Theory and Bioethics

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Theory and Bioethics

First published Tue May 18, 2010

As a species of practical ethics, bioethics exhibits a complex and contested relationship

to philosophical theory. On the one hand, many ho teach and rite in this

interdisciplinary field are philosophers ho naturally belie!e that their specific

contribution to the field"their #expertise,$ if you ill"consists in the application of

distinctly philosophical methods, includin% !arious &inds of ethical theory, to practical

problems arisin% in biomedical research, clinical medicine, and public health. 'ut on the

other hand, many ho or& in the area of bioethics, includin% many philosophers, are

hi%hly s&eptical of the so(called #applied ethics$ model of moral reasonin%, in hich

exemplars of hi%h theory )e.%., conse*uentialist utilitarianism, +antian deontolo%y,

ri%hts(based theories, natural la, etc. are directly #applied$ to practical problems.

-ndeed, most philosophically(inclined contributors to the bioethics literature ha!e

escheed hi%h moral theory in fa!or of !arious modes of moral reasonin% fallin% on aspectrum beteen the stron% particularism of !arious strains of casuistry or narrati!e

ethics, on one end, and the mid(le!el norms of the enormously influential #principlism$

of 'eauchamp and hildress, on the other )'eauchamp and hildress, 200/.

1 Accordin% to philosophers obert +. Fullinider )2008 and 3ill +ymlic&a )1//4,

bioethics in the public domain can and should %o about its business as a species of

ethical reflection independently of any reliance upon hi%h(flyin% ethical theory.

This article explores the contro!ersy concernin% the role of philosophical theory for

practical ethics in %eneral and bioethics in particular. The main body of this entry

dialectically can!asses the respecti!e claims for #hi%h theory,$ for particularistic #anti(theory,$ and for !arious species of #mid(le!el$ theori5in% in beteen these extremes. A

discursi!e taxonomy of the &inds of philosophical theories deployed in practical ethics

"i.e., metaethical, normati!e, metaphysical"is pro!ided in a supplement.

1. 3hat6s theory to practice, and practice to theory7

2. The heroic phase of ethical theory and #applied ethics$

2.1 The allure of hi%h theory

2.2 The allure of ideal political philosophy

. 9roblems ith bioethics concei!ed as applied hi%h theory

.1 The ubi*uity of moral pluralism.2 :hortcomin%s of ideal political theory

. ;eliberation as necessary ad ?aultin% theories and moral pluralism

=. The case for anti(theory in bioethics

=.1 :tron%ly particularist casuistry
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=.2 @pistemolo%ical moral particularism

>. :ome problems for the stron% casuistry anti(theory position

4. Toards a #theory modest$ bioethicsB ;efinin% #theory$ don

4.1 Conideal theory in bioethics

4.2 Conideal modalities of ar%ument

4. on!er%ence on method4.= on!er%in% on reflecti!e e*uilibrium

D. onclusion

'iblio%raphy

Other -nternet esources

elated @ntries

1. What's theory to practice, and practice to theory?

;eterminin% the precise nature of the relationship beteen bioethics and ethical theoryis complicated by the absence of a canonical definition of #theory.$ Althou%h

philosophers ha!e self(consciously en%a%ed in ethical theori5in% since the days of the

ancient Eree&s, they ha!e not %i!en much thou%ht to hat it is that ma&es certain &inds

of ethical reflection distinctly theoretical as opposed to other, more practical intellectual

pursuits. :o hen e in*uire into the nature of the relationship beteen bioethics and

moral or political theory, it ill ob!iously matter a %reat deal hether e define

#theory$ narroly"restrictin% it to a small cluster of paradi%matic examples, such as

classical or contemporary !ersions of utilitarianism or +antianism"or more broadly so

as to encompass many different modes of moral reflection, includin% feminist criti*uesof reproducti!e technolo%ies, !irtue ethics, or !arious conceptual and normati!e

accounts of coercion and exploitation in biomedical research. The broader our definition

of #theory,$ the more commonsensical ill be the claim that theory should play an

important role in bioethics.

Thin%s %et e!en more complicated hen e recall that bioethics is not a monolithic

field it encompasses a !ariety of distinct but interrelated acti!ities, some of hich mi%ht

be more amenable to the deployment of philosophical theory than others.2 At the most

concrete and immediate le!el, there is clinical bioethics, hich amounts to the

deployment of bioethical concepts, !alues and methods ithin the domain of thehospital or clinic. The paradi%matic acti!ity of clinical bioethics is the ethics consult, in

hich perplexed or orried physicians, nurses, social or&ers, patients or their family

members call upon an ethicist )amon% others, e.%., psychiatrists and layers for

assistance in resol!in% an actual case. These case discussions ta&e place in real time and

they are anythin% but hypothetical. 3hile those ho discuss bioethics in an academic

context can afford to reach the end of the hour in a state of perplexed indeterminacy, the
http://plato.stanford.edu/entries/theory-bioethics/#EpiMorParhttp://plato.stanford.edu/entries/theory-bioethics/#SomProForStrCasAntThePoshttp://plato.stanford.edu/entries/theory-bioethics/#TowTheModBioDefTheDowhttp://plato.stanford.edu/entries/theory-bioethics/#NonTheBiohttp://plato.stanford.edu/entries/theory-bioethics/#NonModArghttp://plato.stanford.edu/entries/theory-bioethics/#ConMethttp://plato.stanford.edu/entries/theory-bioethics/#ConRefEquhttp://plato.stanford.edu/entries/theory-bioethics/#Conhttp://plato.stanford.edu/entries/theory-bioethics/#Bibhttp://plato.stanford.edu/entries/theory-bioethics/#Othhttp://plato.stanford.edu/entries/theory-bioethics/#Relhttp://plato.stanford.edu/entries/theory-bioethics/notes.html#2http://plato.stanford.edu/entries/theory-bioethics/#EpiMorParhttp://plato.stanford.edu/entries/theory-bioethics/#SomProForStrCasAntThePoshttp://plato.stanford.edu/entries/theory-bioethics/#TowTheModBioDefTheDowhttp://plato.stanford.edu/entries/theory-bioethics/#NonTheBiohttp://plato.stanford.edu/entries/theory-bioethics/#NonModArghttp://plato.stanford.edu/entries/theory-bioethics/#ConMethttp://plato.stanford.edu/entries/theory-bioethics/#ConRefEquhttp://plato.stanford.edu/entries/theory-bioethics/#Conhttp://plato.stanford.edu/entries/theory-bioethics/#Bibhttp://plato.stanford.edu/entries/theory-bioethics/#Othhttp://plato.stanford.edu/entries/theory-bioethics/#Relhttp://plato.stanford.edu/entries/theory-bioethics/notes.html#2


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clinical ethicist is acutely aare that the bedside is not a seminar room and that a

decision must be reached.

:econd, there is policy(oriented bioethics. -n contrast to the clinical ethicist, ho is

concerned ith the fate of indi!idual patients, the bioethicist cum policy analyst is called

upon to assist in the formulation of policies that ill affect lar%e numbers of people.

:uch policy discussions can ta&e place on the le!el of indi!idual hospitals or healthsystems, here administrators, medical and nursin% staff, and bioethicists debate, inter

alia, the merits of competin% policies on medical futility or do(not(resuscitate orders or

they can ta&e place in the more rarified atmosphere of !arious state and national

commissions char%ed ith formulatin% policy on topics such as clonin%, access to health

care, or%an transplantation, or assisted suicide. Althou%h such commissions operate at

much hi%her le!els of %enerality than the clinical ethicist in the trenches, both of these

&inds of bioethical acti!ity tend to be intensely practical and result(oriented. The clinical

ethicist ill usually be ary of in!o&in% philosophical or reli%ious theory because her

interlocutors usually ha!e neither the time nor the inclination to discuss matters on thisle!el, hile the bioethicist on the national commission ill soon reali5e the

impossibility of for%in% a consensus ith his or her peers on the basis of theory alone.

Finally, at the other end of the practice(theory spectrum, there is bioethics as a

theoretical pursuit of truth, a !ariant unhindered by the resolutely practical constraints of

the clinic and commission. The academic is free to thin& as deeply or to soar as hi%h into

the theoretical empyrean as she ishes. Gnli&e the clinical ethicist, she is unhindered by

time constraints, medical custom, la, or the need to reach closure on a decision. The

seminar lasts all semester, and it mi%ht ser!e a %ood educational purpose to lea!e one6s

students e!en more confused at the end than they ere at the be%innin%. And unli&e thebioethicist cum policy analyst, the academic doesn6t ha!e to orry about findin% a

common lan%ua%e or bendin% to the necessities imposed by pluralism or sponsorin%

a%encies of %o!ernment. -t is here ithin the academic domain that the relationship

beteen philosophical(reli%ious theory and bioethics ill tend to be most explicit and

most elcome, althou%h e!en here bioethicists need to be responsi!e to the abo!e

constraints should they desire the fruits of their intellectual labors e!entually to ha!e

some influence on public policy. 9resumably, a standard moti!ation for en%a%in% in

practical ethics is to influence practice.

Althou%h - ha!e s&etched abo!e three different &inds of acti!ities that can all be lumpedunder the common rubric of #bioethics,$ it should be &ept in mind that each of these

constituent elements of bioethics influences the others"e.%., bioethical theory can

influence reasonin% in policy settin%s, and clinical practice can sometimes prompt the

theoretician to reexamine some of his basic assumptions. -t should also %o ithout

sayin% that *uite often the same indi!iduals can and do en%a%e in !arious areas of

bioethical acti!ity, alternati!ely, as clinicians, teachers, theoreticians, and as consultants

to industry or %o!ernment.


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:o much for preliminary remar&s. Het us no mo!e on to a more dialectical examination

of the role of theory in bioethics. 3e shall be%in ith the respecti!e cases for and

a%ainst deployin% hi%h moral theory. 3e ill then proceed to examine the case for anti(

theory in bioethics, and ill close ith a brief on behalf of a #theory modest,$ as

opposed to theory free, approach to bioethical problems. -nterested readers are

encoura%ed to consult the supplement to this entry, hich offers a discursi!e typolo%y ofthe !arious &inds of theory deployed in bioethics.

2. The heroic phase of ethical theory and applied ethics

2.1 The allure of high theory

As the era of contemporary practical ethics daned in the early 1/D0s, it as natural for

philosophers and reli%ious moralists to assume that their role in the di!ision of labor

ithin this buddin% field ould call for much more than the modest metaethical chores

traditionally allotted to them, such as pro!idin% definitions for terms li&e #ri%ht$ and#%ood$ )Iare 1/>2. -nspired by the example of John als6 monumental theory of


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redistribution in health care on the basis of libertarian premises borroed from obert

Co5ic& )1/D=. 3hat &inds of moti!ations mi%ht be adduced to explain and endorse

such resort to hi%h theory in bioethics7

Theoretical issues crop up e!eryhere in bioethics, and most of the ethical


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Another !irtue of theory concerns the importance of achie!in% consistency in our moral


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accordin% to als, ould ideally ha!e sufficient means to %o!ern itself democratically

)or at least #decently$, so that in or&in% out the terms of ideal %lobal


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theory that e &no of condemns sla!ery"achels6s &ey case study su%%estin% the

possibility of a rational consensus on theory"still lea!es us a lon% ay from reachin%

consensus on a theory that could successfully ad


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utilitarianism, contractarianism, or natural la"ill e!entually run out of %as before it

reaches the le!el of concrete decision ma&in% re*uired by practical ethics. -n most cases,

the theorist ill ha!e to reluctantly conclude that se!eral policy options are sufficiently


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simultaneously demote the place of hi%h theory ithin bioethics and to substitute for it

!arious modes of thou%ht, such as !ersions of principlism, casuistry and narrati!e, that

are closer to the %round and more in touch ith common moral understandin%s )Hondon

2001. As e shall see, some particularists ar%ue a%ainst hi%h normati!e theory on the

%round that it is either impossible );ancy 2004 or of little !alue. 3hile - do not intend

to affirm or deny the substance of this &ind of theory s&epticism here, it should be notedin passin% that one can do hi%h le!el theory in one6s spare time and attach %reat !alue to

it, hile still maintainin% that it should not be deployed in practical domains such as

bioethics.

3.) *aulting theories and !oral pluralis!

The final problem ith appeals to hi%h philosophical theory to be mentioned here

applies only to that subset of theories resemblin% !ault(li&e structures held to%ether by a

small number of &ey principles, such as the +antian cate%orical imperati!e or the

principle of utility. :uch theories ha!e a tendency to pa!e o!er the manifest complexityof our moral li!es in order to ma&e the orld safe for one or to principles. 3hen

confronted ith !alues or principles of ordinary morality that cannot be easily explained

by such fa!ored philosophical principles, or that appear to contradict them, the theorist

is often dri!en to concoct explanations that ha!e all the immediate plausibility of

9tolemaic epicycles, a discredited, ube Eoldber% account of planetary motion prior to

opernicus.> -n discussin% the problem of %lobal hun%er, for example, 9eter :in%er

has been confronted directly by a contradiction beteen his !ersion of impartial

utilitarianism and common morality6s permissi!eness for fa!orin% &ith and &in ):in%er

200=. :hould e reduce oursel!es to the le!el of mar%inal utility in the course ofassistin% the distant needy, as the theory ould dictate, or can e spend lar%e amounts of

our income to support our ailin% parents in decent nursin% homes, as common morality

ould %rant7 Gtilitarians often try to finesse such ob


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(. The case for anti+theory in ioethics

At the other extreme, bioethics has itnessed the emer%ence of se!eral interestin%

!arieties of anti(theory, includin% !arious strains or combinations of casuistry, narrati!e

ethics, feminism, and pra%matism. Althou%h each of these alternati!e methodolo%ical

approaches features more moderate !ariants that reser!e a le%itimate place for moral

principles and e!en for some &inds of theory, their stron%er anti(theory incarnationsunite in re


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More precisely, moral certitude )or our best approximation thereof is to be found in so(

called paradi%m cases, here our intuitions are most stron%ly reinforced. Moral analysis

of a %i!en situation be%ins, then, ith a scrupulous in!entory of the particular facts of

the case"i.e., the ho, hat, here, ho much, for ho lon%, etc."on hich our

"for hom


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(.2 piste!ological !oral particularis!

-t is precisely on this point that hard(core bioethical casuistry con!er%es ith the

epistemolo%y of moral particularism as forcefully elaborated in the or& of Jonathan

;ancy )2004, 200/. Accordin% to ;ancy, theories that accord an important


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obser!ations. First, e can all a%ree ith ;ancy that sound moral


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may consistently present themsel!es to us as ha!in% a more or less stable !alence, he

denies that this sort of inducti!ely deri!ed pattern carries ith it any


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. To"ards a theory !odest ioethics/ &efining theory do"n

Ia!in% duly noted the appeal and shortcomin%s both of hi%h moral theory and of

particularist anti(theory, it is time to mo!e toard a more plausible middle %round

mar&in% the intersection of bioethics and philosophical theory. -s there then a role for

theory in bioethics, and, if so, hat &inds of theory7

.1 0onideal theory in ioethics

-n addition to ideal political theory, hich pro!ides us ith an ob


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hich *uestions of


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.3 on#ergence on !ethod

-t is no accident, then, that since its inception in the 1/40s and PD0s, the field of bioethics

has lar%ely escheed both hi%h moral theory and direct application of ideal political

philosophy. -nstead, most of the contributors to this field, includin% most bioethicist(

philosophers, ha!e embraced one or more methods desi%ned, in the clumsy but accurate

phrase of ass :unstein )1//4, to facilitate #incompletely theori5ed a%reements$ onmoral problems in medicine, public health, and biomedical research. These mid(le!el

methods include the principlism of 'eauchamp and hildress the casuistry of Jonsen

and 'aruch 'rody the focus on #narrati!e ethics$ and interpreti!e techni*ues

championed by Ioard 'rody )2002, +atherine Mont%omery )Iunter )1//1, and

ita haron )2004 the !irtue ethics of 9elle%rino )1// and ;rane )1//> the

pra%matism of Fran& Miller and Joseph Fins )1//4 and the feminism of Mar%aret Hittle

)1//4, :usan :herin )2008 and many others./ Althou%h casuistry, narrati!e, !irtue

ethics, pra%matism, and feminism first emer%ed in contemporary debates as challen%ers

to the re%nant method of principlism durin% the 1/80s and(/0s, each claimin%supremacy o!er both principlism and other methods, the boundaries beteen these ri!al

methodolo%ies ha!e blurred si%nificantly in the inter!enin% years, so much so that all of

these methods mi%ht no be said to be mutually complementary, non(exclusi!e modes

of moral in*uiry for doin% ethics in the public domain. )'eauchamp 1//>, Arras 200D

The con!er%ence of all these initially ri!al methodolo%ies into a idely shared mid(le!el

approach to bioethical problems has been facilitated by to de!elopments in the

literature. First, each faction has made a con!incin% case for its particular

methodolo%ical emphasis. This has re*uired each approach to ac&noled%e or

incorporate elements dran from other methodolo%ies and, accordin%ly, to soften itsclaims to methodolo%ical supremacy. For example, the casuistry of Jonsen and Toulmin

arose as a robust particularist challen%e to the principlism of 'eauchamp and hildress.

They too& the latter to tas& for the abstractness and deducti!ism alle%edly on display in

early editions of the 9rinciples of 'iomedical @thics, ar%uin% instead for a case(based,

#bottom up$ approach to ethics that resembled the An%lo(American common la both in

its emphasis upon concrete particulars and in its conception of principles as emer%in%

from our en%a%ement ith cases. This challen%e led 'eauchamp and hildress to

concede the important role of particulari5ed case


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methodolo%ies no appeared to be more a matter of emphasis than of principle )or the

lac& thereof )+uc5es&i 1//8.

.( on#erging on reflecti#e e$uiliriu!

The second ma


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ithin bioethics. One salient example as on display in the famous #'aby ;oe$

contro!ersy of the mid(1/80s in hich the ea%an Justice ;epartment attempted to

impose a #non(discrimination principle$ upon health care or&ers in neonatal intensi!e

care units. :ubse*uent commentary debated the appropriateness of applyin% a principle

%o!ernin% discrimination a%ainst racial minorities and omen in education,


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political, and social theories in constrainin% the results of C@, such as those reached at

the le!el of fields li&e bioethics.

Althou%h 3@ mi%ht ell be the optimal method for the ultimate


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a!ailable conceptual resources, and then attempts to sol!e the problem by ta&in% thin%s

apart, reorderin%, cullin% out, ei%hin%, specifyin%, splicin% in, and puttin% them all

bac& to%ether. ):tout 1/88, p. D> 9hilosophers in bioethics are bricoleurs par

excellence.

Theories of limited scope, built up from materials at hand, play an important conceptual

and normati!e function in debates o!er abortion and euthanasia );or&in 1// ando!er such pi!otal concepts as #coercion,$ #commodification,$ #harm,$ and

#exploitation$ in the broad areas of research and reproducti!e ethics. -n response to a

%ood deal of sloppy criticism of ne reproducti!e technolo%ies and research in

de!elopin% countries, usually claimin% that !arious practices should be morally

condemned for alle%edly bein% harmful, coerci!e or exploitati!e, ords that seem to

ha!e become all(purpose terms of abuse for disfa!ored practices, philosophers ha!e

en%a%ed in fruitful mid(le!el theori5in% about the meanin% and moral import of such

concepts. Most often, this &ind of theori5in% %ets done ithout any appeals to ultimate

hi%h(le!el moral theory. -t be%ins by ta&in% stoc& of a problem at hand the theorist thenloo&s around for a!ailable conceptual resources for sheddin% li%ht on it. :ometimes

those resources ill be culled from hi%h theory )e.%., the +antian notion of respect for

persons or 9arfit6s non(identity problem, but more often than not they ill be inspired

by philosophers such as Joel Feinber% )1/8=K1/88 and Alan 3ertheimer )forthcomin%,

ho do not ear their ultimate philosophical alle%iances on their respecti!e slee!es. The

analysis %ros out of attenti!e descriptions of ordinary lin%uistic usa%e and common

moral and le%al responses to !arious situations, and then proceeds to as& exactly hat it

is about harmful, coerci!e or exploitati!e beha!iors that should merit our moral

disapprobation, and under hat circumstances )@manuel and Ia&ins 2008. This &indof theori5in% is both una!oidable and indispensible in a field li&e bioethics, and it has

done much to clarify and ad!ance often heretofore muddled public debates but it need

not claim alle%iance to any particular denomination of hi%h moral theory.

Another important example of this &ind of modest theori5in% is pro!ided by

philosophical reflections on the theme of #e*ual opportunity$ as related to the allocation

of health care and the social determinants of health );aniels 200D. Althou%h Corman

;aniels6s influential account of #


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understandin%s in ethical(political theory and, thus, a %ood example of ho influence

beteen bioethics and theory runs in both directions. As ;aniels and his collea%ues ha!e

demonstrated, the ad!ent of %enetic technolo%ies and the promise of direct inter!ention

on the human %enome raise a host of interestin% challen%es to our standard notions of

e*ual opportunity )'uchanan et al. 2000. Co that our basic human capabilities are

sloly becomin% matters of deliberate choice rather than the random results of the%enetic lottery, e suddenly become morally responsible for possible actions or

omissions a!ailable to us. :hould e restrict our understandin% of e*uality of

opportunity to those standard deficiencies in the social structure )e.%., sexism, racism

that inhibit people from en.

Theories focused on the ethics of research ith human sub


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;ebates o!er the allocation of or%ans and their possible commodification

)hildress 1//4, Murray 1//4.

9hilosophical reflection on the moral status of embryos in the context of

contro!ersies surroundin% abortion, embryo research, and parental responsibilities

for offsprin% ):teinboc& 1//4, obertson 1//4, Elo!er 2004.

de!elopment of a #population(based$ ethic for public health. )9oers and Faden

2004, Anand et al., 2004, Jennin%s and Arras 2010, 'attin et al. 200/.

Feminist theories of abortion and reproducti!e technolo%ies )Hittle 200, :herin

2008.

eflection on the ethics of enhancin% human traits throu%h %enetic manipulation

)Elo!er 2004, 'uchanan 2010, Ereen 200D, Iarris 200D, 9resident6s ouncil

200.

. onclusion

A%ain, hat6s theory to bioethics, and bioethics to theory7 As e ha!e seen all(too(ellby no, there is no short anser to this *uestion. @!erythin% depends upon ho e

characteri5e bioethics )i.e., as clinical, policy(oriented, or academic, and ho e

understand theoryB i.e., as hi%h, !aultin% theory, mid(le!el theori5in% tailored to specific

problems, the result )or an element of reflecti!e e*uilibrium, and so on. - suspect that

the paradi%m of hi%h theory inspires )or haunts most an%uished in*uiries into the

relationship beteen practical ethics, includin% bioethics, and philosophicalmoral

theory. 'ut once e reali5e )1 that hi%h theory, especially in its non(pluralistic forms, is

a spectacularly ill(suited medium for bioethical reflection in the clinic and policy circles,

and )2 that ideal political theory, hile pro!idin% us perhaps ith a description of9aradise -sland, doesn6t pro!ide us ith a map tellin% us ho to %et there under nonideal

conditions, then it becomes clear that nonideal, mid(le!el theori5in% is the site of the

philosophical action in bioethics and related fields.12 Gnderstood in this more modest

sense, #theory$ is a completely natural and should be an entirely uncontro!ersial

element of bioethics or of any practical ethical reflection. -ndeed, it6s hard to ima%ine

hat the field ould loo& li&e ithout it.
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Theory and Bioethics