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Our diversity of moral and metaphysical views creates a diversity of bioethics of care, a diversity of what it is to care for others. Consider the gulf between theists and atheists. Theists recognize reality as having ultimate meaning, while atheists regard reality as ultimately coming from nowhere, going nowhere, and for no ultimate purpose. That about which one should care and how one should care will look quite different, depending on whether one’s horizon of concern is set within the horizon of the finite and the immanent, or whether it is aimed at transcendent concerns, as recognized by traditional Christians and Jews. Major cultural fault-lines separate massively divergent moral and metaphysical views of reality, as well as of the bioethics and the ethics of care. The collision of these moral and metaphysical visions led to the genesis of bioethics and then to its fracturing into a plurality of bioethics and into a plurality of understandings of the content and focus of care.
In assessing the conflicts characterizing contemporary bioethics and the ethics of care, it is important to distinguish among individuals who have particular moral views, communities of persons who share a morality along with a common, content-full view of care, societies spanning diverse moral communities, and states that are often temporarily under the control of one dominant community and its morality. In short, a state is not one moral community, and moral communities are separated by diverse moralities and bioethics of care.
There are usually also intermediate institutions that may more or less be nested with a moral community or be marked by a struggle between communities and their moralities. For example, should an institution in caring for those in need encourage an internal or an external locus of responsibility? Should a hospice encourage final repentance for one’s sins? There will be institutions with very particular moral identities. Their integrity will be tied to a particular vision of caring, as with an Orthodox Jewish nursing home or a Roman Catholic hospital. Again, all caring is particular: it is shaped by particular concerns.
This presentation gives an account of
- why there is not a single, canonical bioethics of care;
- why bioethics supported a false expectation of consensus about the nature of care;
- why bioethics cannot deliver on its promises to provide a common bioethics of care;
- how we might go to the future while recognizing our controversies about the nature of care.
I. Moral pluralism and its intractability
A. Taking moral diversity seriously: we do not agree about the proper focus for our commitments of care or about what it means to care for others, because we do not share one morality, one account of human flourishing, or one account of the meaning of life. To care is to care about the good of others, and about the nature of the good there is much dispute. For example, is it a caring act to provide abortion, artificial insemination from a donor, and/or euthanasia?
1. What counts as a morality?
A morality is a generally coherent set of settled judgments about what it is to act rightly, about how to pursue the good, and about what it means to be virtuous as well as have a good character.
2. Do we really face a plurality of moralities and a plurality of bioethics of care?
Polarized political-moral disagreements across the world reflect our diversity of moral and metaphysical views and constitute the culture wars (James Davison Hunter, Culture Wars, 1991). Moralities are separated by substantive foundational disagreements regarding such issues as the moral propriety of abortion, homosexual acts, social-welfare states, capital punishment, physician-assisted suicide, and the importance of repentance and absolution before death. Moralities are different when they support discordant views about cardinal elements of human life, such as when it is obligatory, permitted, or forbidden to take human life, have sex, and re-distribute property. For example, is it an act of real care to offer abortion and euthanasia to the impoverished or to those in intractable pain, or are such acts acts of maleficence, not true acts of caring?
3. We are separated by different moralities and accounts of the content of care because
a) within divergent moralities, key human goods are differently ordered. Depending on how one ranks liberty, equality, prosperity, and security, one will endorse a social-democratic polity such as Canada, or one will endorse an elitist, capitalist-Confucian polity such as Singapore. Each will sustain a different view about what it is to care in a health care system. Different moralities are also often separated by different right-making conditions and by ranking common right-making conditions differently.
b) some moralities along with accounts of care may even involve special values or concerns, such as holiness and obedience to God, which are not shared with other moralities.
c) different rankings of goods and right-making conditions will ground substantially different bioethics of care, different views of what it means rightly as well as wrongly to show care to others. Such rankings fashion the particularity of a view from somewhere.
4. Why do we face a plurality of bioethics and of ethics of care?
Because there is a plurality of moralities, there is a plurality of bioethics and a diversity of ethics of care. There is, for example, a growing Chinese bioethical literature that focuses on nurturing a bioethics of care that recognizes the ontological priority of the family over that of isolated, atomic individuals. This care recognizes one’s life within an integrated family to be more important than individual autonomy.
5. Does moral diversity entail a moral relativism? No!
In the face of moral pluralism, there can still be moral truth. It may only be that secular moral reflection is unable to determine the nature of that truth. One may be forced to accept a secular epistemological moral skepticism but not a metaphysical moral skepticism. There may indeed be a canonically right way to care.
B. Moral pluralism and the culture wars: the roots of the plurality of the bioethics of care
1. Agrippa, a 3rd-century philosopher, observed that there are five reasons (his pente tropoi) to hold that philosophical argument will not resolve foundational moral disputes: after 800 years, no one had succeeded in conclusively resolving the disputes at hand, disputants argue from their own perspective and therefore past each other, and disputants argue in a circle or beg the question or engage in an infinite regress, absent common basic premises and rules of evidence.
2. Bioethics (including the bioethics of care) is irreducibly plural, and
3. we are destined to live in the culture wars, because the advocates of disparate positions in major moral and public policy controversies do not share common moral and metaphysical premises or rules of evidence. We therefore disagree about what is compassed in showing rightly-directed care.
C. From at least the 18th century, a gulf opened in Western European cultures, further separating the traditional Christian cultures of an already fragmented Europe (e.g., fragmented by the Reformation, the Third Years’ War [1618-1638], and the Civil War [1642-1649]) from a secular, post-traditional culture framed inter alia by the Enlightenment, the French Revolution, the Napoleonic interventions, and, finally, by mid- to late-20th-century secularizing changes in constitutional law (North American and West European). The public forum in the West was recast from being normatively Christian to being normatively secular so that the dominant culture of the West now bears the marks of being shaped after the disestablishment of Christianity. This disestablishment helped both engender bioethics and define the contemporary culture wars in Europe and the Americas. In addition, there is no one secular moral vision. Consider the conflict among libertarian, classical liberal, and social-democratic moral perspectives on what it is to care for others. These differences compound the differences that separate those whose appreciation of care is limited by the horizon of the finite and the immanent, and those whose concerns for care are directed by transcendent concerns.
D. Although we disagree about foundational moral and metaphysical issues, there are nevertheless passionate declarations of consensus. There are assertions of a common moral agreement, evidence to the contrary notwithstanding. Why, given moral pluralism, would consensus be affirmed?
1. The assertion of consensus may in part be due to a self-deception on the part of those who embrace a supposed consensus; they may be captured by their own ideology or false consciousness.
2. Consensus may in part be invoked because claiming the existence of a consensus can serve as a rhetorically useful device to give moral and political authority to one’s views.
3. Consensus may also seem to be possible, given the logic of the creation of ethics committees and commissions that favors appointing persons who already share substantial overlapping points of agreement. A committee marked by real moral difference would produce endless debates.
4. Consensus may also be expected because the original bioethics had its roots in a Roman Catholic institution (Georgetown University) where the universalist claims of natural law were recast in terms of Enlightenment commitments to human rights and human dignity, leading to the illusion that there could be a unitary bioethics of care.
II. Bioethics emerged in the early 1970s to provide secular moral guidance for health care and the biomedical sciences. The bioethics movement was tantamount to an attempt to realize Enlightenment hopes to establish a universal human morality binding all humans in one community. It was taken for granted that rationally grounded moral consensus could be achieved.
A. Although the term bioethics is at least eighty years old with roots in a concept of a moral obligation to living things (Fritz Jahr, “Bio-Ethik. Eine Umschau über die ethischen Beziehungen des Menschen zu Tier und Pflanze,” Kosmos. Handweiser für Naturfreunde 24.1 [1927]: S. 2-4), with Van Rensselaer Potter re-engaging the term in 1970, bioethics took on its contemporary significance in 1971 with the beginnings of the Center for Bioethics at Georgetown University. The bioethics of the 1970s was made in America in response to local socio-cultural circumstances.
1. Medical ethics in the USA had been marginalized as the medical profession was transformed from a guild to a trade through US Supreme Court decisions and through a suspicion of elites.
2. The professional standard for the disclosure of information for consent to treatment was replaced by the reasonable-and-prudent-person or objective standard, so that the authority of individuals gained salience over that of medical professionals.
3.Christianity’s de jure and de facto establishment was abolished and attempts were made to secularize the public forum and public policy. Traditional moral, religious, and social structures were brought into question, challenging the moral authority of priests, ministers, and rabbis.
B. Bioethics promised to fill the moral vacuum as government bodies, hospitals, health care professionals, patients, their families, and society as a whole called for moral guidance about how properly to engage medicine and the biomedical sciences. There was a call for a moral vision, as well as for a concrete view of what is involved in giving care.
1. The secular equivalent of a theology, a moral vision, was produced for cultural orientation. Bioethics offered a moral framework for intellectual guidance as well as a foundation for secular culture, public policy, individual choices, and an understanding of care in health care.
2. The secular equivalent of a cadre of priests and chaplains was created to provide bioethics consultation, serve on ethics committees, and direct ethical care in health care. New secular chaplains were produced to direct and support care.
III. The failure of Enlightenment hopes: Bioethics and the ethics of care are plural
A. Bioethics, including the bioethics of care, is fragmented by an intractable moral diversity. Bioethics cannot keep its earlier promises.
1. As a secular field, diversity, not consensus, is ever more salient.
2. Given our moral diversity, clinical bioethics provides relatively little actual content-full normative guidance about what it is to care properly for others. That is, clinical bioethicists relatively infrequently give normative moral guidance. Instead, they usually
a) provide legal advice, Straightforward normative
b) mediate conflicts, and advice would often be
c) clarify concepts and analyze arguments. disruptive.
B. Moral disputes about what it is to care properly in matters of life and death, from abortion to euthanasia remain. The bioethics of care is inevitably a battleground in the culture wars.
IV. Care in the battlegrounds of the culture wars: Where do we go from here?
A. We should honestly face our moral diversity and the circumstance that changes are taking place that undermine the illusions of a possibility of consensus. Across the world, bioethics projects are emerging that are grounded in moral visions different from that which was at the roots of the original American bioethics. Even persons such as John Rawls recognized that reasonable humans do not and will not share one comprehensive doctrine that can sustain a single substantive bioethics of care. Even Rawls retreated from strong claims that were in, or could be read into, A Theory of Justice (1971).
1. Rawls, for example, retreated from speaking of the morally rational to speaking of the politically reasonable: he abandoned the hope of a common comprehensive moral viewpoint.
2. Even this default position of Rawls is more expansive than is justified, given what Agrippa recognized some 1700 years ago. There is not one sense of a proper bioethics of care.
B. In the face of intractable moral diversity:
1. as a point of prudence, one should avoid totalizing approaches by engaging such devices as conscience clauses and the avoidance of all encompassing bioethical policies that preclude particular hospitals and health care institutions from maintaining their own views of care.
2. One will need to explore how the sparse morality that can bind moral strangers can also allow persons with diverse bioethics of care to collaborate in the face of real moral differences.
C. Among the tasks to be faced is the need to recognize and explore how religiously affiliated hospitals and health care institutions are properly shaped and directed by specific particular visions of proper caring that transcend the horizon of the finite and the immanent, which visions are core to the moral identity and integrity of these institutions.
references
For a more detailed presentation of the issues sketched above, see
- H. Tristram Engelhardt, Jr., The Foundations of Bioethics (Oxford, 1996),
- The Foundations of Christian Bioethics (M & M Scrivener, 2000) and
- Global Bioethics: The Collapse of Consensus (M & M Scrivener, 2006)
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