Does Clinical Ethics Distort the Discipline?

Abstract

In the early 1970s, in one of my first articles on bioethics, I wrote that the principal aim of the field should be to help the medical practitioner deal with concrete cases. While I would hardly want to overlook the needs of the practitioner, I now wonder if that is the right place to center our attention. I take it that "clinical ethics," as that term has come to be used, focuses on the individual and particular cases faced by clinicians. But just what happens to a field when it takes cases as its point of departure? Can that strategy, in the name of reality, actually distort reality? Does "reality" lie in the particularity of individual cases - where most clinicians think it does - or in a more general, abstract, and universal realm, no less real but just more hidden? Or is it some complex mixture of both? It is that third possibility I want to explore, but beginning with some reservations about the case approach, much loved in medicine. As it turns out, I think, medicine itself has an analogous tension, in the old struggle between medicine as science and medicine as art. There are a number of drawbacks to using cases as the point of departure for bioethics. One of them is the difficulty in making good ethical judgments in particular cases. Another is the way in which background settings, values, and history often provide the morally decisive context for case judgments. Still another is what I have come to think of as the tyranny of the story, trying to get at larger issues by means of stories. Moral judgments and particular cases. Most cases present one of three options: (1) they clearly point in the direction of some commonly accepted moral rule or principle that will quickly resolve them - in which case there is little to discuss; (2) they pit two valid but opposing principles against each other, leaving much to discuss but little in the way of principle to resolve the dilemma - these are the cases that go to court; or (3) they are so complex in their features, many of them nonethical, that only prudence, practical reason, and virtuous intent (in some Aristotelian mix of that kind) will suffice for a resolution - ethical theory won't do the job. Most people who work in clinical ethics report that third category to be common. Much of their effort, they say, turns on trying to get the facts straight, clearing up misconceptions and misunderstandings, trying to overcome emotional confusion, and the like - all requiring skills that have comparatively little to do with ethical theory. In fact, it does not require an ethicist to do this kind of work: it can well be left to the sensitive clinician. Moreover, those skilled in the teaching of medical ethics, while they may cater to the fondness for cases among medical students, usually focus their effort on getting students to move beyond cases, to learn how to think about ethics in a more general way. As Dan Clouser once humorously but seriously put it, he sees his job with students as seducing them into seeing the necessity of moving from the particular to the general. Cases and their settings. Part of the task of making that move is to understand how history and social context shape not only the kinds of cases that appear but also the range of values and responses brought to them. Why do doctors see the kind of moral cases they do? How has such and such a problem come to be labeled a moral problem? The long-term task of bioethics should be to help us determine what are suitable and appropriate moral problems and dilemmas to have in the first place. Instead of limiting our attention to the ethical puzzles posed by new treatment modalities, we should be no less concerned with which modalities come to be used at all. Too much clinical ethics turns out to be a form of cleaning up a moral mess that probably should not have existed in the first place. Our job, that is, should have a preventive element: keeping some moral dilemmas from presenting themselves to clinicians. …