Voices and Time

Abstract

My critique of the casuist proposal serves to highlight several points of interest. With its insistence on practical reason as at once more grounded in our moral history and more capable of appreciating the exigencies of moral discourse, Jonsen and Toulmin’s approach strikes me as very productive. It nevertheless has certain unanswered problems, as was suggested, and in the end remains too centered on the ethics consultant’s relation to the physician—both of which are simply taken for granted as having priority as regards the identification and resolution of moral difficulties in clinical situations. (It bears notice at the outset that many of the more than 2,500 consultations I conducted between 1981 and my retirement in 2002, involved serious cross-professional and cross-specialty issues: for instance, how quarrels with obstetrics affected which babies were after birth given over to neonatology for care; or, how care for critically ill patients was differently perceived by nurses and by doctors.) Hardly any attention is paid to those persons whose circumstances are most often at issue—patients and their significant others—and almost none to other clinical participants whose words and actions help to constitute the clinical encounter and clearly help to shape the moral issues embedded in any clinical encounter—nurses, physician consultants, therapists, and many others.