Abstract
Since the publication of the first edition of Tom Beauchamp and James Childress’s Principles of Biomedical Ethics there has been much debate about what a proper method in medical ethics should look like. The main rival for Beauchamp and Childress’s account, principlism, has consistently been casuistry, an account that recommends argument by analogy from paradigm cases. Admirably, Beauchamp and Childress have modified their own view in successive editions of Principles of Biomedical Ethics in order to address the concerns proponents of casuistry and others have had about principlism. Given these adjustments to their view, some have claimed that principlism and casuistry no longer count as distinct methods. Even so, many still consider these two conceptions of bioethical methodologies as rivals. Both accounts of the relationship between casuistry and principlism are wrong. These two conceptions of methodology in biomedical ethics are significantly different, but the differences are not the ones pointed out by those who still claim that they are distinct positions. In this article, I explain where the real similarities and differences lie between these two views.
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Notes
I am breaking with convention somewhat in presenting casuistry in this fashion. Jonsen no longer presents his views in the same way that he did when he was writing with Toulmin, and it is normal to introduce casuistry by explaining it via Jonsen's newer statement of the position. I have two reasons for favoring the Jonsen and Toulmin presentation. First, those who like to emphasize the differences between casuistry and principlism often draw on earlier statements of the position, especially Toulmin's own. Second, those who like to emphasize the similarities between the positions often draw on Jonsen's more recent statements of the position (including Jonsen himself), sometimes claiming that Jonsen's position has changed substantially, implying that it used to be significantly distinct from principlism but is not now. I want to emphasize that even the earlier statements of the position are not radically distinct from the most recent version of principlism.
For this reason, Beauchamp and Childress argue that balancing cannot be collapsed into specification. That is, since balancing is so situation specific, many times, the reasons that make a principle weightier in the present case will not apply to cases in general, and so there is no reasonable specification of principles to be made.
Of course some deny that it is of any significant benefit, or that if it is, it is outweighed by the other benefits of being deaf.
After all, Jonsen, Toulmin, and Beauchamp were co-authors of the Belmont Report.
Jonsen and Toulmin are channeling Aristotle here, in particular, his distinction between theoretical and practical syllogisms. Their appropriation of the distinction can be misleading, though. For example, reasoning in the theoretical domain is not limited to thinking in line with the theoretical syllogisms; there are types of theoretical reasoning that are not deductive, e.g., induction [3, p. 31]. Instead, deductive syllogism is the ideal in this domain, the type of reasoning that is to be aimed at when possible. Also, they cannot be trying to win the argument against deductivist approaches in ethics by claiming that practical syllogisms are definitive of all thinking in the practical domain and that all deductivist approaches consequently do not even count as conceptions of ethical thought. Rather, the claim is, with Aristotle, that thinking about ethical issues is not properly done along deductivist lines because there are no true, absolute claims from which to derive a necessary conclusion.
As with most criticisms of the desire for an ethical algorithm, it is not entirely clear what the specific problem is with the desire Jonsen and Toulmin mean to point out. One problem could be that there just are not any true absolute principles, so all arguments that include an absolute principle have a false premise. A separate complaint could be that even if there are absolute principles, appealing to them when thinking about ethical issues leads to a sort of rule fetishism. That is, it leads one to forget that careful judgment is required for their application, which leads one to fail to notice the subtleties of particular cases. I think it is reasonable to assume that Jonsen and Toulmin mean to point out both of these problems.
While Jonsen and Toulmin use the term “universal” to describe principles that are context independent, they mean absolute. Absolute principles apply to actions and determine their moral valence independently of contextual factors like other prima facie relevant moral considerations. Universal principles are principles that apply to the actions of all persons independently of facts about them, like their cultures, etc.
Despite this distinction, when I speak of bioethical methodology, generally, I will mean both the methods of coming to make a judgment about a case and justifying that judgment; after all, thinking about ethical issues often involves an extended process of doing both of these things. When it is appropriate to speak only about methods of reaching a judgment or methods of justifying that judgment to others, though, as it is right now, I will make it explicit.
I should point out that both of these issues are distinct from epistemic issues (in my more restricted sense). One might think, with the traditional coherentist or foundationalist, that whether one has a justified belief has nothing to do with the actions one takes when coming to have that belief. Or one might think, with the reliabilist, that whether one has a justified belief is independent of what one could say about why that belief is a good one.
It is sometimes thought that such a position entails a sort of relativism. This is not the case. Or, rather, if it is, then every type of inquiry is subject to the same relativism. That is, all the hallmark examples of objective discourse, e.g., mathematics and the hard sciences, require one to be inculcated with the relevant outlook before one can go on to participate in the discourse.
To saddle them with such a view, one on which moral norms are something like innate ideas in the minds of moral inquirers, is to subject them to the same type of unsympathetic reading that leads one to say that casuists believe in a type of “immaculate perception.”
A sketch of how moral change works is an important advance, which the seventh edition of Principles of Biomedical Ethics makes beyond the previous editions [4, pp. 412–415].
A second feature they point out is that moral knowledge consists in the practical ability to recognize the morally relevant features of concrete situations and not in the acceptance of a list of moral principles. Beauchamp and Childress have gone some way to absorbing this into principlism, so it does not count as a significant difference, though it may have at one time [4, chs. 2, 4]. For this reason I will not discuss it any further.
Jonsen and Toulmin make it clear that they agree [3, pp. 330–332].
Jonsen and Toulmin sometimes speak as if the fact that children learn moral concepts from experience with particular cases automatically entails their view that moral understanding is grounded in cases. This is not the case, however; for it is perfectly coherent for one to think that we come to “cotton on” to our concepts by being confronted with cases, but that the concepts themselves are abstract entities that are semantically independent of particular cases.
Actually, “allows” is ambiguous. It could just mean “explain” in the sense of, what explains our grouping behavior? A plausible answer to that question might look a lot like an answer to the same question when it is directed at something like a thermostat. That is, what explains the way my thermostat groups states of affairs with respect to temperature in my house are the physical facts about the thermostat. Because I assume that Arras is not after such an explanation of our own behavior, I also assume that what he means to ask after is what justifies our groupings, perhaps in addition to causing them.
It is also worth pointing out that the principlist is just as much subject to Arras's concerns as is the casuist. We saw in the above discussion of Strong that the principlist does not always decide between competing specifications of a principle by appealing to some other principle. Presumably, principlists do not recommend that strategy for the very reason that this would lead to a regress of principles. Presumably, also, the principlist would say the same thing about her conception of justification. That is, she would not hold that her judgments of when the four basic principles apply would stand in need of further principles explaining why the principles apply, nor would she think that she needs further principles to explain the inference from the application of one of the four principles to the conclusion that an action is prima facie right or wrong.
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Acknowledgments
I am grateful to Tom Beauchamp and an anonymous referee for helpful comments on an earlier draft of this paper.
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Cudney, P. What really separates casuistry from principlism in biomedical ethics. Theor Med Bioeth 35, 205–229 (2014). https://doi.org/10.1007/s11017-014-9295-3
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DOI: https://doi.org/10.1007/s11017-014-9295-3