Johan Brännmark argues that in medical ethics it is better not to employ general ethical propositions that transcend the domain that medical ethics intends to cover (Brännmark 2019). He thus favours a ‘disunitarian’ approach, not only in medical ethics but in all kinds of domain-specific ethical theorizing. When unitarians advance domain-specific norms for certain fields of applied ethics, they try to legitimize these by demonstrating that they are in line with the most general principles in ethics. In contrast, disunitarians focus exclusively on whether the domain-specific norms are appropriate for the domain at hand without engaging any domain-transcending principles. Indeed, “…the disunitarian approach involves giving up on the level of completely general principles or norms as a meaningful subject-matter for ethical inquiries...” (Brännmark 2019). For disunitarians the highest-level principles for any domain would still be domain-specific. Domain-transcending theorizing is regarded as superfluous, indeed even detrimental.
In order to substantiate the appropriateness of disunitarianism as a ‘working assumption’ Brännmark advances the following three arguments. He first points out that there is hardly any agreement on the most abstract principles in ethics. Subsequently, he maintains that disunitarianism allows a better testing of principles against intuitions. Finally, he argues that it facilitates more workable principles for the non-philosophical practitioners who have to use them in their professional practice (Brännmark 2019). Each of these arguments triggers interesting questions for further debate, some of which we wish to highlight. First though, it is worthwhile having a closer look at the idea of disunitarianism itself.
Far from claiming he has unearthed the final truths about disunitarianism Brännmark aims to generate more discussion about the fundamental methodological choices in medical and indeed, more generally, in applied ethics (Brännmark 2019). He presents disunitarianism as a claim about the highest level of abstraction of ethical principles eligible to be employed within a specific domain. According to disunitarianism all eligible principles, even the most abstract ones, must still be domain specific. Unitarians on the other hand assume that specification starts with abstract top-level ethical principles down to domain-specific principles and then further down to specific ethical judgments. Accordingly, they conceptualize all fields of domain-specific ethics as instantiating the same abstract ethical theory as their common ethical core. Disunitarians, in contrast, do away with this shared abstract core and start specification at the level of domain-specific principles, whereby—at least theoretically—they can organize each domain-specific ethics subdiscipline completely different, as long as its principles are appropriate to the domain at hand (Brännmark 2019).
Obviously, the disunitarian claim leans heavily on the concept of domain, which Brännmark defines as a set of “interconnected practices” (Brännmark 2019). In order to further delineate the concept of practices Brännmark references Rawls’ notion of “any form of activity specified by a system of rules which defines offices, roles, moves, penalties, defenses, and so on, and which gives the activity its structure” (Rawls cited in Brännmark 2019). Brännmark admits that the demarcation of domains as sets of interconnected practices is likely to be less than razor-sharp. For practical purposes, however, he maintains that the domains covered by currently existing fields of applied ethics, such as business ethics, environmental ethics, and medical ethics, give reasonably clear examples of what is meant by the notion of domain. Moreover, the main point is that disunitarians do not resort to domain-transcending ethical theory (Brännmark 2019).
The question is whether the concept of domain is herewith sufficiently demarcated. After all, the concept seems to be pivotal when it comes to a proper understanding and implementation of the disunitarian approach, which bans summoning domain-transcending theory to one’s aid when engaging in domain-specific ethical theorizing. In order to go about in accordance with the disunitarian methodology it is thus imperative to have a clear idea of the contours of the domain at hand.
Assuming, for example, one endeavored to analyze a certain ethical issue in nephrology, disunitarianism would not allow consulting any ethical principles going beyond the proper domain that subsumes the field of nephrology. In order to be a good disunitarian it is therefore important to have a clear idea of the proper domain and thus to know which levels of abstraction of ethical theory are inadmissible. Here are some candidates of what might be seen as the proper domain subsuming nephrology in ascending order of generality: (1) internal medicine, (2) medicine, (3) healthcare, (4) the complex of practices in healthcare and the life sciences, or (5) some other even more general domain. If one were to choose (1), it would be precluded to summon any principles of medical ethics to one’s aid in the analysis of ethical issues in nephrology as these would count as domain-transcending. If one were to pick (2), one would be allowed to work with principles of medical but not healthcare ethics. If one selected (3), it would be permissible to use principles of medical and healthcare ethics but not bioethics (assuming these also cover the life sciences). This example illustrates that presuppositions about the demarcation of domains have practical consequences when engaging in disunitarian ethics. More clarity on the concept of domain would therefore be helpful.
The first argument in favor of disunitarianism: lack of convergence at the top level
Brännmark maintains that “… it is not obvious that the standard approach, unitarianism as an implicit working assumption, is the most reasonable one, especially given the lack of convergence that we have seen throughout a very long history of ethics.” (Brännmark 2019). He goes on to state that since it is easier to gain consensus about mid-level rather than top-level ethical principles and given our poor track record in achieving consensus on abstract ethical theories, we better give up on top-level ethical theorizing altogether.
This conclusion seems a bit radical though. First, one might ask whether there is any convincing evidence for the assumption that consensus is easier to attain on mid- than top-level ethical theorizing. Has there ever been any methodologically sound empirical research to test Brännmark’s hypothesis?
Second, even if there were a solid empirical evidence base in favor of Brännmark’s claim, one might still turn the argument around and take the difficulty of reaching agreement on top-level ethical theorizing as a good reason to put more effort into it. Could it be that Brännmark’s argument is analogous to the mathematician who argues we should give up on attempting to prove a certain mathematical theorem because of the many failed historical attempts? Why stop trying to achieve something just because it is difficult?
Third, why is it important at all to achieve convergence in ethics? Philosophy in general has not yielded any substantial and long-lasting convergence around its main theories. It is not obvious that this circumstance would count as a valid argument for giving up on philosophical endeavors altogether. Of course, any practical problems triggered by a lack of ethical consensus should be tackled by deliberative procedures fit to deal with pluralism. Incidentally, going back to the first point, even if one adhered to a disunitarian methodology, different persons might nevertheless have diverse, indeed even inconsistent views on the appropriateness of domain-specific principles, which would likewise necessitate practical means of dealing with pluralism.
The second argument in favor of disunitarianism: reliance on intuitions
Brännmark’s argument departs from the assumption that ethical principles can be tested against intuitions. A necessary condition for decision makers to be able to advance “skilled intuitions” is that they be in a “high-validity environment” that provides “adequate opportunities for practice” (Brännmark 2019). Whilst medicine would fulfil this condition as a specific practical field where agents learn and gain experience through regular feedback, the broad field of human agency would not qualify as such. Skilled intuitions are more likely to occur within contextualised practical settings with structure and regularity than within the anaemic realms of philosophical abstraction, according to Brännmark.
It is not clear though, how this consideration would actually work in favor of disunitarianism. Presuming, for the sake of discussion, that intuitions were the only manner of testing ethical principles, why would it be impossible to test principles of various different degrees of abstraction with these highly skilled intuitions from high-validity environments? Apparently Brännmark sees no problem in testing domain-specific principles against the skilled intuitions of practitioners. Why would this be any different for domain-transcending ethical principles? Supposing a philosopher had advanced some principles whose scope goes beyond the domain at hand, why would it suddenly be impossible to test these against said skilled intuitions? Admittedly the testing would perhaps demand multidisciplinary collaboration of practitioners with experience in contextualised practical settings and philosophers who are likely to be more at ease with abstract matters. However, a multi-disciplinary approach might be good practice for testing domain-specific principles as well.
The third argument in favor of disunitarianism: publicity of moral norms
Brännmark’s line of thought is based on the assumption that “… in the articulation of our basic principles we need to think in terms of the workability of those principles when released into the wild …” (Brännmark 2019). After all, these principles should facilitate deliberation about ethical challenges. Brännmark argues that domain-specific principles are more intelligible for non-philosophers than domain-transcending ones.
Even if one accepted the premises of Brännmark’s argument, this would not seem to commit one to disunitarianism. After all, unitarianism does not do away with domain-specific principles. Following a unitarian approach one could therefore have exactly the same discussion about domain-specific principles as if one were approaching the issue from a disunitarian perspective.
Supposing, for example, a philosopher advanced a set of domain-specific principles established through a process of specification of some very high-level principles. Practitioners working with the philosopher’s domain-specific principles in order to tackle a specific problem would go about balancing, specifying and applying them in the same way as if these principles had been developed from a disunitarian perspective. The only difference would be that in a unitarian theoretical framework these domain-specific principles would have been developed in line with a set of domain-transcending abstract principles, whilst they would lack that particular trait in a disunitarian theoretical framework. For non-philosophical practitioners trying to analyze specific ethical questions within their professional field with the help of domain-specific principles these differences would not matter very much.
If, however, instead of applying, balancing and specifying the domain-specific principles, practitioners endeavored to adjust them, the differences between unitarianism and disunitarianism would become more important. In that case adherents of the former would also consider the issue of alignment with top-level principles whilst the latter would only focus on appropriateness for the domain at hand. In this scenario a unitarian methodology might arguably lead to more difficulties for practitioners embarking on this task. Nevertheless, it is not self-evident that adjustment through exclusive assessment of the appropriateness of the domain-specific principles for a certain domain is any easier than an adjustment that also takes into account the alignment with top-level principles. Even if that were the case though, why could the adjustment not be performed in a multi-disciplinary setting involving philosophers more at ease with abstract ethical principles?
Brännmark, J. 2019. The independence of medical ethics. Medicine, Health Care and Philosophy. https://doi.org/10.1007/s11019-018-9842-1.
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Gordijn, B., ten Have, H. Giving up on abstract ethical theory. Med Health Care and Philos 22, 1–3 (2019). https://doi.org/10.1007/s11019-019-09885-8