International Congress on Medical Ethics, Teheran

Talk by Jonathan Glover: Choosing Between Competing Ethical Theories

1. INTRODUCTION.

Medical ethics is controversial because the practice of medicine raises very difficult dilemmas, where good people disagree about what is right, and often a single person is pulled both ways. Some dilemmas are about honesty: how far should a doctor be completely honest in telling a patient about the high probability that his or her condition will result in death? There is a tension between being truthful and wanting to spare the patient distress. Some dilemmas arise out of a conflict between the interests of a patient and others in the society. If the doctor knows a male patient has a sexually transmitted disease (perhaps AIDS), should the patient's wife (perhaps another of the doctor's patients) be warned, or should the first patient's confidentiality be respected? A similar problem is raised if the patient has epilepsy and is planning to drive without telling the authorities of his condition. There is a tension between respecting confidentiality and the thought that other lives are at risk.

Some dilemmas are about life and death. When, if ever, is abortion justified? How far should doctors go in using technology to prolong life when someone has a fatal and painful condition? When resources are scarce, and not everyone can be given life-saving treatment, how should the decision be reached as to whose life is saved? Other issues arise out of the application of technology to the creation of life. How far should we use such techniques as in vitro fertilisation? Should people be allowed to choose the sex of their child? In taking these difficult decisions, some doctors go by intuition, by what feels right to their conscience. Other doctors think that it is not enough to go by such feelings or intuition, and that some account is needed of what is a good reason for choosing one way rather than another. One of the tasks of philosophers is to think about the difference between good and bad reasons for doing things. And philosophers have come up with general approaches which do give guidance in these medical dilemmas. The difficulty is that there are different general approaches, which give different answers to some of the medical questions.

One approach is utilitarianism, which says that an action is right to the extent that it increases happiness and reduces misery. This makes actions not right or wrong in themselves, but right or wrong according to their consequences. Among the practical problems for such a theory are the difficulty of measuring happiness and misery, and the difficulty of being confident about exactly what the consequences of an act will be. But, in a rough and ready way, we often have enough idea of the likely effects of an action for utilitarianism to be a broad guide in many medical dilemmas. For instance, in cases of a very painful fatal illness, utilitarianism suggests that it would be wrong to use technology to prolong life unnecessarily.

Another approach suggests that there are duties which have to be carried out independently of any assessment of the consequences of doing so. Some think, for instance that it is the duty of a doctor to preserve life, and that questions of the pain or misery that may be involved are irrelevant. This approach clearly disagrees with the utilitarian view in the case of the patient with the terminal illness.

Another view is that people have rights, which must be respected. If the rights include, for instance, the patient's right to confidentiality, this must be respected. Even if the doctor staying silent leads to others being harmed (the wife of the man with the sexually transmitted disease, or the person injured in the car crash caused by the driver's epilepsy) the right to confidentiality must still be respected. One problem for this view is to give an account of how it is decided what rights people have. Another problem arises where different rights are in conflict. For instance, if there is a right to life, is it a possible violation of the wife's right to life not to tell her that her husband has AIDS? Rights theories conflict with utilitarianism. In some cases, the best consequences, in terms of happiness and misery, may be brought about by performing an abortion. But, if the foetus has a right to life, this must be respected regardless of any utilitarian calculation of consequences.

Each of these views gives guidance in medical dilemmas. But the fact that there are rival approaches giving different guidance is less helpful. The obvious next question is whether it is possible to gain a higher vantage point from which to decide between these rival views. Does any of them have firmer foundations than the others?

2. THE SEARCH FOR FOUNDATIONS.

One way of giving foundations to morality is by appealing to a moral authority. In different cultures, the moral authorities have varied, but they are often religious authorities, either institutions or people or books thought to have divine inspiration. One problem with such an approach is that there will often be disputed questions about how to interpret the views of the authority and how to apply them in specific cases. There is also a deeper problem. The decision that it is right to accept a particular person, institution or book as a moral authority is itself a moral one. And this moral decision seems to need justification, yet it is hard to see how such a justification could appeal to the moral authority without circularity.

Another approach is to attempt to base morality on reason. In Europe, one great exponent of this approach was Immanuel Kant. He believed there is an objective moral law, which can be discovered by reason, rather in the way that objective mathematical truths are discovered by reason. An objective moral law must be universal: its rules must be ones which everyone can obey. Kant thought this was the key to how the moral law can be discovered by reason. The question to ask about any act is "Could everyone do that?" Many actions would be self-defeating if everyone did them. Consider borrowing money, and breaking the promise to pay it back. If everyone tried to do this, they would not succeed. So many broken promises would mean that people would stop believing in them and would no longer lend money. Kant thought that immoral acts could be recognised by this purely rational test: that they have the feature of not being ones everyone could do.

There are several problems with this attempt to provide a rational basis for ethics. One is that everything depends on how the act is described. If all doctors always lied to terminally ill patients, this might be self-defeating, as no-one would trust them any more. But if the act is described in more detail, for instance as "lying to a patient with terminal cancer, and who would be devastated to know the truth", it is less clear that this could not be a universal policy. The test is inconclusive, as it gives different answers to the same case differently described. There is also a question about whether it is true that all immoral acts are self-defeating when universalised. Also, the test at best provides a filter, excluding some actions because they could not be universally carried out. There still may be a range of alternative actions which all pass the test, and so the guidance given is incomplete. The idea of a purely rational basis for ethics is attractive, but the fact that Kant's attempt to provide it is flawed is discouraging. This does not show that no attempt could succeed, but it is not clear that any other attempt has been more successful.

Another attempt to provide foundations for ethics appeals to human interests and needs. (Utilitarianism is one theory of this kind.) But there is a question which may be asked about the whole project: if someone does not think human needs and interests matter, what reason can be given to show that they do? As with basing ethics on appeals to authority, this particular foundation seems to leave a question unanswered at a deeper level.

None of these attempts to provide foundations seems decisive. This suggests a further thought: perhaps searching for foundations is not the best way to think about ethics?

3. ETHICS WITHOUT FOUNDATIONS.

Looking for foundations is to try to find axioms from which particular ethical claims can be derived, in the way theorems in geometry are derived from Euclidean or other axioms. But perhaps the axiomatic approach is not the right one? An alternative approach is to start in the middle. In many practical disciplines, architecture for instance, we do not think that competence consists in obeying rules which are derived from axioms. The skills of an architect are learnt in practice, and consist of such things as developing a feel for materials, shapes and volumes, and knowing what will cohere with what. A similar approach is possible in ethics. If, for the moment at least, we put aside the search for foundations, what we have to start with are two kinds of things: our intuitive responses to particular cases, and some general principles we find plausible. Making use of these intuitions and principles, and especially by bringing them into contact with each other, we can start to discover a lot about what we most deeply value. But with both of them, for our knowledge to grow we have to be active in our thinking, and not just accept either intuitions or principles passively and uncritically. Kant said about science and philosophy that we have to interrogate nature not like a pupil but like a judge. This applies to interrogating our ethical intuitions and principles as well.

Start with our intuitions. Take life and death cases. We do not always have the same intuitions, but virtually all of us have some. For instance, most of us have the intuition that a doctor, deciding whether to keep some very seriously ill patient alive, should never let the patient die because the patient has left some money to the doctor in a will. Many of us have a different intuition about abortion in a case where a young girl has been raped from the one we have in a case where a woman wants an abortion because the pregnancy will interfere with a holiday. Some people think these moral intuitions are the voice of conscience, and that they are all we need. If we have these intuitions in particular cases, why bother with general principles? Why not just be guided by our intuitions?

One reason for doubt about this is that different people have different intuitions. If we are to discuss medical ethics (or any other part of ethics) rationally, we need to have more to say than just "this is how I feel". We need reasons if our intuitions are not to be mere prejudices. Another reason for doubt is that, even for a single person, intuitions may not be consistent: they may turn out to conflict with each other. To take an illustration from a field outside medical ethics, many people have the intuition that taxes should be reduced. But often the same people have the intuition that the government should provide better schools, hospitals and roads. Of course, these intuitions could be made consistent, by support for savings in other areas of spending, or by some way of making national income grow. But most people do not have these ways of rescuing consistency: their intuitions simply do not form a consistent whole. In ethics, unless we stand back from our intuitions and criticise them, there is a real danger that our approach is open to the same criticism.

Let us turn now to principles. Again we should not passively accept the principles which at first sight seem plausible. Our principles too need to be interrogated not like a pupil but like a judge. One principle which many of us are attracted to is that of the sanctity of life. Most of us have a deep intuitive revulsion against killing people. If we are asked why killing people is wrong, it is tempting to say that the reason is that life is sacred. But, as soon as we have said this, questions can be asked. Is all life sacred? Even that of plants and insects? Surely it is not murder to pull up a weed or to kill a mosquito? The principle needs to be reformulated. Perhaps we should say, "Taking human life is always wrong". But this too raises questions. Is taking human life always wrong? Even in self defence? Even in a just war? And what copunts as human life? Someone who has irreversibly lost consciousness is human, and his or her heart may still be beating. By traditional criteria such a person is alive. But is it clear we want our principle to exclude turning off life support machines in such a case? On this case, different people have different intuitions. I am not here taking sides on the case, but saying that we need to think about it in formulating an adequate principle about the wrongness of killing. An adequate principle should have something to say about what cases do or do not count as exceptions to the prohibition on killing and there should be reasons for inclusions and exclusions.

When we start to think about our principles, things usually turn out to be more complicated than we expected. The principle when simply formulated may have implications which we find intuitively unacceptable. (For instance that it is wrong to kill a mosquito.) Then, if we are rational enough to care about consistency, something has to give. Either we have to reject our intuition, or we have to abandon or modify our principle. In taking the decision which to do, we find out a lot about our values, about what we most deeply care about. By this process of exploration, of mutual adjustment of principle and intuition, each person may hope to reach what John Rawls has called "reflective equilibrium": a state where intuitions and principles, both criticised and modified, may be in harmony with each other. Perhaps it is something of an idealisation to hope that anyone fully reaches this happy state, but at least we can get closer to it and, in doing so, develop a more coherent set of values.

But this alone will not be enough to settle disagreements between different people. Your coherent set of values may differ from the equally coherent values of someone else. Here reasoning can come in. Where two of us disagree, we can each go through the reasoning which led us to our own view. I can press you as to whether you really find acceptable all the consequences of the principles you adopt. And you can do the same to me. (We are both using the method of thinking about ethics introduced into philosophy by Socrates, and which still seems to me perhaps the greatest thing philosophy has to teach.) In such discussions, sometimes you may give a bit of ground, and sometimes I may do so. We may hope to make some progress towards agreement. It is my experience that often real progress is made. But it has to be said that there is no guarantee that, in the end, all people of good will must agree. There is the real possibility of ultimate disagreement about some things. We can always go on trying to reach agreement, and sometimes our success proves that it would have been a mistake to have given up too soon. But we may not always succeed. I know people, who I greatly respect, whose views are very different from mine, and sometimes the differences survive long and thorough reasoning and discussion. The method of Socrates gives the hope of agreement, but not the certainty of it.

4. THE CONVERSATION OF MANKIND.

In one way, this conclusion embarrasses me. I was asked to talk today about how to choose between competing ethical theories. If anyone hoped that I would be able to talk about some decisive test, some ultimate criterion or foundation, they will have been disappointed. But, in the absence of any decisive test, we can still make real progress. The method of Socrates has not yet been exhausted. We may hope for some further convergence between people, as continuing discussion lays bare the underlying structure of alternative approaches. We still have a long way to go in thinking through the questions of ethics.

The continuing discussion of these perennial questions, which follows from our inability to reach immediate agreement, is not something entirely to regret. This ethical discussion is part of what has been called "the conversation of mankind". A large group of people meets in an assembly room for a discussion. Sometimes one person has the floor, and sometimes everyone talks at once. Sometimes there is angry shouting, sometimes a murmur that suggests great seriousness. Sometimes there are friendly exchanges and sometimes the discussion is interrupted by laughter. Because the meeting goes on for a long time, some people leave, but others come in to take their place. We, the human race, have been talking to each other, and arguing with each other, about right and wrong as far back as there are historical records. And, because some of the earlier contributions have been written down, we are engaged in a conversation, not just with each other, but with people of other times. We can learn from them, and to some extent hope to see further by standing on their shoulders. The conversation is not by any means over yet, and we do not know what progress is still to be made.

Even apart from the greater understanding we may hope for, it seems to me that to take part in this conversation at all is something marvellous. This continuing human conversation about right and wrong is itself one of the reasons why it is good to be human. It is part of the slow process by which the human race becomes more thoroughly awake. As a teacher of philosophy arguing with my students, or as a person discussing ethics with my wife, my children, or my friends, I feel very lucky to be playing an infinitessimally small part in this extraordinary conversation. One thing about the conversation is that we can all take part. It is a huge room and there is all the time in the world. So the conversation, which at earlier times in other places included Socrates and Kant, also includes, in a very modest way, us talking to each other today in Teheran.

There are some things which make the conversation go better, and which make progress more likely. One is tolerance. We should aim for a climate where people feel free to say things we may not like. The original contributions to the conversation are often the ones which at first people find disturbing. They may be the ones we have most to learn from, and we will be the ones to gain if we create a climate where they too are listened to. We should not forget that Socrates, one of the past contributors to the conversation, and whose marvellous way of thinking I have drawn on, was executed because his ideas seemed shocking to his contemporaries. When we are inclined to respond to someone's ideas with intolerance, we need to ask ourselves if we can be sure that our judgment is less fallible than that of the Athenians.

The other thing I can think of which makes the conversation go well is the willingness to listen sympathetically. We all know people who talk all the time, giving their own opinions on all subjects, and not listening in turn. But, when a different style of conversation is adopted, surprising possibilities of agreement may appear. In Leo Tolstoy's book Anna Karenina, there is a passage about this, expressed in the thought of one of the characters: "Levin had often noticed in discussions between the most intelligent people that after enormous efforts, and endless logical subtleties and talk, the disputants finally became aware that what they had been at such pains to prove to one another had long ago, from the beginning of the argument, been known to both, but that they liked different things, and would not define what they liked for fear of its being attacked. he had often had the experience of suddenly in the middle of a discussion grasping what it was the other liked and at once liking it too, and immediately found himself agreeing, and then all arguments fell away useless. Sometimes the reverse happened: he at last expressed what he liked himself, which he had been arguing to defend and, chancing to express it well and genuinely, had found the person he was disputing with suddenly agreed."

Medical ethics, as part of the conversation of mankind, brings together people of different disciplines: doctors, nurses, philosophers, theologians and lawyers, as well as linking us with those who thought about these issues in the past. But, of course, the conversation of mankind far transcends medical ethics. I like to think that this Congress also transcends medical ethics. Part of the conversation of mankind takes place across the boundaries between different cultures and different religious traditions. I hope that in this Congress we can contribute to this.

As you, our hosts, and we, your guests, talk to each other, we know that we do so against a background of relations between our countries which has not always been happy, and that there are still disagreements. It means a lot to me that, against this background, you have extended the hand of friendship by inviting us. I hope that we can reciprocate, so that out of our discussions can grow a real intellectual friendship. Friendship does not mean that we will agree about everything. There are layers of friendship. At first there is often a politeness, where topics of disagreement are avoided. But, as the friendship grows, it starts to become possible to discuss more and more. Disagreements do not disrupt the friendship because both sides see the good will that lies behind what is said. Openness, even about disagreements, is compatible with friendship and is also the way to make progress in the conversation of mankind. It is my hope that some of us in this Congress may make a start on this kind of friendship. And, if we manage to listen sympathetically to each other, and to express ourselves well and genuinely, we may like Levin, find ourselves seeing what the other likes and liking it too, so that all arguments fall away useless.