Abstract
This paper discusses the possibility of finding an ethic of at least partial and perhaps ever-growing content in a world not that of moral strangers (where we have nothing except our desire to live freely to unite us) and one of moral friends (in which values, goals and ways of doing things are held in common). I argue that both the world of moral strangers which Engelhardt's world view would support, as the world of moral friends which is the one Pellegrino seeks both are untenable and that furthermore both can lead to a similar state of affairs. I suggest a dynamic world of moral acquaintances in which different belief systems and ways of doing things can come to some broad agreements about some essential thing. This is made possible because although we do not share the intimate framework Pellegrino might suggest, yet we are united by a much broader framework than the one moral strangers share.
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It is virtually impossible to list all of the contributions to the field of medical ethics Dr. Edmund Pellegrino has made throughout his life-time. The most important cannot be referenced: by his life, by his teaching, by his influence on American medical education and by his personality Ed has helped in fundamental ways establish the field itself. Dr. Pellegrino's writings in the field always seem to start out from the tacit assumption that the ethics of the health profession are only a part of the wider area of the philosophy of the field and that unless “doing medical ethics” is underwritten by an understanding of that philosophy, “doing medical ethics” is apt to become merely another technology. Pellegrino ED, Thomasma DC. For the Patient's Good: The Restoration of Beneficence in Health-care. New York, NY: Oxford University Press), 1989.
The libertarian philosophy of Prof. H. T. Engelhardt can be gleaned from a large number of publications. Central to the argument presented here are two of his main works: Engelhardt HT. Bioethics and Secular Humanism: The Search for a Common Morality. Philadelphia PA: Trinity Press Internat, 1991, and Engelhardt HT. Foundations of Bioethics. 2nd ed New York: Oxford University Press, 1996. Basic to the libertarian point of view are the works of Nozick; see: Nozick R. Anarchy, State and Utopia. New York, NY: Basic Books, 1974.
Pellgrino, Thomasma; For the Patient's Good. Professors Pellegrino and Thomasma argue cogently that “beneficence in trust” compels care-givers to respect their patient's autonomously made choice. From the totality of Professor Pellegrino's work, however, one would assume that this respect would have great limits. While no physician could, for exaple, against his or her personal moral point of view be forced to perform a procedure he or she found morally obnoxious (a point of view which is reasonable and which I fully share), such a point of view would certainly wish society to establish rules and regulations which would preclude anyone from acceding to the patient's wishes. Not only could, for example, performing active euthanasia never be seen as the obligation of a physician against his or her personal moral point of view, performing euthanasia should be eentirely forbidden for all. Such beneficence in trust would, therefore, be seen as occurring not only within the confines of a given society (within its laws and regulations) but the laws and regulations themselves would be forged within the confines of a particular world view.
The reason for instituting various laws rather than to leave transgression up to the vengeance of relatives and friends was that leaving such things up to private vengeance disturbed “the king's peace:” that is, it disrupted society and reduced it to incessant tribal warfare. With the institution of laws and for the same reason resorting to private vengeance to redress a wrong rather than appealing to the law became a punishable offense.
Throughout his work, John Dewey relies upon the method of “reflective inquiry” which is a response to an unsettled situation. It is invoked whenever non-reflective ways of doing things prove unsatisfying in arriving at a workable “solution.” Problems are dealt with not to be once and for all solved but with a pragmatic “end-in-view,” which not only facilitaties dealing with the problem but which seeks a “solution” which in itself is a stepstone to further inquiry. Problems are not solved: indeterminate situations are made more but never fully determinate. Reflective inquiry is a form of thought-experiment in which the “end-in-view” helps formulate the question more fully and helps to select the material which would further inquiry itself. Among others see Dewey J. Logic the Theory of Inquiry. In: John Dewey: The Later Works Vol 12. Boydston J.A. and Poulos K., eds. Carbondale, IL: Southern Illinois University Press, 1986: Dewey J. Logical conditions for the scientific treatment of morality. In: John Dewey: The Middle Works Vol 3. Bodston JA and Rucker D., eds. Carbondale, IL: Southern Illinois University Press, 1977: as well as Dewey J. The Quest for Certainty. New York, NY: G. P. Putnam Sons, 1960.
The works of John Dewey both as they relate to methods of inquiry, ethics or to social and political structure are essential to these ideas. For inquiry see: Dewey J. Logic: the Theory of Inquiry. In: John Dewey: The Later Works Vol 12. Dewey J. Logical conditions for the scentific treatment of morality. In: John Dewey: The Middle Works Vol. 3 For ethics see: Dewey J.: Human Nature and Conduct. In: John Dewey: The Middle Works Vol 14. Bodston J.A. and Baysinger P., eds.). Carbondale, IL: Southern Illinois University Press, 1988: Dewey J. Ethics. In: John Dewey: The Later Works Vol 7. Bodston J.A., ed. Carbondale, IL: Southern Illinois University Press, 1989.
The arguments of Rousseau here are central to our thesis. Briefly put, Rousseau holds that the innate sense of compassion urges humans and higher animals to “do something” about the suffering of another unless doing so is felt to be detrimental to one's own existence. But Rousseau also feels that the morality develops only after the initiation of social structures enabled by the social contract and that this morality depends upon the structure of the society. Certain societies which have degeneratd so that power, wealth and opportunity are unjustly distributed will distort morality and will distort the way the compassion can express itself. In societies of this sort, self-regard can become transmuted into a pathological sort of self-love which stifles compassion or panders to it only when doing so is safe. Self-regard may prevent us from jumping into a ranging torrent to save another when our chance of doing so is slight and the danger to us is enormous. Self-love would prevent us from helping the poor when doing so is not dangerous but merely inconvenient to our own opulence. Works central to this thesis are: Rousseau J.J. Du contrat social; Emile and Discours sur l'origine et les fondement de l'inequalite parmi les hommes. In: Rousseau: Oeuvres Complete. Vol 2. Paris, France: Editions du Seuil, 1971.
For a summary (unfortunately not translated) see: Kronauer U. Vom Nutzen und Nachteil des Mitleids. Frankfurt a/M: Keip Verlag 1990; and Hamburger K. Das Mitleid. Stuttgart, Deutschland: Kltt-Cotta 1985.
Kant I. Kritik der Praktischen Vernunft. In: Immanuel Kant Werkausgabe. Band VII. Frankfurt a/M, Deutschland: Suhrkamp, 1968. Nevertheless Kant does not deny that compassion is ethically important. I am indebted for this understanding to Dr. Friedrich Heubel who drew my attention to a pertinent passage in Kant's Die Religion Innerhalb der Grenzen der Bloszen Vernunft. But although Kant does acknowledge that compassion has a role to play and although he may be construed to say that fostering such a sentiment is ethically valuable he, nevertheless and quite consistently, argues that only the rationally created moral law can be ethically decisive.
Schopenhauer A. Preisschrift #x00FC;ber die Grundlagen der Moral. In: Arthur Schopenhauer Kleinere Schriften. Band III. Arthur Schopenhauer Sämtliche Werke. Wolfgang Frhr. von Löhneisen, ed. Frankfurt a/M, Deutschland: Suhrkamp, 1989: 742.
I have discussed the role of compassion in ethics and the interplay between sentiment and rationality in Loewy EH: Compassion, reason and moral judgment. Cambridge Quarterly of Health Care Ethics. 1995; 4: 446–475, as well as in Loewy E.H. Moral Strangers, Moral Acquaintances and Moral Friends: Connectedness and Its Conditions. Albany, NY: State University of New York Press, 1996 (in press). metaep7.tex; 6/03/1997; 23:09; v.5; p.18
John Dewey's vision of democracy as not merely a political process but as a moral ideal which, unless it is realized, defeats any real notion of political democracy is essential to a point of view which embraces a world of “moral acquaintances.” See: Dewey J. The Public and its Problems. In: John Dewey: the later works. Vol 2. Boydston, J.A., Walsh, B.A., eds. Carbondale, IL: Southern Illinois University Press, 1991; Dewey J. Creative democracy: the task before us. In: John Dewey: The Later Works. Vol 10. Boydston, J.A., Sharp, A., eds. Carbondale, IL: Southern Illinois University Press, 1991.
Roughly 20% of persons are totally uninsured and entirely dependent upon capricious charity; those on Medicaid (varying but somewhere between 15 and 20%) may have theoretical access but often can find no care giver or institution willing to accept them; those on Medicaid (perhaps another 20%) are not fully insured (medications and devices are not covered, they have to pay a deductible and some cannot afford to pay for part B without which only in-hospital care is covered ); and, depending upon how the words “fully” or “adequately” are defined at least another 25% are not “fully” or adequately” covered. For references to these facts see: Roemer ML National Health Systems of the World (Vol I: The Countries 1991; and Vol. II: The Issues 1993). New York, NY: Oxford Univrsity Press, 1991, 1993.
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Loewy, E.H. FINDING AN APPROPRIATE ETHIC IN A WORLD OF MORAL ACQUAINTANCES. Theor Med Bioeth 18, 79–97 (1997). https://doi.org/10.1023/A:1005701301772
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DOI: https://doi.org/10.1023/A:1005701301772