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Clinical pragmatism and bioethical method

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Clinical pragmatism and bioethical method
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Smith, Gregory James
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vii, 73 leaves : ; 28 cm

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Bioethics ( lcsh )
Pragmatism ( lcsh )
Clinical medicine -- Moral and ethical aspects ( lcsh )
Medical ethics ( lcsh )
Bioethics ( fast )
Clinical medicine -- Moral and ethical aspects ( fast )
Medical ethics ( fast )
Pragmatism ( fast )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

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Includes bibliographical references (leaves 65-73).
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Department of Humanities and Social Sciences
Statement of Responsibility:
Gregory James Smith.

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Full Text
CLINICAL PRAGMATISM AND BIOETHICAL METHOD
by
Gregory James Smith
B.A., The Colorado College, 1969
J.D., Cornell University, 1972
A thesis submitted to the
University of Colorado Denver
in partial fulfillment for the degree of
Master of Humanities
2009


2009 by Gregory James Smith
All rights reserved.


This thesis for the Master of Humanities
degree by
Gregory James Smith
David L. Hildebrand
April 6.2009


Smith, Gregory James (M.H.)
Clinical Pragmatism and Bioethical Method
Thesis directed by Assistant Professor David L. Hildebrand
ABSTRACT
This paper discusses the concept of clinical pragmatism, a view of pragmatism
championed by Joseph J. Fins, et al., set within the context of John Deweys moral
theory and method of moral decision-making. In the decision-making process,
Dewey focuses on experience and inquiry and three critical factors at work (the good,
duty and virtue). For Dewey, each factor is independent and should operate as such
to facilitate good decision-making. This paper describes the problems that arise when
one of these factors is taken in advance as theoretically primary and how they
function interdependently. This paper takes Deweys method and argues for its use in
bioethical problem-solving in the clinical encounter. To this end, it argues for a
pragmatic approach in the Deweyan model for resolving bioethical problems,
defending against concerns which have been raised about Deweys approach and
contrasting that approach with that of preference utilitarianism, a principal proponent
of which is Peter Singer. Using examples drawn from key problem areas and a case
study, the paper demonstrates the advantages of clinical pragmatism over preference
utilitarianism. In the clinical setting, resolutions to bioethical problems are not
simply hypothetical exercises or thought experiments, but are encounters where
decisions, recommendations or actions have to be made or taken, affecting the lives
of health care professionals, patients and their families.
This abstract accurately represents the content of the candidates thesis. I recommend
its publication.
Signed
David L. Hildebrand


DEDICATION
I dedicate this thesis to my parents, Patricia M. Smith and G. Paul Smith and to my
wife, Marcia B. Smith.


ACKNOWLEDGEMENT
My thanks to my advisor, David L. Hildebrand, for his patient guidance, contributions
to and support of my research. I also wish to thank the other members of my
committee, Robert D. Metcalf and Mark Yarborough, for their timely and helpful
participation and insights throughout this process.
I also want to thank Myra Bookman, Director, Margaret L. Woodhull, Assistant
Director and Lis Shepard, Graduate Assistant in the MH/MSS Program at the
University of Colorado Denver, whose constant support, encouragement and direction
have been extremely helpful to me.
In addition, I want to thank current and former members of the faculty of the School
of Medicine at the University of Colorado Denver, particularly Frederic W. Platt, for
their enthusiastic support, encouragement and dialogue, along with Kimberly K.
Garchar of the Philosophy Department at Kent State University for her steady
guidance and thoughtful critiques, together with a number of my colleagues in the
law, especially Linda S. Siderius and Casey Frank, who have been a real source of
strength for me.
Further, it would not have been possible for me to devote the time to study, class
work, reading and writing without the steadfast support of my legal assistant, Debra
K. Ludwig, who kept the demands of my law practice at bay every working day, so as
to allow me the breathing space for the quiet reflection that intellectual endeavor
requires.
Also, it would have likely been impossible to reach this point without the support and
encouragement of Colorado College alumni and staff, along with other friends and
my family members, who strongly backed my return to the classroom as a graduate
student after an absence of nearly forty years.
Finally, I wish to thank my undergraduate advisor, William R. Hochman of the
History Department at Colorado College, who has always encouraged and supported
my efforts without fail and who, in his 80s, continues to teach and inspire young men
and women to pursue the life of the mind and to take an active interest in issues
affecting civil liberties and public policy.


TABLE OF CONTENTS
CHAPTER
1. Introduction and Overview of Bioethics..............1
Introduction.................................1
Overview of Ethics and Bioethics.............4
2. Overview of Pragmatism and Clinical Pragmatism.....10
Overview of Pragmatism......................10
Overview of Clinical Pragmatism.............12
3. Overview of Utilitarian Ethics.....................24
4. Application of Preference Utilitarianism and Clinical
Pragmatism to Bioethical Problems..................33
5. Conclusion.........................................38
APPENDIX
A. Process Of Decision Making Template................40
B. Clinical Pragmatism: A Case Method Of Problem-
Solving............................................41
C. Washington Hospital Centers Checklist.............45
D. The Four Topics Chart For Case Analysis............46
NOTES..........................................................48
BIBLIOGRAPHY...................................................65
vii


CHAPTER 1
INTRODUCTION AND OVERVIEW OF BIOETHICS
Introduction
In this thesis, I propose to discuss the concept of clinical pragmatism, a view
of pragmatism as applied to bioethics championed by Joseph J. Fins, et al.1 and as
applied to psychiatry by David H. Brendel.2 Clinical pragmatism is based upon John
Deweys moral theory, which focuses on experience, inquiry and the process of
decision-making. I also intend to explore each of three factors identified by Dewey
as being critical to moral decision-making (the good, duty and virtue) and the
attendant problems that arise when one of them is taken in advance as theoretically
primary and how they function interdependently.3
In arguing for a pragmatic approach to bioethical problems, I will also
contrast that approach with utilitarianism, an important approach to these problems
that finds considerable support in contemporary bioethics. In particular, I will be
comparing clinical pragmatism to preference utilitarianism, a principal proponent of
which is Peter Singer.4 Very briefly, building on the work of Jeremy Bentham, John
Stuart Mill and R.M. Hare, et al., Singer argues in favor of a form of utilitarianism,
but one that is not identical to classic utilitarianism. Singers view is that the
difference lies in that best consequences is understood as meaning what, on
1


balance, furthers the interests of those affected, rather than merely what increases
pleasure and reduces pain.5 Singer intends to enshrine utilitarianism as the default
setting of ethical thinking. 6 Part of my task in this thesis is to show that, if there
is to be a default setting in this arena, the default should be to the use of Deweys
method, rather than Singers.
Using examples from key problem areas and a case study illustrating
bioethical problems in the clinical context, where decisions or recommendations are
made daily affecting the work of health care professionals and the lives of real
patients and their families, I then demonstrate the advantages of clinical pragmatism
over preference utilitarianism.
One way of approaching the ethical problems presented by cases such as these
would be to utilize a decision-making protocol, such as exemplified by the eight-step
ethical decision making template currently in use on the Anschutz Medical Campus
of the University of Colorado Denver7. A copy of the template is appended to this
thesis as Appendix A. A more detailed template proposed by Edward M. Spencer is
appended to this thesis as Appendix B, along with an abbreviated clinical checklist
template in use at Washington Hospital Center for Ethics appended to this thesis as
Appendix C and a template using the four topics method suggested by Albert R.
Jonsen, et al., which is appended to this thesis as Appendix D.8 Without reviewing
the steps in detail now, in Step 4 of Appendix A we are asked to consider the values
at stake in the case. Among these values would be the four most commonly accepted
2


principles of bioethics, as listed below with a very brief and inadequate definition of
each of the principles:
Respect for Autonomy - respect the person of the patient
Nonmaleficence - do no harm to the patient
Beneficence - do good for the patient
JUSTICE - fairness to the patient or giving to each what is due
These four principles are the essential components in the framework used by a
number of current ethicists, particularly Tom L. Beauchamp and James F. Childress,9
whose approach has been labeled as principalism or less kindly as the Georgetown
Mantra. In this approach each of the four principles represents a serious, though not
absolute, moral duty that must be weighed against other duties in resolving an ethical
conflict or dilemma.10 Although these principles are subject to criticism,11 they are
also widely accepted, so, as a part of my endeavor here, I intend to explore the extent
to which such principles may find a place in Deweys method. Considering these
issues in light of Deweys work may help to determine whether clinical pragmatism
supports, supplements or represents an alternative to the so-called principalist
approach represented by the application of the above four principles, whether applied
broadly or narrowly. In the view of Margaret Olivia Little, Assistant Professor of
Philosophy, Georgetown University,12 such principles, if applied broadly should be
considered as clusters of obligations, values and virtues, while, if applied narrowly
should be considered as specific moral obligations. For Little, moral obligations
amount to requirements the community can demand of us and have a legalistic flavor
3


reminiscent of entitlements for the recipients. Some moral obligations apply in a
general way to all of us (similar to Immanuel Kants imperfect duties, one of which is
beneficence), while others are specific to our role in life, such as the duty of care for
patients implicit in being a health care professional. In addition to such obligations,
which do not exhaust morality, according to Little, the scope of morality includes
engagement with values (broad goals or ends that regulate our aspirations) and virtues
(character traits or excellences that honor values).
Overview of Ethics and Bioethics
Very briefly, ethics may be defined as the branch of philosophy that studies
morality through the critical examination of right and wrong in human action.13 One
sometimes finds the terms ethics and morality used interchangeably and perhaps no
fatal error arises in so doing. In attempting to distinguish them, one may use the term
morality as referring to the customs, principles of conduct and moral codes of an
individual, group or society.14 One may also use the term bioethics as falling within
the general purview of applied ethics, the employment of normative ethics.. .in the
analysis of specific, practical issues, although the term practical ethics may be more
apt.15 One may use the term normative ethics as referring to the effort to define
specific standards or principles to guide ethical conduct in determining values,
making moral assessments and justifying human action.16
The term bioethics is generally thought to have been coined by Van
Rensselaer Potter in Bioethics: Bridge to the Future17 in the 1970s. The term, taken
4


literally, means life ethics, but it has been given a different meaning in the context
involved here by others than the one Potter intended. According to Potters view:
The first ethics dealt with the relation between individuals; the Mosaic
Decalogue is an example. Later accretions dealt with the relation
between the individual and society. The Golden Rule tries to integrate
the individual to society: democracy to integrate social organization to
the individual.. .An ethic may be regarded as a mode of guidance for
meeting ecological situations so new or intricate, or involving such
deferred reactions, that the path of social expediency is not discernible
to the average individual. Animal instincts are modes of guidance for
the individual in meeting such situations. Ethics are possibly a kind of
community instinct-in-the-making.18
While our concerns here are philosophical in nature, rather than ecological,
todays environmental challenges make Potters words still ring true, even though
nearly four decades have passed since he wrote them in 1971. More directly
connected to our immediate task, however, may be his notion of community instinct-
in-the-making.19 The notion of community was used earlier by Dewey and others20
for other purposes and will be discussed later in this thesis, but may yet hold one of
the keys to a thorough consideration of the source and proper use of bioethics in the
everyday lives of health care professionals, patients and their families. In this process
of involving or attempting to understand the role of community here, Potter strongly
urges us to construct a bridge between science and the humanities when he says:
The purpose of this book is to contribute to the future of the human
species by promoting the formation of a new discipline, the discipline
of Bioethics. If there are two cultures that seem unable to speak to
each other science and the humanities and if this is part of the
reason that the future seems in doubt, then possibly we might build a
5


bridge to the future by building the discipline of Bioethics as a bridge
between the two cultures.21
When considering Potters notion of a bridge, one is reminded of the
extensive use of, deference to and adoption of what is essentially the scientific
method in Deweys recommended manner of problem-solving and decision-making
of all kinds, moral and otherwise, as discussed below. I understand Potter to be
arguing for the creation of the bridge between science and the humanities for the sake
of bioethics and ultimately to permit humans to survive and thrive in the face of
serious ecological challenges.22 In Potters view, a science of survival must include
both biological knowledge and human values23 as part of the building blocks of a
new wisdom that is so desperately needed.24 Potter questions whether ethics should
be limited to a disinterested study, however, when he observes:
In the past ethics has been considered the special province of the
humanities.. .taught along with logic, esthetics and metaphysics as a
branch of Philosophy. Ethics constitutes the study of human values,
the ideal human character, morals, actions and goals in largely
historical terms, but above all ethics implies action according to moral
standards.25
Potter is not alone when calling for action in such matters. Singer makes a
similar point when he observes:
.. .ethics is not an ideal system that is noble in theory but no good in
practice. The reverse of this is closer to the truth: an ethical judgment
that is no good in practice must suffer from a theoretical defect as well,
for the whole point of ethical judgment is to guide practice.26
6


As explicated by Albert R. Jonsen, Potters definition of bioethics as a part of
27
his vision for a new conjunction of scientific knowledge and moral appreciation
has been appropriated to identify a related but much narrower vision: the ethical
analysis of a range of moral questions posed to medical practice by the advances in
the biomedical sciences and technology. Beauchamp and Childress provide a
further definition, as follows:
We understand biomedical ethics as one type of applied
ethics the application of general ethical theories, principles,
and rules to problems of therapeutic practice, health care
delivery, and medical and biological research.29
More briefly, bioethics has been said to refer to the exploration of ethical
dilemmas that relate directly to the fields of medicine and health care.30 While
perhaps difficult to improve upon, definitions such as these seem quite inadequate for
a field which literally covers issues from abortion to transplants and from biomedical
research to surrogate pregnancy and all the contemporary health and related social
problems in between. Another effort at a definition is found in the Encyclopedia of
Bioethics as follows:
.. .from another perspective, the kinds of questions raised by these
[biomedical, environmental and social science] advances are among
the oldest that human beings have asked themselves. They turn on the
meaning of life and death, the bearing of pain and suffering, the right
and power to control ones life, and our common duties to each other
and to nature in the face of grave threats to our health and wellbeing.
Bioethics represents a radical transformation of the older, more
traditional domain of medical ethics; yet it is also true that, since the
dawn of history, healers have been forced to wrestle with the human
7


fear of illness and death, and with the limits imposed by human
finitude.31
Since bioethics encompasses numerous and important issues in our lives,
perhaps it is best understood broadly as one with impacts in science (including
medicine, biology and ecology) and technology, but also in the disciplines of the
social sciences, philosophy, religion and literature.32 For the purposes of this thesis,
however, the application of bioethics will be focused upon decision-making in the
clinical setting in the United States, although the appeal of and interest in so-called
hot button issues like abortion, physician-assisted suicide and many others seem, for
scholars and the general American public alike, as strong now as in earlier years, if
not more so. Some other limitations are necessary as well. For example, while the
impact of the law on health care in the United States over the last several decades has
been substantial, a discussion of how the law became an instrument for change in this
area and whether the effect of the laws impact has been positive or negative for
health care professionals, institutions and their patients must be reserved for another
day.33
I have chosen the clinical setting as my focus because for clinical
professionals, bioethics has to do with the very soul of medicine and with their own
moral identification (emphasis added) and because it is in the interaction between
health care professional and lay patient that the rubber hits the road as it were.34
Making decisions involving ethical issues in the clinical setting may be called the
8


practice of clinical ethics. John C. Fletcher and Edward M. Spencer further describe
the term as follows:
Clinical ethics is a practical discipline that deals with real-world
problems and practices in the healthcare arena. It focuses on
controversies and issues surrounding the care of patients in different
settings: acute care (in hospitals and clinicians offices), long-term
care, rehabilitation, home care, and hospice care.35
Fletcher and Spencer also emphasize the importance of clinical ethics being
done at the bedside:
We believe the best way to study clinical ethics is via attention to the
most frequent and difficult ethical problems that confront clinicians,
patients and their families who are at or near the bedside the arena of
illness and healing. In these situations, decisions need to be made and
actions must be taken. We call this doing ethics or moral problem-
solving.36
Pragmatism, with its focus on a situation, one involving real-life, flesh-and-
blood people and their problems,37 offers flexible solutions which, rather than
constrain the actors in the medical drama.. .should increase their freedom by helping
them to explore.. .alternatives.38 In Chapter 2,1 provide an overview of pragmatism
in the Deweyan model, pragmatism being the one philosophical outlook that is
native to the United States39 and so perhaps uniquely suited as a method to provide
solutions to ethical problems arising in the American clinical context.
9


CHAPTER 2
OVERVIEW OF PRAGMATISM AND CLINICAL PRAGMATISM
Overview of Pragmatism
Briefly stated, pragmatism has been defined in Adventures in Philosophy as:
.. .a philosophical movement.. .which holds that both the meaning and
the truth of any idea is a function of its practical outcome.
Fundamental to pragmatism is a strong antiabsolutism: the conviction
that all principles are to be regarded as working hypotheses rather than
as metaphysically binding axioms.. .William James... [developed
pragmatism].. .as a theory of truth. True ideas, according to James are
useful leadings, they lead through experience in ways that provide
consistency, orderliness and predictability.. .Dewey made inquiry,
rather than truth or knowledge, the essence of [his approach].40
As more fully discussed below, Dewey viewed ethical decision-making as no
different than other kinds of decisions that we make. Others have pointed out that
making ethical decisions is a part of everyday life41 even if the weight of such
decisions may not be substantial. We may decide to lie to a relative about her
cooking in order to avoid hurting her feelings, to break (or keep) a promise to a friend
because (or even if) it turns out to be inconvenient to honor a commitment or not to
stop and help a motorist in distress because we are late to work or due to a fear for
our safety.
While making even an otherwise lightweight ethical decision can give us
pause, the problems dealt with in the bioethical context are often of another order of
10


magnitude altogether, accompanied as they may be with the thickness of the moment,
wherein the vague is present all around us, but where we must yet make decisions and
act upon them.42 James makes the point about such momentous decisions when he
quotes James Fitzjames Stephen, a Nineteenth Century English lawyer, judge and
author, as follows:
In all important transactions of life we have to take a leap in the
dark.. .If we decide to leave the riddles unanswered, that is a choice; if
we waiver in our answer, that, too, is a choice: but whatever choice we
make, we make it at our peril.. .we stand on a mountain pass in the
midst of whirling snow and blinding mist, through which we get
glimpses now and then of the paths which may be deceptive. If we
stand still we shall be frozen to death. If we take the wrong road, we
shall be dashed to pieces. We do not certainly know whether there is
any right one.43
As we prepare to take that leap in the dark, while we attempt to steer our
course safely between Scylla and Charybdis or between freezing to death and being
broken apart upon the rocks below, pragmatism is available as a tool to guide us on
our journey along the path through the mountains of ethical conflicts and dilemmas
that arise both in everyday life and in the arena of bioethics.
As briefly described above, pragmatism as a distinctly American movement in
philosophy is based upon the work of James and Dewey, who built upon but also
diverged from the earlier work of Charles Sanders Peirce. For my purposes here,
although I will refer to work of other thinkers as well, when I use the term
11


pragmatism, I mean the version of that philosophical approach as advanced by
Dewey.
For Dewey, inquiry is not a process where one passively observes the external
world and draws from such observation ideas corresponding with reality. Deweys
pragmatism is, instead, a naturalistic approach that viewed knowledge as arising
from an actual adaptation of the human organism to its environment.44 What we are
looking at here, then, is a process, described more fully below, where Deweys
method of moral decision-making is addressed. As described in the Internet
Encyclopedia of Philosophy, moral decision-making begins when one encounters:
[an]...obstacle to...human action, proceeds to active
manipulation of the environment to test hypotheses, and issues
in a re-adaption of organism to environment that allows once
again for human action to proceed.45
Overview of Clinical Pragmatism
The practice of medicine, nursing, physical therapy and the other health care
professions have been variously described over the years as an art, rather than a
science or as an art, based upon the foundation of the scientific method or as a
science of uncertainty and an art ofprobability.46 Without deciding which of these
descriptions may be the more apt, I intend to argue that what has been referred to as
clinical pragmatism by Fins, et al. and Brendel are good examples of the proper use
of Deweys method of moral decision-making. For this purpose, clinical pragmatism
is described by Fins, et al., as follows:
12


In approaching moral problems, the method of clinical pragmatism
seeks solutions that are workable in the real contexts of clinical
settings in which clinicians and patients interact. Owing to the
negative connotations sometimes associated with pragmatism, it
needs to be stressed that clinical pragmatism is not meant to promote
whatever works to serve the agenda of physicians. Pragmatists often
have been accused of promoting experience at the expense of
principle, but this is a caricature of pragmatic philosophy and method.
Clinical pragmatism embraces principles; however, it understands
them as tools for guiding conduct, not as absolute fixed moral laws.
The goal of clinical pragmatism is to reach consensus on good
outcomes in cases that pose moral problems by a thorough process of
inquiry, discussion, negotiation, and reflective evaluation.47
There is likely little debate about the importance of moral decision-making as
a part of human behavior, particularly in the realm of bioethics, where the issues
presented and the decisions made can literally be those involving life and death. I
claim that the pragmatic approach to problem-solving, as proposed by Dewey, is the
one best-suited to a thorough yet usable method of making these bioethical decisions.
This is so because of the nature of the problems themselves are difficult and nuanced,
as discussed above and because Deweys method of moral decision-making turns
away from so-called traditional or analytic philosophy, offering instead pragmatic
ethics, upon which I will elaborate further. As more fully discussed below, the
starting point in making ethical judgments, as outlined in Deweys method of moral
decision-making is when an agent encounters a particular situation in which it is felt
by the agent that a significant moral choice is to be made. In such a situation, the
agent is presented with two or more alternatives for action, each of which is
supported by values the agent holds dear. Here, the values are seemingly locked in an
13


irreconcilable conflict, causing the agent to have doubt as to the proper course of
action.
One practical way to implement clinical pragmatism is the use of checklists or
templates to guide the process, such as the examples which are appended to this paper
as Appendix A-D. While each of these templates has its own vices and virtues, the
development of habits by use of such checklists or templates may help the actor focus
on the situation, so that when the actor encounters ethical problems, the actor
understands the need to approach the problems in a thorough-going way, to
empathize with the felt values of the others involved, understanding that some of
these values may arise from their own different traditions, cultures, beliefs and
practices. I believe Dewey would approve the use of checklists or templates for a
variety of reasons, but particularly because such use actually works and perhaps such
checklists and templates, training in their use and the habits thus developed may
enable those using them to consistently apply clinical pragmatism for the
considerable benefit of their patients.
For illustrative purposes, we may consider the following case study, in the
context of a pediatric practice:
JT is a fifteen year old boy who is being seen in your office for a
sports physical. Your office uses a questionnaire to screen for
adolescent risk factors. One of the questions is have you ridden in a
car with someone who has been drinking or using drugs? JT
answered .yes and on further questioning, it is discovered that his father
has several DUI arrests and is on probation. The family car has a
breathalyzer attachment (interlock) which prevents the car from
14


starting if alcohol is detected on the breath. JT has his learners permit
and is beginning to drive and he starts the car after breathing into the
interlock. Several times his father has been drinking and has had JT
start the car and then the father drives.48
If we were to simply list the values or principles in conflict in this case study,
we can see why moral inquiry is called for in the case involving JT described above.
Looking at the case through the lens of the principalist approach might lead to the
analysis that follows. His physician would likely want to respect JT s autonomy by
keeping in confidence what JThas told the physician about his fathers behavior. At
the same time, the physician might be guided by the principle of nonmaleficence in
wanting to avoid harm (to JT, other family members, passengers, pedestrians and
other motorists) by keeping JTs father from behind the wheel. In addition, the
physicians conduct might be informed by the principle of beneficence in a desire to
do good for JT and others to preserve the family unit intact and avoid potentially
harmful discord. Thus, even if the laws requirements for disclosing potential child
abuse are put aside for the moment to consider these other issues, there is no obvious
way to resolve the conflict among values and principles that exists, and thus, moral
inquiry needs to be performed.
For Dewey, moral inquiry is a complex and ongoing activity. In this activity,
one must strive to evaluate all relevant factors and neither practice nor philosophical
theories dominate the process, but each informs the other in an ongoing discourse,
functioning in an analogous way to the bridge described by Childress referred to
15


above between theory and practice. Deweys moral decision-making method 49
includes these steps: (1) the agent is presented with a problematic situation, where the
presence of something being wrong can be felt by the agent; such situations are not of
the simple variety and are not easily addressed by actions directed by mere habit,
such as whether to stop our walking companion from stepping into the path of an
oncoming car; (2) the agent locates and defines the problem by gathering relevant
facts and data; (3) the agent imagines several possible hypotheses to solve the
problem; (4) the agent selects the best hypothesis that fits the available data, as the
best solution to solve the problem and (5) the agent experiments with what is thought
to be the best hypothesis; he tries it out to see if it really works to solve the problem.
If the experiment is a success, the problem is solved and the process can end for the
time being, to be restarted or continued if new or additional facts or data are
encountered or if the consequences of acting upon the decision are not as anticipated
or produce undesirable results. If the experiment does not work, the agent would
repeat steps (2) through (5) again by returning to gather more facts and data,
generating further hypotheses, engaging the imagination to lead to the best
hypothesis and trying more experiments with the best hypothesis, until the problem is
solved. Rather than apply some over-arching universal guideline to this particular
moral situation (and thus damage our ability to trust our individual intellect),50
Dewey urges us to use our intellect in this method, akin to the scientific method long
used for other kinds of inquiry and which Dewey believes is well-suited to the
16


resolution of moral and other problems in life. If done well, this exercise of our
moral imagination may optimize the solution to the problematic situation for all
concerned.
Over time, several concerns have been raised about Deweys argument and
the approach of pragmatism to moral problems. These concerns can be generally
categorized as (a) the elimination of obligation; (b) the danger of subjectivism; and
(c) the specter of relativism.51 To each of these concerns, it might first be said that
pragmatism allows use of moral theories and is a moral theory itself in a meta-ethical
sense, but may be better dealt with here as a method rather than as a separate moral
theory. This view of pragmatic method will be further developed in my thesis.
Dewey has a response to the concerns referred to above, which I have summarized
below along with including a summary and critique of the preference utilitarianism
approach offered by Singer, et al.
As to the question of obligation, while pragmatism itself is not criterial, it
accepts the notion that ethical criteria exist. There are many obligations that arise
during our lives derived from family relationships, the culture in which we live, etc.,
so obligations do not mysteriously disappear under pragmatism.
The subjectivism charge arises from a misunderstanding of the nature of the
self. Although pragmatic ethics says that the actor (moral agent) is the decision-
maker, that does not mean that anything goes or that Mussolini-type dictators should
be considered as ethical. Perhaps the unstated assumption of the subjectivism
17


concern is that we humans are actually isolated solitary selves, when in fact this is not
the case, since we are connected in many ways with other selves in the world and
with various cultural institutions as well. Deweys view is that ones selfhood arises
in conjunction with ones relationship to society, the world, nature, etc., so those
raising the subjectivism concern paint a picture of the self that is wrong-headed. This
incorrect assumption about the self leads them to the wrong conclusion about
pragmatism as well.
The final and perhaps most serious charge against pragmatic ethics is that this
is relativism: since pragmatism holds that there are no fixed criteria to be applied to
all morally problematic situations, we are free to ignore or define away significant
aspects of such problems by, for example, using a self-serving construct of virtuous
behavior. Like the charge of subjectivism, this charge is also essentially based on an
incorrect assumption as to the nature of the self. Since we are not radically isolated
from others, cultural institutions, the world, nature, etc., the lack of fixed criteria does
not lead to an answer such as it depends being appropriate to all ethical questions,
such an answer being described by Dewey as preposterous. 52
Dewey shows us what is worth retaining among moral theories, all of which
are at play in our moral experience.53 To better understand the difference between
pragmatism and the canon of traditional philosophy, it is important to review the
process of moral decision-making, including a description of situations, experience
and inquiry. We have previously reviewed Deweys five-step process for moral
18


decision-making, which method is applicable to all kinds of problems (moral
decision-making is not really any different from other kind for Dewey). Here, Dewey
is explaining what we do in making a moral decision, but he is not providing a
prescription of what to do.
Under pragmatism, morality permeates our experience, since we make
decisions on such issues frequently. People are often thought of as having strayed
from the straight and narrow proper moral path. We say of someone who has strayed
like this that she was distracted by desire or that he is a dim bulb to explain the
deviation from the course thought proper. Or, if we want to abandon the thought
process altogether, we can simply apply a label to the person evil, degenerate, etc.,
rather than conclude that such missteps occur for the same reason that causes most
planes to crash pilot error.
In outlining the process for moral decision-making, Dewey is rejecting the
simple analysis of all moral situations as being just a conflict of good and of evil54
because the more conscientious the agent is and the more care he expends.. .the
more he is aware of the complexity of this problem.. .he hesitates among ends, all of
which are good.. .among duties which obligate him.55 Dewey concludes that what
he describes as current moral theory is inadequate for true moral decision-making and
creates false conflicts between good on one hand and evil on the other because such
theories do not recognize the problematic character of these situations. Such theories
also postulate a single principle as an explanation of moral life, 56 whether of ends,
19


which are reducible to one simple end, supreme or universal good, regardless of
whether that universal good is called happiness.. .pleasure... [or].. .self realization.
57 In this traditional theory, the right is only the means or the manner... of attaining
the good.58 The other traditional approach, Dewey says, is the morality of laws...
wherein law.. .prescribes what is legitimate or obligatory and Moral good becomes
that which is in agreement with juridicial imperative 59
Dewey cannot accept any such unitary principle, such as urged by the
proponents of preference utilitarianism, because, although such a principle has the
virtue of simplicity, it has the vices of being abstract, arbitrary and contrary to
empirical fact-observation.60 Further, since uncertainty is inherent in bioethics, more
information is required to be gathered for decision-making than to simply inquire as
to the preferences or interests of those involved in the situation. Dewey also observes
that moral progress and improving our character require us to make delicate
distinctions, to perceive previously unnoticed aspects of good and evil, recognizing
that doubt and choice also intrude into this entire process.61 For Dewey, there are
separate origins for good and right, allowing equal room for desire and duty62, where
the task of the moral agent is to develop and exercise the capability to judge their
respective claims.63 Dewey discusses good, duty and virtue, what he calls the three
independent variables or factors and their necessary application to moral decision-
making, 64 whereby proper decision-making results in proper conduct, worthy of
praise rather than of blame (sympathetic resentment) by others.65
20


Deweys method of moral inquiry, as described above, could be referred to as
moral science because of the perceived continuity between moral science and such
sciences as physiology, medicine and psychiatry.. .in moral science our
concern.. .is.. .with human nature existing and operating in an environment. 66
Consistent with Deweys notions of political and social improvement as being
desirable, morality can be a tool for change and improvement. So, upon completion
of the use of the method in a given case, we may conclude that we have arrived at a
satisfactory resolution. ... [T]o declare something as satisfactory says it will do.
This is put in the context of a prediction, a look into the future. Since some of our
current cultural values can be undermined by the conclusions of the natural sciences,
69 it is all the more important that moral science be applied in accordance with this
method, whereby all the other sciences are brought to bear in understanding the
activities of human life.70
Tragedy is a basic fact of our moral life and we must acknowledge genuine
precariousness and the essentially conflictual nature of life. While neither
precariousness nor conflict may ultimately disappear, things can be improved for the
better, as we use the natural sciences for the detection of concrete human woes
and.. .remedying them.71 In this way, for example, life may become less physically
precarious or hunger and illness may be brought to heal. Morality cannot be reduced
to an algorithm, in part because of the effect of our feelings, the live nature of moral
situations and the impact of chance in our lives. Despite these impediments and the
21


lack of paint by number solutions, we can move along the path in the process of
growth, of improvement and progress.. .Growth itself... [being].. .the only moral
end. 72 A broad spectrum of problems can be dealt with by moral science, those
with low stakes, like making a false excuse to avoid a dinner engagement, to those
involving matters of great moment, like decisions involving life and death. Dewey,
then, wants us to apply our intelligence as the means of inquiry to the solution of
problems arising from moral situations, those in which judgment and choice are
involved. 73 Moral habits can be useful as a way of keeping us grounded to our past
experience and as helpful tools for our intelligence, but they must be subject to
continuing review to avoid moral myopia or blindness, where our minds are closed to
new evidence and thus incapable of growth. Dewey urges that we solve these moral
problems, not by appeal to universal rules that govern all situations, nor by appeal to
mere preferences or desires, but by using the tools we already have, including those
of habit and rules of thumb, which can be helpful in understanding the meaning of
what we are seeing.74 When fact patterns repeat themselves from one situation to
the next, we should recognize that there are very few unique situations that share no
similarities with prior or contemporaneous ones. The key benefit of the method is
that it is tied to the future, for it allows predictions of consequences and thus may
provide guides to our conduct in times to come, as we resolve conflicting desires and
alternative apparent goods and find the right course of action, the right good. To
be successful at this endeavor of moral deliberation, we must apply our intelligence
22


and our feelings to the situation at hand, evaluating the quality of an act by observing
its consequences measured by general happiness as well as the other criteria discussed
above. 76
Thus, the way pragmatism works has many advantages, especially as such
approach is constructed by Dewey. The guidance provided by James is helpful as
well, but any attempt to reconcile his views with those of Dewey is beyond the scope
of this thesis. My effort here is to take a broad Deweyan approach, looking to Dewey
to characterize the moral situation and the pattern of inquiry to deal with that
situation, while looking to James in particular for his sensitivity to the interplay of
human emotions and insights. In so doing, I have borrowed from what I consider to
be the strengths of each thinker to move toward a usable pragmatic approach to
bioethical method. Having summarized the pragmatic view, I must now turn to the
utilitarian approach.
23


CHAPTER 3
OVERVIEW OF UTILITARIAN ETHICS
As discussed above, classic utilitarianism is based upon the work of Bentham
and Mill, whose principle of utility (greatest happiness principle) declares that actions
are right if they produce the greatest balance of happiness (pleasure) over
unhappiness (pain). Other goods may be considered to fall under happiness, such as
love, beauty, friendship, knowledge and success for this purpose. The classic
utilitarian approach is typically divided into two camps: rule utilitarianism and act
utilitarianism. For the act utilitarian, each situation is unique, so right or wrong is
determined by applying the principle of utility to each individual circumstance. By
contrast, the rule utilitarian contends that the principle of utility should be applied to
the rules underlying the acts; such rules may thereby be developed and subsequently
tested for application in similar situations. If correctly followed, the rules so
developed will, it is argued, provide the best consequences, greatest social utility and
best outcomes for all over time. The application of both act and rule utilitarianism
present problems, however. Following the act utilitarians approach could produce
different actions in situations sharing quite similar facts and circumstances; this
approach essentially requires a back to the drawing board initial step to analyze each
situation. Following the rule utilitarians approach would involve creating a
24


staggering number of rules to guide our ethical lives with a corresponding or even
greater number of exceptions to those rules, plus the opportunity of conflict between
and among rules in certain situations.77 Any attempt to fully resolve the long-
standing dispute between these two camps of utilitarians is beyond the scope of this
thesis, but one major criticism advanced by the rule camp against the act one is that
the act method would, in a given fact situation, permit or perhaps even require
conduct which would be overwhelmingly acknowledged as immoral by many.
More recently, Singer (who is generally classified as residing in the act camp)
has promoted the notion of individual preferences or interests as the basic equivalent
of utility most useful for application in moral decision-making. By so doing,
Singer has departed from classic utilitarianism in favor of his own approach,
influenced by the work of Hare. This approach finds the ethically right action to be
the one that maximizes the preferences or interests of those involved. Singer
contends that the use of such preferences is consistent with his approach, which is
seeking the solution that has the best consequences for all affected. This
represents an abandonment, perhaps for practical reasons, of the effort to measure
utility in terms of the extent, duration or cause of happiness, as done in the more
classical utilitarian approaches.80
As mentioned above, ethical issues are commonplace in our lives and Singer
does not disagree with this notion. In determining whether a choice, issue or decision
has a significant ethical dimension, however, Singer wants to apply what he calls
25


practical ethics to matters which are both relevant and susceptible to philosophical
reasoning,81 As Singer observes, I regard an ethical issue as relevant if it is one that
any thinking person must face. [These issues may not arise daily, but],. .can arise at
ft?
some time in our lives. They are also issues of current concern [in society].
Once it has been determined than an issue has relevance in this sense, then we
must decide whether philosophical reasoning can be of assistance in dealing with the
issue. If the matter at hand is comprised only of a factual dispute, such as whether
genetically engineered crops pose any risk to humans, animals or our natural
environment, then Singer suggests that philosophy may not be of much help in such
cases. However, where there is no factual dispute, but instead we find that a
conflict of ethical viewpoints is present, Singer argues that conflicting ethical
views.. .give rise to disagreement over what to do. Then the kind of reasoning and
analysis that philosophers practise really can make a difference.84
In applying philosophical reasoning to these problems, Singer emphasizes the
virtues of disagreement and dialogue:
Objections and counter-arguments are welcome. Since the days of
Plato, philosophy has advanced dialectically and philosophers have
offered reasons for disagreeing with the view of other philosophers.
Disagreement is good, because it is the way to a more defensible
position.85
Objections and counter-arguments raised against the utilitarian view have,
however, not swayed Singer, but have only served to reinforce my conviction that
the consequentialist approach to ethics.. ..is fundamentally sound. In formulating
26


his approach to moral decision-making, Singer is making use of a distinction
originated by Hare, who divided moral reasoning into two types: the everyday or
intuitive level and the more reflective or critical level.87 In building on this two-level
approach, Singer argues that preference utilitarianism... [should]...enable us to apply
one version of utilitarianism88 to all such problems and for all living creatures,
human and animal alike.
While others have attempted with more or less success to distinguish ethics
from morality, Singer does not do so and expressly uses the terms interchangeably,
perhaps without creating confusion at the outset of his principal work on this subject.
He describes his project as follows: this book is about practical ethics.. .the
application of ethics or morality.. .to practical issues like.. .abortion, euthanasia, and
OA
the obligation of the wealthy to help the poor.
Although he interchanges ethics and morality, Singer contends it is important
to know what we are doing when we discuss ethical questions90 and that we
understand what ethics is not. For Singer, ethics is not about something designed to
stop people from having fun,91 nor is it a set of prohibitions particularly concerned
with sex.92 Those who position themselves to be defending morality generally are
actually only defending their own particular code of morality, according to Singer.
Despite popular concerns over issues like promiscuity, homosexuality, pornography,
HIV-AIDS, etc., he contends that there is nothing special about sex in this respect
27


[ethical decision-making]...the same could be said about decisions about driving a
car.
93
As noted above, Singer shares the concerns of others that ethics must be
useful in practice and applicable to the real world to be of any value. To be both
useful and of value, ethics cannot only consist of a system of short and simple
rules94 such as ones that would prohibit lying, stealing and killing. Simple rules
such as these may conflict in an unusual situation and slavishly following them, even
in the absence of the unusual, may lead to disaster.95 In contrast to the conflicts and
disasters of an ethics of simple rules or the problem of dealing with a set of rules that
is complicated, specific or hierarchically ranked, Singer offers the benefits of
consequentialism. As he observes:
Consequentialists start not with moral rules but with goals. They
assess actions by the extent to which they further these goals. The
best-known.. .consequentialist theory is
utilitarianism.. .[which].. .regards an action as right if it produces as
much or more in the increase of the happiness of all affected by it than
any alternative action, and wrong if it does not.. .The consequences of
an action vary according to the circumstances in which it is performed.
Hence a utilitarian can never properly be accused of a lack of realism,
or of a rigid adherence to ideals in defiance of practical
experience...[She].. .will judge lying bad in some circumstances and
good in others, depending upon its consequences.96
Singer distinguishes his utilitarian views from other views based upon
religion, relativism or subjectivism, all of which he believes are an inadequate
foundation for ethics.97 Ethical judgments must, he contends, be more than mere
expressions of attitudes. He agrees with the subjectivists that no independent
28


realm of ideal ethics exists apart from us, but denies that ethical judgments are
immune from criticism, that there is no role for reason or argument in ethics, and that,
from the standpoint of reason, any ethical judgments are as good as any other.99
Although Singer concedes the lack of an ideal realm for ethics, he contends that
practical ethics can have a solid foundation because of the possibility of ethical
reasoning.100 Defending, giving reasons for or justifying our ethical decisions is a
part of living according to ethical standards, but any justification solely based on
self-interest is inadequate.101 Harkening back to Shakespeare, Macbeths
justification for his murder of Duncan, so that I can be king in his place will not do
because it is solely based upon the actors self-interest.102 As Singer argues: self-
interested acts must be shown to be compatible with more broadly based ethical
principles if they are to be ethically defensible for the notion of ethics carries with it
the idea of something bigger than the individual.103
Even though self-interest is not enough alone for justification and there is no
ideal realm of ethical truth to which we may refer, Singer suggests that some
universality of view is required. For example, in the application of a principle like
the Golden Rule, we are enjoined, in Singers words, to give the same weight to the
interests of others as one gives to ones own interests.104 The universal aspect of
ethics attributed to it by many thinkers over time, despite other differences on
application, methods or theory, is the key element we should take away from the
ongoing philosophical dialogue about ethics.105 As Singer observes:
29


..what they [other philosophers].. .have in common.. .is.. .that an
ethical principle cannot be justified in relation to any partial or
sectional group. Ethics take a universal point of view.. .[but
no].. .particular ethical judgment must be universally applicable.
Circumstances alter causes.. .in making ethical judgments.. .[we
must].. .go beyond our own likes and dislikes to the universal law, the
universal judgment, the standpoint of the impartial spectator or ideal
observer.. .[which].. .does provide a persuasive.. .reason for taking a
broadly utilitarian position.106
Returning to Hares distinction of the two levels of moral reasoning, Singer
suggests that the calculation of the interests of those affected and the course of action
needed to maximize those interests which is to be made is not one for the everyday
decision-making of life, but rather when we encounter very unusual circumstances,
or perhaps when we are reflecting on our choice of general principles to guide us in
the future. What Singer is arguing for here is a form of utilitarianism, but not in
its classic form because what he means by best consequences is said to be what, on
balance furthers the interest of those affected rather than merely what increases
pleasure and reduces pain. Singer does not, however, urge an abandonment of
what he calls ethics universal aspect, wherein are found ideals such as rights of the
individual, the sanctity of life, justice, etc.109 Acknowledging the potential
incompatibility of utilitarian theory with any universals such as these, he argues for a
view that places utilitarianism into a position where it is:
.. .a minimal one [position], a first base that we reach by universalising
self-interested decision making. We cannot.. .refuse to take this step.
If we are persuaded we should.. .[also].. .accept non-utilitarian moral
30


rules or ideals, we need to be provided with good reasons for taking
this further step.110
Among these non-utilitarian moral mles or ideals which Singer embraces is
that of equality equality as an accepted principle, not equality in fact, whether of
strength, beauty, intelligence or wisdom.111 For Singer, adopting the principle of
equality results in equal considerations of the interests involved, but may not result in
equal treatment being given to each affected person. In the triage situation to which
he refers, there are two injured patients, one of whom is in slight pain and the other of
whom is in very severe pain. Due to a shortage of morphine, there is not a sufficient
supply to adequately relieve the pain of both patients. The emergency medical team
must make a choice between partially relieving the pain of the one suffering severely
while fully relieving the pain of the one with less suffering or fully relieving the pain
of the one with greater suffering and leaving the one less afflicted to go without. For
Singer, the latter choice is ethically preferable since .. .[the] unequal treatment is an
attempt to produce a more egalitarian result.112
For Singer, as noted above, certain principles based upon ideals, such as
equality, should be brought into our calculus of moral decision-making. For the
everday kind of decision aside, what works is the application of intuitive moral
principles...like a good tennis coachs instructions... [which are geared toward
percentage tennis or].. .what will pay off most of the time.113 For the decisions
requiring more reflective or critical thinking to determine whether the actions under
31


consideration will comport with the preferences of those affected, more work is
required. It is in this process, Singer argues, that we can universalize our own
interests to achieve the best outcome for all concerned.114 In this view, an action
consistent with these preferences is right and good, while the contrary action would
be wrong and bad.
Other moral principles in addition to equality deserve consideration according
to Singer, such as those referred to above as being a part of the principalist approach
to bioethics. The further application of preference utilitarianism to bioethical
problems will be more fully discussed below, but when compared to Deweys
method, Singers preference utilitarianism seems single-minded in its approach. As
Stephen Buckle has observed about Singers argument:
The basic sequence of the argument is thus as follows: we begin with a
natural attitude of self-interest; we universalize across all the
individual self-interests in a population, thereby extending our narrow
regard for our own interests into an equal regard for the interests of all.
Our natural desire to get what we desire is thus transformed into the
desire to bring about (as much as possible of) what everyone desires -
whatever they happen to desire, since all desires are equal.115
32


CHAPTER 4
APPLICATION OF PREFERENCE UTILITARIANISM AND CLINICAL
PRAGMATISM TO BIOETHICAL PROBLEMS
The process of decision-making in the bioethical context has been formulated
in a variety of ways by a number of thinkers over the years that bioethics has been
evolving into a separate field of expertise or discipline in the United States.116 One
formulation might be described as who counts', that is, who counts in making the
determination that a bioethical problem has been encountered and who counts in
making the decisions to resolve that problem. Another formulation along the same
lines but in a more dramatic fashion has been proposed: who lives, who dies, who
decidesln%
Whether the more or less dramatic formulation may have appeal, what appears
to be consistent are components within the methods that deal with at least these areas:
(a) determining that a bioethical problem exists; (b) gathering the necessary facts and
circumstances surrounding that problem; (c) gathering together the parties in
interest (including the patient, family, friends, health care professionals and others)
who will be affected by or will be participating in making the decision; (d)
determining the values, interests and preferences (including philosophical positions or
principles, moral views, religious or other beliefs, etc.) of the interested parties; (e)
proposing possible solutions to the problem; (f) examining the consequences of
33


proposed solutions, to the extent that it is possible to determine the same; and (g)
making and implementing one or more of the agreed solutions.
As noted above in Chapter 3, Singers preference utilitarianism would have
those participating in this process use the utilitarian approach as the default
theoretical approach of our ethical thinking. In contrast, Deweys pragmatic
approach to ethical problem-solving does not adopt any single element as the default
theoretical method necessarily predominating the process, even though he certainly
includes the consequences of actions as an important part of the entire method.
Further, Dewey would not limit the values (preferences) to be considered to those
affected by the decision, but takes a broader approach to this part of the review than
does Singer, since Deweys method would allow, for example, consideration of the
values, traditions and beliefs generally held in our society as a part of the decision-
making process. Thus, while Dewey is not bound to any rigid theoretical
commitments to traditional values deeply held by others, he also does not dismiss
them as unimportant in his ethical decision-making method, either.
A further problem arises when relying on preferences, in the way that Singer
does. As he has conceded119, preferences of individuals are only valid benchmarks
for action when those individuals are fully informed or enlightened as to all
possibilities that might be theirs in a socially liberal (or liberated) culture or society.
For example, if in a particular African society where female circumcision (sometimes
referred to as female genital mutilation or FMG in the West) is the norm for young
34


women, a particular young woman prefers stay with the status quo and to follow the
norm and have the procedure done, knowing no better, Singer admits that preferences
such as these are not the informed or enlightened preferences to which he is referring
as being critical to take into account in ethical decision-making. Without imposing
Western values on other cultures, it is difficult to see how Singers universal
approach focusing on preferences would work outside of the Western secular
democracies, where tribal traditions, taboos, rituals or the word of the Imam, Pope,
minister or priest do not govern everyday lives of citizens in a thorough-going and
mandatory way, as may be true elsewhere. Although distinctively American in its
origins, Deweys inclusive approach, which takes into account societys customs and
values (including faith-based or religious ones) could prove to be more universally
useful in other cultures than Singers approach.
Returning to the case of JT, if we were to focus on preferences as Singer
suggests, there appear to be several at stake in that scenario. The scenario does not
tell us much about the preferences of those involved, but perhaps some preferences
can be reasonably inferred from the facts. The physicians preferences may be to
protect the health and safety of JT and to keep intact a positive physician-patient
relationship with him. JT s preferences may be to pass the physical examination, so
he can play sports at school, without having the physician cause any problems
between his parents or problems for his alcoholic father with the authorities. The
mothers preferences may be to avoid conflict in the family and any interaction by the
35


authorities with the family members, especially her husband. Which set of
preferences should have priority so as to trump the others here? In other words, who
counts? In situations such as this, with multiple conflicting preferences, all of which
appear to have some validity, Singer appears to offer little assistance to resolve the
dilemma, because other than a general injunction to weigh the preferences in
accordance with their strengths, little guidance is provided as to how to choose
among the various competing preferences that may be present in a given situation.120
By contrast, Dewey offers us some help in dealing with problematic situations
like this. Since we are not locked in to a single criterion (preferences), we may and
indeed must look at the broader picture. All things considered, what is the best
resolution possible in a problematic situation like JT s? Applying the method of
clinical pragmatism would require a thorough-going review of the facts and
circumstances present, in addition to being mindful of all relevant values, preferences,
etc., along with consideration of the possible consequences of any decision to take
action or not to do so. In JTs case, taking no action could well lead to deadly results
both for the father and for anyone else who happened to be on the streets (or in his car
as a passenger) when he is both intoxicated and driving. The local news reports are
full of tragic examples weekly if not daily of the risks involved of drinking and
driving.
As with taking no action in JTs case, taking any action also may cause harm.
Informing the authorities of the situation may cause disharmony in the home,
36


punishment or loss of driving privileges for the father, distrust of the physician by JT
and other harms easily imagined. Weighing these harms against what could easily be
the greater harm of risk to life, limb and property of continuing to let the father drink
and drive, one might argue that the best course of action here for the physician is to
make the report. While other risks and potential harms remain, like many dilemmas
where there is or appears to be no one solution that fixes all problems and avoids all
risk and harm, at least the most serious risk of harm may be avoided.
Using Deweys method and stepping through the process, the physicians
hypothesis faces one more test: what are the results? Without knowing more from
our scenario, we cannot answer this question, but Deweys experimental method
would require that the question be asked. If a similar case were later encountered by
this physician, or if further opportunity or need for intervention with this family were
to present itself, then the physician could explore other hypotheses and act upon those
in an effort to further mitigate the apparently unavoidable risk and harm that is likely
to occur to JT s family, regardless of which option is chosen for decision and action
here.
37


CHAPTER 5
CONCLUSION
Although the language of science is found throughout Deweys writings, the
better view may be that of an art being practiced. Guided by Dewey, D. Micah
Hester calls our attention to what he calls moral artistry, as follows: rather than
basing an account of moral rationality on principles and rules.. .1 put forth an ethic
based on imaginative, intelligent habits namely, the notion ofmoral artistry.121
Steven Fesmire observes that Dewey views ethics as .. .the art of helping people to
live richer, more responsive, and more emotionally engaged lives.122 Consistent with
this approach, Dewey is critical of applying rules to specific moral problems, rather
than what he calls genuine principles. For Dewey, rules are guidelines that are ready-
made and fixed, practical, formalistic and legalistic, while principles evolve with our
experience and are intellectual, providing a method or scheme forjudging the
appropriate conduct to be followed.123 Along with other factors (virtues, casuistry,
beliefs, care ethics, feminist theory, consequences, etc.), the principles elucidated by
Beauchamp and Childress referred to in Chapter 1 could be among the factors
considered under a thorough-going Deweyan approach in stepping through the
decision-making process. For the reasons discussed above, I contend that Deweys
approach, as embodied in clinical pragmatism, is superior to preference utilitarianism.
38


Deweys approach is superior because, while it does recognize the importance of the
consequences of actions taken in moral decision-making,124 it does not rely on a
single principle, end or good, or solely upon the parochial preferences, interests or
desires of any particular individuals or groups. Also, as compared to preference
utilitarianism, pragmatism does not regard any factor involved in a situation, such as
the consequences of any action taken in response to the situation, to be foundational,
so as to trump all other factors. It is also superior because it is more flexible and
adaptive, thus better suited to resolving the difficult and complex problems these
cases involve and represents the most workable way of including our common moral
heritage in making these important bioethical decisions by health care professionals
acting in concert with, for and by patients and their families. As noted above, this
common moral heritage could include the values inherent in and as expressed by the
principles constituting the Georgetown Mantra referred to above, but would not be
limited to those values alone. Deweys method, then, would allow for a practice of
bioethics to occur in a broadly-based and thoughtful way, which can maintain its
1 'll
own integrity without the support and guidance of fixed and external foundations,
ever seeking better solutions to the bioethical dilemmas that confront us now and in
the future.
39


APPENDIX A
STEP 1
STEP 2
STEP 3
STEP 4
STEPS
STEP 6
STEP 7
STEP 8
PROCESS OF DECISION MAKING TEMPLATE
(University of Colorado Denver \ PRMD 5000)
What are the ethical questions? (Put them in the form of a should
question/s.)
What is your first reaction to this case? (What is your gut telling
you to do on an emotive level?)
What are the clinically relevant facts?
What facts do you need to eather?
What are the values at stake for all of the relevant parties? (Not
just as stated, but the values from the point of analysis Dont just
name the values; tell how they apply. What is/are the conflict(s)
among values?)
What could you do? (List options.)
What should you do? (Make a choice. Include a discussion of how
you would actually do it the process.)
Justify your choice. (Give reasons to support your choice. Refer
back to the values in step 4. Are there any options that shouldnt be
done? Explain. Whey did you choose the options you did? Anticipate
objections to your reasons and respond to them. What do relevant
codes of ethics say? What do your readings say?)
How could this ethical issue have been prevented? (Would any
policies/guidelines/practices be useful in changing any systemic problems?
If this problem could not have been prevented, explain why you think so.)
40


APPENDIX B
CLINICAL PRAGMATISM: A CASE METHOD OF PROBLEM-SOLVING
Fletchers Introduction to Clinical Ethics, 3rd Edition (pp. 340-341) Table A.2.1.
1. Assessment
a. What is the patients medical condition?
i. Identification of medical problems and history
ii. Diagnosis/diagnostic hypotheses
iii. Predictions and uncertainty regarding prognosis (What are the
prospects for full or partial recovery? Is the patient terminally
ill?)
iv. Provisional formulation of goals of treatment and care
v. Treatment recommendations and reasonable alternatives
b. What are the relevant contextual factors?
i. Demographic factors (age, gender, education)
ii. Life situation and lifestyle of patient
iii. Family relationships
iv. Setting of care (home or institution)
v. Socioeconomic factors (such as insurance coverage)
vi. Language spoken
vii. Cultural factors
viii. Religion
c. Is the patient capable of decision making?
i. Legal incompetent (for example, the patient is a child or a court
has determined the patient to be incompetent)
ii. Clearly incapacitated (for example, patient is unconscious)
iii. Diminished capacity (for example, patient is diagnosed with
depression or other mental disorder interfering with
understanding or judgment)
iv. Fluctuating capacity
v. Prospects for enhancing capacity
d. What are the patients preferences?
41


i. Understanding of condition
ii. Views on quality of life
iii. Values relevant to decision making about treatment
iv. Current wishes for treatment
v. Advance directives
vi. Reasons for seeking treatment that is regarded as medically
inappropriate or refusing treatment that is regarded as
medically indicated.
e. What are the needs of the patient as a person?
i. Psychic suffering and possible interventions for relief
ii. Interpersonal dynamics
iii. Resources and strategies for helping patient cope
iv. Adequacy of home environment for care of patient
v. Preparation for dying
f. What are the preferences of family/surrogate decision makers?
i. Competence as surrogate decision maker
ii. Judgment and evidence of relevant patient preferences
iii. Opinions on quality of life of patient
iv. Opinions on best interest of patient
v. Reasons for seeking treatment that is regarded as medically
inappropriate or refusing treatment that is regarded as
medically indicated
g. Are there interests other than, and potentially conflicting with, those of
the patient?
i. Interests of family (for example, concerns about burdens of
caring for patient or disagreements with preferences of patient)
ii. Interest of fetus
iii. Scarce resources and competing needs for their use
iv. Interests of healthcare providers (for example, professional
integrity)
v. Interests of healthcare organization
h. Are there issues of power or conflict in the interactions of the key
actors in the case that need to be addressed?
i. Between clinicians and patient/family
ii. Between patient and family members
iii. Among family members/surrogates
42


iv. Between members of the healthcare team (for example,
between attending physicians and house staff, between
physicians and nurses)
i. Have all the parties involved in the case had an opportunity to be
heard?
j. Are there institutional factors contributing to moral problems posed by
the case?
i. Work routines
ii. Fears of malpractice/defensive medicine/legal problems
iii. Biases favoring disproportionately aggressive treatment or
neglect of treatable conditions
iv. Cost constrains/economic incentives
2. Moral diagnosis
a. Examine how the moral problems in this case are being framed by the
participants. Determine whether this framing should be reconsidered
and replaced by an alternative understanding.
b. Identify and rank the range of relevant moral considerations.
c. Identify any relevant institutional policies pertaining to the case.
d. Consider ethical standards and guidelines, drawing on consensus
statements of commissions or interdisciplinary or specialty groups.
e. Consider similar cases and discussions in the literature that might shed
light on the analysis and resolution of moral problems in the case.
f. Identify the morally acceptable options for resolving the moral
problems posed by the case.
3. Goal setting, decision making, and implementation
a. Consider or reconsider and negotiate the goals of treatment and care
for the patient
b. Consider ideas (hypotheses) for possible intervention to meet the
needs of the patient and resolve moral problems.
c. Deliberate regarding merits of alternative options for resolving the
moral problems.
d. Endeavor to resolve conflicts.
e. Assess whether ethics consultation is necessary or desirable.
43


i. Is there persistent conflict between clinicians and
patients/surrogates or among clinicians regarding how to
resolve the moral problems posed by the case?
ii. Would ethics advice be helpful in understanding or providing
guidance on moral issues presented by the case?
f. Negotiate acceptable plan of action.
g. If negotiation, including ethics consultation, fails to achieve
satisfactory resolution, consider judicial review.
h. Implement plan of action.
4. Evaluation
a. Current evaluation
i. Is the plan of action working? If not, why not?
ii. Do the observed results of implementing the plan indicate the
need for a modification of the plan?
iii. Have conditions changed in a way that suggest the need to
rethink the plan?
iv. Are interactions between clinicians and the patient or surrogate
helping to meet the needs of the patient, to respect the patient
as a person, and to serve the goals of the plan of care?
v. Are there relevant interests, institutional factors, or normative
considerations that have not been adequately addressed in
planning for the care of the patient?
b. Retrospective evaluation
i. What opportunities for resolving the moral problem were
missed?
ii. How did the care received by the patient match up to standards
of good practice?
iii. What factors contributed to a less than optimal resolution of the
problems posed by the case?
iv. Was the process of problem solving satisfactory in this case?
v. What might have been done to improve the care of the patient?
vi. Are there desirable changes in institutional policy, feasible
changes in the clinical environment, or educational
interventions that might help to prevent or resolve the moral
problems posed by similar cases?
44


APPENDIX C
WASHINGTON HOSPITAL CENTERS CHECKLIST
Washington Hospital Center's ethics checklist
Washington
Hospital Center
Add relevant ethical issues to progress notes and report on rounds
Patients wishes unclear/refusal of treatment
Questionable capacity to consent to, or refuse, treatment
Disagreement involving relatives/surrogates/caregivers
End-of-life (adv dir/POA, DNR/AND, withdraw/withhold Rx)
Goal of care clarification/appropiiateness of current treatment
Confidentiality/disclosure
Resource or fairness issue
Other (please note)
No notable ethical issues
For a consult Center for Ethics, 202-877-0246 (ph), 6050 or 8529 (pagers)
Sokol, D. K BMJ 2009;338:b879
Copyright 2009 BMJ Publishing Group Ltd.
45


APPENDIX D
THE FOUR TOPICS CHART FOR CASE ANALYSIS
Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, 6th Edition (pp. 11,
223).
Medical Indications
The Principles of Beneficence and Nonmaleficence
1. What is the patients medical problem? History? Diagnosis? Prognosis?
2. Is the problem acute? Chronic? Critical? Emergent? Reversible?
3. What are the goals of treatment?
4. What are the probabilities of success?
5. What are the plans in case of therapeutic failure?
6. In sum, how can this patient be benefited by medical and nursing care, and
how can harm be avoided?
Patient Preferences
The Principle of Respect for Autonomy
1. Is the patient mentally capable and legally competent? Is there evidence of
incapacity?
2. If competent, what is the patient stating about preferences for treatment?
3. Has the patient been informed of benefits and risks, understood this
information, and given consent?
4. If incapacitated, who is the appropriate surrogate? Is the surrogate using
appropriate standards for decision making?
5. Has the patient expressed prior preferences, e.g., Advance Directives?
6. Is the patient unwilling or unable to cooperate with medical treatment? If so,
why?
7. In sum, is the patients right to choose being respected to the extent possible
in ethics and law?
Quality of Life
The Principles of Beneficence and Nonmaleficence and Respect for Autonomy
46


1. What are the prospects, with or without treatment, for a return to normal life?
2. What physical, mental, and social deficits is the patient likely to experience if
treatment succeeds?
3. Are there biases that might prejudice the providers evaluation of the patients
quality of life?
4. Is the patients present or future condition such that his or her continued life
might be judged undesirable?
5. Is there any plan and rationale to forgo treatment?
6. Are there plans for comfort and palliative care?
Contextual Features
The Principles of Loyalty and Fairness
1. Are there family issues that might influence treatment decisions?
2. Are there provider (physicians and nurses) issues that might influence
treatment decisions?
3. Are there financial and economic factors?
4. Are there religious or cultural factors?
5. Are there limits on confidentiality?
6. Are there problems of allocation of resources?
7. How does the law affect treatment decisions?
8. Is clinical research or teaching involved?
9. Is there any conflict of interest on the part of the providers or the institution?
47


NOTES
1. Joseph J. Fins, Matthew D. Bacchetta and Franklin G. Miller, Clinical
Pragmatism: A Method of Moral Problem Solving, in Pragmatic Bioethics,
2nd ed., Glenn McCree, Ed., The MIT Press, Cambridge, MA (2003), pp. 29-
44.
2. David H. Brendel, Healing Psychiatry: Bridging the Science/Humanism
Divide, The MIT Press, Cambridge, MA (2006).
3. John Dewey, Three Independent Factors in Morals in The Essential Dewey,
Volume 2, Larry A. Hickman and Thomas M. Alexander, Eds., Indiana
University Press, Bloomington, IN (1998), pp. 315-320.
4. Peter Singer, Practical Ethics, 2nd Edition, Cambridge University Press,
Cambridge (1993).
5. Singer, Practical Ethics, p. 14.
6. Stephen Buckle, Peter Singers Argument for Utilitarianism, Theoretical
Medicine and Bioethics, Vol. 26, No. 3, pp. 175-194 (2005).
7. Jacqueline Glover, et al., Facilitators Handbook for PRMD 5000 (Ethics in
the Health Professions), University of Colorado Denver (2005-2008). Also
see Albert R. Jonsen, Mark Siegler and William J. Winslade, Clinical Ethics:
A Practical Approach to Ethical Decisions in Clinical Medicine, 6th Edition,
McGraw-Hill Medical Publishing Division, New York (2006); Jacqueline
Glover, Ethical Decision-Making Guidelines and Tools in Ethical
Challenges in the Management of Health Information, 2nd Ed., Jones and
Bartlett Publishers, Sudbury, MA (2006); and Deborah Bennett-Woods,
Ethical Decision Models, Regis University (2005).
8. Edward M. Spencer, A Case Method for Consideration of Moral Problems,
in Fletchers Introduction to Clinical Ethics, 3rd Edition, John C. Fletcher,
Edward M. Spencer and Paul A. Lombardo, Eds., University Publishing
Group, Inc., Hagerstown, MD (2005), pp. 339-347 (Appendix 2); Fiona
Godlee, Ethics Checklists and Sharing Patients Information, British
48


Medical Journal, 338:b913 (March 7, 2009); Albert R. Jonsen, Mark Siegler
and William J. Winslade, Clinical Ethics: A Practical Approach to Ethical
Decisions in Clinical Medicine, 6th Edition, McGraw Hill Medical Publishing
Division, New York (2006), p. 223.
9. Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics,
6th Edition, Oxford University Press, New York (2009).
10. Deborah Bennett-Woods, Ethics at a Glance, Regis University (2005), p. 2
11. As Deborah Bennett-Woods has observed: Although very influential in
contemporary bioethics, principalism has been widely criticized on several
counts. For example, because principalist approaches are not rooted in
particular overarching values, there is no widely accepted standard for
resolving the inevitable conflicts between principles. Individual principles
may be interpreted or weighted differently by different individuals or may not
accurately represent particular cultural viewpoints and assumptions. In fact,
there is no common agreement on exactly what principles are morally relevant
and to what extent some principles are more or less foundational to other
principles. Finally, critics contend that principalist approaches fail to consider
important aspects of character and virtue -based approaches or relational
approaches such as care ethics. Bennett-Woods, Ethics, p. 6. Bonnie
Steinbock has also raised concerns about the principalist approach. She
observes: Principalism has been criticized by casuists, feminists, partisans of
narrative ethics, and pragmatists as too abstract, deductive and top down; as
being insufficiently attentive to particulars, relationships, storytelling and
process. Bonnie Steinbock, Introduction in The Oxford Handbook of
Bioethics, Bonnie Steinbock, Ed., Oxford University Press, Oxford, (2007), p.
4. D. Micah Hester has also been critical of the principalist approach because,
among other things, he maintains that this approach allows no role for context.
He has observed: [I] suggest.. .that the arguments they [Beauchamp and
Childress] develop give us vacuous principles that are in practice useless for
moral medicine.. .[they] make the move from considered judgments up to
principles and then throw away the ladder, claiming that they have found the
starting point for investigation clearly implied by our experienced judgments
in the first place. D. Micah Hester, Community as Healing: Pragmatist
Ethics in Medical Encounters, Rowman & Littlefield Publishers, Inc.,
Lanham, MD (2001), pp. viii, 24.
49


12. Margaret Olivia Little, Lecture, Introduction to Bioethics, Intensive
Bioethics Course, Georgetown University, Kennedy Institute of Ethics (June
4, 2007).
13. Bennett-Woods, Ethics, p. 2.
14 .Ibid.
15. Ibid. There is a danger in describing bioethics too narrowly as applied ethics.
As Janies F. Childress has observed: Early bioethics, in the 1970s, was often
viewed as a species of applied ethics; bioethics denoted the reflective
activity of applying an ethical theory or ethical principles to the domains of
the biological sciences, medicine and healthcare. The language of applied
ethics implies more action guidance from theory or principles than is usually
available, and it has been now been largely discarded in favor of the language
of practical ethics.. .not all methods for addressing moral problems entail
applying, in a deductivist fashion, ethical theories, frameworks, or
perspectives. James F. Childress, Methods in Bioethics in The Oxford
Handbook of Bioethics, Bonnie Steinbock, Ed., Oxford University Press,
Oxford, (2007), pp. 15-16.
16. Ibid.
17. Van Rensselaer Potter, Bioethics: Bridge to the Future, Prentice-Hall, Inc.,
Englewood Cliffs, NJ (1971).
18. Ibid. p. v.
19. Ibid. Recent scholarship suggests that the interest in the ecological aspects of
Potters vision have not been entirely forgotten, however. See, e.g., David
Magnus, The Green Revolution in Bioethics, The American Journal of
Bioethics, Vol. 8, No. 8, pp. 1-2 (2008).
20. Hester, Community. Hester describes his effort as an attempt to reconceive
physician-patient relationships in light of a pragmatic understanding of moral
intelligence and artistry performed by socially situated selves that develop into
and arise out of community as healing. Ibid. p. 5.
21. Potter, Bioethics, p. vii.
50


22. James F. Childress also uses the concept of a bridge, but in another context.
He observes: The authors understand clinical ethics as a bridge between
theoretical bioethics and the bedside. Ideas move both ways on the bridge-
not merely from theorists to practitioners, but also from practitioners to
theorists. In this process, both activities are enriched. James F. Childress,
Forward in Fletchers Introduction to Clinical Ethics, 3rd Edition, John C.
Fletcher, Edward M. Spencer and Paul A. Lombardo, Eds., University
Publishing Group, Inc., Hagerstown, MD (2005), p. v.
23. Potter, Bioethics, p. 2.
24. Ibid.
25. Ibid. p. vii.
26. Singer, Practical Ethics, p. 2.
27. Albert R. Jonsen, A History of Bioethics as Discipline and Discourse, in
Bioethics: An Introduction to the History, Methods and Practice, Nancy S.
Jecker, Albert R. Jonsen and Robert A Pearlman, Eds., Jones and Bartlett
Publishers, Sudbury, MA (2007), p. 3.
28. Ibid.
29. Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics,
2nd Edition, Oxford University Press, New York (1983), pp. ix-x.
30. Deborah Bennett-Woods, Health Care Ethics Glossary, Regis University
(2006).
31. Stephen G. Post, Ed., Encyclopedia of Bioethics, volume 1, 3rd Edition,
Macmillan Reference USA, New York (2004), p. 278.
32. Ibid. pp. 278-279.
33. Roger B. Dworkin, Limits: The Role of the Law in Bioethical Decision
Making, Indiana University Press, Bloomington, IN (1996). Dworkins
thoughtful consideration of these matters is worthy of further study. He states
his case forcefully, as follows, at p. 2:
51


These developments [new medical technologies and social changes]
and others force us to pay careful attention to ethics, the branch of
philosophy directed at developing moral principles and modes of
moral reasoning. Courses in medical ethics are now common in
medical and other health professional schools, and even at the
undergraduate level. The literature about bioethics is enormous, and
the number of centers devoted to its study grows steadily. This is
hardly surprising. Careful and rigorous thought rooted in the wisdom
of the ages seems a sensible approach for coming to grips with the
tormenting issues posed by biomedical advance.
But careful thinking is hard and often does not point clearly in one
direction. People are impatient; they want to know the right thing to
do right now. If they are doctors, patients, or family members, their
desire for quick, clear answers is easy to appreciate. A doctor who
needs to decide today whether to accede to the wishes of a twenty-
five-year-old quadriplegic to cease artificial feeding will want some
firmer, faster basis for decision than a seminar on Aristotle, Plato,
Mill, Kant and Rawls.
Partly because of the desire for speedy, certain answers; partly because
of a popular lack of understanding of the relationship between law and
ethics; partly because of ignorance about law and the legal system; and
partly because of the belief that law is magic, concern for medical
ethics has often become a plea for medical law. Thus law exists about
death and dying, organ transplants, genetic counseling and screening,
reproductive technologies, etc., and more law is made about these
subjects every day. The law is asked and often tries to resolve
questions of medical ethics.
This is not improper. Real questions about real people and about
public policy are posed by biomedical developments. Real
disagreements exist. The law is a primary vehicle for resolving
disagreements about public policy and the treatment of real persons.
To suggest that the law has no role to play in the area of biomedical
advance would be both stupid and unrealistic. Yet blind faith in the
laws ability to resolve bioethical problems or unthinking acquiescence
in the dominant role of the law would be equally unsound. Much of
the law that exists today is ill advised.
52


34. James F. Drane, Clinical Bioethics: Theory and Practice in Clinical Decision-
Making, Sheed & Ward, Kansas City, MO (1994), p. xv; Hester, Community,
p. viii. As Frederic W. Platt, et al., have observed concerning the primacy of
clinical encounter: Patients want their physicians to listen to them, to
understand their concerns, to help them understand what is happening to their
bodies, to reassure them, and to help them heal.. .Shared decision-making
requires the clinician to know the biological facts and probabilities; elicit and
understand the patients ideas, feelings and values; discover how much
involvement the patient wants in the decision-making process; give
information that will be useful to the patient in making decisions; and share
power and influence. Frederic W. Platt and Geoffrey H. Gordon, Field
Guide to the Difficult Patient Interview, 2nd Edition, Lippincott, Williams &
Wilkins, Philadelphia, PA (2004), pp. xv, 106.
35. John C. Fletcher and Edward M. Spencer, Clinical Ethics: History, Content
and Resources in Fletchers Introduction to Clinical Ethics, 3rd Edition, John
C. Fletcher, Edward M. Spencer and Paul A. Lombardo, Eds., University
Publishing Group, Inc., Hagerstown, MD (2005), p 3. As Philip C. Hebert has
observed: Ethics is about right and wrong and the reasons that we give for
our choices and actions. This is clearly central to medicine, since doing the
right thing for ones patients minimizing suffering and treating illness has
not only factual but also a moral dimension. Clinical ethics.. ..is concerned
with moral problems arising out of the care of patients. One must often make
decisions that go beyond the facts to hand. Such decisions are ethical in that
[they] appeal to what one may do, should do or ought to do." Philip C.
Hebert, Doing Right: A Practical Guide to Ethics for Physicians and Medical
Trainees, Oxford University Press, Toronto (1996), p. 1.
36. Ibid. p. 4.
37. Robert M. Veatch, Amy M. Hadad and Dan C. English, Case Studies in
Biomedical Ethics, Oxford University Press, New York (2010), p. 3. As
Veatch, et al., have observed: If ethical conflict is serious enough, it will be
necessary to address, at least implicitly, all four of the fundamental questions
of ethics: (1) What are the source, meaning and justification of ethical
claims?; (2) What kinds of acts are right?; (3) How do rules apply to specific
situations?; and (4) What ought to be done in specific situations? Ibid. p. 4.
38. Hebert, Doing Right, p. 2. Hebert further observes: Clinical ethics is
different from ethics as a philosophical discipline.. .At the end of the
encounter with the patient, no matter what the uncertainties, one must have
53


some plan of action. Ibid. Hebert concurs with Dworkins concerns noted
above about the limits of applying the law to bioethical problems. As he
observes: What the law has to say should not be a discussion stopper.
Medicine is about doing what is best for patients, while the law has larger
social interests to serve. Thus, the law cannot always have the last word about
medical morality. Ibid.
39. Darnell Rucker, The Chicago Pragmatists, University of Minnesota Press,
Minneapolis (1969), p. v. Jonathan D. Moreno has observed that: the social
institution of bioethics has an undeniably American flavor and that bioethics
is mainly an American field in its origins and.. .in its style.. .bioethics
emphasizes themes such as moral authority and pluralism and.. .is consensus
oriented. Jonathan D. Moreno, Is There an Ethicist in the House? On the
Cutting Edge of Bioethics, Indiana University Press, Bloomington, IN (2005),
pp. 51-52. Like Rucker, Joseph L. Blau makes note of pragmatisms
American roots. He observes: Of all the philosophies we discuss here,
pragmatism has seemed to many to be the most distinctively American in its
outlook.. .the American philosopher, however academic his philosophy, has
been no academic recluse. He has a familiarity with the farm, the factory, and
the marketplace which is bred of the associations of his life, and not gained
solely from the reading of books.. .they [are].. .reflecting in their philosophies
the interpenetration of practice and theory. Joseph L. Blau, Men and
Movements in American Philosophy, Prentice-Hall, Inc., Englewood Cliffs,
NJ (1958), pp. 228-229.
40. Pragmatism in Adventures in Philosophy (American Philosophy),
http://www.radicalacademy.com/amphilosohv7a.htm (accessed October 7,
2008).
41. Jeffrey Weiss, Ethical Questions Exist in Everyday Life, Times Picayune
(January 2,1999).
42. William James. The Sentiment of Rationality and Some Hegelisms in The
Will to Believe and Other Essays in Popular Philosophy, Longmans, Green
and Co., London (1898), pp. 77-78, 270.
43. William James, The Will to Believe in American Ethics: A Source Book
from Edwards to Dewey, G. W. Stroh and H. G. Callaway, Eds., University
Press of America, Lanham, MD (2000), p. 275.
54


44. Richard Field, John Dewey in Internet Encyclopedia of Philosophy,
www.iep.utm.edu/d/dewev.htm (accessed October 7, 2008).
45. Ibid.
46. One possibility for a better description of the art of health care practice is
Aristotles practical reason, a usage urged by Kathryn Montgomery in How
Doctors Think, Oxford University Press, Oxford (2006).
47. Fins, et ah, Clinical Pragmatism, p. 29. Wayne Sheltons description of
pragmatic ethics include this observation: Pragmatic ethics begins with the
reality of lived experience of human beings, who are connected biologically,
socially and politically within a natural environment. Thus, the moral life is
connected to the conditions that best foster human flourishing and reduce
suffering. Right and good are the ends of moral inquiry, not assumptions
grounded in normative religion or philosophical theory. Many have taken this
approach as a step toward moral relativism and crisis of value. But
pragmatists believe the turn toward naturalism is the occasion to fully grasp
the vital role of human beings in shaping their own fate, and promoting a
better society. Human beings highest aspirations justice, peace and
alleviation of suffering lie in the enhancement of human intelligence and
forms of inquiry that allows humans to better understand how to craft a better
future for everyone. Wayne Shelton, The Role of Empirical Data in
Bioethics: A Philosophers View in Empirical Methods for Bioethics: A
Primer, Liva Jacoby and Laura A. Siminoff, Eds., Elsevier-JAI Press, Oxford
(2008), p.15.
48. Glover, et al., Facilitators Handbook, pp. 30-32.
49. Gregory F. Pappas, Deweys Ethics: Morality as Experience in Reading
Dewey Interpretations for a Postmodern Generation, Larry A. Hickman,
Ed., Indiana University Press, Bloomington, IN (1998), p. 108. Also see
Charles Morris, The Pragmatic Movement in American Philosophy, George
Braziller, New York (1970), p. 92. Jonathan D. Moreno supports the notion
that the pragmatic method is a naturalism and as including a rejection of
dualisms. He has observed: when faced with a concrete dilemma, moral or
otherwise, people do not consult theory, but they apply themselves to the
problem.. .[which] includes application of what one knows about general
rules, but.. .also.. .applications of ones experience with previous similar
problems as well as judgment, intuition, temperament and gut feelings.
Moreno, Ethicist, p. 59.
55


50. John Dewey, Reconstruction in Moral Conceptions in American Ethics: A
Source Book from Edwards to Dewey, G.W. Stroh and H.G. Callaway, Eds.,
University Press of America, Inc., Lanham, MD (2000), pp. 436-447; Pappas,
Deweys Ethics, p. 102. As Dewey has observed: A physician has to
determine the value of various courses of action and their results in the care of
a particular patient. He forms ends-in-view having the value that justify their
adoption, on the ground of what his examination discloses is the matter or
trouble with the patient. He estimates the worth of what he undertakes on
the ground of its capacity to produce a condition in which the trouble will not
exist, in which, as it is ordinarily put, the patient will be restored to health.
He does not have an idea of health as an absolute end-in-itself.. .On the
contrary, he forms his general idea of health as an end and a good (value) for
the patient on the ground of what his techniques of examination have shown
to be the troubles from which patients suffer and the means by which they are
overcome. John Dewey, Theory of Valuation, University of Chicago Press,
Chicago (1939), p. 46.
51. Dewey, Reconstruction, p. 436.
52. Ibid.
53. Dewey, Three Factors, pp. 315-320. In an earlier work, Dewey argued that
The completest possible interaction of an impulse with all other experiences,
or the completest possible relation of an impulse to the whole self constitutes
the predicate, or moral value, of an act. John Dewey, Study of Ethics, A
Syllabus, The Inland Press (1897) (Reprint by Kessinger Publishing Co.),
p.22. Combining this thought with what I understand Dewey to be saying in
Three Factors it appears that unless all the three factors are brought to bear
and considered by the intellect, the resulting judgment will be flawed as not
complete. As Fesmire observes in John Dewey, p. 57, Plainly, seeing any
of these situations through the lens of one factor as a matter of duty not
virtue, or rights not consequences, and so on relegates other factors that
require coordination. The pragmatic pluralist refuses to play the winner-take-
all game.. .To spotlight only one of these questions risks bringing inquiry to a
premature close. Tunneled perception inhibits deliberation at least as much as
it helpfully focuses it.. .on the view that there are plural primary factors in
moral situations, the role of moral philosophy shifts. It functions not to
provide a moral bedrock, but to clarify, interpret, evaluate and redirect our
natural and social interactions.
56


54. Dewey, Three Factors, p. 315.
55. Ibid.
56. Ibid. p. 316.
57. Ibid.
58. Ibid.
59. Ibid.
60. Ibid.
61. Ibid.
62. Ibid.
63. Ibid.
64. Dewey, Three Factors, p. 316. Steven Fesmire, John Dewey & Moral
Imagination Pragmatism in Ethics, Indiana University Press, Bloomington,
IN (2003), pp. 56-61, contains an elaboration on this topic, arguing for the
primacy of imagination as follows: Others, including.. .Dewey.. .favor a
radically reconstructed conception of ethics that entreats people to attend
more fully to the concrete elements entering into the situations in which they
have to act. What is needed, Dewey urged, is to reject the quest for a single,
fixed and final good and transfer the weight and burden of morality to
intelligence, with the aim of ameliorating the muddles of moral life. In
Three Independent Factors in Morals, Dewey argues that ethical theorists
should cease asking which principle is the ultimate and unitary one and
attempt instead to reconcile inherent conflicts between irreducible forces that
characterize all situations of moral uncertainty. He identifies three such forces
that need to be coordinated: individual ends (the origin of consequentialist
ethics), the demands of communal life (the origin of theories of duty and
justice in deontological ethics), and social approbation (the principal factor in
virtue theories). The preference for three primary factors may be an aesthetic
one for Dewey, and he knowingly exaggerates differences among the three.
What is more interesting is his idea that moral philosophers have abstracted
one or another factor of moral life as the central one and then treated this as a
foundational source of moral justification to which all morality is reducible.
57


Other factors are encompassed within this nexus of commensurability. Hence,
ethical theories are categorized according to their chosen bottom line.
65. Dewey, Three Factors, p. 319.
66. Blau, Men, p 350.
67. Ibid. p. 351.
68. John Dewey, The Construction of Good in The Moral Writings of John
Dewey, James Gouinlock, Ed., Haftier Press, New York (1976), p. 150.
69. Ibid. p. 147.
70. Blau, Men, pp. 350-352.
71. Dewey, Reconstruction, p. 436.
72. Ibid. pp. 163-164. As more fully discussed below, in addition to rejecting any
characterization of Dewey as a utilitarian or as a virtue ethicist, Pappas
criticizes the notion that Dewey proposes any single end, whether described
as growth, flourishing or the like.
73. Ibid. p. 168.
74. Ibid
75. Ibid p. 164.
76. Fesmire, John Dewey, p. 92. As Cheryl Misak has observed: that is, as
Peirce and Dewey stressed, we are always immersed in a context of inquiry,
where the decision to be made is a decision about to believe from here, not
what to believe were we to start from scratch from certain infallible
foundations. Cheryl Misak, New Pragmatists, Clarendon Press, Oxford
(2007), p. 3.
77. Bennett-Woods, Ethics, p. 22-23. Some general criticisms of a utilitarian
approach, as formulated by Raymond S. Edge, et al., are as follows:
1. The calculation of all the possible consequences of our actions, or worse
yet or inactions, appears impossible; 2. Utilitarianism may be used to sanction
unfairness and the violations of rights. In order to maximize one persons or
58


one groups happiness, it may be necessary to infringe on the happiness of
another individual or group; 3. Utilitarianism is not sensitive to the agent-
relativity of duty. We are inclined to think that parents are obligated to care
for their children, and that physicians are wrong to harm patients. Both of
these examples could be allowed under utilitarianism, if doing so maximized
overall utility; 4. Utilitarianism does not seem to give enough respect to
persons. Under this theory, the ends justify the means, so it may be moral to
use a person merely as a means to our ends; 5. Under utilitarianism, it is
justifiable to prevent others from doing what we believe to be harmful acts to
themselves. Such a paternalistic view could justify unacceptable
governmental intervention into the private lives of individuals; and 6.
Utilitarianism alone does not provide a basis for our own moral attitudes and
presuppositions. If followed, utilitarianism may recommend behaviors that
are in conflict with personal fundamental moral beliefs and give rise to a sense
of loss of self. Raymond S. Edge and John Randall Groves, Ethics of Health
Care: A Guide for Clinical Practice, Delmar Publishers, Albany, NY (1999),
pp. 22-23. Lawrence M. Hinman has weighed in on the use of preferences as
the highest good in utilitarianism. As he has observed, Preference
satisfaction is more measurable [than, say, happiness], but it provides no
foundation to distinguish between morally acceptable preferences and morally
objectionable preferences, such as racism. Lawrence M. Hinman,
Contemporary Moral Issues: Diversity and Consensus, 2nd Edition, Prentice-
Hall, Inc., Englewood Cliffs, NJ (2000), p. 6.
78. Peter Singer, Practical Ethics, Second Edition, Cambridge University Press,
Cambridge (1993), p. vii.
79. Ibid. p. 5.
80. Julian Baggini, Defending Consumerist Ethics: an interview with Peter
Singer, The Philosophers Magazine Online,
http://www.philosophersnet.com/magazine/article.php?id=75&el=true
(accessed March 4,2009).
81. Singer, Practical Ethics, p. vii.
82. Ibid. pp. vii-viii.
83. Ibid.
84. Ibid. p. x.
59


85. Ibid.
86. Ibid.
87. Ibid. p. xi.
88. Ibid. p. 1
89. Ibid.
90. Ibid.
91. Ibid. p. 2
92. Ibid.
93. Ibid.
94. Ibid.
95. Ibid. p. 3
96. Ibid. pp. 1-15.
97. Ibid. p. 7.
98. Ibid. pp. 7-8.
99. Ibid. p. 8.
100. Ibid. p. 10.
101. Ibid
102. Ibid. p. 11
103. Ibid. p. 12.
104. Ibid. pp. 11-12.
60


105. Ibid. p. 13.
106. Ibid. p. 14.
101. Ibid.
108. Ibid.
109. Ibid. pp. 16-21.
110. Ibid. pp. 23-24.
Ill .Ibid. p. 93.
112. Ibid. p. 94 Robert M. Veatch, et al., raise the question of a conflict
between the utilitarian view and that arising from the Hippocratic tradition in
medicine. As they have observed: Problems arise from tension between
classic utilitarianism (which counts benefit to all in society equally) and
traditional, or Hippocratic, health care ethics. Hippocratic ethics.. .focuses on
the individual patient and sometimes give special weight to avoiding harm
through the prescriptive duty of advocacy. Veatch, et al., Case Studies, p.
11. James F. Drane emphasizes the importance of Hippocratic tradition when
he observes since Hippocrates, the cornerstone of ethical practice has been,
Do what benefits the patient (positive form) or Do no harm (negative
form). Assessing the risks and benefits of every intervention, then, is at the
heart of medical ethics. Drane, Clinical Bioethics, p. 26.
113. Ibid.
114. Ibid.
115. Buckle, Stephen, Peter Singers Argument for Utilitarianism,
Theoretical Medicine and Bioethics, Vol. 26, No. 3 (2005), p. 178. Dewey
does not embrace the equality of desires or interests, either. As he has
observed: That all interests stand on the same footing with respect to their
function as valuations is contradicted by observation of the most ordinary of
everyday experiences. It may be said that an interest in burglary and its fruits
confers value upon certain objects. But the valuations of the burglar and the
policeman are not identical, any more than the interest in the fruits of
productive work institutes the same value as does the interest of the burglar in
61


pursuing his calling as is evident in the action of a judge when stolen goods
are brought before him for disposition. Dewey, Valuation, p. 19.
116. The literature seems to be divided on whether bioethics is such a field or
discipline or can even aspire to that status. See, e.g., Christopher Crowley, A
New Rejection of Moral Expertise, Medicine, Health Care and Philosophy,
no. 8, pp. 273-229 (2005).
117. This formulation was provided to me in discussions with Kimberly K.
Garchar, Assistant Professor, Department of Philosophy, Kent State
University. As Robert M. Veatch, et al, have observed: Having learned to
recognize the difference between the factual and evaluative dimensions of a
case in health care ethics, one will constantly encounter the problem of who
ought to decide..Veatch, et al, Case Studies, p. 7 (emphasis added).
118. Linda Jacobs Altman, Bioethics: Who lives, Who Dies and Who Decides,
Enslow Publishers, Inc., Berkeley Heights, NJ (2006). As Altman has
observed: Ethics, bioethics included, is not an exact science. It evolves along
with social institutions, as a way of ordering human relationships.. .ethical
codes do not exist to create perfection; they exist to provide grounding and
guidance in the face of new challenges. Ibid. p. 98.
119. Baggini, Defending.
120. Peter Singer, Peter Singer A Philosophical Self Portrait, in The
Penguin Dictionary of Philosophy, 2nd Edition, Thomas Mautner, Ed.,
Penguin Books, London (2005), pp. 572-573.
121. Hester, Community, p. 5.
122. Fesmire, John Dewey, p. 92
123. John Dewey, Moral Judgment and Knowledge in The Essential
Dewey, Volume 2, Larry A. Hickman and Thomas M. Alexander, Eds.,
Indiana University Press, Bloomington, IN (1998), p. 336.
124. Although one might disagree with classifying Deweys work in this way,
some commentators have described Dewey as promoting a broad
consequentialism. See, e.g., James Campbell, Understanding Dewey, Open
Court, Chicago and LaSalle, IL (1996). Here, Campbell observes that: He
[Dewey] offers a broad consequentialism, evaluating actions by their effects
62


upon the common welfare, the general well-being and defending growth as
the criterion for evaluating the effects. Ibid. pp. 111-112. Others have
referred to American pragmatism as a somewhat rebellious offspring of this
[consequentialist] view. Harvey Cormier, Consequentialism in American
Philosophy: An Encyclopedia, John Lachs and Robert Talisse, Eds.
Routledge, New York (2008), p. 129. Despite this offspring assertion,
Cormier later distinguishes pragmatism and consequentialism as follows:
there is a telling difference between pragmatism and other
consequentialisms.. .utilitarianism and other moral views like it are
foundational philosophical theories. They all send us out in pursuit of final
goals the value of which is known and fixed in advance. Pragmatism, by
contrast, promotes pursuit of particular consequences, but not any particular
consequences.. .Dewey used this [approach].. .to promote indefinitely
continuing education [and] increasing development of the capacities of
individuals. Ibid. p. 130.
125. As Judith Andre has observed: keeping utilitarianism in mind, people
asked what happiness or suffering would result if we allotted a scarce life-
saving technology.. .according to criteria of social worth, choosing, say, the
mother of six over the town drunk. Questions like these are
enlightening.. .only a convinced utilitarian would take this line of inquiry as
final, but almost everyone else thinks that questions about consequences,
about happiness and suffering, are important parts of ethical inquiry. Judith
Andre, Bioethics as Practice, University of North Carolina Press, Chapel Hill,
NC (2002), p. 63 (emphasis added). As James F. Drane has observed: as a
vision of ethical right and wrong, it [utilitarianism] is open to criticism, and is
roundly criticized, especially when it presumes to be the only theory. Drane,
Clinical Bioethics, p. 26. Steven Fesmire reminds us that: Dewey sharply
criticizes utilitarians for separating means from ends and privileging cold
calculation over imagination.. .Dewey esteems utilitarianisms naturalism and
respect for social consequences, but he decries the attempt.. .to reduce all
moral judgments to calculating future profit and loss of an antecedently fixed
end, generally conceived as pleasure. Fesmire, John Dewey, pp. 75-76.
126. As articulated by James F. Drane, John Dewey, the father of American
Pragmatism (1859-1952) applied the methods of science to the problems of
ethics. He believed that ethics and other humanistic disciplines made little
progress because the use outmoded technologies, while the better technologies
of inquiry are used to understand the physical world. The problem of
restoring integration and cooperation between a man's beliefs about the world
in which he lives and his beliefs about the values and purposes that should
63


direct his conduct is the deepest problem of modem life. Drane, Clinical
Bioethics, pp. 38-39.
127. Gregory Fernando Pappas, Dewey, John: Ethics in American
Philosophy: An Encyclopedia, John Lachs and Robert Talisse, Eds.
Routledge, New York (2008), p. 182.
64


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