Theory
Michael A. Gillette, Ph.D.

In past issues of "Centerline" I have discussed a series of ethical theories that might be used to address the moral problems that we face in the clinical setting. To many, that discussion must have seemed excessively theoretical, offering no apparent application to "real world" decision making. Many who have been following these ethics notes are probably left wondering if any theory could possibly be applied in a fruitful manner to practical choices, or if there is any objective truth to ethics at all.

These questions regarding ethical theory are common, and can be countered in various ways. First, it is necessary to show that we do not accept a truly subjectivist view of ethics. While many are fond of claiming that everyone is entitled to his or her own ethical perspective, this claim quickly falters in the face of questions regarding murder, theft, or any other example of behavior that we commonly believe to be wrong.

It is quickly maintained that murder can't be right because it harms people. In effect, by murdering I am forcing my moral view on someone else, which as noted above, is unacceptable. If this is the answer that is given to defend the claim that there is no objective truth in ethics, then the subjectivist position can be shown to be self-contradictory. When one attempts to defend subjectivism and the prohibition against murder at the same time, one simultaneously maintains that there is no real truth in ethics and that it is really wrong to force your view on others. Simple subjectivism is obviously in trouble.

"O.K." the protagonist might respond, "so I'm not a subjectivist. It is still unreasonable to attempt to apply theory to practical problems. Theories are far too removed from reality, too neat and clean for the real world"

Even this claim can be debated. Surely utilitarianism shows up in every cost-benefit analysis we make. Obviously deontology is at work when we assert the existence of basic human rights. Clearly virtue theory explains the special obligations we feel toward our friends, family and nation. But for those who do not like to follow carefully developed theories when practical difficulties arise, and for those who love theory but cannot quite decipher the demands of metaethical doctrine, there is yet another approach.

In recent additions of "The Hastings Center Report", the premier journal in the field of medical ethics, articles have abounded regarding the structure of medical ethics consultation and the role of the medical ethics consultant. Some have argued that the ethics consultant should be thought of as an architect who shapes an environment in which moral thinking can flourish. Others have called for a resurrection of the 'situational ethic' which was first develop by Joseph Fletcher four decades ago. All of these articles have explained how it is possible to move away from technical theory and still retain a meaningful practice of ethics. This method of doing ethics is called casuistry.

According to casuistry, or the casuistic approach, what matters most when we make ethical choices is that the decisions which we make properly represent the values that we as individuals and as members our culture actually hold. This is not as simple a matter as it appears. Many of us have divergent intuitions regarding specific ethical issues. Many of us disagree with each other. Sometimes we even feel conflicting emotions within ourselves, finding it difficult to understand our own thoughts and feelings regarding moral problems.

The answer, according to casuistry, is to engage in a careful accounting of our intuitions and an examination of the reasons for thinking and feeling as we do. The project in which we must engage is that of clarifying our view. We must create consensus and consistency in the place of disagreement and confusion.

To illustrate by example, consider the patient who refuses to accept medical treatment that is necessary to save his life. While the utilitarian would consider the results of forcing treatment or allowing the refusal, and while the deontologist will compare and contrast competing rights, the casuist will consult examples.

The casuistic response is based on consultation with our intuitions. We must describe a case where refusal of treatment is clearly acceptable. We must then describe a situation is which we would all agree that forcible treatment is the proper action. Next, we must examine these cases to find the reasons why we feel that treatment can be refused in one situation and not the other. Finally, we must examine the situation at hand to see which paradigm, either that of refusal or forced treatment, it most closely matches.

Only by working from our own experience, and learning from our own judgments that we accept as clearly valid, can we develop a consistent way of looking at moral difficulties. And it is only this consistency of opinion and the ability to appeal to shared notions of what is right in clear cases that will be able to generate agreement between persons.

According to the casuist, all that is important that we as a group are able to form useful and consistent moral opinions. Our moral opinions will be right when we can understand them and defend them with good reasons and examples.