## 1. What is Moral Theory? What is Bioethics?



The question of the relation between moral theory and bioethics is
made difficult by a number of factors, not the least of which is the
absence of any one account of what constitutes philosophical theory.
There are, of course, the standard moral theories of introduction to
moral philosophy--consequentialism, deontology, and virtue
ethics. And we also speak of mid-level theories, such as moral
principlism and casuistry, though the extent to which such approaches
are strictly speaking theoretical is somewhat unsettled. What do we
mean by moral theory? What characterizes an approach to moral
philosophy and bioethics as theoretical? Add to such questions the
fact that bioethics itself is not a monolithic discipline, and our
topic is complicated right from the start.


### 1.1 Varying Accounts of Moral Theory



On some accounts, a theoretical approach to a philosophical issue or
problem is defined by intellectual tendencies toward some combination
of generalization, universality, systemization, abstraction,
explicitness, and the capability to generate recommendations. For
instance, Martha Nussbaum holds that there are certain necessary and
sufficient criteria for ethical theory (Nussbaum 2000: 234-236).
On her view, ethical theory:


* Gives recommendations about practical problems;
* Shows how to test correctness of beliefs, rules, and
principles;
* Systematizes and extends beliefs;
* Has some degree of abstractness and generality;
* Is universalizable;
* Is explicit.



Generalization, universality, and abstraction are also taken by others
to be hallmarks of moral theory (Arras 1997: 74; 2003; Louden 1990).
Even so, some philosophical approaches to moral and bioethical
questions that do not satisfy all or even any of the criteria set out
above are referred to as theories. For instance, moral particularism,
which aspires neither to the formulation of generalizations nor to
systemization
 [2]
 is sometimes referred to as a moral
 theory.[3]
 Further still, one might even hold that beyond the criteria listed
above, moral theory employs a certain argumentative mode, with a
certain tone and style (Louden 1992: 156; Nussbaum 2000: 239).



There is more one could say here on agreement and disagreement on what
counts as theoretical within philosophy, including something about
what might qualify as an anti-theoretical approach to morality and
bioethics (Clarke 1987; Clarke & Simpson 1989; Fotion 2014; Louden
1990). But our main point for the moment is that what counts as moral
theory is not perfectly clear, which complicates the question of the
relation between moral theory and bioethics. We need not here
stipulate one definition of what we shall count as a theoretical
approach to bioethical problems moving forward. Suffice it to say that
the question of the relation between theory and bioethics will be
approached by canvassing various methodological approaches to treating
problems and questions in bioethics.


### 1.2 The Pursuits of Bioethics



Turning now to what counts as bioethics, the label does not indicate a
unitary pursuit, what with bioethics' academic, policy-oriented,
and clinical instantiations (McMillan 2018: 11-16; Battin 2013:
2). When it comes to bioethics as an academic or scholarly pursuit,
the practical constraints of clinical decision making, and the
timelines imposed by commissions, are non-existent, freeing the
bioethicist of the need to reach closure on a decision or to resolve a
complex issue. As it has been put, for the academic bioethicist and
her students, it does not matter if you end the seminar more confused
than when you started it. It is within this academic domain that the
relationship between bioethics and moral theory will be most explicit,
the role of moral theory most intently debated, and moral theory
probably most welcome.



Looking at policy-oriented bioethics, here the bioethicist assists in
the development of policies affecting large numbers of people on
issues of bioethical relevance (such as the rationing of kidney
dialysis services, or the availability of medical assistance in
dying). There are challenges upfront with the bioethicist's
invoking moral theory of any sort in tackling policy challenges as a
member of a national commission, say, or as a member of her regional
health authority's ethics committee, or as a member of any other
sort of policy-oriented working group. For starters, there is the fact
that she is likely to be in the vast minority as a group member with
philosophical training. But that aside, there is the further challenge
of the unlikelihood of agreement amongst working group members on
which moral theory should rule the day or govern the decision at
 stake.[4]
 There is the third category of clinical ethics, a pursuit taking
place as health care is practiced on the ground. As we will see in
more detail shortly, the relevance of moral theory to clinical ethics
turns heavily on the operative conception of clinical ethics. In
particular, it relies upon our conception of the goals of the clinical
ethics consultation (the main activity of clinical bioethics), and
upon our conception of the role of the clinical ethics consultant.



What constitutes what we call applied ethics is just as fraught a
question as the one of the relationship between theory and bioethics,
and it implicates our take on that relationship. We now turn to that
question.


## 2. What is the Nature of Applied Ethics?



We have briefly reviewed the variety of tasks and problems to which
bioethics addresses itself. But we should also briefly examine the
ways in which bioethics, and its broader cousin applied ethics, is and
has been conceptualized. Such an examination is important within the
context of this entry in that questions about the nature of applied
ethics are often implicitly questions about the relation between the
theoretical and the applied, or between "theory" and
"practice". The very term applied ethics suggests that the
discipline involves an application of some sort or other moral theory
to the practical problem or question at hand. Arthur Caplan writes
that many contributors to the field of bioethics take applied ethics
to involve the application of existing theories and principles to
moral problem in medicine (Caplan 1980: 25-26). But what does it
mean to apply an existing theory to a practical problem? How easily
can the distinction between applied ethics and ethical theory be
sustained? As it turns out, many say that the field of applied ethics
cannot be what the name would lead us to suppose it is.


### 2.1 Problems with the "Applied Model" of Applied Ethics



Caplan argues that there are problems with such a model of applied
ethics (which many call "the applied model"). To start,
many moral problems arise within medicine for which moral theories
have no answers. The applied model of applied ethics also presumes
that those involved in the analysis and solution of a moral problem
take it that the nature and description of the problem or quandary is
not in dispute, where in reality it is often not clear exactly what is
the moral issue at stake (Caplan 1980: 28; 1989; Agich 2001; and
Magelssen, Pedersen, & Forde 2016). This model also
implicitly involves a naive suggestion, argues Caplan, namely
that by dint of expertise in moral theory, the well-trained
philosopher can almost immediately solve moral dilemmas in the
intensive care unit or the emergency department (Caplan 1980: 27).
Moreover, adherence to such a model of applied ethics forecloses the
opportunity for medical ethics (or other fields of applied ethics) to
inform theory construction, as the direction of influence on that
model moves only from theory to the practical.


### 2.2 Applied Ethics and Disagreement on Theory



Further disruption of the application model came shortly afterwards
from both Tom Beauchamp and Alasdair
 MacIntyre.[5]
 Beauchamp challenges the application model of applied ethics, defined
largely as above: ethical theory develops general and fundamental
principles, virtues, rules, and the like, and applied ethics treats
particular contexts through less general, derived principles, virtues,
and so on. In a 1984 issue of *The Monist* dedicated to
"Ethics and the Modern World", Beauchamp and MacIntyre
each probe the relation between moral theory and applied ethics.
Beauchamp argues for the elimination of the distinction between the
two, citing the lack of significant difference between them in terms
of philosophical activity or method. Philosophers doing applied ethics
do what philosophers have always done, says Beauchamp--they
analyze concepts, for instance, and submit to critical scrutiny
various strategies that are used to justify beliefs, policies, and
actions. The application model also problematically presumes a
unilateral direction to the flow of ethical knowledge, from moral
theory to practical cases and problems. But in fact, says Beauchamp,
moral theory has much to learn from practical contexts (Beauchamp
1984).


### 2.3 Applied Ethics and Rule Application



MacIntyre tells us that applied ethics cannot be the sort of activity
it is commonly supposed to be. He turns our attention to the
complexities surrounding the notion of what it would mean to apply a
moral rule. If applied ethics is in fact an application to cases of
the rules of morality, we should expect to find that disagreements
over moral rules reproduce themselves within debates on matters of
practical ethics. But in a high proportion of cases these theoretical
disagreements, of which there are plenty, are not in fact replicated.
Large disagreement on what are the rules of morality turn out to be
compatible with large agreement within the domain of applied ethics.
Noting how common such situations are (situations in which clear
disagreement exists on what are the rules of morality, while fairly
easy agreement can be reached on concrete moral issues), MacIntyre
holds that it cannot be the case that we first and independently
comprehend the rules of morality and then secondly enquire as to their
application under particular circumstances.



As MacIntyre has it, no rule exists apart from its application (and he
admits that his argument entails the rejection of any conception of
moral principles or rules as timeless and ahistorical). Often times,
he suggests, it appears as though agreements among a group of decision
makers is being reached through rational argumentation, but in fact
often group members are reopening debates about perennial
philosophical questions. This is particularly so in medical ethics,
MacIntyre tells us. Our common conception of applied ethics does
indeed rest on a mistake (MacIntyre 1984).


### 2.4 Toulmin on the Tyranny of Principles



Stephen Toulmin, in his well-known paper "The Tyranny of
Principles", recounts his experience on the National Commission
for the Protection of Human Subjects of Biomedical and Behavioral
Research (Toulmin 1981). Agreement amongst members of the commission
was relatively easy to reach even on difficult cases, even in the face
of thoroughgoing moral theoretical disagreement amongst members. His
main point in the paper is not to directly address the nature of
applied ethics, but to argue for a regaining of what he calls the
"ethics of discretion", calling into question the role of
moral principles. En route, though, he undermines the application
model of applied ethics, through his discussion of how much agreement
on practical problems there can be among theorists of radically
different stripes. According to Toulmin, this shows us that applied
ethics is not a matter of applying a theory to a problem, in that
there can be agreement on how to resolve a practical issue amongst
those who strongly disagree on which moral theory ought to prevail.
Again, we have an emphasis upon a lack of reproduction of theoretical
disagreement in dealing with issues in practical ethics. One might
question whether such agreement on particular cases paired with
theoretical disagreement shows that the applied model ought to be
abandoned. Nevertheless, Toulmin's experience prompted him to
wonder what final appeals to principles really achieved.



One final point for the moment on the disruption of the distinction
between ethical theory and applied ethics: as will be discussed in
more detail in
 section 4,
 many would say there recently has been widespread adoption of
reflective equilibrium as the method of justification in bioethics
(Arras 2007). One important implication of this adoption is a blurring
of the distinction between moral theory and applied ethics, what with
the fact that on reflective equilibrium, our responses to real cases
inform our theorizing as much as our theories inform our handling of
cases.



We have just seen reasons to think that we cannot neatly separate
moral theory and applied ethics. Even so, moral theory in some form
plays a crucial if not indispensable role in bioethics. We will now
look at the relevance of high theory.


## 3. Bioethics and High Moral Theory



As the discipline we now call bioethics emerged in the early 1970s,
moral philosophers and political theorists were primed to contribute
to debates on any number of practical issues in areas such as law,
economics, the environment, business, research on human beings, and
medical practice. These academics were understandably hopeful both
that their knowledge of moral theory would prepare them to apply their
theoretical understanding to real-world problems, and that their
skills in critical analysis would be appreciated. Even today, such
confidence in the usefulness of moral theory to the solving of
practical problems is manifest in the introductions to bioethics
textbooks, many of which include discussions of at least the basics of
consequentialism, virtue theory, deontology, and so on.


### 3.1 The Attractions of High Theory



The attractions of high theory were, and are, significant, and indeed,
such moral theories have provided the groundwork for many an approach
to bioethical issues. Examples here include Alan Donagan's
Kantian-inspired work on informed consent (Donagan 1977), Tristram
Engelhardt's libertarian critique of redistribution in health
care (Engelhardt 1986 [1996]), and Joseph Fletcher's utilitarian
approach to a broad range of issues in bioethics (Fletcher 1974).



What might explain such recourse to high moral theory? What are the
attractions of high moral theory for the bioethicist? Let us consider
three important possibilities. First, in bioethics as in everyday
life, our routine moral coping skills work often enough. When they do
not, though, we need recourse to more structured and systematic moral
guidance. On these occasions, high moral theory, such as
consequentialism and deontology, looks helpful and attractive. Besides
offering guidance, such theory provides the resources for moral
justification, especially helpful when we are pressed to explain our
bioethical or everyday moral decisions. Second, when we appeal to
mid-level principles (such as the principle of justice or the
principle of beneficence), we sometimes need help in weighing,
balancing, and adjudicating between those principles. High moral
theory could well provide such help, by providing a form of moral
standard. Recall Sidgwick's argument in support of
utilitarianism, that it could provide guidance in resolving conflicts
among ordinary duties that everyday (non-theoretical) moral thinking
cannot resolve on its own (Sidgwick 1874). In a similar vein, Martha
Nussbaum defends the need for moral theory in part by emphasizing what
she takes to be its power in helping us weigh various rules against
each other in varying circumstances through its setting of a normative
standard (Nussbaum 2000). Third, high moral theory can help us achieve
consistency in our moral lives, as well as a systematic perspective.
There is benefit, the thought goes, to bringing moral theory to bear
upon various facets of our ordinary and bioethical lives, because of
the systematicity and coherence it can provide. Bernard Gert is one
for whom such systematization, at least within bioethics, takes
priority (Gert, Culver, & Clauser 2006).


### 3.2 Problems with Bioethics Conceived as An Appeal to High Moral Theory



The days of bioethics conceived of as high theory were short lived,
however, and the reasons plentiful. For starters, there is the
question of which moral theory should prevail. Even if one has no
problem choosing a moral theory in the first place, one is bound to
have difficulty in successfully defending that choice of theory
against its alternatives (Magelssen, Pedersen, & Forde
2016: 27). The intractability of the debates between utilitarians and
deontologists, say, should give anyone pause when staking out her
positions on bioethical matters with the guidance of her preferred
moral theory. This is one thing for the academic bioethicist. But it
is quite another for the clinical ethicist (for instance) to attempt
to settle the moral matter at hand through recourse to (say)
Kant's categorical imperative. Not only is she likely to be
surrounded by non-philosophers (where recourse to the intricacies of
such high flying moral theory is liable to fall flat), but we must ask
why the public to whom she might be accountable should be subject to
her preference for Kantianism. The same would hold true for the
bioethicist working in the public policy arena.



Second, that challenge aside, there are disagreements within the ranks
of any given theory. Consider rule versus act utilitarianism, for
instance, or disagreement amongst Rawlsians. Third, some cite tensions
between some versions of high theory and democracy. Publicity, many
hold, ought to be a fundamental norm governing policy making in a
democratic society (Rawls 1971). Requiring such publicity would
preclude justifications that no one outside an elite class of
philosophers can understand. One need not be a theory sceptic, then,
in order to demote the place of high theory within bioethics; one need
only recognize the tension between doing bioethics in a democracy, and
rarefied moral theory (Bertram 1997; London 2001).



Fourth, and this is focused on the usefulness or lack thereof of high
moral theory within the clinical ethics context, using theories in the
prescribed way may be very demanding for the clinical ethicist without
high level philosophical training. Furthermore, the comprehensiveness
of the justifications promised by high moral theory may be unnecessary
within that context (Magelssen,, Pedersen, & Forde 2016:
27). Fifth, and reminiscent of Caplan's problems with the
applied model of applied ethics earlier discussed, it is doubtful that
any high-level philosophical theory can generate straightforward
answers to complicated applied problems. Norman Daniels, whose work on
justice and access to health care was inspired by Rawls' theory
of justice, came to admit that philosophical theory is insufficiently
fine-grained for actual policy making, and that it needs to be
complemented by justly structured political deliberation (Daniels
1996: 144-175; 2007: ch. 4). The general thought here is that
high philosophical theory is ill-equipped to deal with practical
decision making on the concrete level (Gutmann & Thompson 1998).
After all, one's preferred moral theory could well, for
instance, endorse several possible policy options, leaving decision
makers wanting for further guidance.



In sum, bioethics as conceived of as an appeal to high moral theory
has been found to have significant limitations, despite its initial
promise. We now to what appears to be a more promising approach.


## 4. The Move to Mid-Level Theorizing: a Principles-Centered Approach



The move to what is often referred to as mid-level theorizing was
(partly) a result of the challenges with high theory just discussed,
and manifested most prominently by the 1979 publication of Tom
Beauchamp and James Childress' influential *Principles
of Biomedical Ethics* (PBE). The approach set out in that book,
and its revised versions appearing in the book's subsequent
editions, feature mid-level moral norms, which take the form of four
moral
 principles.[6]
 Beauchamp and Childress' four principles are:


1. the principle of autonomy (the value of self-direction regarding
one's life and choices),
2. the principle of beneficence (the value of enhancing the welfare
of others),
3. the principle of nonmaleficence (the value of avoiding imposing
harm on others), and
4. the principle of justice (the value of according each person her
due) (Beauchamp & Childress 2019a; Arras 2017: 5).



Coming on the heels of Joseph Fletcher and Paul Ramsey's early
work in what we now call bioethics--both Fletcher and Ramsey were
moral theologians, whose work, while very different from one
another's, was based on Christian moral theology--Beauchamp
and Childress offered the promise of a moral framework that could
appeal to a pluralist and secular
 society.[7]
 Beauchamp and Childress have different theoretical starting points,
with Beauchamp describing himself as a rule-utilitarian, and Childress
a Christian deontologist (Arras 2017: 3; Beauchamp & Childress
1979: 40: 2019b: 9). This underlines the approach as one that refrains
from promoting a single theory over all others, and as one that
requires no underlying theoretical or metaphysical commitments for its
uptake.


### 4.1 A Move Away from Deduction, and Reflective Equilibrium



Beauchamp and Childress' approach has evolved since the
book's first edition, and one important aspect of this evolution
is the move away from deductive reasoning, or (in other words) away
from a "top down" application of principles to cases.
Their initial take on the relation between moral theory, principles
and cases was that



> 
> 
> theory justified principles, that principles justified moral rules,
> and that rules justified moral judgments in particular cases. (Arras
> 2017: 11)
> 
> 
> 



This, at least, was the impression given by a diagram appearing in the
first edition of the book (Beauchamp & Childress 1979: 5), which
many took to endorse such a top down model. The approach was met with
resistance, with those in favor of case-based reasoning (also known as
casuistry) objecting to what at least appeared to be a unidirectional
movement from principles to cases. Intuitive, case-based judgments
seemed to be left out of the picture, and the possibility of a
dialectical relationship between principles and our responses to cases
ignored. In fact, and as a result of an evolution of their approach,
Beauchamp and Childress now fully ascribe to this position on the
reciprocal relationship between our responses to cases and moral
principles. This is evidenced by their current commitment to
reflective equilibrium as the methodology of bioethics. Briefly,
reflective equilibrium is a process by which our considered responses
to actual cases influence our moral principles, and those
improved-upon principles then provide enhanced guidance for our
response to further cases. This is a way of doing moral philosophy
originally formulated by Rawls (Rawls 1971: 48-51; Daniels 1979;
Arras 2007: 47). Cases and principles work in tandem, then, as opposed
to moral principles being applied deductively to cases. A distinction
is made between narrow and wide reflective equilibrium. Narrow
reflective equilibrium involves interplay between our responses (or
intuitions) about cases and the moral principles used to structure
such intuitions, as explained above, where wide reflective equilibrium
brings in additional moral and social theories. Beauchamp and
Childress endorse wide reflective equilibrium (Arras 2017: 182).



That Beauchamp and Childress take (wide) reflective equilibrium to be
such a crucial component of their approach is an important aspect of
their approach as it currently stands. As their view has evolved over
subsequent editions of PBE, reflective equilibrium has grown to have a
more and more prominent role. An important result of this embrace of
reflective equilibrium is that, paired with Beauchamp and
Childress' appeal to the common morality, we have a hybrid
approach to justification, hybrid in the sense of embracing both
coherentism and foundationalism. Reflective equilibrium is the source
of coherentism, with the appeal to the common morality meant to
provide a foundation. Before moving on to a closer look at the notion
of the common morality, we should note that this hybrid approach
differs from accounts of reflective equilibrium we might find in
political theory, for example, and in other areas of practical ethics.
Those more standard accounts involve achieving moral justification by
bringing the various elements of our moral reflection into contact
with one another, with none of these elements regarded as foundational
and all of them regarded as open to revision. By contrast, Beauchamp
and Childress accord foundational status to the common morality, and
it is the common morality that underwrites their four principles.


### 4.2 The Common Morality



Since the third edition of PBE, the source of the four principles has
been not high theory but the common morality. For Beauchamp and
Childress, the common morality is what they take to be a universal
morality, one to which all morally serious persons are committed
(Beauchamp & Childress 2019b). The content of the common morality
is dictated by the primary objectives of morality, which include, for
example, the amelioration of human misery. It encompasses certain
rules of obligation (tell the truth, keep promises), and endorses
certain standards of moral character, such as honesty and integrity
(Arras 2017: 21-3).



Importantly, this common morality is historicist, in that its
authority is established historically, through the success of its
related norms in advancing human flourishing across time and place.
However, unlike many historicist accounts, the common morality is not
relativist, as its norms are to be applied universally. Beauchamp and
Childress accord the common morality a special place within their
approach, a place shielded from the jostling involved in the quest for
coherence through wide reflective equilibrium. The common morality is
thus the foundationalist aspect of their account. Moral conclusions,
then, are justified through both coherence (via the method of
reflective equilibrium), and through foundationalism, being connected
to the principles of the common morality (Arras 2017: 23; Beauchamp
& Childress 2019b: 11).


### 4.3 Criticisms of the Principles-Centered Approach



There is a pluralistic element to Beauchamp and Childress'
approach, which is manifested, in part, by the fact that the approach
avoids a single overarching principle in favor of the short list of
four moral principles. This has lead some to criticize Beauchamp and
Childress' approach for an alleged lack of systematicity--a
fatal flaw, according to some, in any philosophical theory (Gert,
Culver, & Clauser 2006). Such critics claim that without a clear
prioritizing of principles, Beauchamp and Childress'
principles-centered approach lacks rigor and leaves too much room for
intuitive judgments in cases where principles conflict. Beauchamp and
Childress respond, first, by rejecting the very idea that they are
offering a philosophical theory, rather than a framework or practical
guide. But perhaps more importantly, they doubt that any priority
ranking of their principles would stand the test of time (Arras 2017:
6-9).



A fairly recent criticism comes from John McMillan, according to whom
Beauchamp and Childress' approach stifles careful reflection
about real issues. McMillan claims that principle-centered methods
cannot lead to the formulation of what he calls "reasoned
convictions about moral problems", and writes that the four
principles approach hinders bringing moral reason to bear upon
practical questions. This is because, as McMillan has it, newcomers to
bioethics will subsume whatever issues are under consideration under
one of the four principles, and then rule that the principle of
autonomy should trump the other three principles. While recognizing
that such a method is not what Beauchamp and Childress intended,
McMillan writes that it is in fact the way the four principles
approach is typically employed (McMillan 2018: 51-53).



Two interesting criticisms of Beauchamp and Childress' latest
moves come from the late John Arras. Arras questions the plausibility
of Beauchamp and Childress' hybrid account, specifically the
account's reliance upon the common morality as a foundation.
Arras asks why Beauchamp and Childress distinguish the norms of the
common morality from (what John Rawls called) our considered moral
judgments, which are themselves revisable. Arras recognizes that
Beauchamp and Childress might motivate their appeal to a foundation on
the ground that coherence alone cannot secure moral truth. In that
case, though, Arras wonders how much additional justificatory
advantage is leveraged by appealing to the foundational common
morality, as reflective equilibrium itself is maximally inclusive of
all pieces of the moral picture (including, presumably, the common
morality's norms). The problem, as Arras has it, is the
conception of the common morality as being in its own moral sphere,
removed from reflective equilibrium's dialectic. Arras is
skeptical that the common morality is in fact untouched by the
vicissitudes of time and the dialectics of reflective equilibrium
(Arras 2017: 24-26).



A second criticism from Arras deals with Beauchamp and
Childress' embrace of wide reflective equilibrium. According to
Arras, it is difficult to comprehend how moral principles can retain
their priority in conceptual analysis in the face of this endorsement
of wide reflective equilibrium (Arras 2017: 182-3). Arras asks
us to recall that within wide reflective equilibrium, no single
cluster of moral considerations (e.g., considered case judgments,
background theories, moral principles) is privileged. What matters in
reflective equilibrium's revising process, in fact, is our level
of commitment to those considerations, rather than the form of the
commitments themselves (Scanlon 1992; DePaul 1993: 57). Thus, our
beliefs about principles, just like our beliefs in background theories
and considered case judgments, are always subject to revision. The
principles-centered approach seems to have sacrificed its
methodological distinctiveness, so Arras' criticism goes, given
how principles appear to have been robbed of their conceptual
priority.



Finally, Beauchamp and Childress themselves recently acknowledge two
misunderstandings of their four principles framework. The first
misunderstanding is that the framework represents American
individualism, with the principle of autonomy taking priority. Their
response is, first, to contest any connection between American
individualism and a respect for autonomy. Further, they emphasize that
their framework's principles are all only *prima facie*
binding. The second misunderstanding is that the framework downplays
the virtues. It has been argued that medical ethics should be
underwritten by virtue-based ethics rather than by principle-based
ethics, and that that approach has a better chance of restoring
humanity to health care (de Zulueta 2015). Here, Beauchamp and
Childress point to various discussions of virtue theory and moral
character appearing in various editions of PBE, including a discussion
in the eighth edition of how virtues and principles might work
together in certain practical scenarios (Beauchamp & Childress
2019b: 11).


## 5. Other Methods of Bioethics


### 5.1 Casuistry



There are other approaches to bioethics that embody alternatives to
high theory. The first, casuistry, can in some sense be understood as
a critical response to early versions of Beauchamp and
Childress' four principles approach. Recall a certain response
to at least early versions of Beauchamp and Childress' approach,
namely that that approach was too abstract and that its alleged
deductivism was objectionable. Advocates of casuistry, or case-based
reasoning, objected to what they at least took to be the
unidirectional "downward" movement from principles to
cases (Arras 2017: 11). Instead, they argued for a more "bottom
up" approach, which would see actual cases, rather than any one
moral theory, as the starting point, and would conceive of moral
principles as in fact emerging from our consideration of cases.



We often speak of casuistry full-stop, and when we do we generally
have in mind an approach to ethics that emphasizes analogical
reasoning with concrete actual cases (the one before us, and
relevantly similar past cases). When one encounters a case, one
harkens back to a relevantly similar case from the past, recalls how
one responded in that case, and "applies" that reasoning
to the case before one. We should, however, recognize the distinction
between two versions of the approach. To start, there is casuistry
understood simply as the practice of addressing particular cases,
treating them through the application of (abstract) principles.
Understood as such, casuistry would seem to be rightly viewed as a
logical complement to approaches to bioethics that take moral
principles to be morally binding (Arras 2017: 46). Casuists here hold
that principles can have an action-guiding or normative force that is
not reducible to our responses to cases, and that the moral knowledge
represented by such principles is not reducible to responses to cases
(Jonsen 1995). Note that when defined in this way, differences between
this moderate version of casuistry and a more traditional top-down
application of moral principles to cases might be difficult to
pinpoint.



A more radical interpretation of casuistry, though, has a different
story to tell about the derivation of moral principles. Where on the
moderate version we approach cases with our moral principles already
established, on this more radical version, principles develop through
our analysis of actual cases (Arras 2017: 47). So the two different
versions adopt different pictures of the source of our moral
knowledge. On the radical version, it is at the level of the concrete
case, rather than at the level of theory, where we find the greatest
confidence in our moral judgments. The claim here is that moral
principles are, at base, merely formalizations of our intuitive
responses to cases, without independent normative force (Toulmin
1981).


#### 5.1.1 Advantages of casuistry



According to its proponents, casuistry as an approach to bioethics has
specific advantages. One is its potential to offer chances of reaching
agreement amongst those of different theoretical commitments,
rendering it particularly well-suited for decision making in a
pluralistic society (Sunstein 1996). Turning to the more applied
medical context, casuistry is well-suited to use by health care
workers, whose orientation is already case-focused, and whose time for
and interest in moral theory is likely quite limited. When it comes to
teaching bioethics, casuistry would call for the use of richly
detailed case studies, which many whose teaching responsibilities
include teaching those in health care would count as a strength (Arras
2017: 55-57).


#### 5.1.2 Criticisms of casuistry



Despite these sorts of advantages, casuistry has been met with
criticism. One is that the approach seems to assume a
straightforwardness when it comes to deciding what counts as a case.
However, as some would have it, deciding what counts as a case (or
not) might well be underwritten by the bioethicist's picture of
the sorts of problems worthy (or unworthy) of appearance on the moral
agenda (O'Neill 1988). It has been argued that that agenda is
overly narrow and sculpted by the interests of, for example, the
medical profession, and a male outlook (Carse 1991). A related but
distinct point concerns what counts as an adequate description of the
issues at play in a case. Casuistry, to its detriment, seems silent on
this matter. Some argue that a strike against the radical version of
casuistry is its recourse to analogical reasoning. Such recourse, so
the thought goes, fails to properly recognize that such reasoning is
not self-standing. Analogical reasoning would seem to need
pre-established principles to give it direction, and radical casuistry
rejects such principles. Moderate casuistry, which does use principles
or generalizations to provide some structure in identifying what is
morally relevant to a case and across cases (Jonsen 1995) would not be
subject to this criticism.



Another concern is that given its disregard for theoretically-derived
principles, radical casuistry may amount to no more than a refinement
of our intuitive responses to cases. It might be thought to be morally
conservative, ill-equipped for social critique, with the casuist as
mere expositor of pre-ordained moral norms (Arras 2017: 60-67).
Finally, the approach seems to require pre-established agreement on
fundamental values in order to reach conclusions, agreement that may
well be lacking in pluralistic modern society.


### 5.2 Narrative Ethics



A further alternative approach to ethics in general and bioethics in
particular is narrative ethics. According to many commentators, it
emerged in response to a so-called "theory-driven"
approach to bioethics, an approach that prioritizes the Enlightenment
ideas of objectivity and universality (Arras 1997: 65). Put
differently, narrative ethics emerged as a response to an impartialist
ethics, one working on the assumption that ethics is mainly a matter
of "right conduct among strangers". According to Hilde
Lindemann Nelson, two proposals on which narrative approaches to
ethics are based are that moral principles are not lawlike but are
modifiable in light of context (presumably by being made more
specific, or by being treated as defeasible), and that the particulars
of a situation "either naturally take a narrative form, or must
be given a narrative structure if they are to have moral
meaning" (Lindemann Nelson 1997a: viii-ix).



Though some will say narrative ethics is somewhat difficult to pin
down as a method, we can think of it as an approach to ethics that
emphasizes storytelling, the importance of the voice and perspective
of the storyteller and/or patient, and a literary sensibility on the
bioethicist's part. Possibilities have been proposed as to what
a narrative approach to ethics might look like, suggestions as to the
sorts of activities in which we might engage when we adopt a narrative
approach to bioethics. These include i) simply reading stories (which
sharpens one's moral sensibilities) (Nussbaum, 1992, 1995), ii)
telling stories (which is a way of making moral sense of an
experience), iii) comparing stories (which brings to mind the work of
the casuists), iv) conducting literary analysis in some form or other,
and v) invoking stories (which we do when we introduce bioethics case
studies) (Lindemann Nelson 1997a: x-xii).



Accounts vary of how narrative ethics actually functions as a tool of
ethical analysis. A first option is that a narrative approach acts as
a supplement to moral principles rather than as a replacement of them.
On this version of narrative ethics, we are looking at a way of doing
bioethics that requires sensitive attention to so-called
"narrative elements" of human experience, such as stories
told by patients, caregivers, and family members. There is no thought
of doing away with a bioethics driven by theories and principles, just
a call to use those tools with a sensitive appreciation of the
first-person accounts of others (Charon 1994). Another way of thinking
about narrative as a supplement to principles is to consider the way
in which principles and cases share a dialectical relationship within
the context of reflective equilibrium. Here, the cases in response to
which we develop considered judgments are themselves narratives. So
again, this conception is accommodating of moral theory, as moral
theorizing and stories are mutually interdependent.



A second option has a narrative approach emphasizing the importance to
ethics of history and culture over a more universalist rationality.
This version of narrative ethics is sometimes known as historical
narrative. Here, right action is endorsed by appeal to the traditions,
norms, and traditional stories of a particular social group. Recourse
is also made to one's social role, and the foundational
narrative underlying that role (think of the physician's social
role in Western culture as shaped by the Hippocratic Oath) (MacIntyre
1981; Burrell & Hauerwas, 1977).



A third option sees a narrative approach acting as a total substitute
for the process of moral justification (Arras 1997: 67- 78), and
as a replacement of theory-driven or principle-centered bioethics. On
this option, which some associate with postmodernism, the emphasis is
upon continual conversation between traditions and narratives. No one
view (tradition or narrative) can be justified over others through
reference to a theory of human nature, of history, and so on. The
ultimate goal here then is not the pursuit of justification for
one's view, but the keeping open of the "moral
space" for continuing conversation between rival views (Rorty
1989). A related aspect of this option is the claim that those who
suffer should tell their own story, without risk of being dominated
and objectified by the case summaries typical of modern medicine
(Frank 1995). While quite specific in their vision of how narrative
ethics might supplement or replace a more standardly theory-driven or
principles-centered approach to bioethics, none of these versions seem
to identify a unique framework for moral reasoning (in the way that,
for example, utilitarianism or deontology do).


#### 5.2.1 Criticisms of Narrative Ethics



Questions have been raised about the viability of a narrative
approach. A general concern is that how an emphasis on narrative
relates to ethics in general. There is also question about how a
narrative approach reaches conclusions about what we are supposed to
do.



Insofar as two central tasks of bioethics are to pass judgments on
actions, policies, and character, and to morally justify actions,
decisions, and policies (or to show that justification is not
possible), it is not clear how narrative ethics can satisfy the aims
of bioethics, or so the concern goes. What is the relationship between
narrative and moral justification? What is the connection between
telling a story, say, and the moral decency of a particular action,
policy, or character?



More specific concerns about the approach track the version of
narrative ethics under consideration. For instance, on the historical
narrative picture (the second option above), some argue there is the
risk of falling back into either a version of ethics at least somewhat
guided by principles, or finding oneself having to sort through
incommensurable narratives with nothing to decide between them. A
worry about the third option (the version on which narrative acts as a
substitute for moral justification) is the threat of an objectionable
subjectivism, brought on by the possibility of mistaking the
narrator's story for ethical truth. A related criticism is that
this version of narrative ethics seems to prioritize individual
coherence over the passing of moral judgment. Some stories, so the
thought goes, may well be internally coherent, while at the same time
being morally questionable (Arras 1997: 81-83).


## 6. Feminist Theory and Bioethics



Another distinctive approach to bioethics employs the insights of
feminist ethics. Feminist approaches to bioethics offer a framework
for approaching bioethics at least in the sense of developing and
adhering to a certain set of theoretical commitments. Some of those
commitments address forms of moral reasoning, some address substantive
commitments about how to bring about a more just social order, and
some address questions about which perspective should take priority in
the analysis of a bioethical issue. Some contend that bioethics has
largely ignored work in feminist ethics more broadly, making it all
the more crucial that a feminist approach to bioethics act as a
corrective to various trends (such as an inattentiveness to social
context, and an emphasis on liberal individualism) (Wolf
1996a). Suggestions abound as to how a feminist approach can, and
in fact does, do that.



To start, a feminist approach can pay special attention to the
experiences of women. Further, it can subject to critical scrutiny the
employment of the concept of a common morality, a concept which
allegedly entrenches bioethics as a conversation amongst experts.
Bioethics as such a conversation excludes alternative viewpoints,
including the viewpoints of laypeople, and of those on the margins. A
feminist approach might invoke standpoint theory, which would draw
upon the insights of the most disadvantaged in society. Finally, a
feminist theoretical approach could demand attention to lived
experience, turning the emphasis away from the abstract theorizing of
non-feminist moral philosophy and bioethics (Wolf 1996a).



Two further benefits of a feminist approach to bioethics have been set
out, apart from how it might directly correct for the effects of a
masculinist moral philosophy and bioethics. First, a feminist approach
both attunes us to the effects of androcentric reasoning in the
analysis of bioethical issues, and mitigates those effects. Second, it
draws our attention to the gendered nature of many concepts key to
bioethical analysis. For instance, in looking at the concepts of
reason and emotion, a feminist approach helps us to see that the
concepts themselves seem partly to be gendered concepts. Reason is, or
at least traditionally has been, associated with the male, and emotion
with the female. The same holds true with the distinction between the
public and private spheres, with the public domain belonging to men,
the private the women's realm. But what's more, we see
that that which is associated with woman (emotion, for example) tends
to be undervalued. As Margaret Little lays it out, traditional moral
epistemology takes reason, and not emotion, to be critical to moral
understanding. It is also important to notice the dualistic nature of
the picture presented above. Just as men and women have traditionally
occupied different spheres, so too have gendered concepts occupied
fixed places on either side of a divide. The domestic sphere, for
instance, is taken to have nothing instructive to offer the world of
economic or political relations, or bioethics (Little 1996).



We can see these sorts of commitments played out in Susan
Sherwin's approach to the abortion question. According to her, a
recognition of gender and sexual politics, and of women's
vulnerability in general and to sexual coercion in particular, are on
her view crucial aspects of a feminist approach. Further, a feminist
approach takes as central the moral prerogative of the women
concerned, rather than focusing on such questions as fetal moral
status, or on the task of formulating a set of general rules as to
when abortion is or is not morally justified. In keeping with this, a
feminist approach denies the possibility of a gender-neutral account
of pregnancy, or of abortion decisions. From a feminist perspective,
the most morally salient feature of pregnancy



> 
> 
> is that it takes place in *women's* bodies and has
> profound effects on *women's* lives (Sherwin 1992:
> 363).
> 
> 
> 



When we look at feminist treatments of physician-assisted dying (PAS),
we again see certain kinds of theoretical commitments come to the
fore. For instance, an adherence to the feminist care perspective
leads Leslie Bender to support PAS (Bender 1992). By contrast, Susan
M. Wolf's application of a feminist approach as manifest by an
emphasis upon the significance of gender leads her to conclude that
PAS should not be legitimized. Pointing to the insidiousness of
certain familiar images--images of feminine self-sacrifice, for
instance--as well as to early prominent cases of
physician-assisted dying and euthanasia in which the physician was
male, the patient female, Wolf warns us of the dangers of the dynamic
between the "powerful expert physician and the woman
surrendering to his care" (Wolf 1996b: 293).



In thinking about feminist approaches to bioethics in connection to
the relation between theory and bioethics, it is not a uniform
approach, seeing as its proponents will not always adhere to the same
set of commitments. (For example, in her work referenced above Bender
adheres to a care-oriented thinking, where other feminist bioethicists
will be more representative of liberal feminism.) A feminist approach
is theoretical at least in its adherence to certain (feminist
intellectual) commitments, even if there is not agreement across the
board as to what those should be. Overall, feminist approaches to
bioethics have made a significant impact and have changed the course
of the conversation in bioethics, even if those approaches are
somewhat varied and represent a theoretical approach to bioethics in
less strictly defined a way than other approaches might. The preceding
discussion focuses upon scholarly contributions; feminist scholars
have also addressed clinical ethics (Sherwin & Baylis 2003). It is
to the clinical realm, and moral theory's role there, that we
now turn.


## 7. Moral Theory and Clinical Bioethics



There are two main areas of discussion within clinical ethics that
relate to the relevance of moral theory to clinical bioethics. The
first concerns what is the appropriate model for clinical ethics
consultation. This has implicit consequences for the role of moral
theory. The second directly examines whether clinical ethics
consultations should rely upon moral theory.


### 7.1 Models of Clinical Ethics Consultation



The American Society for Bioethics and Humanities (ASBH) sets out
three possible models of clinical ethics consultation, endorsing one
of them. Each model implicitly involves a picture of the role, or lack
thereof, of moral theory. On the pure consensus model, the sole goal
of ethics consultation is to forge agreement among those involved in
the consult (ASBH 2011: 7). It would seem that there is no role for
moral theory on this approach to clinical consultation, as mediation
is the sole objective, with no eye held toward whether the consensus
reached is morally justified through appeal to moral norms, accepted
values, or moral theory. This model is generally taken to involve too
weak a picture of the aims of clinical ethics consultation, and too
minimal a picture of the clinical ethicist's expertise and role.
On the second model, the authoritarian model, the clinical ethicist
is, by contrast, the primary moral decision maker. This model is
generally taken to involve an overblown picture of the clinical
ethicist's authority and abilities, and of the infallibility of
her perspective. The major downfall of this model, according to the
ASBH, is that the clinical ethicist disregards the decision-making
authority of others, such as a patient's family and the health
care team. Here again, moral theory has no explicit role, though it
does seem possible and even likely that the clinical ethicist, in
making her unilateral decision, invokes some moral theory or other in
doing so.



The third model, the ethics facilitation approach, is the approach
endorsed by the ASBH, and there is general consensus in the field that
this is the best model for clinical ethics consultation. Here, the
consultant helps to make clear the moral issues at play, aids in
communication, integrates the viewpoints of relevant stakeholders
(ASBH 2011: 7). Importantly for the current discussion, this approach
involves two main parts: identifying and analyzing of what is the
moral issue at stake, and facilitating of a principled ethical
resolution. This second task is of particular interest to us here,
because one would think that the building of such a resolution would
involve looking to moral theory of some type or other, in addition to
simply consulting the ethics literature. How else will one adjudicate
whether the resolution falls within clearly accepted ethical
principles? After all, the clinical ethicist is tasked not only with
facilitating a resolution, but with suggesting a range of ethically
acceptable options and providing a rationale for each option. In
specifying an acceptable range of possible options, an ethics
consultant will draw on a knowledge of relevant institutional
policies, laws, the scholarly literature, and presumably also of moral
theory.


### 7.2 Clinical Ethics and Moral Theory



Turning to the second area of discussion, we have a more explicit look
at the role of moral theory in clinical ethics consultation. Four
important roles for moral theory in clinical ethics consultation have
been suggested:


1. aiding in the initial awareness and identification of the moral
challenges;
2. assisting in the analysis of moral challenges;
3. contributing to a sound process and dialogue;
4. inspiring an attitude of reflexivity and interpretation
(Magelssen, Pedersen, & Forde 2016, 27-31).



The advantages of a clinical ethicist's being familiar with
moral theory have also been discussed. There is some advantage not
just in using a moral theory to help one analyze and formulate
arguments, but also in considering the variety of perspectives and
questions made perspicuous by various ethical theories, and the issues
they illuminate. As well, when it comes to the consistency of a
clinical ethicist's own argumentation, familiarity with moral
theory will help clinical ethicists spot weaknesses in their own
arguments or in those of others.



However, matters are not quite so simple. To start, it is possible for
those with no training in moral philosophy to have a solid handle on
the moral dilemma with which they are dealing. And at the same time,
some say, having a philosopher, one who is an expert in moral theory,
as a clinical ethicist does not guarantee that the ethics consult will
be of high quality. Knowledge of moral theory within the clinical
ethics realm is not always clearly helpful, and its possible benefits
are not without accompanying drawbacks. First, if used too strictly,
and adhered to too inflexibly, moral theories can hamper moral
imagination and intuition, and obscure access to the insights of, for
example, common morality. Second, those in command of a wide range of
moral theories might be tempted to draw upon the moral theory that
actually justifies a course of action already preferred or even
settled upon, rather than use what is deemed in advance to be the best
moral theory to work through what is the justifiable course of action
(or what are the best action options). Third, moral theories can
mislead, by, for instance, being used to frame cases in ways that
emphasize irrelevancies. And fourth, without quite advanced knowledge
and skill, ethical theories may easily be misunderstood and used
improperly. An example here would be taking Kantian moral theory to
mandate no person ever being treated as a means
(Magelssen, Pedersen, & Forde 2016). The message here
is that knowledge of moral theory can sometimes actually be an
impediment to good clinical ethics.



Overall, moral theory has a role to play in clinical ethics, at least
if we accept the goals of ethics consultation as assumed by the
generally accepted model of ethics consultation. The more explicit
conversation in this area recognizes the advantages the use of moral
theory offers clinical ethics and the consultation process. However,
the discussion in the literature also cautions against a wholesale
endorsement of the notion that those working in clinical ethics are
always better for having an in-depth knowledge of moral theory.


## 8. Conclusion



What is the relation between moral theory and bioethics? There is no
straightforward answer to this question. So much depends upon whether
we consider bioethics in its academic, clinical, or policy-oriented
instantiations. And further, there is wide variance in what we have in
mind when we talk about moral theory. Besides this, the very
distinction between moral theory, on the hand, and the problems and
issues to be addressed in the practical realm, on the other, has been
called into serious question. Still and all, it is difficult to
imagine bioethics (in any form) in the total absence of moral theory.
Especially if modestly conceived as a set of substantive organizing
assumptions about morality, and a commitment to a certain approach to
moral reasoning, it is difficult to view moral theory as anything
other than indispensable to bioethics.