Theories or No Theories—Is Anything Evolving?

R. M. Hare suggested half a century ago: “If philosophers are going to apply ethical theory successfully to practical issues, they must first have a theory.” ¹ Apart from the obvious literal interpretation—if you want to apply something, you must have that something—he may have been right or wrong. Many bioethicists do well without explicit theories and even those who rely on theories develop them all the time. ^{2 , 3 , 4 , 5 , 6 , 7} This special section contains eight contributions pertaining to the topic.

The Role of Theories and Arguments

The first four entries discuss the role of theories and extant arguments in bioethics. Can good bioethical work be done without involving grand theories? What was the vision of the field’s pioneers on its workings? Apart from the discipline’s obvious pragmatic aim, does it have room for pragmatism as an ethical theory? Does the nature and use of bioethical arguments evolve as the real-life phenomena studied become more familiar and mundane?

Søren Holm opens the proceedings by addressing the first question. According to him, purely critical and empirical contributions to bioethics can easily survive without involving major theoretical frameworks. As long as the aim is to show flaws in existing views and policy suggestions, authors can simply point out inconsistencies in the argumentation or discrepancies in the presentation of the facts of the case in hand. When it comes to constructive efforts, however, the situation is different. If the aim is to provide a new argument or a new approach, reliance on a wider moral or political view is often required. And even analyses that do not initially seem to lean on substantive ethical doctrines have to seek support from theory fragments or formal principles such as analogies and reflective equilibria. ⁸

Mathias Schutz examines the early programmatic declaration in Daniel Callahan’s 1973 essay “Bioethics as a Discipline.” ⁹ Callahan made a plea for a comprehensive approach embracing all the academic fields that are involved in solving the biological, medical, psychological, social, political, and cultural issues in biomedical research, clinical work, and healthcare arrangements. His ideal was systematic knowledge and understanding. Instead, bioethics soon became a project concentrating on particular issues—abortion, euthanasia, the ethics of genetics, to name a few—and dominated by philosophy, clinical medicine, and law, at the expense of theology, history, and the social sciences. The advent of principlism a few years later was an attempt to reconcile belief systems and faith traditions, but it also turned bioethics into a problem-solving machine with no time for wider connections. ^{10 , 11 , 12}

The way bioethical inquiries should be conducted has, of course, been vividly discussed ever since. Suggestions, in addition to principlism, have included theory-driven consequentialism ^{13 , 14 , 15 , 16 , 17 , 18 , 19 , 20} and deontology; ^{21 , 22 , 23 , 24} practice-based casuistry and virtue ethics; ^{25 , 26 , 27 , 28 , 29 , 30} justice-oriented political philosophy; ^{31 , 32 , 33} feminist approaches; ^{34 , 35} post-colonial perspectives; ^{36 , 37 , 38} and pleas to delimit the normative force of conceptual analyses. ^{39 , 40 , 41 , 42 , 43 , 44 , 45} A focal topic debated is often the practical usefulness of academic considerations.

Henrik Rydenfelt addresses this issue in light of Charles S. Peirce and John Dewey’s idea of experimental inquiry solving ethical problems. Moral views and public policies can be supported by using a method familiar from the natural sciences, the confirmation and disconfirmation of hypotheses through experimentation. The hypotheses are the views and policy suggestions; and the evidence that can be used to verify or falsify them, according to Peirce, is provided by feelings as “emotional interpretants.” Dewey also argued that moderate democratic development is to be preferred to unrestrained social and political change. ^{46 , 47 , 48 , 49 , 50}

Jonathan Glover echoed Peirce’s idea in his 1977 book Causing Death and Saving Lives. Matti Häyry in 1994 summarized his position as follows:

Glover argued in his book that contemporary moral, social, and political issues can be studied systematically by methods which are not unlike those used in scientific research. Moral principles can, according to Glover’s view, be falsified by appeals to inconsistency and incoherence, and further tested by observing the responses provoked in various individuals by their application to reality. Glover believed that the logical and conceptual tests of consistency and coherence can objectively establish or refute general moral principles, whereas the role of people’s moral responses is, due to the possibilities of manipulation and cultural differences, more problematical. The task of applied ethicists in the model is to develop moral rules and regulations which are maximally acceptable and reasonably applicable to real-life moral issues. ⁵¹

Häyry went on to formulate a multistep reiterative method of applied ethics based on Glover’s outline. In addition to the logic-responses division, two intertwined tasks were identified for the philosopher: cognitive deprogramming and rational reconstruction. As for the first:

Conceptual cognitive deprogramming consists of the analysis and critical assessment of the terms and arguments which have been used in the formulation of everyday moral rules and principles. If the terminology in use is ambiguous, or if the inferences made are invalid, the rules and principles in question must be either reformulated or rejected. Emotional cognitive deprogramming, in its turn, centres on the use of idealized or imaginary examples. These examples are normally designed to portray how, under particular hypothetical circumstances, apparently reasonable moral rules and principles lead to actions which have intuitively unacceptable consequences. Imaginary cases cannot be employed to establish moral views or to refute them absolutely or objectively, but if they are well chosen, they can in many cases provide good grounds for abandoning certain prima facie approvable ethical rules and principles. ⁵²

Once all questionable alternatives have been refuted, the philosopher should try to rationally reconstruct a view that would fare better. There is a limitation, however, in the moral response, or emotional, part of the analysis:

While conceptual consistency and logical soundness may yield to objective criteria, intuitive acceptability is often the function of the deep values which persist in the community under scrutiny. The conclusions of the applied ethicist are in these cases ad hominem, or of the form: “Since your own basic norms, values and beliefs are this-and-this, and you presumably wish to be consistent, you ought to consider it your duty or right to have or to do that-and-that.” Reconstruction instead of free creation is therefore frequently needed. ⁵³

In the methods of applied ethics defined by these passages, elaborating on Glover’s sketch, the bioethical community would have had the scientific, experimental approach Rydenfelt calls for, complete with Peirce’s emotional interpretants as the backbone of the intuitive examination and Dewey’s requirement of cautious democracy in the ad hominem nature of the conclusions. For better or for worse, however, the proposal has gone largely unnoticed by the community for 30 years.

Sergei Shevchenko and Alexey Zhavoronkov highlight one reason for the avoidance of strict, timeless logic in the analyses of moral conundrums. New medical and biomedical developments sometimes raise fears that prevent ethicists from using one-to-one comparisons with earlier, better-known practices. The developments—the spread of the human immunodeficiency virus, ^{54 , 55} advances in genetic screening, ^{56 , 57 , 58} the rapid rise of neuroscience, ^{59 , 60} and the like—then receive special treatment under the banner of exceptionalism. For the people who have the conditions or should receive services or treatments, this can mean exclusion. Familiarity with the condition or technology often removes, in time, the perceived need for the exception and exclusion. ⁶¹

New and Revised Theories and Arguments

The four remaining contributions present new and revised ideas for the consideration of bioethicists and discuss their merits. Theories can be built from scratch, using notions from other fields as springboards, or they can lean on concepts and doctrines already in circulation. In both cases, they systemize and balance our basic intuitions, an approach defined by Henry Sidgwick in his 1874 book The Methods of Ethics. ⁶² He first established the credibility of the fundamental intuitions of justice (like cases should be treated alike), prudence (we should pursue our long-term self-interest), and the universality of goodness (everybody’s interests should count equally). Armed with these, he assessed the main contenders for an overarching ethical theory: intuitionism (for him, both prevailing traditional morality and Kantian and Aristotelian doctrines), rational egoism (I am allowed to pursue my interests and so is everyone else), and universal altruism (utilitarianism). In the end, he could not make a final decision between rational egoism and universal altruism, ⁶³ a conundrum that we shall witness in one of our contributions.

Steven Firth presents a new theory of disability, claiming that all existing approaches fail to capture the essence of the phenomenon. The medical model treats disability as a disease, an individual’s malfunctioning; and the social model sees it as a political construction caused by the unwillingness of others to make proper adjustments. ^{64 , 65} Firth’s picture theory sees disability as the negative experience a person has confronted with the inability to perform tasks related to daily living or to reaching life goals taken for granted by the nondisabled. When the medical model asks “What is it?” and the social model “Why is it?” Firth’s picture theory asks “How does it feel?” ⁶⁶ This concentration on people’s own experiences can also be extended to characterizations of life’s quality and value more generally. ^{67 , 68}

Firth’s definition could easily be seen as complementary to the standards views, each having their own angle. The medical approach attempts to be objective, the social model is deliberately intersubjective, and the picture theory can be seen as their subjective counterpart. Interestingly, Firth’s account seems to exclude those who cannot picture their own lives in comparison with others—and who therefore cannot see the negativity of their experience. People with profound intellectual and multiple disabilities could be an example. They are disabled medically and (possibly) socially but not pictorially. They are not consciously facing an inability to reach their goals but rather experiencing their own particular human condition.

Matti Häyry proceeds in a more Sidgwickian manner and tries to find a balance between basic utilitarian and liberal intuitions—an endeavor that has engaged him before. ^{69 , 70 , 71 , 72 , 73 , 74 , 75} His starting point is negative utilitarianism—the view that our first and foremost duty is to eliminate and prevent bad, not to maximize good, as in the classical utilitarianism of Jeremy Bentham. ⁷⁶ Following his liberal convictions, Häyry makes two revisions to the creed. He names two values—the need to avoid suffering and the need not to have one’s autonomy dwarfed—and postulates that only clear cases of need frustration without conflicts of basic interests generate moral duties straightforwardly. When the fundamental needs of several agents or patients clash, the cases must be assessed (also) by nonutilitarian criteria. ⁷⁷

Karim Akerma provides a critical commentary to Häyry’s suggestion. He observes that the revised view could match people’s intuitions marginally better than the more orthodox version of negative utilitarianism—which would make ending sentient life on earth a moral duty. He argues, however, that a slightly less orthodox reading of the doctrine would remedy the situation without the need to introduce autonomy as an almost independent principle like Häyry does. If the end of moral action is to reduce suffering and if suffering is understood as a category wider than mere physical pain, respect for people’s own choices would be automatically included in complete assessments. ⁷⁸ Akerma’s analysis highlights the difference between those who abide by pure, aggregative utilitarianism and those who waver when an individual’s self-direction ceases to be an entitlement and becomes a measurable factor in a utility calculation.

Matti Häyry and Amanda Sukenick present what they call a new argument for antinatalism. Also touched upon in the contributions by Akerma and Häyry, antinatalism is a view that assigns a negative value to reproduction and maintains that people should not have children. Häyry and Sukenick argue that standard defenses of the creed are complicated and counterintuitive to the degree that a novel angle is needed. They identify talk about non-existing beings—“The unborn have a right not to become existent.”—difficult for lay audiences to grasp and propose a shift of focus to those who already live. The authors maintain that pronatalism is such a strong force that children are almost automatically indoctrinated into believing in its blessings. And since the indoctrination takes place before they can form their own opinions, the arrangement violates their right to an open future. This postnatal mental imposition, Häyry and Sukenick conclude, makes the cycle of procreation undesirable. ⁷⁹