journal of medical ethics, I976, 2, 18-23
Is a moral consensus in medical ethics possible?' Basil Mitchell Oriel College, Oxford At the moment in Britain and elsewhere the debate inside and outside of Parliament on various medical issues which are essentially moral never ends. Everybody has his own point of view - or principles. But what emerges for society to adopt can often be called in lay terminology 'compromise'. Professor Mitchell argues in this paper that a moral consensus is possible and indeed ought to be achieved, as today the medical practitioner can no longer make his decision only in accordance with the strict code of ethics of the medical profession. The task of the philosopher, says Professor Mitchell, is to interpret the actions and attitudes demanded by modern medical practice. I wish to discuss the question of the possibility of a moral consensus in the context of the concern which is expressed in the title of Professor Hare's
lecture: 'Medical ethics: Can the moral philosopher help?' Its relevance is obvious. What use is the moral philosopher to medical ethics if there is no chance of a consensus? Yet it can scarcely be a secret that philosophers disagree more or less radically not only about concrete moral issues but about the scope and character of moral philosophy. Many of us, myself included, would prefer to rely on the ethical discriminations of an experienced doctor than upon those of a moral philosopher. And this is not particularly surprising. It very often happens that in practical situations the best judgments are made by people who have had repeatedly to make responsible choices in situations of the sort. This is especially the case when there exists a long and honourable tradition as there does in the medical profession. The moral position in medicine today Nevertheless this complete reliance upon a professional ethic of a largely intuitive kind, is I suggest, becoming increasingly difficult, for three reasons. i) There is less of a moral consensus in our society at large than there used to be. It is, some say, on the way to becoming, if it is not already, a 'plural society'. Hence moral positions which could once be taken for granted cannot be taken for 'This paper was originally delivered as a lecture to the London Medical Group in a series entitled: 'Moral
philosophy and medical ethics'. The opening lecture was delivered by Professor R M Hare under the title: 'Medical ethics: Can the moral philosopher help ?'.
granted quite so readily any longer. There are plenty of examples of controversy in the medical field: abortion, contraception, euthanasia, suicide and anything that has to do with sexual morality. 2) The scope of medical practice has been much enlarged and its aims therefore are less simply stated. It used to be the sole aim of medicine to cure disease and physical disease at that. Hence the aim was the patient's health; and physical health was not difficult to recognize, though it might be hard to define. But medical techniques may now be called upon for purposes which are not directly related to the health of the individual patient, eg, in relation to contraception, abortion, sterilization, penal treatment, sex changes and cosmetic operations of various kinds. Even in so far as the doctor's aim is still restoration to health there are problems as to what constitutes health, and, when not all the attributes of health are obtainable, which to prefer. This is especially the case with mental health. Is it, for example, more important that the patient should adjust to his environment or that he should 'be himself'; that he should be free from anxiety or that he should be responsible? How, particularly in a penal context, should the line be drawn between behavioural changes that may properly be induced by medical treatment and those that should be left to persuasion, including education ? 3) So long as the sole aim of medicine was the curing of disease, the doctor could claim without fear of contradiction that the entire field of medicine was subject to the ethics of his profession. Now there is a tendency on the part of many people to treat the doctor simply as a technician whose job it is to give the public what it wants. No doubt the conscience of the individual doctor has to be safeguarded, but the ethic of the medical profession as such is judged irrelevant. It is for society or the individual patient (who sees himself rather as a client or a consumer than as a patient) to determine whether a man should be sterilized, or a fetus aborted, or a child of I2 placed on the pill. To the extent that this attitude is accepted, medical ethics are no longer coextensive with medical practice. In any case, as the range of operations for which medical skill is required but which is not concerned with the cure of disease increases, there is a growing range of ethical problems which require discussion between the medical profession and others.
Is a moral consensus in medical ethics possible
Specific problems of medical research Let me add for good measure the problems that arise in connexion with medical research. The medical profession joins with non-medical scientists in research whose object is mainly the control of disease but also the expansion of knowledge for its own sake. Neither of these objectives can be identified with the interest of the individual patient who may nevertheless be involved in the research. The ethical problems associated with research may be divided into those which do and those which do not involve the individual patient. THOSE INVOLVING THE INDIVIDUAL PATIENT
The patient may be treated too much as a 'guinea pig'. The usual safeguard is to ensure that an independent doctor is clinically responsible for the patient, but is this enough? The use of controls would seem to require that some patients are not given treatment which on the available evidence is most likely to benefit them. In so far as they are given placebos they are in addition, presumably, deceived as to the treatment they are getting. THOSE NOT INVOLVING THE INDIVIDUAL PATIENT
The research may involve methods of doubtful morality. The whole question of vivisection and other experimental use of animals is relevant here. One does not have to be a fanatic to be disturbed by some reports of research into, eg, drug addiction in monkeys, involving them in degradation as well as suffering. Justification would presumably lie in the possible benefits to humans, but one is bound to ask whether there are limits to what can be justified in this way and whether it makes a difference that, in this case, the human ills for which relief is sought are self-induced. The research may be likely to endow men with powers which it is arguable that they would be better without, eg, to determine the sex of children or to bring an embryo to full term outside the womb. (It is worth noticing that a third aim of medical research is here involved: to extend human control over natural processes. Genetic manipulation would be another example.) Should such research go forward if its consequences are liable to be bad or largely unpredictable ? Are there, in any case limits, not based simply upon estimation of consequences, upon man's right to modify his basic biological constitution ? The application of moral philosophy to the medical debate For such reasons as these it is not, I think, possible, however much one would prefer it, to confine the discussion of medical ethics to the medical profession entirely or to rely on intuition backed by experience. New problems have arisen requiring
19g
fresh decisions and some of them at least are problems which clearly concern others as well as doctors. There is, as Professor Hare makes clear in his paper, no possibility of moral philosophers settling these questions on their own. They lack the technical knowledge and they lack the accumulated wisdom which, though no longer sufficient, are still necessary to the consideration of these problems. But I agree with Professor Hare in thinking that moral philosophers can make a useful contribution to a cooperative effort to solve these problems. He writes: '[The philosopher] comes in because moral problems, of which problems in medical ethics are an example, cannot be discussed without using a lot of words whose meaning and logical properties are not at all clear.... Philosophy is a training in the study of such tricky words and their logical properties, in order to establish canons of valid argument or reasoning, and so enable people who have mastered it to avoid errors in their reasoning (confusions or fallacies) and so answer their moral questions with their eyes open.' Words and arguments do not occur in a vacuum. Their meaning and their force is for the most part related to the contexts in which they are used, so that the philosopher has to become familiar with these contexts, which he can only do by listening to and sharing the discourse of those who are at work in them. As Professor Hare says: 'Philosophers cannot give their patients pills which the patients can just swallow. Philosophy itself is the medicine, and it has to be understood, to some degree at any rate, by the patient himself'. It is equally true that philosophers cannot write their prescriptions without knowing something about medicine and without sharing, at least in imagination, the predicament of the doctor. I think it would be fair to say that Professor Hare himself believes that philosophy, properly applied, can elicit a moral consensus. 'It is my belief', he writes, 'that once the issues are thoroughly clarified in this way [ie, so as to enable people to avoid errors in their reasoning (confusions or fallacies)] the problems will not seem so perplexing as they did at first, and, the philosophical difficulties having been removed, we can get on with discussing the practical difficulties which are likely to remain serious' 1. The consensus would be elicited in the following way. Those who are confronted by a practical problem calling for an ethical decision are invited to consider first what course of action would best serve the interests of those immediately concerned in this particular case and second whether, in the interests of society as a whole, it would be better if a general rule were adhered to which dictates a different action in this particular case. (A man's interest is taken to be, roughly, what he wants, or would want, if he were fully apprised of 'My square brackets and italics.
20 Basil Mitchell all the relevant facts). The problem of euthanasia provides an illustration. We can conceive situations in which the best thing for all concerned in a particular case would be to kill the patient, but cwe have to ask not only what is for the best on this particular occasion for the parties affected, but what is best for society as a whole. All the members of society are likely to be gravely harmed if doctors are brought up with such attitudes that they can even contemplate such an act. The interests of all are therefore best served if doctors simply put such thoughts out of their mind'. 'This', says Professor Hare, 'sounds like an absolutist kind of thing to say; but there are good utilitarian reasons for saying it.' Let me say at once that I agree entirely with all that Professor Hare says about the need to balance people's interests fairly but it seems to me that he oversimplifies at each of the stages that he distinguishes: I) the stage at which the question is, 'What is in the interest of the parties immediately involved?' and II) the stage at which he arrives at general principles. Indeed I doubt if it is possible to keep the two stages entirely apart in the way he tries to do. THE EXAMPLE OF EUTHANASIA
To take Professor Hare's own example of euthanasia, he argues that we normally have no hesitation in saying that it is in the interest of the patient and his family and associates that he should live, although we might in certain circumstances believe that it would be better for him if he were dead. Nevertheless, he suggests, we might be right in adhering to a strong general principle forbidding euthanasia because of the acknowledged dangers of letting this principle go. Now this mode of argument does have considerable force and I do not at all want to dispense with it, as will appear later. It has the very great practical advantage of carrying weight with people of rather different moral standpoints, and, to that extent, it does render a consensus easier. Nevertheless I suggest that it does not do justice to all the considerations that weigh with many opponents of euthanasia. They would say, I thinlk, that it is always or almost always in a man's interest to live because life is a value of a peculiarly fundamental kind as being the necessary condition for the enjoyment of all other values. They might insist on the sanctity of life; if they were Christians, as a gift from God; or, if they were humanists, because of man's dignity as a rational being. And they would believe these things to be true even of the man who wants to die. In other words, they would not regard the question whether it is in a man's interest to die as equivalent to the question whether he wants to die, even if this is further qualified so that it becomes 'wants to die or would want to die if he were fully apprised of all the relevant facts'.
It is not entirely easy to make the distinction clear in the case of life because in this instance the two conceptions of interest do so often and so obviously coincide. Most men most of the time want to live. Let us take another example also from within the medical field.2 Suppose a hypothetical non-addictive drug which permanently makes the taker more contented with his life and less capable of using his talents; if someone wished to take the drug, knowing that this would be its effect, would it be acting in his interest for another person to offer it to him ? As Professor Hare uses the word 'interest' it would, as I understand it, be in the man's interest to offer him the drug; though Professor Hare would hasten to add (thus transferring the argument to stage II) that, if the drug were distributed widely, it would be against the general interest. With this we may agree. The point is that many people (myself among them) would regard it as against the individual's interest quite independently of this further consideration. Why should we feel this ? Because we have a conception of what it is to be a complete human being and this includes the capacity to make responsible decisions, and it is against a man's interest to have this capacity impaired, even if he wants it to be. Some people might think otherwise; they might, for example, attach more importance to pleasure and the avoidance of pain than to self-determination, and I think one could discern behind this difference fairly fundamental differences in their overall philosophies of life. THE EXAMPLE OF ABORTION
Perhaps one can see a similar difference of approach in the case of abortion. As Professor Hare rightly points out in discussing this problem, the matter cannot be settled just by applying to it the rule which prohibits the taking of innocent human life. It has first to be shown that the fetus is, in the relevant sense, an innocent human life. Professor Hare recognizes that it is not just an arbitrary decision to call a fetus a human being: 'Fetuses, it may be said, are like human beings in certain important respects. But the question remains, Are these respects sufficient to make us include fetuses under the prohibition on murder? On this question no light has been shed by these verbal manoeuvres.' How could light be shed? It seems to me to be crucial to determine the question whether or to what extent the fetus shares the rights of a human being and that turns on the question whether or to what extent it is a human being. It is not enough, I think, to declare that it is like a human being - indeed at an early stage it is not much like a human being; one has also to bear in mind that it will in the ordinary course of nature 2See Personality and Science, pp IOO-IOI, for further discussion.
Is a moral consensus in medical ethics possible? 21 become quite unambiguously a human being. Some times faced with the choice between, eg, making will argue that the only safe principle, therefore, is life easier for the patient and diminishing his sense to treat the fetus as, in all respects, a human being of responsibility, where a decision imposes a from the start; others will use some such expression judgment as to which condition is best for the as 'potential human being' and claim that, in case patient. (It is this which makes not entirely unof conflict, its interests may justly be to some reasonable the wish expressed by some religious degree subordinated to those of human beings. By people to be treated by a psychiatrist who is himself contrast those who regard the fetus as entirely at religious.) the disposal of the mother seem to be committed to denying it any share in human status; and this OF PRESCRIBING THE CONTRACEPTIVE PILL FOR YOUNG might be because their ethic is experience-orientated GIRLS rather than person-orientated. If you attach The question of prescribing the contraceptive pill importance primarily to the person as such you for young girls has received a lot of publicity but will be impressed by the continuity between the comparatively little thorough discussion. It exempfetus and the person it is to become; if you attach lifies the situation, to which I referred earlier, importance to the person chiefly as the bearer of in which the medical profession is asked to provide experiences you will care less about the fetus, a service which is not directly related to the prowhich as yet has no experiences, and could normally motion of health or the cure of disease. There is be replaced by another potential bearer of an ethical question whether contraceptives should experiences. be made available to those who are arguably too young to have a responsible sexual relationship, Conflicting views of interests but whether it is primarily or at all a question of The problem of abortion is a peculiarly difficult one, medical ethics is open to dispute. Let us for a moment and it is arguable thatwhere people differ about it this look at the ethical problem itself, leaving aside the is not attributable to a difference of opinion as to what question whether it belongs to medical ethics. is in the interest of the fetus, but rather to a differ- Those who favour giving the pill to all who ask ence of opinion as to whether the fetus has interests for it, no matter what their age, argue their case on at all and, if it has, how they are to be weighed straightforwardly utilitarian grounds. If, they say, against other interests. Differences about interests the girl is going to have intercourse and nothing is can be more clearly discussed in two of the other going to stop her, it is better for her not to have a cases I mentioned earlier, that of mental health and baby. It is better also for society not to have unwanted babies and unmarried mothers, and it is of the child on the pill. better for the baby itself not to be born in these OF MENTAL HEALTH circumstances. The alternative to contraception is, It is notoriously difficult to achieve a value-free in any case, likely to be abortion, which itself ought concept of mental health. Baroness Wootton writes: to be avoided in the girl's own interest. Those who 'Long indeed is the road to be travelled before we think the pill should not be prescribed may appeal can hope to reach a definition of mental-cum- to utilitarian arguments as well, but will generally physical health, which is objective, scientific and not rely on them alone. They will urge that what wholly free of social value judgments' (Wootton, the girl proposes is in itself morally wrong, that, I959). She then quotes an authority on Japanese aside from this, she is not yet able to sustain a psychotherapy who remarks, 'The Japanese psycho- responsible relationship and is liable to suffer in analyst, faced with the problem of curing a mentally consequence. Moreover, the rights of the parents ill person, must first of all diagnose him as "ill" are being infringed. They are responsible for the because he does not adhere to the rigidly pre- bringing up of their children precisely because scribed culture patterns I have outlined. The children are judged not to be mature enough to "ccure" upon which the analyst then embarks make important decisions, yet here is a very constitutes the opposite of a cure by western important decision being taken without reference standards. Instead of endeavouring, as do occidental to them. In the case where the doctor concemed is psychoanalysts, to free the individual from his also their own doctor he has his duty to them to inner thongs, the Japanese analyst actually tightens consider as well as his duty to the child. those thongs.' (p 2IO). Social adjustment is, thereMoreover, and here there enters a utilitarian fore, a somewhat shaky criterion of mental health argument of the kind appropriate to Professor and one that is in any case increasingly hard to Hare's stage II, even if, in this individual case, the apply in a 'plural society'. No doubt in practice it best thing would be to prescribe the pill, this may is generally only necessary, and indeed only not be the best policy overall. For a society which possible, to free the individual from the more takes it for granted and tacitly accepts that unobvious psychological impediments which get in restricted premarital intercourse will occur is one the way of any kind of normal functioning. But it in which the incidence of it will tend to increase is hard to believe that the psychiatrist is not some- and spread to ever younger age groups. Since there
22 Basil Mitchell will always be a proportion of those at risk who will not take precautions, however readily available they are, the eventual number of unwanted babies or of abortions may well be greater than it would have been if attitudes had been less permissive from the start. I have not taken account of the legal age of consent; presumably it is a further charge on the doctor's conscience if he is conniving at the breaking of the law, though he may take the view that, in such a situation, the interests of his patient are paramount. THE INTERESTS OF THE INDIVIDUAL AND THE INTERESTS OF SOCIETY
There are, then, different views as to what ought to be done in such situations which reflect, to some extent at least, different views as to what is in the interest of those immediately concerned, and this is the main point I am trying to make. But there is also the further question, to what extent the medical profession as such should be expected to have a voice in the matter. The individual doctor has, of course, to make up his mind what he will do and he is bound to consider the interests of his patient, but would he be justified if he regarded it as essentially a personal decision to be dictated by his own conscience; or should he rather regard himself as acting in some sense as the agent of 'society' on the basis that his job is simply to carry out a policy agreed by other social agencies ? Or should such matters come within the ambit of a professional ethic consciously developed by the medical profession itself ? To sum up what I have been saying about interests. There would be general agreement with Professor Hare's contention that we must, other things being equal, do all we can to consult the interests of those immediately involved. I have been suggesting that not everyone would agree to defining a man's interests in terms of what he wants or would want if he were fully apprised of the situation. Of course that a man should get what he wants is, as a rule, in his interest but not always and not by definition. I would suggest that one's conception of what is in a man's interest is inevitably guided to some extent by one's view of human nature and this is affected by one's entire world view. This, if true, raises problems about the possibility of a moral consensus, which I will take up at the end of this article. ABSOLUTE VALUES AND UTILITARIAN PRINCIPLES
For the moment let me return to the second point at which it seems to me that Professor Hare's account requires to be modified, namely, in regard to what he says about principles. He aims to reconcile the 'absolutist' position with the 'utilitarian' one by distinguishing two stages in the argument. The first is the stage we have just been considering at which one concentrates on the
interests of those immediately concemed; the second is the stage at which one asks whether it would be in the general interest to decide the particular case in the way that seems best at the first stage. I cannot put it more clearly than, once again, in his own words: 'The point I am trying to make is that, even on the utilitarian view, there are certain principles which we ought all to try to preserve, and that anything which damages the general acceptance of them is always harmful; and that even though in some rare particular cases it might be more in the interests of the parties, taken as a whole, to break these principles, the good doctor and the good man simply will not consider doing it.' I said at an earlier point in my discussion that I doubted whether one could keep the two stages apart to the extent that Professor Hare tries to do. Suppose we take the often discussed but nevertheless genuine and important problem whether those who are dying should be told the truth about their condition. Most people, I think, would feel that an absolute rule is out of place and that in the particular case one must pay attention to everything that affects the patient's interest; also that one can and should be influenced by the likely effects in general of any policy one adopts in the present instance. In attending to the particular case some doctors will attach predominant importance to telling the truth, others to avoiding distress. Few would insist that the truth should be told no matter what its effect on the patient, and few would hold that the patient's feelings should be considered at no matter what cost to the truth. All would agree that one should avoid unnecessary distress, and that not to be caused unnecessary distress is clearly in the patient's interest. But the inclusion of the word 'unnecessary' implies that some distress might be necessary, because inevitably involved in something else that was in the patient's interest. And surely it is better for a man that he should know his situation, especially at a time when he may wish to be close to his family and to make his peace with them and with God. How often has one seen husband and wife divided by a well intentioned reluctance to tell the truth at such a time. It is also arguable that a general policy of telling the truth will strengthen the public confidence in doctors and hence benefit patients in the end; so that there is an independent utilitarian justification, of the sort Professor Hare has in mind, for a fairly strong, though not invariable, policy of telling the truth. All I am saying is that when considering the particular case in the first instance, before this utilitarian argument has come into the reckoning, one already has accepted the principle of tel!ing the truth, a principle which, though not absolute in the sense of being incapable of being overridden, nevertheless has its own independent weight. If you ask why, as a general rule, one should tell the truth, I think I should say
Is a moral consensus in medical ethics possible? 23 that fundamentally it has to do with the importance
of human communication which is both a good thing in itself and the necessary means to much else that is good in human life. I have said that people differ as to the relative importance they attach to truth and the avoidance of distress in such a situation and this difference does, I suggest, usually reflect different conceptions of human nature. Those, for instance, who, for whatever reason, regard self determination as an essential human characteristic, would tend to lay more stress on truth than those who do not. In fact I think one would find the same sort of disagreement and for the same sort of reasons as in the drug case I mentioned earlier.
A moral consensus in medical ethics is possible To return at last to the question, 'Is a moral consensus possible ?', taken in the context ofmedical ethics. I asked at the beginning, 'What use is the moral philosopher to medical ethics, if there is no chance of a consensus ?' Professor Hare says in his paper that moral philosophy is a controversial subject and puts forward his own theory as one that is admittedly controversial. I have differed from him on a number of points and it would not be difficult to find a moral philosopher who would differ from both of us. Would it not be better, then, to leave medical ethics to those who practise medicine rather than to call in such dubious assistance ? In reply to this I should want to say: i) That, for reasons I gave earlier, it has become increasingly difficult for doctors to rely on their unaided intuition, worthy of respect though that is. Technical developments have raised new problems; the scope of medical practice has widened beyond its traditional realms; there is less of a moral consensus in society at large. Once moral problems have come to the surface there really is no alternative to a careful examination of them unless you are prepared to ignore them. As Professor Hare makes clear, there is no question of philosophers simply providing the solutions - even if the medical profession would stand for it. But it is the job of philosophers to elucidate the meanings of words, to clarify arguments and, I would think also, to look for a coherent philosophy of life; so that their help should not be rejected out of hand. For their part philosophers not only have a duty to help if they can, but cannot expect to get to the bottom of moral problems without the assistance of those who have to face them daily in a position of responsibility. 2) I do not see any reason for believing that a consensus is in principle impossible, though I can only state this dogmatically now. Even my insistence in this article that moral attitudes may be influenced (quite properly) by the individual's entire philosophy of life does not imply that agreement could not conceivably be reached. It is more likely to be reached if people make the effort
of sympathetic imagination required to understand one another's standpoint than if they just agree to differ. A willingness on all sides, while not blurring differences, to do full justice to the other's position can often result at least in a convergence of opinion. 3) There is still in any case in our own society a very high degree of moral consensus in spite of the talk about a 'plural society'. This is easily overlooked because attention is concentrated very naturally on the points of contention. That we should relieve pain, respect life, tell the truth, preserve confidences, give weight impartially to competing interests, these and many other principles are not in dispute. Moral philosophers may disagree as to what is their rational basis and they may be subject to different interpretations, but philosophers have to accept them as given if they are to take morality seriously at all. If I had the opportunity of preparing this paper all over again I should try to argue that morality is based fundamentally on human needs, and that what C S Lewis once called the 'grand platitudes of practical reason' derive from the most obvious and inescapable of these; but that men also have needs that are less obvious, though no less important, and that our judgment about these inevitably reflects our conception of human nature. In our society the degree of moral consensus still, I think, goes beyond the platitudes, though less so than formerly. 4) It happens often (though not invariably) that when a complex moral issue has been thoroughly ventilated by people of different persuasions they will reach agreement about what should be done, although the reasons they offer are not entirely the same. Something of the sort must often occur on a jury or in a committee. This is no doubt sometimes because people are better at reaching a sensible judgment than they are at stating and analyzing their reasons; sometimes because the same conclusion may in fact follow from different premises. 5) In this connexion I think the method proposed by Professor Hare can offer help in reaching a consensus. If people can agree, as in practice they often can, about some of the factors which are important, these may form the basis for a utilitarian argument of the kind he described, which the parties can recognize as overriding their other differences. Finally, although, given the intrinsic difficulty of some of the problems and the genuine differences of standpoint that are to be found in our society, we shall not always agree, the habit of fair and sympathetic scrutiny of the opposing positions will at least ensure that those positions are held by their adherents in their most defensible forms and not in a blindly partisan fashion. References Hare, R M (in press). Medical ethics: Can the moral philosopher help ? Wootton, Barbara. (I959). Social Science and Social Pathology. George Allen and Unwin.
Is a moral consensus in medical ethics possible?' Basil Mitchell Oriel College, Oxford At the moment in Britain and elsewhere the debate inside and outside of Parliament on various medical issues which are essentially moral never ends. Everybody has his own point of view - or principles. But what emerges for society to adopt can often be called in lay terminology 'compromise'. Professor Mitchell argues in this paper that a moral consensus is possible and indeed ought to be achieved, as today the medical practitioner can no longer make his decision only in accordance with the strict code of ethics of the medical profession. The task of the philosopher, says Professor Mitchell, is to interpret the actions and attitudes demanded by modern medical practice. I wish to discuss the question of the possibility of a moral consensus in the context of the concern which is expressed in the title of Professor Hare's
lecture: 'Medical ethics: Can the moral philosopher help?' Its relevance is obvious. What use is the moral philosopher to medical ethics if there is no chance of a consensus? Yet it can scarcely be a secret that philosophers disagree more or less radically not only about concrete moral issues but about the scope and character of moral philosophy. Many of us, myself included, would prefer to rely on the ethical discriminations of an experienced doctor than upon those of a moral philosopher. And this is not particularly surprising. It very often happens that in practical situations the best judgments are made by people who have had repeatedly to make responsible choices in situations of the sort. This is especially the case when there exists a long and honourable tradition as there does in the medical profession. The moral position in medicine today Nevertheless this complete reliance upon a professional ethic of a largely intuitive kind, is I suggest, becoming increasingly difficult, for three reasons. i) There is less of a moral consensus in our society at large than there used to be. It is, some say, on the way to becoming, if it is not already, a 'plural society'. Hence moral positions which could once be taken for granted cannot be taken for 'This paper was originally delivered as a lecture to the London Medical Group in a series entitled: 'Moral
philosophy and medical ethics'. The opening lecture was delivered by Professor R M Hare under the title: 'Medical ethics: Can the moral philosopher help ?'.
granted quite so readily any longer. There are plenty of examples of controversy in the medical field: abortion, contraception, euthanasia, suicide and anything that has to do with sexual morality. 2) The scope of medical practice has been much enlarged and its aims therefore are less simply stated. It used to be the sole aim of medicine to cure disease and physical disease at that. Hence the aim was the patient's health; and physical health was not difficult to recognize, though it might be hard to define. But medical techniques may now be called upon for purposes which are not directly related to the health of the individual patient, eg, in relation to contraception, abortion, sterilization, penal treatment, sex changes and cosmetic operations of various kinds. Even in so far as the doctor's aim is still restoration to health there are problems as to what constitutes health, and, when not all the attributes of health are obtainable, which to prefer. This is especially the case with mental health. Is it, for example, more important that the patient should adjust to his environment or that he should 'be himself'; that he should be free from anxiety or that he should be responsible? How, particularly in a penal context, should the line be drawn between behavioural changes that may properly be induced by medical treatment and those that should be left to persuasion, including education ? 3) So long as the sole aim of medicine was the curing of disease, the doctor could claim without fear of contradiction that the entire field of medicine was subject to the ethics of his profession. Now there is a tendency on the part of many people to treat the doctor simply as a technician whose job it is to give the public what it wants. No doubt the conscience of the individual doctor has to be safeguarded, but the ethic of the medical profession as such is judged irrelevant. It is for society or the individual patient (who sees himself rather as a client or a consumer than as a patient) to determine whether a man should be sterilized, or a fetus aborted, or a child of I2 placed on the pill. To the extent that this attitude is accepted, medical ethics are no longer coextensive with medical practice. In any case, as the range of operations for which medical skill is required but which is not concerned with the cure of disease increases, there is a growing range of ethical problems which require discussion between the medical profession and others.
Is a moral consensus in medical ethics possible
Specific problems of medical research Let me add for good measure the problems that arise in connexion with medical research. The medical profession joins with non-medical scientists in research whose object is mainly the control of disease but also the expansion of knowledge for its own sake. Neither of these objectives can be identified with the interest of the individual patient who may nevertheless be involved in the research. The ethical problems associated with research may be divided into those which do and those which do not involve the individual patient. THOSE INVOLVING THE INDIVIDUAL PATIENT
The patient may be treated too much as a 'guinea pig'. The usual safeguard is to ensure that an independent doctor is clinically responsible for the patient, but is this enough? The use of controls would seem to require that some patients are not given treatment which on the available evidence is most likely to benefit them. In so far as they are given placebos they are in addition, presumably, deceived as to the treatment they are getting. THOSE NOT INVOLVING THE INDIVIDUAL PATIENT
The research may involve methods of doubtful morality. The whole question of vivisection and other experimental use of animals is relevant here. One does not have to be a fanatic to be disturbed by some reports of research into, eg, drug addiction in monkeys, involving them in degradation as well as suffering. Justification would presumably lie in the possible benefits to humans, but one is bound to ask whether there are limits to what can be justified in this way and whether it makes a difference that, in this case, the human ills for which relief is sought are self-induced. The research may be likely to endow men with powers which it is arguable that they would be better without, eg, to determine the sex of children or to bring an embryo to full term outside the womb. (It is worth noticing that a third aim of medical research is here involved: to extend human control over natural processes. Genetic manipulation would be another example.) Should such research go forward if its consequences are liable to be bad or largely unpredictable ? Are there, in any case limits, not based simply upon estimation of consequences, upon man's right to modify his basic biological constitution ? The application of moral philosophy to the medical debate For such reasons as these it is not, I think, possible, however much one would prefer it, to confine the discussion of medical ethics to the medical profession entirely or to rely on intuition backed by experience. New problems have arisen requiring
19g
fresh decisions and some of them at least are problems which clearly concern others as well as doctors. There is, as Professor Hare makes clear in his paper, no possibility of moral philosophers settling these questions on their own. They lack the technical knowledge and they lack the accumulated wisdom which, though no longer sufficient, are still necessary to the consideration of these problems. But I agree with Professor Hare in thinking that moral philosophers can make a useful contribution to a cooperative effort to solve these problems. He writes: '[The philosopher] comes in because moral problems, of which problems in medical ethics are an example, cannot be discussed without using a lot of words whose meaning and logical properties are not at all clear.... Philosophy is a training in the study of such tricky words and their logical properties, in order to establish canons of valid argument or reasoning, and so enable people who have mastered it to avoid errors in their reasoning (confusions or fallacies) and so answer their moral questions with their eyes open.' Words and arguments do not occur in a vacuum. Their meaning and their force is for the most part related to the contexts in which they are used, so that the philosopher has to become familiar with these contexts, which he can only do by listening to and sharing the discourse of those who are at work in them. As Professor Hare says: 'Philosophers cannot give their patients pills which the patients can just swallow. Philosophy itself is the medicine, and it has to be understood, to some degree at any rate, by the patient himself'. It is equally true that philosophers cannot write their prescriptions without knowing something about medicine and without sharing, at least in imagination, the predicament of the doctor. I think it would be fair to say that Professor Hare himself believes that philosophy, properly applied, can elicit a moral consensus. 'It is my belief', he writes, 'that once the issues are thoroughly clarified in this way [ie, so as to enable people to avoid errors in their reasoning (confusions or fallacies)] the problems will not seem so perplexing as they did at first, and, the philosophical difficulties having been removed, we can get on with discussing the practical difficulties which are likely to remain serious' 1. The consensus would be elicited in the following way. Those who are confronted by a practical problem calling for an ethical decision are invited to consider first what course of action would best serve the interests of those immediately concerned in this particular case and second whether, in the interests of society as a whole, it would be better if a general rule were adhered to which dictates a different action in this particular case. (A man's interest is taken to be, roughly, what he wants, or would want, if he were fully apprised of 'My square brackets and italics.
20 Basil Mitchell all the relevant facts). The problem of euthanasia provides an illustration. We can conceive situations in which the best thing for all concerned in a particular case would be to kill the patient, but cwe have to ask not only what is for the best on this particular occasion for the parties affected, but what is best for society as a whole. All the members of society are likely to be gravely harmed if doctors are brought up with such attitudes that they can even contemplate such an act. The interests of all are therefore best served if doctors simply put such thoughts out of their mind'. 'This', says Professor Hare, 'sounds like an absolutist kind of thing to say; but there are good utilitarian reasons for saying it.' Let me say at once that I agree entirely with all that Professor Hare says about the need to balance people's interests fairly but it seems to me that he oversimplifies at each of the stages that he distinguishes: I) the stage at which the question is, 'What is in the interest of the parties immediately involved?' and II) the stage at which he arrives at general principles. Indeed I doubt if it is possible to keep the two stages entirely apart in the way he tries to do. THE EXAMPLE OF EUTHANASIA
To take Professor Hare's own example of euthanasia, he argues that we normally have no hesitation in saying that it is in the interest of the patient and his family and associates that he should live, although we might in certain circumstances believe that it would be better for him if he were dead. Nevertheless, he suggests, we might be right in adhering to a strong general principle forbidding euthanasia because of the acknowledged dangers of letting this principle go. Now this mode of argument does have considerable force and I do not at all want to dispense with it, as will appear later. It has the very great practical advantage of carrying weight with people of rather different moral standpoints, and, to that extent, it does render a consensus easier. Nevertheless I suggest that it does not do justice to all the considerations that weigh with many opponents of euthanasia. They would say, I thinlk, that it is always or almost always in a man's interest to live because life is a value of a peculiarly fundamental kind as being the necessary condition for the enjoyment of all other values. They might insist on the sanctity of life; if they were Christians, as a gift from God; or, if they were humanists, because of man's dignity as a rational being. And they would believe these things to be true even of the man who wants to die. In other words, they would not regard the question whether it is in a man's interest to die as equivalent to the question whether he wants to die, even if this is further qualified so that it becomes 'wants to die or would want to die if he were fully apprised of all the relevant facts'.
It is not entirely easy to make the distinction clear in the case of life because in this instance the two conceptions of interest do so often and so obviously coincide. Most men most of the time want to live. Let us take another example also from within the medical field.2 Suppose a hypothetical non-addictive drug which permanently makes the taker more contented with his life and less capable of using his talents; if someone wished to take the drug, knowing that this would be its effect, would it be acting in his interest for another person to offer it to him ? As Professor Hare uses the word 'interest' it would, as I understand it, be in the man's interest to offer him the drug; though Professor Hare would hasten to add (thus transferring the argument to stage II) that, if the drug were distributed widely, it would be against the general interest. With this we may agree. The point is that many people (myself among them) would regard it as against the individual's interest quite independently of this further consideration. Why should we feel this ? Because we have a conception of what it is to be a complete human being and this includes the capacity to make responsible decisions, and it is against a man's interest to have this capacity impaired, even if he wants it to be. Some people might think otherwise; they might, for example, attach more importance to pleasure and the avoidance of pain than to self-determination, and I think one could discern behind this difference fairly fundamental differences in their overall philosophies of life. THE EXAMPLE OF ABORTION
Perhaps one can see a similar difference of approach in the case of abortion. As Professor Hare rightly points out in discussing this problem, the matter cannot be settled just by applying to it the rule which prohibits the taking of innocent human life. It has first to be shown that the fetus is, in the relevant sense, an innocent human life. Professor Hare recognizes that it is not just an arbitrary decision to call a fetus a human being: 'Fetuses, it may be said, are like human beings in certain important respects. But the question remains, Are these respects sufficient to make us include fetuses under the prohibition on murder? On this question no light has been shed by these verbal manoeuvres.' How could light be shed? It seems to me to be crucial to determine the question whether or to what extent the fetus shares the rights of a human being and that turns on the question whether or to what extent it is a human being. It is not enough, I think, to declare that it is like a human being - indeed at an early stage it is not much like a human being; one has also to bear in mind that it will in the ordinary course of nature 2See Personality and Science, pp IOO-IOI, for further discussion.
Is a moral consensus in medical ethics possible? 21 become quite unambiguously a human being. Some times faced with the choice between, eg, making will argue that the only safe principle, therefore, is life easier for the patient and diminishing his sense to treat the fetus as, in all respects, a human being of responsibility, where a decision imposes a from the start; others will use some such expression judgment as to which condition is best for the as 'potential human being' and claim that, in case patient. (It is this which makes not entirely unof conflict, its interests may justly be to some reasonable the wish expressed by some religious degree subordinated to those of human beings. By people to be treated by a psychiatrist who is himself contrast those who regard the fetus as entirely at religious.) the disposal of the mother seem to be committed to denying it any share in human status; and this OF PRESCRIBING THE CONTRACEPTIVE PILL FOR YOUNG might be because their ethic is experience-orientated GIRLS rather than person-orientated. If you attach The question of prescribing the contraceptive pill importance primarily to the person as such you for young girls has received a lot of publicity but will be impressed by the continuity between the comparatively little thorough discussion. It exempfetus and the person it is to become; if you attach lifies the situation, to which I referred earlier, importance to the person chiefly as the bearer of in which the medical profession is asked to provide experiences you will care less about the fetus, a service which is not directly related to the prowhich as yet has no experiences, and could normally motion of health or the cure of disease. There is be replaced by another potential bearer of an ethical question whether contraceptives should experiences. be made available to those who are arguably too young to have a responsible sexual relationship, Conflicting views of interests but whether it is primarily or at all a question of The problem of abortion is a peculiarly difficult one, medical ethics is open to dispute. Let us for a moment and it is arguable thatwhere people differ about it this look at the ethical problem itself, leaving aside the is not attributable to a difference of opinion as to what question whether it belongs to medical ethics. is in the interest of the fetus, but rather to a differ- Those who favour giving the pill to all who ask ence of opinion as to whether the fetus has interests for it, no matter what their age, argue their case on at all and, if it has, how they are to be weighed straightforwardly utilitarian grounds. If, they say, against other interests. Differences about interests the girl is going to have intercourse and nothing is can be more clearly discussed in two of the other going to stop her, it is better for her not to have a cases I mentioned earlier, that of mental health and baby. It is better also for society not to have unwanted babies and unmarried mothers, and it is of the child on the pill. better for the baby itself not to be born in these OF MENTAL HEALTH circumstances. The alternative to contraception is, It is notoriously difficult to achieve a value-free in any case, likely to be abortion, which itself ought concept of mental health. Baroness Wootton writes: to be avoided in the girl's own interest. Those who 'Long indeed is the road to be travelled before we think the pill should not be prescribed may appeal can hope to reach a definition of mental-cum- to utilitarian arguments as well, but will generally physical health, which is objective, scientific and not rely on them alone. They will urge that what wholly free of social value judgments' (Wootton, the girl proposes is in itself morally wrong, that, I959). She then quotes an authority on Japanese aside from this, she is not yet able to sustain a psychotherapy who remarks, 'The Japanese psycho- responsible relationship and is liable to suffer in analyst, faced with the problem of curing a mentally consequence. Moreover, the rights of the parents ill person, must first of all diagnose him as "ill" are being infringed. They are responsible for the because he does not adhere to the rigidly pre- bringing up of their children precisely because scribed culture patterns I have outlined. The children are judged not to be mature enough to "ccure" upon which the analyst then embarks make important decisions, yet here is a very constitutes the opposite of a cure by western important decision being taken without reference standards. Instead of endeavouring, as do occidental to them. In the case where the doctor concemed is psychoanalysts, to free the individual from his also their own doctor he has his duty to them to inner thongs, the Japanese analyst actually tightens consider as well as his duty to the child. those thongs.' (p 2IO). Social adjustment is, thereMoreover, and here there enters a utilitarian fore, a somewhat shaky criterion of mental health argument of the kind appropriate to Professor and one that is in any case increasingly hard to Hare's stage II, even if, in this individual case, the apply in a 'plural society'. No doubt in practice it best thing would be to prescribe the pill, this may is generally only necessary, and indeed only not be the best policy overall. For a society which possible, to free the individual from the more takes it for granted and tacitly accepts that unobvious psychological impediments which get in restricted premarital intercourse will occur is one the way of any kind of normal functioning. But it in which the incidence of it will tend to increase is hard to believe that the psychiatrist is not some- and spread to ever younger age groups. Since there
22 Basil Mitchell will always be a proportion of those at risk who will not take precautions, however readily available they are, the eventual number of unwanted babies or of abortions may well be greater than it would have been if attitudes had been less permissive from the start. I have not taken account of the legal age of consent; presumably it is a further charge on the doctor's conscience if he is conniving at the breaking of the law, though he may take the view that, in such a situation, the interests of his patient are paramount. THE INTERESTS OF THE INDIVIDUAL AND THE INTERESTS OF SOCIETY
There are, then, different views as to what ought to be done in such situations which reflect, to some extent at least, different views as to what is in the interest of those immediately concerned, and this is the main point I am trying to make. But there is also the further question, to what extent the medical profession as such should be expected to have a voice in the matter. The individual doctor has, of course, to make up his mind what he will do and he is bound to consider the interests of his patient, but would he be justified if he regarded it as essentially a personal decision to be dictated by his own conscience; or should he rather regard himself as acting in some sense as the agent of 'society' on the basis that his job is simply to carry out a policy agreed by other social agencies ? Or should such matters come within the ambit of a professional ethic consciously developed by the medical profession itself ? To sum up what I have been saying about interests. There would be general agreement with Professor Hare's contention that we must, other things being equal, do all we can to consult the interests of those immediately involved. I have been suggesting that not everyone would agree to defining a man's interests in terms of what he wants or would want if he were fully apprised of the situation. Of course that a man should get what he wants is, as a rule, in his interest but not always and not by definition. I would suggest that one's conception of what is in a man's interest is inevitably guided to some extent by one's view of human nature and this is affected by one's entire world view. This, if true, raises problems about the possibility of a moral consensus, which I will take up at the end of this article. ABSOLUTE VALUES AND UTILITARIAN PRINCIPLES
For the moment let me return to the second point at which it seems to me that Professor Hare's account requires to be modified, namely, in regard to what he says about principles. He aims to reconcile the 'absolutist' position with the 'utilitarian' one by distinguishing two stages in the argument. The first is the stage we have just been considering at which one concentrates on the
interests of those immediately concemed; the second is the stage at which one asks whether it would be in the general interest to decide the particular case in the way that seems best at the first stage. I cannot put it more clearly than, once again, in his own words: 'The point I am trying to make is that, even on the utilitarian view, there are certain principles which we ought all to try to preserve, and that anything which damages the general acceptance of them is always harmful; and that even though in some rare particular cases it might be more in the interests of the parties, taken as a whole, to break these principles, the good doctor and the good man simply will not consider doing it.' I said at an earlier point in my discussion that I doubted whether one could keep the two stages apart to the extent that Professor Hare tries to do. Suppose we take the often discussed but nevertheless genuine and important problem whether those who are dying should be told the truth about their condition. Most people, I think, would feel that an absolute rule is out of place and that in the particular case one must pay attention to everything that affects the patient's interest; also that one can and should be influenced by the likely effects in general of any policy one adopts in the present instance. In attending to the particular case some doctors will attach predominant importance to telling the truth, others to avoiding distress. Few would insist that the truth should be told no matter what its effect on the patient, and few would hold that the patient's feelings should be considered at no matter what cost to the truth. All would agree that one should avoid unnecessary distress, and that not to be caused unnecessary distress is clearly in the patient's interest. But the inclusion of the word 'unnecessary' implies that some distress might be necessary, because inevitably involved in something else that was in the patient's interest. And surely it is better for a man that he should know his situation, especially at a time when he may wish to be close to his family and to make his peace with them and with God. How often has one seen husband and wife divided by a well intentioned reluctance to tell the truth at such a time. It is also arguable that a general policy of telling the truth will strengthen the public confidence in doctors and hence benefit patients in the end; so that there is an independent utilitarian justification, of the sort Professor Hare has in mind, for a fairly strong, though not invariable, policy of telling the truth. All I am saying is that when considering the particular case in the first instance, before this utilitarian argument has come into the reckoning, one already has accepted the principle of tel!ing the truth, a principle which, though not absolute in the sense of being incapable of being overridden, nevertheless has its own independent weight. If you ask why, as a general rule, one should tell the truth, I think I should say
Is a moral consensus in medical ethics possible? 23 that fundamentally it has to do with the importance
of human communication which is both a good thing in itself and the necessary means to much else that is good in human life. I have said that people differ as to the relative importance they attach to truth and the avoidance of distress in such a situation and this difference does, I suggest, usually reflect different conceptions of human nature. Those, for instance, who, for whatever reason, regard self determination as an essential human characteristic, would tend to lay more stress on truth than those who do not. In fact I think one would find the same sort of disagreement and for the same sort of reasons as in the drug case I mentioned earlier.
A moral consensus in medical ethics is possible To return at last to the question, 'Is a moral consensus possible ?', taken in the context ofmedical ethics. I asked at the beginning, 'What use is the moral philosopher to medical ethics, if there is no chance of a consensus ?' Professor Hare says in his paper that moral philosophy is a controversial subject and puts forward his own theory as one that is admittedly controversial. I have differed from him on a number of points and it would not be difficult to find a moral philosopher who would differ from both of us. Would it not be better, then, to leave medical ethics to those who practise medicine rather than to call in such dubious assistance ? In reply to this I should want to say: i) That, for reasons I gave earlier, it has become increasingly difficult for doctors to rely on their unaided intuition, worthy of respect though that is. Technical developments have raised new problems; the scope of medical practice has widened beyond its traditional realms; there is less of a moral consensus in society at large. Once moral problems have come to the surface there really is no alternative to a careful examination of them unless you are prepared to ignore them. As Professor Hare makes clear, there is no question of philosophers simply providing the solutions - even if the medical profession would stand for it. But it is the job of philosophers to elucidate the meanings of words, to clarify arguments and, I would think also, to look for a coherent philosophy of life; so that their help should not be rejected out of hand. For their part philosophers not only have a duty to help if they can, but cannot expect to get to the bottom of moral problems without the assistance of those who have to face them daily in a position of responsibility. 2) I do not see any reason for believing that a consensus is in principle impossible, though I can only state this dogmatically now. Even my insistence in this article that moral attitudes may be influenced (quite properly) by the individual's entire philosophy of life does not imply that agreement could not conceivably be reached. It is more likely to be reached if people make the effort
of sympathetic imagination required to understand one another's standpoint than if they just agree to differ. A willingness on all sides, while not blurring differences, to do full justice to the other's position can often result at least in a convergence of opinion. 3) There is still in any case in our own society a very high degree of moral consensus in spite of the talk about a 'plural society'. This is easily overlooked because attention is concentrated very naturally on the points of contention. That we should relieve pain, respect life, tell the truth, preserve confidences, give weight impartially to competing interests, these and many other principles are not in dispute. Moral philosophers may disagree as to what is their rational basis and they may be subject to different interpretations, but philosophers have to accept them as given if they are to take morality seriously at all. If I had the opportunity of preparing this paper all over again I should try to argue that morality is based fundamentally on human needs, and that what C S Lewis once called the 'grand platitudes of practical reason' derive from the most obvious and inescapable of these; but that men also have needs that are less obvious, though no less important, and that our judgment about these inevitably reflects our conception of human nature. In our society the degree of moral consensus still, I think, goes beyond the platitudes, though less so than formerly. 4) It happens often (though not invariably) that when a complex moral issue has been thoroughly ventilated by people of different persuasions they will reach agreement about what should be done, although the reasons they offer are not entirely the same. Something of the sort must often occur on a jury or in a committee. This is no doubt sometimes because people are better at reaching a sensible judgment than they are at stating and analyzing their reasons; sometimes because the same conclusion may in fact follow from different premises. 5) In this connexion I think the method proposed by Professor Hare can offer help in reaching a consensus. If people can agree, as in practice they often can, about some of the factors which are important, these may form the basis for a utilitarian argument of the kind he described, which the parties can recognize as overriding their other differences. Finally, although, given the intrinsic difficulty of some of the problems and the genuine differences of standpoint that are to be found in our society, we shall not always agree, the habit of fair and sympathetic scrutiny of the opposing positions will at least ensure that those positions are held by their adherents in their most defensible forms and not in a blindly partisan fashion. References Hare, R M (in press). Medical ethics: Can the moral philosopher help ? Wootton, Barbara. (I959). Social Science and Social Pathology. George Allen and Unwin.
