What I offer here are some philosophical reflections on work done roughly in the last quarter of the twentieth century in bioethics.  (See, among other texts, Arras and Rhoden, 1989; Beauchamp and Childress, 1994; Beauchamp and McCullough, 1984; Beauchamp and Walters, 1989; Edwards and Graber, 1988; Jonsen, Siegler, and Winslade, 1998; Levine, 1991; Mappes and Zembaty, 1986; Monagle and Thomasma, 1997; Munson, 1992.) I offer the reflections in the spirit of American Pragmatism--not as represented recently by Richard Rorty (1979, 1982, 1991), but in the older, progressive tradition of John Dewey (1929, 1934, 1948) and George Herbert Mead (1964), with some reference to the still older views of William James (1897).

    Robert Veatch (1989) quotes a representative, Russell Roth, of the American Medical Association as saying it is not up to philosophers but to the medical profession to set its moral rules:

So long as a preponderance of the providers of medical service--particularly physicians--feel that the weight of the evidence favors the concept that the public may be better served--that the greatest good may be best accomplished--by a profession exercising its own responsibility to the state or to someone else, then the medical profession has an ethical responsibility to exert itself in making apparent the superiorities of [this] system (p. 155).

    Far and away the most popular summation of this foundational approach is provided in Tom Beauchamp's and James Childress's Principles of Biomedical Ethics (1994).  As a critic of the approach, Albert Jonsen (1990), puts the matter, the first edition of the Beauchamp and Childress book filled a vacuum in the early years of the bioethics movement:  it "provided the emerging field of bioethics with a methodology" that was in line with "the [then] currently accepted approaches of moral philosophy" and thus "could be readily taught and employed by practitioners" (p. 32).

                Jonsen goes on with a neat summary:

That method consisted of an exposition of the two major "ethical theories," deontology and teleology, and a treatment of four principles, autonomy, nonmaleficence, beneficence, and justice, in the light of those theories.

The four principles have become the mantra of bioethics, invoked constantly in discussions of cases and analyses of issues (p. 32).

    Michael Bayles, in Professional Ethics (1989), provides what was once probably the most widely used single author textbook for professional ethics generally.  Like Beauchamp, Bayles is a utilitarian, but his approach can be adapted easily to any other ethical theory.  Bayles endorses a general rule:  "When in doubt, the guide suggested here is to ask what norms reasonable persons [generally, not just in the professions] would accept for a society in which they expected to live (p. 28)."

    He goes on, however, with this pithy summary of what comes next:

There are several levels of justification.  An ethical theory is used to justify social values.  These values can be used to justify norms.  The norms can be either universal (applying to everyone) or role related (applying only to persons in the roles).  Roles are defined by norms indicating the qualifications for persons occupying them and the type of acts they may do, such as represent clients in court.  Norms can then be used to justify conduct (p. 28).

    Joan Callahan's Ethical Issues in Professional Life (1988), while perhaps not as popular as Bayles's textbook once was, is a popular anthology.  It is perhaps most notable for its dependence on the notion of "wide reflective equilibrium."  As her sources, Callahan cites John Rawls, Norman Daniels, and Kai Nielsen, but she could as easily have cited dozens of other philosophers espousing one version or another of what Kurt Baier calls the "moral point of view."

    Here is how Callahan's somewhat wordy summary of the approach begins:

 Things are much the same in ethics [as in science].  We begin with our "moral data" (i.e., our strongest convictions of what is right or wrong in clear-cut cases) and move from here to generate principles for behavior that we can use for decision making in cases where what should be done is less clear (p. 10).

But, as in science, we sometimes have to reject our initial intuitions about what is right or wrong since they violate  moral principles we have come to believe are surely correct.  Thus, we realize we must dismiss the initial judgment as being the product of mere prejudice or conditioning rather than a judgment that can be supported by morally acceptable principles.

 On the other hand, sometimes we are so certain that a given action would be wrong (or right) that we see we must modify our moral principles to accommodate that judgment.

Moral experience and moral theories are dialectically related:  We develop theories to illuminate experience and to determine what we ought to do, but we also use experience to test, corroborate, and revise theories.  If a theory yields conclusions at odds with our ordinary judgments--for example, if it allows human subjects to be used merely as means to the ends of scientific research--we have reason to be suspicious of the theory and to modify it or seek an alternative theory (1994, pp. 15-16).

    A notable example is the team of Edmund Pellegrino and David Thomasma (1981, 1988), who say they base their approach on Aristotle and phenomenology--but mostly on good clinical practice (1981, p. xi).

    In one of their books devoted to the foundations of bioethics, Pellegrino and Thomasma (1988) summarize their approach:

Our moral choices are more difficult, more subtle, and more controversial than those of [an earlier] time.  We must make them without the heritage of shared values that could unify the medical ethics of [that] era.  Our task is not to abandon hope in medical ethics, but to undertake what [Albert] Camus called "the most difficult task of all:  to reconsider everything from the ground up, so as to shape a living society inside a dying society."  That task is not the demolition of the edifice of medical morality, but its reconstruction along three lines we have delineated:  (1) replacement of a monolithic with a modular structure for medical ethics, with special emphasis on the ethics of making moral choices in clinical decisions; (2) clarification of what we mean when we speak of the good of the patient, and setting some priority among the several senses in which that term may be taken; and (3) refurbishing the ideal of a profession as a true "consecration" (p. 134).

    These range from putting the patient's good above the physician's self-interest through respecting colleagues in other health professions and accepting patients' beliefs and decisions to "embody[ing] the principles" in professional life (1988, pp. 205-206).   While admitting that such an oath is not likely to meet with general acceptance "given the lack of consensus on moral principles" today, Pellegrino and Thomasma end with this plea:

We invite our readers to consider this amplification of our professional commitment as a means of meriting the trust patients must place in us and as a recognition of the centrality of the patient in all clinical decisions (1988, p. 206).

    Beauchamp and Childress (1994, p. 46) attempt to play down this issue, at least as regards utilitarian and deontological theories:  "The fact that no currently available theory, whether rule utilitarian or rule deontological, adequately resolves all moral conflicts points to their incompleteness."  Admitting that there are many forms of consequentialism, utilitarianism, and deontology, as well as approaches that emphasize virtues or rights, they conclude by defending a process--which they say "is consistent with both a rule-utilitarian and a rule-deontological theory"--rather than an absolute theoretical justification (p. 62).

    Not all bioethicists are satisfied with this treatment of theoretical disagreement.  H. Tristram Engelhardt (1986, 1991), in particular, has devoted much time and energy to arriving at a more satisfying solution.  He begins his daunting effort to provide a true foundation for bioethics (1986, p. 39) with a framework:  "Controversies regarding which lines of conduct are proper can be resolved on the basis of (1) force, (2) conversion of one party to the other's viewpoint, (3) sound argument, and (4) agreed-to procedures."  Engelhardt then demolishes the first three as legitimate foundations for the resolution of ethical disagreement, beginning with the easiest:  "Brute force is simply brute force.  A goal of ethics is to determine when force can be justified.  Force by itself carries no moral authority" (p. 40).

    Engelhardt then attacks any assumed religious foundation for the resolution of moral controversy, calling "the failure of Christendom's hope" to provide such a foundation, either in the Middle Ages or after the Reformation, a major failure.  He then adds, "This [religious] failure suggests that it is hopeless to suppose that a general moral consensus will develop regarding any of the major issues in bioethics" (p. 40).

    Engelhardt then turns to properly philosophical hopes:  "The third possibility is that of achieving moral authority through successful rational arguments to establish a particular view of the good moral life."  But he adds immediately:  "This Enlightenment attempt to provide a rationally justified, concrete view of the good life, and thus a secular surrogate for the moral claims of Christianity, has not succeeded" (p. 40).  The evidence for this Engelhardt had supplied earlier--and it parallels the obvious disagreements among schools of thought referred to by Beauchamp and Childress.

    This leaves only the fourth possibility:  "The only mode of resolution is by agreement.  . . . One will need to discover an inescapable procedural basis for ethics" (p. 41).  This may sound like Beauchamp's and Childress's retreat to process, but Engelhardt wants to make more of it than that.  "This [procedural] basis, if it is to be found at all, will need to be disclosable in the very nature of ethics itself."

Such a basis appears to be available in the minimum notion of ethics.  . . . If one is interested in resolving moral controversies without recourse to force as the fundamental basis of agreement, then one will have to accept peaceable negotiation among members of the controversy as the process for attaining the resolution of concrete moral controversies (p. 41).

    The generally poor reception that Engelhardt's foundational efforts have received (see Moreno, 1988, and Tranoy, 1992, among others)--as opposed to the wide recognition he has received for particular contributions to the discussion of concrete controversies--could suggest that there might be something fundamentally wrong about the search for ultimate ethical justification in bioethics.

    This suggestion leads to the final group of authors to be mentioned in these reflections on philosophical bioethics.  Albert Jonsen (1990, p. 34) mentioned earlier as a critic of the Beauchamp and Childress approach, says this:

In light of the diversity of views about the meaning and role of ethical theory in moral philosophy, we need not be surprised at the confusion in that branch of moral philosophy called "practical" or (with a bias toward one view of theory) "applied ethics."

It is this that the clinical ethicists notice and that leads some of them to answer the theory-practice question by wondering whether it is the right question and whether the connection between these classic antonyms is not just loose or tight, but even possible or relevant (p. 34).

    Without saddling these other authors with casuistry as the approach,  Jonsen (1990) also puts his and Toulmin's critique of applied ethics within the recent tradition of anti-theorists headed by Richard Rorty (1979, 1982, 1991) and Bernard Williams (1985).  (In a review of The Abuse of Casuistry, John Arras 1990, adds Stuart Hampshire 1986, and Annette Baier 1984.)

    In short, recent bioethics, philosophically construed, is a confusing battleground, with contributions from absolute foundationalists to case-focused rejectors of theory and a variety of approaches in between (or all around).

    It should be remembered--for purposes of this chapter but more generally--that bioethics has never been exclusively or even primarily a philosopher's affair.  Indeed, it could be claimed that philosophers are and ought to be outsiders to the real communities making the important bioethical decisions (Churchill, 1978, pp. 14-15).

    One of the earliest calls for the post-World War II medical research community to police itself ethically came from a physician, Henry K. Beecher, writing in the Journal of the American Medical Association (1966) and the New England Journal of Medicine (1966)--both regular sources of bioethics commentary right down to the present.

    Beecher's calls for reform were followed up by sociologists:  for example, Bernard Barber et al., Research on Human Subjects: Problems of Social Control in Medical Experimentation (1973), and Renée Fox, Experiment Perilous: Physicians Facing the Unknown (1974).

    Historians also became interested--see, for example, James Jones, Bad Blood: The Tuskegee Syphilis Experiment (1993).

    Celebrated cases also did a great deal to coalesce the field, from Karen Quinlan and Elizabeth Bouvia to Jack Kevorkian, from Baby Doe to Baby M., from celebrated heart transplant cases to proposals for mandatory testing for the AIDS virus (see Pence, 1994).  What even the briefest reflection on these cases reminds us is how bioethics involves patients, families, hospital administrators, lawyers and judges, government officials, and even the public at large.

    And public involvement reminds us, further, that significant numbers of commissions have been involved, from the local level--e.g., the New York State Task Force on Life and the Law--to the national level--the (U.S.) National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, or a Netherlands Government Committee on Choices in Health Care--to the international level,  for example, the Draft Report of the European Forum of Medical Associations.

    Philosophers have, obviously, been involved in setting up prestigious bioethics institutes.  But the institutes themselves are important parts of the bioethics community, with impressive numbers of non-philosophers on their mailing lists.  And physicians (e.g., Willard Gaylin at the Hastings Center, along with many others) and lay people (the Kennedy family supporting the Kennedy Institute) have also played major roles.

    For me, the most proper locus of bioethics decisionmaking is in typically small local groups of physicians, nurses, administrators, lawyers, and local public officials--all together with patients and their families--wrestling with specific cases and issues within their own communities.

    This shows up already in one of the earliest bioethics textbooks, that of Samuel Gorovitz et al. (1976, with six co-editors and at least another half dozen people directly involved).  And this small-group focus continues right down to the present, most notably in the incredible diversity of ethics committees and other groups that have sprung up in hospitals and all sorts of health care institutions since the promulgation of the Reagan Administration's Baby Doe regulations and the enactment of the (U.S.) Patient Self-Determination Act in 1991.  (On bioethics committees, see McCarrick, 1992, pp. 285-305.)

    Philosophical bioethicists, it seems to me, do some of their best work in these groups, as they work collectively to solve local cases and issues and to formulate policies for their own institutions.

    William James (1897, see 1987, p. 520)--faced at the end of the nineteenth century with much the same sort of disagreement about the foundations of ethics that there is a hundred years later about the foundations of bioethics--summed up the situation this way:

Various essences of good have thus been found and proposed as bases of the ethical system.  Thus, to be a mean between two extremes; to be recognized by a special intuitive faculty; to make the agent happy for the moment; to make others as well as him happy in the long run; to add to his perfection or dignity; to harm no one; to follow from reason or universal law; to be in accordance with the will of God; to promote the survival of the human species.

    In many ways this sounds like Engelhardt's condition of the possibility of ethical discourse, but James would never accept Engelhardt's characterization of the approach as Kantian-transcendental.  It is simply a procedural rule for particular communities of ethical truth-seekers attempting to find a satisfactory concrete solution for particular problems--in a process that must inevitably go on and on without end.  Concrete ethical solutions are not dictated by an abstract commitment to the conditions of ethics, but must be worked out arduously through struggle and competing ideals.

    John Dewey was as opposed to transcendental foundations as James.  In the mood of The Quest for Certainty (1929), Dewey would probably have been bemused--and also angry--at the persistent academic search for an ultimate foundation for our practical decisions in bioethics.  But in the more open spirit of Reconstruction in Philosophy (1948) Dewey would have attempted to see how the "principled" approach (e.g., of Beauchamp and Childress) is "in effect, if not in profession" (in Dewey's words) "connected with human affairs."  In that book, Dewey continues his attack on "ethical theory" as "hypnotized by the notion that its business is to discover some . . . ultimate and supreme law"; instead, he proposes that ethics be reconstructed so that we may "advance to a belief in a plurality of changing, moving, individualized goods and ends, and to a belief that principles, criteria, laws are intellectual instruments for analyzing individual or unique situations" (pp. 162-163).

    In A Common Faith, (1934) Dewey adds that community efforts to solve social problems progressively can generate an attitude akin to religious faith that makes social problem solving a meaningful venture.

    And in Liberalism and Social Action (1935), Dewey tries to lead the way in applying his approach to the "confusion, uncertainty, and conflict" that marked his times--just as the bioethics community is attempting to do today with respect to confusions, uncertainties, and conflicts that arise in health care today.

    George Herbert Mead (1964, p. 266), an opponent of both utilitarian and Kantian approaches to ethics, offers in place of those (he thinks) inadequate systems a positive formulation of what ethics should mean:

The order of the universe that we live in is the moral order.  It has become the moral order by becoming the self-conscious method of the members of a human society.  . . . The world that comes to us from the past possesses and controls us.  We possess and control the world that we discover and invent.  And this is the world of the moral order.

    If we pay attention to these American Pragmatists, I think that what we can say about bioethics in the last quarter of the twentieth century is that philosophers contribute most when they contribute to the progressive social problem solving of particular communities.  Some do this, admittedly, at the national (President's Commission) or even international level (e.g., philosophical advisors to the World Health Organization), but even in those cases they do so as members of groups made up of physicians, lawyers, and other concerned citizens.  And most do so at the local level--where, in Mead's words, they are only being truly ethical if they are contributing to the progressive social problem solving (case resolution, policy formulation, etc.) of some particular group in which they represent only one voice, and a small one at that.

    Does this self-awareness on the part of philosophers as to their limited role in bioethics suggest any lessons for us?

    The most obvious lesson is humility.  Philosophers can and do help to clarify issues (sometimes even answers), but the real moral decisions in bioethics, for the most part, are made by others.

    Another lesson has to do with the urgency of the real-world problems that bioethics faces--which are, after all, what got philosophers involved in the first place.  Medicine and the health care system generally--including those parts of it that operate in open or covert opposition to the entrenched power of physicians and hospitals--face enormous problems today, from rampant inflation and calls for rationing to the questioning of the very legitimacy of high-technology medicine.  All the while, doctors and nurses, etc., must continue to face life and death issues every day--from calls for active euthanasia to the AIDS crisis--not to mention the daunting task of caring for ordinary ills of ordinary people who, with increasing frequency, cannot pay for their medical care.

    It is probably inevitable, given the structure of philosophy today as an academic institution, that philosophical bioethicists will continue narrow technical debates among themselves about ultimate justifications of bioethical decisions.  But academicism and careerism in bioethics should be recognized for what they are--distractions (however necessary, for some purposes) from the real focus of bioethics.

    Beyond these lessons for philosophers, does American Pragmatism have any lessons to provide to the bioethics community more generally?  Probably only this:  that we should all heed James's call for tolerance and openness to minority views.

    Bioethics has come a long way in just twenty-five or so years.  Significant consensus has been achieved on issues from informed consent to be a research subject to the importance of asking patients what they want done--if anything, especially of a high-technology sort--in their last weeks and days and hours.  But equally significant issues remain--as they always will in a society open to change.  And all of us, from the smallest local bioethics group to the international community, ought to remain open to change.

As William James (1877, see 1967, p. 625) said:

Every now and then . . . someone is born with the right to be original, and his revolutionary thought or action may bear prosperous fruit.  He may replace old "laws of nature" by better ones; he may, by breaking old moral rules in a certain place, bring in a total condition of things more ideal than would have followed had the rules been kept.

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