Spring, 2004
By Leigh Turner
PhD Assistant Professor, Biomedical Ethics Unit Department of Social Studies of Medicine Faculty of Medicine, McGill University
Anyone examining the last three decades in the history of medicine, healthcare and biotechnology can identify both longstanding zones of ethical conflict and areas of relatively stable social norms. Morality is neither fully stable and ordered or dominated by conflict. 1 With some topics, individuals from many different cultural, religious, philosophical and political traditions are able to reach shared understandings. In other instances, cultural and religious differences play an important role in generating and perpetuating moral disputes. Serious moral conflicts occur in Canada, the United States, New Zealand and Australia, but they rarely threaten to destroy the entire social order.
Contemporary liberal democracies are multicultural, multifaith, pluralistic societies. Globalization is dispersing individuals, families and larger social networks from small geographic niches to cities and towns around the world. 2 Most democratic societies contain multiple political traditions with very different understandings of social justice, individual liberty and conceptions of the common good. Similarly, the religious landscape in many societies is remarkably variegated. In Chicago, Miami, New York and Los Angeles, it is possible to visit mosques, temples, churches, synagogues and other religious institutions serving as gathering places for innumerable religious communities. These communities often have very different understandings of health, illness, suffering, death, dying, aging, medicine and healing. Most of us live in multifaith societies. 3
Despite the multifaith, multicultural nature of contemporary societies, the most well-known and widely used methods and theories in bioethics make some very large assumptions about the existence of shared, common moral norms or intuitions held by all "reasonable" or "moral" individuals. For example, the principlist ethical framework of Beauchamp and Childress assumes the existence of a "common morality" that can be found throughout history and across different cultural settings. The "common morality," they argue, "contains moral norms that bind all persons in all places; no norms are more basic in the moral life." 4 Describing the contents of the common morality, Beauchamp and Childress write:
Since virtually everyone grows up with a basic understanding of the institution of morality, its norms are readily understood. All persons who are serious about living a moral life already grasp the core dimensions of morality. They know not to lie, not to steal property, to keep promises, to respect the rights of others, not to kill or cause harm to innocent persons, and the like.4
Without engaging in comparative, crosscultural analysis or detailed historical research, Beauchamp and Childress make empirical claims about the universality of the common morality. Acknowledging that "amoral, immoral or selectively moral persons" do not recognize the common morality, Beauchamp and Childress insist "we believe that all persons in all cultures who are serious about moral conduct do accept the demands of the common morality." 4 Developing this claim, they state, "we think it is an institutional fact about morality, not merely our view of it, that it contains fundamental precepts. These fundamental precepts alone make it possible for persons to make cross-temporal and crosscultural judgments and to assert firmly that not all practices in all cultural groups are morally acceptable." 4 Individuals persuaded by common morality approaches rarely pause to consider whether the empirical claims of proponents of the common morality approach are accurate. However, there is a crucial difference between making normative claims about how humans ought to act and making transhistorical, cross-cultural claims about the empirical status of particular moral practices. Beauchamp and Childress assume that "virtually everyone" is raised with a basic understanding of various moral norms. While these claims might coincide with what we would like to think about human nature and human conduct, they ignore historical and anthropological research challenging such broad generalizations about moral practices. Notions of property and private possessions are culturally shaped. Lying, deception and nondisclosure can be sanctioned in particular social contexts. Deliberately inflicted violence against the innocent is a staple of human history.
Beauchamp and Childress, along with other proponents of common morality approaches, provide a very sunny view of human nature and a common moral sense operating across societies and throughout time, but rarely provide anthropological, historical or sociological evidence in support of these claims. Let me emphasize that I am not taking issue with the substance of morality typically described by common morality theorists. Clearly, I am not making an argument for lying or harming the innocent. Rather, I am challenging the common and unsubstantiated assertions that we can find broad empirical support for the common morality through time and across different cultural settings. 5,6,7,8,9
The problem with the "common morality" framework of Beauchamp and Childress is that it ignores the powerful role of culture and religion in shaping very different understandings of morality, family life, illness, suffering, healing and death. They make numerous assumptions about what individuals find "intuitive." Principlist bioethics has yet to grapple in a serious manner with the scholarship on "local knowledge" and the cultural shaping of "common sense." Principlist bioethics largely overlooks the challenges posed by the work of such anthropologists as Clifford Geertz and Richard Shweder. 10,11
Though I am critical of the empirical claims made by Beauchamp and Childress, I can sympathize with their effort to develop a cross-cultural, universal core of moral norms that can be used to judge cultural practices around the world. What critic of the common morality approach would want to defend many of the practices Beauchamp and Childress oppose? Still, the substance of the common morality is vaguely described and the challenges posed by plural moral traditions are underestimated. The ethical framework of Beauchamp and Childress offers limited insight into how the principles of biomedical ethics are supposed to resolve conflicts where fundamental differences exist concerning what it means to be a thoughtful, moral individual and member of a particular community.
Much like principlists, case-based proponents of practical moral reasoning, also known as "casuists," similarly assume that humans share a common morality providing cross-cultural moral intuitions and maxims about ethical and unethical practices. 12 Casuists, like principlists, minimize the powerful role of cultural and religious norms in shaping different understandings of what constitutes "common sense" approaches to ethical issues. Proponents of case-based "clinical" moral reasoning have yet to fully grapple with the challenges of case-analysis and policy formation in multicultural, multifaith societies. Case-based moral reasoning relies upon the existence of widely shared tacit moral knowledge. However, with many subjects, the moral intuitions of some citizens can be quite at variance with what other interlocutors find ethical and reasonable.
Just as cultural and religious pluralism raises challenges for principlists and casuists, more "emotivist" modes of reflecting upon ethical issues underestimate the significance of different cultural models of "common sense" moral reflection. Leon Kass, chair of the President's Council on Bioethics, makes a detailed case for "the wisdom of repugnance." 13 Much like the work of principlists and casuists, Kass's discussion of the intuitive wisdom of repugnance insufficiently attends to the cultural and historical variability of reactions of "disgust" and "revulsion." The wisdom of "repugnance" can have only limited usefulness as an effective guide for moral deliberations or the creation of social policy when individuals have markedly divergent responses to whether a particular practice or phenomenon is "repugnant."
Having briefly noted how different approaches in bioethics pay little attention to the role of culture and religion in shaping understandings of moral practice, I would like to consider just one example of an issue where religious and cultural norms often play a role in generating different understandings of what constitutes "ethical" conduct.
While many moral norms have broad public support, substantial backing in courts and legislatures, and endorsement in hospital policies and professional codes of ethics, there are other topics where substantial disagreement exists. In Canada, the United States and many other countries, for example, ethical disputes persist concerning "medical futility" or questions about what constitutes "appropriate" forms of end-of-life care when patients or family members demand medical care deemed "nonbeneficial" by healthcare providers. Within North America, the debate concerning how to craft policies and respond to individual cases reveals very different understandings of how best to care for seriously ill patients. Some disputants insist upon the importance of respecting religious and cultural norms concerning doing everything possible to keep a patient alive. Other commentators emphasize the significance of the quality of life of patients and the ethical obligation to treat patients with dignity. They argue that there are moral limits to demonstrating respect for cultural and religious differences.
Debates over medical futility are not reducible to religious and cultural conflicts. However, cultural and religious norms sometimes lead family members to request further medical interventions to preserve life regardless of quality-of-life considerations, provide an occasion for a "miracle," or meet obligations imposed by religious doctrines and texts. 14,15 Bioethicists are free to contest the religion-based moral claims of family members. Still, bioethicists need to recognize that these family members have very clear moral intuitions of their own about what it means to act responsibly when a family member is ill. Reference to "moral intuitions" or "common sense" does not provide much help in such situations.
Longstanding debates are not limited to disputes concerning end-of-life care. Such topics as the ethics of embryonic stem cell research and stem cell therapies, germline gene therapy and physician-assisted suicide reveal tremendous public controversy. Citizens from different cultural, religious, political and philosophical traditions differ over how various biomedical technologies are best regulated. While I dwell upon the topic of medical futility," many other examples could be provided of ethical disputes where cultural and religious norms play important roles in shaping diverse understandings of what constitutes ethical, responsible conduct.
Too often, bioethicists exaggerate their capacity to bring longstanding ethical debates to ultimate closure. They mistakenly claim that morality is settled, orderly, and in state of reflective equilibrium when this account tells only one part of a very complex story. In pluralistic societies, we find both relatively stable social norms as well as conflicting understandings of how we should live and die. Several of the dominant approaches in bioethics rely upon the notion of shared, common, intuitively obvious moral norms. However, many of the issues addressed by bioethicists reveal the existence of disagreements over what constitutes "common sense" moral reasoning. Disputes about ethical issues in medicine, healthcare and biotechnology often occur along cultural and religious fault lines. Such conflicts emerge in clinical settings, the deliberations of advisory bodies and professional organizations, and in legislative arenas.
We need to better recognize limits to bioethics and acknowledge that finding common modes of addressing ethical issues very difficult in multicultural, multifaith, heterogeneous societies. There are some ethical issues that simply do not seem to be near "closure" or "resolution." Canonical methods, theories and other tools of ethical deliberation in bioethics glide over deep social and moral conflicts rather than acknowledging the depth of ethical controversies found in pluralistic societies. Bioethics has its limits. Perhaps it is better to recognize these limits than to claim that some method, theory or technique of reasoning is available that will magically resolve longstanding moral conflicts.
Footnotes
1 Turner L. Zones of consensus and zones of conflict: Questioning the "Common Morality" presumption in bioethics. Kennedy Inst Ethics J 2003;13(3):193-218.
2 Giddens A. Runaway World: How Globalization is Reshaping our Lives . New York: Routledge, 2000.
3 Sowell T. A Conflict of Visions: Ideological Origins of Political Struggles . New York: Basic Books, 2002.
4 Beauchamp TL, Childress JF. Principles of Biomedical Ethics . New York: Oxford University Press, 2001;3-5.
5 Carrithers M, Collins S, Lukes S (eds). The Category of the Person: Anthropology, Philosophy, History . Cambridge: Cambridge University Press, 1985.
6 MacPherson CB. Political Theory of Possessive Individualism: Hobbes to Locke . Oxford: Oxford University Press, 1964.
7 Nisbett RE. The Geography of Thought: How Asians and Westerners Think Differently...and Why. New York: The Free Press, 2003.
8 Nisbett RE, Cohen D. Culture of Honor: The Psychology of Violence in the South . Boulder, Colorado: Westview Press, 1996.
9 Schmidt B, Schroder I (eds). Anthropology of Violence and Conflict . London: Routledge, 2001.
10 Geertz C. The Interpretation of Cultures . USA: BasicBooks, 1973 and Available Light: Anthropological Reflections on Philosophical Topics. Princeton, NJ: Princeton University Press, 2000.
11 Shweder R. Why Do Men Barbecue? Recipes for Cultural Psychology . Cambridge, MA: Harvard University Press, 2003,
12 Jonsen AR, Toulmin SE. The Abuse of Casuistry: A History of Moral Reasoning . Berkeley: University of California Press, 1988.
13 Kass L. The wisdom of repugnance. The New Republic 1997; June 2:17-26.
14 Orr RD, Genesen LB. Requests for "inappropriate" treatment based on religious beliefs. J Med Ethics 1997;23(3):142-7.
15 Brett AS, Jersild P. "Inappropriate" treatment near the end of life: conflict between religious convictions and clinical judgment. Arch Intern Med 2003;163(14):1645-9.
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The opinions expressed in the journal, Lahey Clinic Medical Ethics,
belong to the individual contributors and do not represent the institutional position
of Lahey Clinic on any subject matters discussed.
