Bioethics: A "New" prudence for an emergent paradigm?

• Author: Bracci, Sharon L.

Stephen Toulmin has pioneered what is by now a familiar view of medicine as a fundamentally moral enterprise. Argumentation theorists will recognize Toulmin's (1981) attention to bioethical discourse that attends value-laden medical practice as one aspect of his broader project to theorize viable models of practical reasoning to supplant abstract modes of formal logic. Toulmin's focus on the ethical issues surrounding contemporary medicine serves to highlight bioethical discourse as an important context for applying practical reasoning principles. (1) This attention to bioethics intersects argumentation scholars' long-standing interest in how the field can contribute to theoretical and pragmatic understandings of deliberation, how argumentation can serve as a tool in effective and ethical decisionmaking. Bioethics, positioned as a paradigmatic case of practical moral reasoning, offers scholars a prism through which to theorize argumentation tools in the service of justificatory deliberative practices.

In this essay, I begin from Toulmin's significant insights into the relevance of bioethical discourse for practical reasoning models of argumentation to make a two-pronged claim: One, although Toulmin has directed important theoretical attention to a bioethical model, I will argue that he, with Albert Jonsen, has focused too narrowly on casuistry, or case morality, as the appropriate mode of reasoning within that model. While bioethical deliberations appropriately attend to case particulars and contingencies when deciding high stakes, technologically-driven, and value-laden issues, any focused attention on casuistry faces considerable limitations. These shortcomings relate to particular understandings that Toulmin and Jonsen hold of casuistic practice and bioethics practitioners. I hope to show that casuistic reasoning as a favored mode of bioethical reasoning suffers from its connection to classical phronesis, which gives rise to some untenable assumptions for contemporary bioethical and practical reasoning. These include the view that relevant cultural norms are stable as they apply to particular cases, that sufficient settled convictions exist to form a consensus on key deliberative points, and that the phronimos' "practiced eye" of experience provides a trustworthy and sufficient guide to ethical deliberation through practical wisdom.

If casuistry is limited by its classical connections to phronesis, what might successful deliberation look like in contemporary bioethical contexts? In a second claim, I call for bioethical reasoning to exploit an even greater role for narratively-informed dialogical virtues to sketch a model of it. These virtues do not merely elicit a data base for analogical reasoning in deliberation; they also, I will argue, forge a crucial dialogical link to an expanded field of experiential wisdom and understanding. An increased focus on dialogical virtues shapes a "new" phronimos for the bioethical model, one whose practiced ear is cultivated through deliberative patterns that are themselves a practice of ethical activity to enlarge deliberators' critical thinking through self scrutiny and moral imagination. (2) This expanded view of the prudential deliberator better serves an expansive bioethical discourse that is built on conflict, is not sustained by consensus, and is an exemplar for broader theoretical inquiry into practical moral deliberation.

To defend these claims of limitation and reformulation, I have organized the essay into three sections: First, after an introduction to the contested nature of the term "bioethics" itself and implications of that conflict for deliberation, I offer some theoretical and methodological connections between casuistry and prudence. Next, I look to a well publicized bioethics case. Through the case I speculate that bioethics' increased focus on casuistic reasoning has limited justificatory value because it is heavily reliant on a straightforward recovery of classical prudence to guide its practice. If the case bears out this speculation, then the case also provides an impulse to theorize an expanded model that more fully exploits the value of case-based reasoning. In a third section, I propose dialogical virtues in the service of a "new" prudential deliberator. Virtues of balanced partiality, reciprocity, moral imagination, and prudential listening, I hope to show, address the unwarranted assumptions regarding exper iential wisdom that weaken the potential moral force of casuistic reasoning in bioethics today.

BIOETHICAL DISCOURSE: FIRST FORMULATIONS AND EMERGENT MODEL

It is useful to summarize some distinctions between early bioethical discourse and the emerging model to recall the inherently contested nature of bioethics and the discourse that comprises it. "Bioethics," a truncated term for biomedical ethics, has been subject to disputed meanings since it was coined. The first use of the term bioethics is attributed to Van Rensaelaer Potter who, in a 1970 article entitled "Bioethics, the Science of Survival," used it to describe and evaluate interactions among human, animals, and the environment (Reich, 1995; Rothman, 1991). "All of them involve bioethics," Potter argued, since "survival of the total ecosystem is the test of the value system" (1970, 127).

But other powerful voices reframed the term to more narrow understandings. In 1971, Georgetown University accepted a $1.35 million grant from the Kennedy Foundation to create an institute that would join biology with ethics, to "put theologians next to doctors." The impulse behind this formulation was a well-publicized case of an infant with Down's syndrome who died, unattended, in deference to parental wishes, in Johns Hopkins University Hospital. Early on, then, the neologism was redefined to include bedside medical issues to be resolved by specific practitioners.

Bioethical discourse in philosophy, religion, and law dominated during this first formulation of the term and expanded its purview to examine ethical issues in research as well as clinical practice. Reasoning focused on deontological, utilitarian, and natural rights theory as well as the four bioethical principles of justice, autonomy, beneficence, and nonmaleficence (Beauchamp & Childress, 1994). This is the bioethics environment Toulmin and his colleague Albert Jonsen came to prominence in when they sat together from 1975 to 1978 on a national commission to study human subject research norms. This experience drives their interest in reviving casuistry in bioethical deliberations as a viable alternative to principled approaches that had failed to forge a consensus in health care contexts on philosophical or religious grounds (1988, vii; also Toulmin, 1981; Jonsen, 1991).

Today, bioethics continues to push contentiously toward Potter's sweeping view, both in the issues engaged and the range of participants to the discourse. The proliferation of bioethics centers and ethical institutes, real and virtual via internet sites on practical ethics and alternative medicine, attests to this contestation. Bioethics has emerged as a much wider interdisciplinary field to include scholars whose intellectual projects and methods of inquiry are vastly divergent. These include academics and practitioners in law, medicine, nursing, social work, genetic counseling, moral philosophy, moral theology, cultural and medical anthropology, public policy, psychology, literary studies, cultural studies, women's studies, communication studies, and environmental studies. Voices from the allied sciences as they relate to medicine include biology (especially genetics), epidemiology, veterinary medicine (especially animal behavior) and neuroscience. The emerging model is increasingly diverse and divisive, re flecting the same skepticism toward the argumentative force of monistic theories and principled accounts that pervades, in varying degrees, the fields and disciplines that comprise it. Ideological struggles between the individualistic assumptions of the early reasoning and emerging communitarian and family concerns have also expanded the dialectical dimensions of bioethical reasoning. This is particularly salient as the tensions between an ethics of autonomous strangers and an ethics of socially situated intimates are made more explicit (Reich, 1995; Crigger, 1996; Potter, 1999; Nelson, 2000; Zussman, 2000).

Put another way, the term is expanding to reflect and accommodate a wider range of interested voices who will be heard; it stands as an exemplar of the larger contest over justifiable forms of practical reasoning in value-laden contexts today. Bioethics is built on conflict, and seeks resolution of issues through justification, not consensus, since these disparate voices have failed to locate shared first principles to adjudicate their differences. The moral weight of particular decisions rests on deliberation that can justify choice, not full agreement. Deliberation on intractable bioethical issues, "cannot make incompatible values compatible" as Gutmann and Thompson note, but it can work to scrutinize and refine particular and shared understandings. How well deliberators recognize, scrutinize, and understand multiple perspectives through their engagement with one another is "at least as important as the conclusion" deliberators reach (1997, 39-40; 1996).

CASUISTRY AND PHRONESIS

Ongoing disaffection with principled approaches to bioethical issues partially explains the attention paid to casuistry when confronting the constraints of clinical urgency, prognosis uncertainty, clashing values, and crises of conscience (Arras, 1991). An added deliberative value, Jonsen and Toulmin (1988) argue, is casuistry's connection to Aristotelian practical wisdom. Both phronesis and casuistry isolate discernment as their central wisdom, derived from the practiced eye of experience. Casuistic wisdom is the habituated ability to see the relationship between rule...