As medicine in the US finds itself in an increasingly troubled state, medical ethics is prospering as never before. While health services flounder, doctors grow unhappier and medical school admissions drop, a new breed of moral philosophers, known as medical ethicists, has been delighted to find a steadily growing demand for its skills. These trends are not, of course, unrelated. Like undertakers and pathologists, medical ethicists have found that the health of their profession and the health of their subjects are related in inverse proportion.
The recent trends in medical ethics also contain ironies. Several developments have conspired to widen the gap between American doctors and their patients: sophisticated diagnostic technology is replacing the medical history and physical examination, hospital care is replacing primary care, and profit-oriented medical centres are replacing the family doctor. But while the worlds of the doctor and the patient are moving further apart, the worlds of the ethicist and the patient are moving closer. It is not rare in the US these days to find moral philosophers accompanying clinicians and medical students as they do their rounds in hospital wards. Philosophers seem to be discovering that in ethics, armchair expertise is no substitute for clinical experience.
At the heart of this emphasis toward closer contact with patients is a final irony. As medicine moves further toward technological solutions to medical problems, medical ethics is returning to a method of moral reasoning which was discarded in the Renaissance and has rarely made an appearance since.
Only five years ago the term 'casuistry' was barely heard outside academic departments of history or religion, much less in hospitals and medical schools. Those who did use the term did not intend it to be a compliment. Rather like the term 'sophistry', 'casuistry' had come to refer to skilled but specious ethical reasoning. It implied the devious misuse of a philosophical art, a superior talent put to malicious ends.
But the casuistry that is emerging in medical ethics has somehow shed these implications of malevolence. It refers rather to a method of reasoning on a case-by-case basis, avoiding abstractions and concentrating on practical action. Like clinical medicine, it is a pragmatic enterprise, relying less on moral theory than on case histories and rules of thumb.
Though casuistry has fallen into disrepute over the past three centuries, at one time it was a respectable method of addressing moral perplexities. Casuistry evolved in the Christian theology of the early Middle Ages as a way of solving 'cases of conscience'. Sometimes called 'case morality' or 'case divinity', casuistry was driven by a need for practical action in situations of moral uncertainty. Typical of the casuistic enterprise would be efforts of a Church scholar to interpret religious prohibitions against lying in cases where telling the truth might lead to great harm. At its zenith in the 16th and 17th centuries, casuistry produced a large body of work on a broad range of moral problems. Many of these problems are still relevant today, such as questions of sexual morality or the justification of violence; others, thankfully, have all but disappeared - for instance, questions regarding the use of judicial torture.
The disrepute into which casuistry eventually fell is usually attributed at least in part to the French philosopher and mathematician Blaise Pascal, who in 1656 published a blistering, satirical attack on casuistry in his Provincial Letter. Writing anonymously on behalf of a small French Catholic sect called the Jansenists, Pascal caricatured the Jesuit casuists (the Jansenists' political enemies) as ingenious defenders of moral laxity, capable of justifying virtually any outrage by way of shrewd moral manoeuvring. Casuistry never really recovered from Pascal's brilliant polemic. In later academic debate, even serious discussion of casuistry was conducted in derisive tones. One hundred years after Pascal's attack, Adam Smith closed his discussion of casuistry in the Theory of Moral Sentiments with this dismissal: 'Books of casuistry, therefore, are generally as useless as they are commonly tiresome.'
But recently, casuistry has been resurrected. And in its current incarnation, casuistry is being turned not towards matters of church doctrine but to moral questions in the hospital and the laboratory. The revival of casuistry in medicine is, in turn, part of a more general swing of philosophical interest in recent decades toward ethical dilemmas in the public domain. For the first half of the 20th century, moral philosophers largely occupied themselves not with practical moral problems (what action would be morally best in this situation?) but with questions concerning the logic and method of moral reasoning (what is the nature of moral judgements?). Actual cases were rarely discussed and the ones that were debated were usually hypothetical scenarios invented to demonstrate a philosophical point.
This began to change in the 1960s and 1970s, when moral issues such as civil rights, conscientious objection and nuclear war were debated and American academics were drawn into the arguments. Technological advances such as intensive-units and organ transplants brought medical ethics to the foreground. At first, 'bioethics' was mainly an extension of the work of moral theologians, who were involved in sensitive medical situations as part of their pastoral work in hospitals and clinics; bioethical issues later began to attract the attention of moral philosophers. Years later an even wider range of people joined the debate on ethical questions in medicine and biology: specialists in literature, history, law, sociology and anthropology. As a result the study of 'cases of conscience' once again acquired an air of academic respectability.
The term 'casuistry', however, was rarely used to describe this sort of practical ethics until the late 1980s, when philosopher Stephen Toulmin and theologian Albert Jonsen began to rehabilitate the term. In a number of separate articles and later in their book The Abuse of Casuistry, Toulmin and Jonsen argue that what practical ethicists find themselves doing today is quite similar to what the casuists were doing in the Middle Ages - and rightly so. Ethics cannot be abstracted from the concrete situations in which moral problems arise, and the pressing concerns engendered by medicine and biology have brought moral philosophers back down to earth. Medicine, says Toulmin, 'saved the life of ethics'.
However, what distinguishes Toulmin, Jonsen and their followers from the mainstream of moral philosophy is not so much their insistence on attention to cases as their method of moral reasoning about those cases. Much of moral philosophy over the past two centuries has focused on developing moral theories: guidelines as to how one ought, morally, to act. Philosophers took science as their model: so, in much the same way that scientists might develop a theory and then use it to explain and predict physical phenomena, it was thought that philosophers should develop moral theories, which, when applied to particular situations, could tell people the morally right way to behave. If philosophers could just develop or discover fundamental moral principles, abstract and general moral truths on which a theory could be built, then how one ought to act in particular cases would follow logically.
In this view, the job of philosophers was to construct the moral theories, not to apply them. Even philosophers sympathetic to the view that ethics must aim at practical application generally thought that application must come after the development of the theory. In his Principia Ethica, the English philosopher G. E. Moore wrote: 'Casuistry is the goal of ethical investigation. It cannot be safely attempted at the beginning of our studies, but only at the end.'
The new casuists, on the other hand, argue that this view of ethics is hopelessly misguided; that we cannot expect to find moral laws from which to deduce logically how to act in particular cases. Toulmin and Jonsen trace the view of ethics as systematised, abstract theory to Isaac Newton's Philosophiae Naturalis Principia Mathematica, which put forward a set of three 'Axioms, or Laws of Motion', which, it was thought, could theoretically explain (eventually) all the phenomena of the natural world. The influence of this work spread beyond the natural sciences to virtually all subjects, and scholars in ethics took its mathematical precision as a model for their own endeavour. Toulmin and Jonsen call this a 'geometrical' view of ethics: a search for universal first principles, from which specific courses of action can be logically deduced.
In contrast, the new casuists anchor their method not in abstract theory, but in concrete particulars. In a morally difficult situation, instead of attempting to reason from universal first principles, the casuists look to 'paradigm cases' - examples of right and wrong about which there is little or no moral disagreement, and which bear similarities to the case at hand. For instance, doctors looking after newborn babies often face the dilemma of deciding whether or not to resuscitate a premature infant whose chances of long-term survival are small, and whose brief life may be handicapped by mental or physical disabilities. Is it morally justifiable to withhold treatment? A casuist might begin to think about such a case by examining paradigms to which the case is similar. How is this case similar to and different from, for example, infanticide, which virtually everyone agrees is morally wrong? How is it similar to and different from the case of a terminally ill adult, who asks not to be resuscitated if her heart stops? Casuistry sees ethics as a matter not of logical deduction, but of rational persuasion. By reasoning from like cases, about which there is little disagreement, casuists bypass the traditional leap to general theory. Their approach is to argue about morally fuzzy cases by comparing them to morally clear ones.
One rationale for bypassing the step up to theory is that our moral experience is rooted in actual circumstances, not in abstractions. As children we are taught first of all about right and wrong in real, concrete situations, and from those individual situations we learn to generalise. Even as adults, we rarely possess coherent, systematised moral theories. Our generalisations usually take the form of rough moral maxims such as lying is wrong and one ought to keep one's promises. But these maxims are far from all-encompassing and straightforward. They often conflict with each other, and they require judicious interpretation when they are applied.
Philosophers have long debated and long disagreed on the nature of 'moral knowledge'. Is my knowledge that needless killing is wrong like my knowledge that my sweater is green? Are there moral principles that are like scientific principles, moral facts that are like scientific facts? The casuists argue that whatever the answer to these sorts of questions - if, indeed, such questions even make sense - any moral knowledge that we do have is not knowledge of general moral principles or abstractions, but knowledge of what one ought to do in specific situations.
An anecdote demonstrates the casuists' point. In the mid-1970s, both Toulmin and Jonsen served on the National Commission for the Protection of Human Subjects of Biomedical and Behavioural Research in the US, a panel set up to produce ethical guidelines for scientific research on human beings. Serving on the commission were 11 people of varying occupations, races, religions and interests: men and women, Catholics and Jews, atheists and theologians, lawyers and medical scientists - in short, not a group that one would immediately expect to reach consensus on ethical issues. Yet while the members of the commission brought to their decisions vastly different points of view, they rarely found themselves in disagreement when they had to decide how to handle particular cases. They began to disagree only when they started to give the reasons for their decisions - that is, when they made the implicit leap to moral 'theory'.
One point of this story is that if ethical investigation aims to reach a consensus upon which all members of a society can agree, then a more efficient way of reaching that consensus is to work not from the top down, as philosophers such as Moore have long suggested, but from the bottom up: to start from cases, not principles. The experience of the commission suggests that even people with very different moral principles can agree on how best to act in particular cases. And in fact, Toulmin and Jonsen report that the members of the commission reached consensus on particular cases before they developed the general guidelines that they were charged to produce.
Medicine in the US is beginning to feel the impact of the case-based method. One obvious consequence has been the growing prominence in medical ethics departments of medical doctors trained in ethics. For a number of years now a majority of American medical schools have employed ethicists to teach ethics and the humanities to medical students and house staff and to offer advice on problematic medical cases. But oddly enough, in the early days of medical ethics only a few of the major figures in the field were medical doctors. The result was often a yawning gap between ethicists' abstract method and doctors' clinical practice. Doctors, however, are generally much more comfortable with the case-based method, which emphasises the skills of clinical practice: pragmatic reasoning, teaching in wards and dealing with patients.
A popular term for this clinically based approach is, aptly enough, 'clinical ethics'. One of the most recent additions to the expanding list of bioethics journals is the Journal of Clinical Ethics, which emphasises a practical, action-oriented approach to ethical difficulties. A similar approach characterises the University of Chicago's Center for Clinical Medical Ethics, which offers a training programme in ethics for physicians. And whereas until recently most scholars in ethics were employed primarily to teach ethics to students in medical schools or philosophy departments, more and more 'clinical ethicists' are being assigned to hospital wards to advise on clinical dilemmas.
A more controversial development has been the growing popularity of 'ethics consultants'. In much the same way that a rheumatologist or a dermatologist might be called in by a GP to consult on a patient with especially puzzling joint or skin problems, an ethics consultant is called in to give advice on cases which present particularly difficult ethical problems. The consultant will typically interview and perhaps examine the patient, review the case with the health care team, and consult with the patient's family. Like any other consultant, he or she will usually leave a note in the patient's chart with recommendations for the patient's management.
Many observers are bothered by a change implicit in the notion of ethics consultation: a shift in decision making from the primary physician to the consultant. In American medicine, when a specialist consultant is called in to advise on a case, it is ordinarily because the primary physician is not equipped to deal with problems of a very specialised nature. Formal ethics consultation seems to suggest to doctors that they are not capable of making ethical decisions on their own - that a specialist is better qualified to make these decisions for them.
Many ethicists worry that instead of encouraging doctors to make more sensitive, thoughtful decisions, which is clearly the goal, ethics consultation encourages them to turn their ethical problems over to someone else. So far the revival of casuistry has been most influential in clinical circles: among those whose work revolves around dilemmas in the hospital, such as the termination of life-sustaining treatment or do-not-resuscitate orders. It is natural that practitioners whose work brings them in touch every day with clinical cases should be attracted to a case-based method of moral reasoning. But casuistry has not yet had much impact on bioethical problems outside the immediate clinical realm, such as those created by new reproductive technologies, or those generated by efforts to map the human genome. Nor does casuistry lend itself as easily to matters of health policy, where attention must be focused on the general rule, rather than the particular case. Despite its limitations, however, casuistry has proven itself a refreshing alternative to more traditional methods of moral reasoning in the clinical domain. What remains to be seen is whether its methods will spread, as in the days of the medieval casuists, to an even broader spectrum of moral dilemmas.
Carl Elliott has degrees in medicine and philosophy and lectures in the Department of Medical Humanities at East Carolina University Medical School in Greenville, North Carolina.
CARL ELLIOTT