Where Ethics Comes from and What to Do about It

Abstract

The practical difficulty with applying ethical theories to particular problems is that ordinarily people pay little attention to theories when they make moral decisions. Instead, we are guided by our ethical beliefs, which are primarily the result of cultural factors beyond our reach - factors subject to rational scrutiny and to change, but largely out of our control. One of the most alarming aspects of describing an ethical problem, and of hearing it described by others, is discovering just how many ways it can be done. How a moral problem is described will turn on an array of variables: the role and degree of involvement in the case of the person who is describing it, the person's particular profession or discipline, her religious and cultural inheritance - indeed, with all of the intangibles that have contributed to her character. What is more, the description any person offers will also vary - notoriously - according to whether an ethical decision has been made or is still to come, whether that decision is now judged to be a sound one or a poor one, whether the consequences were intended or unforeseen. Consider a relatively common case: a middle-aged man with multisystem organ failure, poor but not hopeless prognosis, now incompetent, experiencing what seems to be considerable pain, whose family is faced with the decision about whether to continue his medical treatment. Think of the possible alternatives to the brief and inadequate description I have offered here. A clinician will describe the patient's medical problems, his hospital course, his treatment, his laboratory work, and so on. A moral philosopher will be less interested in the medical details of the case than she will the moral ones, and her description will be constructed from a vocabulary of terms such as autonomy, justice, and beneficence, and the patient's goals, values, and wishes. The patient's wife will describe not a "case," but a continuing chapter in her life. A chaplain, social worker, nurse, or hospital administrator will offer still another description, as will the patient's daughter, his minister, his friends, his colleagues, and his enemies. The perceptions of each of these will change as the patient's story unfolds: what seemed to be minor decisions at one time now appear disastrous; incidents that might have been overlooked now seem to be portents. And any description offered will reflect whether the patient is in a Tel Aviv teaching hospital, a Heidelberg Krankenhaus, or a Chicago V.A- facility. Perhaps the most frustrating feature of describing a moral problem is the gulf between moral description and moral experience. No description, it seems, can do justice to the realities of our moral problems.[1] It is extraordinarily difficult, if not impossible, to capture the countless subtleties that go into the perceptions and judgments of each person involved: the hopes, fears, prayers, guilt, pride, and remorse; the conflicting emotions that accompany irrevocable decisions; the self-imposed pressure to carry through with an action once a decision has been made. Much of what goes into actual moral choices remains unarticulated. To express these things, even to perceive them consciously, requires a talent possessed by few of us other than novelists and poets. A second problem comes from the realization that in describing a given case, one has done much of the ethical work already. A person's moral judgment is reflected in what he chooses to include in a description: whether he mentions that the patient's wife has visited her critically ill husband only twice over the past three weeks, whether he reports a bed shortage in the ICU, if he notes that the patient's children stand to inherit the dying man's estate, how he describes the patient's prognosis, whether he brings up the option of palliative care, if he notes that the nursing staff feels strongly that treatment should be stopped, whether he mentions that the patient was an IV drug abuser. …