Volume 2, Issue 5 -- July 1999

Bioethics and Philosophy

Members of different health professions are increasingly bringing their own particular expertise to bioethical discussions and decision making. Once the wild and relatively unexplored terrain of lawyers and philosophers, bioethics is fast becoming more widely accepted as an area of necessary and informed discussion for all health professionals.

In this changing context, it may be useful to back up for a moment and to ask what particular benefits philosophy brings to bioethical discussions and decision making. Many readers of In Touch will perhaps have endured - perhaps even enjoyed - a bioethics course taught by a philosophy professor. For those who have, I hope the following comments will serve to put what you learned into a broader, more historical perspective. For those who haven't, let what I say below serve as an introduction to one important way in which you might approach discussions about differing values in the delivery of health services.

Philosophy and Ethics

From the beginning of recorded history, philosophy has concerned itself with the most basic questions of human existence, questions about the existence of God, the meaning of life, and the nature of truth and human knowledge. Ethics is the branch of philosophy that concerns itself most directly with ultimate questions about the good and the right: what is it, ultimately, that makes good things good, and right things right?

For much of the twentieth century, philosophy, and ethics along with it, was caught up in debates about language and meaning. For example, when we say that something is good, what exactly do we mean by this? Do we mean that the thing in question has some particular property all on its own, quite apart from its relationship to us, or do we mean to be saying something about ourselves, namely, that we like the thing in question?

An example will help here. Many of us would say that friendship is a good thing. But is friendship good because of something about it, or because of something about us? When we declare friendship to be a good thing, are we saying something that is true about us, namely, that we find friendship to be to our liking, or are we saying something about friendship, that it is good in and of itself, whether we happen to like it or not?

As engaging as such questions might be for abstract reflection, if philosophy had continued on this tack it would not have much to tell health professionals. But in the 1970s, philosophical ethics shifted course and turned its attention away from questions of meaning to more applied questions about good and bad, right and wrong. A watershed book was John Rawls' A Theory of Justice, published in 1971.

Rawls' main conclusion in his book was that in a just society, wealth and income should be distributed fairly among all members of society. Depending on what one means by fairness, this may or may not be a startling conclusion. But Rawls' book is perhaps more important for how he reached his conclusion rather than for the conclusion itself. His approach was to balance our considered judgments about justice, judgments that are more or less settled as a matter of social debate, with whatever deeper principles of justice we would agree to in a hypothetical situation that was specially constructed to rule out personal bias.

By considered judgments, Rawls meant beliefs that through social upheaval and debate have become widely accepted as being true: for example, that racism is wrong, or that freedom of conscience ought to be a fundamental right in any free and democratic society. By deeper principles of justice, Rawls had in mind general social rules, enforced by governments, for determining who should get what. To broker agreement on deeper principles of justice, Rawls thought citizens in a democracy should reason from a morally neutral point of view.

Suppose, hypothetically, that we did not know our current position, whether social, cultural, economic or other, in society. But suppose that we did know that whatever our position, we would be concerned to have available to us the material resources necessary to pursue our own individual idea of the good life. From this neutral perspective, what deeper principles of justice would we choose to distribute wealth and income? And could these principles be balanced with our considered judgments to form a consistent set of beliefs about social justice?

Rawls thought that the answer to this last question was yes, and that the process of balancing considered judgments with hypothetical reasoning from a morally neutral point of view led to a set of principles he called "justice as fairness."

Fairness, alas, is another discussion for another day. Our focus here is on Rawls' general approach to deeper questions about social justice, since it is this general approach that I think is one of the most important things philosophy brings to discussions in bioethics.

In a bioethical discussion where values differ, the first thing a philosopher will want all parties in the discussion to do is to clarify, and to balance, the set of values that each individual brings to the discussion. How do the different value judgments involved in the discussion square with other, more settled value judgments? Are some a better fit than others? Secondly, suppose one were to take an unbiased view of the situation. Suppose, that is, that one didn't know one's own values, but knew that whatever values each person involved in the situation held, these values would matter greatly to that particular person. From this morally neutral point of view, how might the situation best be resolved, for all those involved?

Rawls' approach was to balance our considered judgements about justice, with deeper principles of justice agreed to in a hypothetical situation constructed to rule out personal bias.

Rawls thought that from a morally neutral point of view we could all agree on one set of principles of social justice. The idea of the preceding paragraph is that from a morally neutral point of view, a point of view that includes other more settled value judgments, all parties to a disagreement about personal or professional values might be able to agree on a single, best resolution of their situation. While this resolution might not be in perfect accord with everyone's values, it might still be the best resolution of the differences that personally or professionally separate the individuals involved. Adopting a morally neutral point of view may enable each to see the importance the others attach to their own values, and it may thus help everyone involved to agree on the question of whose values should take precedence in the situation before them.

Let me conclude by saying that this is only one philosophical approach to questions about conflicting values. My discussion of this particular approach is meant to highlight the fact that people can productively disagree about values. Such disagreements can lead us to a better understanding of our own values, as well as the values of others. Better understanding often brings with it greater tolerance for different values, and sometimes, a resolution of a value conflict that everyone involved can live with, even if not fully endorse.

But sometimes not, and not all philosophers would endorse this particular approach to conflicting values, or this approach alone. What I hope to have provided for readers of In Touch is one idea of how philosophy can move bioethical discussions forward, if not toward perfect agreement, then at least toward a resolution that is tolerable for all those involved.

Upcoming Conference

This year, the Canadian Bioethics Society will be hosting its annual conference in Edmonton from October 28-31, 1999. One of the highlights of the conference will be the participation of members of the Board of the International Association of Bioethics.

Members of the IAB Board will participate in a one day pre-conference that will explore the boundaries of health ethics in a global context addressing issues relating to the possibility of a global bioethic. The impact that economic position has on the discussion of ethical issues and the role of cultural values in the conception and practice of health ethics will be explored.

Two post-conferences will also be held following the CBS meeting. The post-conferences are entitled "Ethics, Health Care, and Resources at the End of Life" and "The Ethics of Health Research Using Qualitative Methods" respectively.

The next early bird registration deadline for the CBS conference is September 10, 1999. For more information, including the registration form, please visit the conference website at http://www.ualberta.ca/~cbs1999/index.html.  

PHEN Board Appointments

The PHEN Board is pleased to announce the appointment of Marg Brewin, Co-ordinator for Palliative Care, Chinook Region, to the Board. Joe MacGillivray, CEO of St. Mary's Health Care Centre in Trochu, has been re-appointed to the PHEN Board for a second three-year term. In addition, the Council of Chairs of the RHAs has confirmed Campbell Miller as an RHA-appointed PHEN Board member for a two-year term. The terms of the following board members expired as of May 1999: Brad Neubauer, Eileen Smyth, Hazel Anaka.

We wish to thank the outgoing board members for their tremendous dedication, contribution and support and look forward to the involvement of the newly appointed members.

Student Research

As reported last month, Network staff are in the process of compiling a resource page for PHEN's website profiling the work of Albertans who are completing or have completed theses, dissertations or research projects in the area of Health Ethics.

If you have undertaken such a project and would be willing to share this with other Albertans through the Network, either by making the research itself available, or by posting an abstract, please contact Frances Brennan at the Southern Alberta PHEN office by phone, or by email at fsbrenna@acs.ucalgary.ca.

Views offered in this article are those of the author and do not necessarily reflect the position of the Provincial Health Ethics Network.