has no physical justification.

Then consider this valid and—opinions vary—sound or unsound argument:

• • If Thomism is right, then cloning human beings by the nuclear transfer method is wrong.

• • Thomism is right (at least in the context of cloning human beings by the nuclear transfer method).

• • Therefore cloning human beings by the nuclear transfer method is wrong.

Again, the inference is valid, as the concepts are used unambiguously and the conclusion logically follows from the premises. The first premise is also probably true. Thomism, the official philosophical doctrine of the Roman Catholic Church, contains principles that can be employed to condemn human cloning by nuclear transfer (the Dolly method).^{Footnote 6} The question that interests me here is, what can we say for or against Thomism as a moral theory, and, even more importantly, on what grounds?

Is Balancing Enough?

The standard approach in applied ethics utilizes the notion of reflective equilibrium for this purpose. According to the notion, we should conduct a balancing exercise between abstract theoretical principles and their more practical implications, both in terms of the norms they generate and in terms of the real-life consequences their implementation would entail.

A good illustration of the first alternative, a conflict of norms, has been presented in the context of racial equality.^{Footnote 7} If we are of an egalitarian persuasion, we may hold the lofty ideal that, among other things, race should be irrelevant in our legislative and policy decisions. But we may also think that, in our current world, it would be a good idea to have special protections for racial minorities, although this seems to go against the first rule. Advocates of the reflective equilibrium model argue that we should in such cases go back and forth between the general and more specific principles until we reach formulations of both that we can accept and that do not contradict each other.

An example of the second, consequence-oriented version of finding a balance is prompted by a traditional critique of utilitarianism. Champions of the doctrine say that we should always in our actions aim at the happiness or well-being of the greatest number of people possible. But what if this can only be achieved by vast restrictions of liberty, or at the expense of the suffering of vulnerable minorities? Although apparently condoned by the general principle, these implications are not accepted by all. Again, modifications are needed to sooth intuitions at all levels.^{Footnote 8}

The method of reflective equilibrium and its associate approaches are probably the closest that we can get to assigning philosophers, as philosophers, a practical role in worldly matters. The perennial problem with these methods is that, like everything else in academic ethics, they can legitimately produce only hypothetical results. If you subscribe to Thomism or egalitarianism or utilitarianism, and if you believe that cloning humans is wrong or that racial minorities need special protections or that liberty should not be restricted in certain ways, then the balance that you have formulated is credible to you and to others who agree with your assessment. Unless you have found the philosopher’s stone of ethics, however, the rest of humanity will remain unimpressed by your conclusions. Why, they will ask, did you choose exactly that theory and why should your intuitions about its practical applications move others? And so we return to the question already raised: what can we usefully say for or against Thomism or egalitarianism or utilitarianism or any other moral theory, and on what grounds?

Two Shared Presuppositions

In philosophical analyses of ethical views and normative judgments, in the context of bioethics as everywhere else, we must at some point turn our attention to the basics of moral and political theories—to their starting points, their constitutive elements, and, above all, their background assumptions, or presuppositions. The soundness of arguments for and against real-life views and judgments depends on the correctness of their underlying theories; and the correctness of the underlying theories is a function of the acceptability of their essential components.

Normative accounts of morality and justice always presuppose certain ideas. One of them is the idea of the freedom of the will. The logic is as follows. Morality and justice are traditionally linked with praise and blame, and we can only be genuinely praised or blamed for actions or inactions that we have ourselves voluntarily chosen. If we behave automatically (as in sleepwalking), we cannot really be held responsible for our deeds—unless we have produced the state of involuntariness ourselves. The opposite of freedom of the will, however—the idea of determinism—implies that all our actions are automatic and caused by external forces. None of them are, if determinism is true, open to judgments of admiration or censure. This is clearly not a premise on which praise-and-blame-based normative theories of morality can be built, and this is why freedom of the will is a given in them.

Another inescapable starting point for these theories is moral realism. This is a metaethical view claiming that our normative moral sentences can be true or false: that they refer to something real, something against which their accuracy can be verified or falsified. When we say, “Scientists ought not to clone human beings,” we suppose, according to this view, that something meaningful is being stated—a fact about the immorality of a certain type of action. This idea does have its critics. There are philosophers who claim that sentences like this are merely expressions of emotion (“Scientists clone humans—yuk!”), or opinion-based inducements to action or inaction (“Let’s not clone humans!”). But normative theories cannot be built on premises that would deny their relevance in real life, so their default value must be moral realism.^{Footnote 9}

Other Unavoidable or Optional Presuppositions

Whereas the ideas of free will and moral realism are indispensable to all normative ethical theories, other presuppositions are, to varying degrees, matters of choice. There are some fundamental decisions that have to be made, and there are considerations that can be seen as optional, or case specific. Any credible view takes, explicitly or implicitly, a stand on questions like the following:

• • What is the world made of? (This may sound far-fetched, but the question is pertinent in the comparison of religious and secular positions. Alternative answers include matter, mind, spirit, and different definitions and combinations of them.)

• • What are human beings like? (Are they egoistic, altruistic, or both? Do they think of others and of morality spontaneously, or do they have to be persuaded or forced to do so?)

• • What is the relationship between individuals, groups, communities, and societies? (Is it better to see people as fundamentally separate entities or as members of groups?)

• • What matters morally? (Do we aim at optimizing the outcomes of our actions in terms of well-being and happiness; do we abide by some essential ethical rules and principles; or is it our goal to respect and safeguard traditional ways of acting and thinking?)

The relevance of many other issues related to norms, values, attitudes, and logic depends on the context in which we are expressing our views. These issues are too varied to be presented here in full, but to give an example, the following list includes some items that, according to my own recent analysis, need to be observed, defined, and accounted for when it comes to the genetic selection and enhancement of human beings by new technologies:

• • Loss of life. (Is this always an equally serious consideration? How is the loss of embryonic life compared to the loss of adult life? How is loss of life resulting from action balanced with loss of life following inaction?)

• • Risk assessment, benefit assessment, and precaution. (What attitudes can we take toward these?)

• • Slippery slopes. (Do we think of these as a genuine threat, or do we hold that references to them are worthless scaremongering?)

• • Parity of reasoning. (How exact are we about the consistency and coherence of our ethical views?)

• • Reproductive freedom and parental autonomy. (These are important in all areas of reproductive ethics.)

• • Parental responsibility. (Ditto.)

• • Nondirectiveness. (This is important—or not, as you may choose—in all medical and genetic counseling.)^{Footnote 10}

And there are many other questions about presuppositions that are important in the many fields into which studies in theoretical and applied philosophical ethics can be extended.

It Is All in the Presuppositions

Let me return to the question, then. What can we usefully say for or against moral theories, views, distinctions, and judgments from the standpoint of philosophical bioethics? It is my conviction that we can expose the presuppositions of these views and present them for all to see, in the hope that people can then make informed choices among alternative solutions. Philosophers can provide decisionmakers with conditional judgments: If you take parental responsibility to mean that no child of yours shall have avoidable hereditary ailments, then support extensive prenatal testing and selection. If you think that nondirectiveness is important in genetic counseling, then do not let physicians oversell their own ideas to their patients. If you believe that human beings are spontaneously altruistic, then do not accept lightly theories that make justice and morality matters of persuasion and coercion. If you see others straying from their stated premises and presuppositions, then feel free to criticize them for that. A philosophical analysis is completed when all the important conceptual fundamentals of the case or doctrine under consideration are laid bare.

Whether or not, after all the philosophical work has been done, ethicists feel that they must make a (nonphilosophical) judgment on the studied views is a question of style. Philosophers can, as human beings and concerned citizens, take sides in bioethical debates, and they can search for reflective equilibria in moral issues, but these are not activities that they should consider their primary professional task. Their primary professional task is to clarify distinctions, explicate arguments, and analyze judgments by examining their background assumptions—their presuppositions. It is important, I believe, to realize that the concrete normative judgments ethicists make will eventually rest on a prior subjective or intersubjective choice of presuppositions, not on any bedrock of perennial philosophical wisdom.

In sum, I do think that philosophical bioethics, as outlined in the preceding considerations, would be an excellent idea.