The following appeared in Volume 98, Number 2 (Spring, 1999) of the APA Newsletters

There seems to be a tendency in modern philosophy and amongst modern philosophers towards more and more specialization. This is quite clearly an understandable tendency given the number of people publishing in the field and hence the amount of material that must be absorbed in order to be able to consider oneself adequately informed. One person can only do so much. In ethics this specialization causes a problem or, if not a problem, then at least, a gap. The gap is that between applied ethics and metaethics. As many moral philosophers will attest, ethics is an essentially practical matter and yet there seems to be a lack of communication between those who think generally about, say, the nature of morality and those who consider general ways of understanding moral decisions that confront physicians, lawyers, engineers and the like.

One way in which this gap is manifest is in the "anthology" method. This method is essentially a pedagogical technique used in applied or introductory ethics. The strategy is to present an overview of the traditional schools of moral thought such as deontology, consequentialism, constructivism and virtue ethics, and then to consider how each of these types of theory addresses a relatively standard set of problematic cases specific to the field in question. By and large, no attempt is made to reconcile the apparent conflicts. Unfortunately, "the student naturally concludes that moral theory is either confused, irrelevant or completely relativistic" (p.2).

Bioethics: A Return to Fundamentals by Bernard Gert, Charles M. Culver and K. Danner Clouser is an attempt to bridge this gap. Whilst the focus of the book is undoubtedly on bioethics, the authors continually insist that their moral theory can and should be extended to other specific regions of applied ethics. Their theory blends the insights of the consequentialist and the deontologist "into a single coherent and comprehensive framework within which all moral problems can be considered" (p.2).

The authors’ intentions in this book are very clear: they wish to develop a moral theory that captures and explains the moral judgements that human beings ordinarily make and to provide the "conceptual tools" that are needed in order to apply the theory to the specific area of bioethics. The book can thus be divided into two parts corresponding to each of these projects. The first part, chapters one through four, concerns the theory, how it is generally applied and a discussion of its relation to its major competitor, what the authors call, ‘principlism’. The second part, chapters five through twelve, includes discussion and argument concerning the key concepts specific to bioethics.

The general theoretical approach taken by the authors is that once a general moral theory is established, understood and justified, the additional component which distinguishes the various ‘regions of application’ (bioethics, engineering ethics, environmental ethics, etc.) is a set of concepts that relate specifically to that region. Thus in order to make judgements in one of these regions one must understand the theory, know how to apply it and also be familiar with the concepts specific to that region. This approach has the effect of making moral theory continuous across applications and thus uniting theoretical or metaethics with applied ethics. It is refreshing and engaging to see moral philosophers thinking in terms of unifying systems, respect for moral intuitions and specific applications.

Overall, the moral theory that is offered by the authors can be understood as a form of rule-consequentialism. What is or is not morally acceptable is largely dependent on moral rules and justifiable violations of them, whilst the criteria for moral acceptability are given in terms of the avoidance of five kinds of harms: death, pain, disability, deprivation of freedom and deprivation of pleasure1. Thus the theory is a rule-based one with the locus of moral value centering on the avoidance of harms. What is right is determined by what is good.

One significant feature of the theory that distinguishes it from other consequentialist theories is the importance of publicity in cases where a violation of a moral rule is being considered. "A consequentialist system is concerned only with the foreseeable consequences of the particular violation, not with the foreseeable consequences of that kind of violation being publicly allowed" (p.46). A central idea throughout the book is that morality is a public system and hence, what is morally acceptable or unacceptable is determined by what would be acceptable to impartial rational agents to whom the system applies.

Both impartiality and rationality play a significant role in the theory. Impartiality is uncontroversially defined and is plausibly linked with publicity. Rationality, on the other hand, is controversially defined. As the authors point out, the standard account of rationality is instrumental involving the process of reasoning combining belief with maximal satisfaction of desires. Defining rationality as primarily related to specific kinds of action is thus a significant departure from the standard account. The discussion of rationality is unclear —it seemed as though the distinctions and multiple embedded definitions could have been organized in a more ‘reader-friendly’ manner. Irrationality is basically defined in terms of actions that are known or ought to be known to cause harms and that are performed in the absence of adequate reasons. Reasons are defined in terms of rational beliefs about the avoidance of harms and the lack of inconsistency as seen by others of "similar knowledge and intelligence". The adequacy of reasons is assessed, again relative to harms and benefits, by "any significant group of otherwise rational people". And finally, individuals are otherwise rational "if they almost never knowingly act so as to suffer any harm without some reason" (p.29).

There are four components that make up the structure of the moral theory: moral rules, moral ideals, the morally relevant features of situations and a detailed procedure for dealing with conflicts2. There are ten moral rules each of which prohibits acting in ways that cause, usually cause or increase the risk of causing each of the five harms. Moral ideals seem to be heavily dependent on the relevant society, community or profession and are intended to encourage individuals to perform those kinds of actions which lessen the amount of harm suffered. The key distinction between the two is that the rules are morally required whereas the ideals are only encouraged. Moral ideals can become moral rules within the context of a community or profession. Hence, caring is a moral ideal for ordinary people but for physicians providing care might be a duty and so, be morally required.

The final two components of the theory, morally relevant features and the decision procedure, both deal with violations of the moral rules. Both are designed to assist in determining whether a particular violation of a moral rule is justified and so to adjudicate in cases of conflict between moral rules and between a moral rule and a moral ideal. The initial step in the decision procedure is to describe the kind of violation in terms of morally relevant features. These features are, with one exception, specified in terms of questions regarding the moral rules and the degree and kind of harms/benefits involved in the particular case3. Once the candidate action has been thus described the second step in the decision procedure is to determine the consequences of this kind of violation being publicly allowed. That is, what would happen if everyone knew that this kind of violation was allowed to occur? The degree to which all rational impartial persons would agree that less harm would be suffered if this kind of violation were publicly allowed is the degree to which the violation is justified. A strongly justified violation is one where all impartial rational persons would agree whereas a weakly justified violation is one where such persons would disagree. A violation is unjustified if no impartial rational persons would agree.

From these remarks we can begin to glimpse the kind of justification that the authors give not only for violations of the moral rules but for the theory as a whole. The overall justification, and indeed, the philosophical method employed by the authors, is premised on common morality, the moral judgements that we ordinarily make—what the authors call the ‘moral system’4. The theory "is intended to be an account of the moral system that is already implicitly used by people when dealing with everyday moral problems" (p.15). This means that almost the entire reason for accepting this moral theory rather than some other is that it best coheres with and accounts for our day to day moral experience. Considered moral judgements and clear moral intuitions are thus the database and the benchmark of adequacy for the theory. At the conclusion of the first chapter the authors sum up the fundamental stance underpinning this strategy:

Although it is clear that we take moral theory seriously, this does not conflict with the seriousness with which we take common morality. Nor does it conflict with our belief in the natural ability of human beings to deliberate insightfully and successfully about moral problems. On the contrary, our moral theory rests upon these foundations. We intend this book to encourage people to have more trust in their basic moral intuitions. (p.13)

The second part of the book deals with the analysis of what the authors take to be the fundamental concepts involved in dealing with the moral problems involved in bioethics. The discussion of these concepts constitutes about two thirds of the book. These concepts are malady, competence, consent, confidentiality, paternalism, death and euthanasia. It is characterized by an impressive degree of completeness and attention to detail.

The approaches to each of the concepts varies somewhat. However the most common strategy adopted by the authors is to give a general outline of the current positions in such a way as to highlight the guiding intuitions informing them. By isolating these intuitions the reader is able to see the initial plausibility of each view. The authors then demonstrate the inadequacies of the respective views using examples and by pitting each view against the other. Having the guiding intuitions behind each view clearly laid out provides the grounds for the move to the authors’ account of the relevant concept. By and large the accounts that are given occupy the middle ground, thus consolidating the best from each of the more extreme views. Examples of this method are found in the chapters on competence, confidentiality and euthanasia. In discussing competence the authors contrast accounts in which the fundamental ideas are understanding and appreciation with those that rely more heavily on rationality. By pointing out that competence is judged relative to abilities of a certain kind, the authors make room for the intuitions guiding both accounts.Competence, particularly as it applies in medical cases, is thus depicted as the ability to make rational decisions of a certain kind. Understanding and appreciation are incorporated into both the notion of a rational decision and the specification of the relevant kind. In the chapter on confidentiality, the authors begin by examining the broader concept of privacy. Confidentiality, they hold, is part of the concept of privacy. Three different conceptions of privacy are presented, "untangled" and integrated: nonintrusion, freedom to act and protection of personal information. The integration results in a definition and three normative guidelines, where the latter are obtained by utilizing the notions of justification and publicity developed as part of the moral theory. In the final chapter, on euthanasia, the authors utilize almost all of what has gone before. After presenting the dilemma confronting physicians in this matter, they consider how best to make the distinction between active and passive euthanasia. Four standard ways of making the distinction are presented: acts versus omissions, stopping treatment versus not starting, ordinary versus extraordinary care and whether death is due to natural causes. Each of these is argued against on the grounds that none make the distinction in a way that has clear moral significance. In order to present their view, the authors return to earlier considerations, the moral theory, the duties of physicians and paternalism. After making the active/passive distinction using the distinction between patient requests and refusals, the final part of the chapter considers application and consequences of the distinction—among others, physician assisted suicide and advance directives.

The chapter on malady is a notable exception to this general method. In this chapter, rather than presenting current views and then giving a critique, the authors use what they call a "method of discovery". This method involves introducing an initial and very broad consideration of the work that the concept does in ordinary use. In this case, someone has a malady when something is wrong. This initial idea is made more precise by considering examples and related concepts. This process of consideration and reconsideration continues until a comprehensive account is obtained. Thus, each of the components of the final account are seen as justified over the course of the investigation. It should be added here by way of explanation that the authors want an account of malady rather than disease or illness largely because they believe that all ‘disease-terms’ have something in common and by using the term ‘malady’ these commonalities can be explored without having to appropriate and so alter another more specific concept.

This chapter although distinct in approach does share general features with other chapters in this part of the book. Those features of particular note are (1) the continual dependence on examples of the ordinary usage of the concepts, (2) the incorporation of value into the concept in question and (3) a reluctance, where appropriate, to decide all cases. Each of these features reflects the method adopted by the authors in the first chapter—the determination to make their analyses conform to and originate in ordinary moral and linguistic practices. The first of these features is fairly obvious however the second and third require some explanation. The authors, I think rightly, observe that some of the concepts under consideration are essentially normative. The way in which people ordinarily use such concepts as, say, illness and disease reflects their underlying value judgements. To ignore this feature would be to alter the concept. The third feature, not attempting to determine each case, also stems from the overall method of the book5. As the authors suggest the complexity of the moral situations which we face and the variation of considered moral judgements that people make, call into question the possibility of deciding either in advance or once and for all, which choice of actions is the right one. The authors’ commitment to common morality dictates that they not attempt to determine each case.

One final characteristic of the second part of the book is the use of cases to illustrate both the application of the authors’ moral theory and their accounts of the particular concepts. The majority of these cases are found in the chapters on paternalism and its justification. The chapters preceding these two, particularly those on competence, consent and confidentiality, are usefully seen as leading into the issue of paternalism and its justification. The authors appear to make use of cases in situations where the discussion of the concepts leads to particular normative pronouncements that require either explanation or justification. The inter-relations between the chapters is made quite clear even though they are distinct chapters concerning separable issues. The chapter concerning malady provides an important underpinning for both the five chapters mentioned and the final two, concerning death and euthanasia.

As a whole the book has many merits, not the least of which is the attention to detail and thoroughness in the considerations and arguments presented, particularly concerning the central concepts of bioethics. The structure and intent of the book is also very clearly outlined and adhered to. There are however a number of foundational questions relating to the moral theory that seemed inadequately developed. At the outset the authors make a good deal of our ordinary moral intuitions and our common moral experience. The theory is grounded in and is intended to reflect our ordinary morality. Indeed, it is intended that we will simply agree with the proposed moral theory. The step from the mass of ordinary moral judgements to the fundamental tenets of the authors’ theory is sometimes all to quick. We are not given enough detail about the features of all of moral experience to be able to conclude that, for instance, the agreement that exists among our moral judgements "is based on agreement about the nature of morality, that it is a public system with the goal of reducing the amount of harm suffered by those protected by it" (p.21). That we all agree about the nature of morality seems questionable and that we all agree that its goal is to reduce the amount of harm suffered seems even more difficult. This problem stems from a lack of discussion of what constitutes moral experience. My suspicion is that a detailed examination of the facts of all moral experience will reveal much less agreement about the basic tenets of morality than the authors suggest. In their defence, the authors claim that "one must already know the essential features of morality (at least in some rough , preliminary way) before setting out to study the phenomenon of morality" (p.5). However, if this is true then surely there should be some argument provided about these essential features—such things cannot be assumed. This matter, I must admit, detracted from the compellingness of the moral theory.

I mention these reservations only briefly because I do not think that they detract either from the aims of the book or from the significant contribution which the detailed and systematic analysis of the key bioethical concepts ought to make to the general understanding of the moral issues involved in the practice of medicine both in particular cases and at a societal level.

1. The authors do not seem particularly averse to this classification. They do separate their theory from Kantian deontology and from act-utilitarianism. Rule-consequentialism is mentioned but only in the context of differences with act-consequentialism (footnote #29, p. 50).

2. The authors’ claim that this is not a rule-based theory is misleading. Each of the components of the theory can, and I would suggest, should be understood as providing the rules of morality. Moral ideals are rules that are often non-specific and are encouraged rather than required. The list of morally relevant features gives criterial rules for interpreting situations and the decision procedure is, quite clearly, a rule for deciding in conflict cases.

3. The exception is the penultimate property, dealing with the intentions of the agent. Although nothing is said concerning how intentions come to have moral value in a consequentialist system, I suspect that it would in the end turn on the notion of publicity.

4. This strikes me as an odd label for common morality since part of the point of requiring a moral theory is to give system to this common morality.