Rethinking Autonomy

A Critique of Principlism in Biomedical Ethics

John W. Traphagan

• Publisher: SUNY Press
• Year: 2012
• ISBN:
  9781438445540
• Topic: Social Sciences
• Subtopic: Cultural & Social Anthropology
• Index: Social Sciences

This groundbreaking book offers a critical examination of the concept of autonomy, one with major implications for biomedical ethics. Working from the perspectives of ethnography and medical anthropology, John W. Traphagan argues that the notion of autonomy as a foundational principle of a common morality, the view dominant in North America, is inadequate as a universal moral category because culture deeply influences how people think about autonomy and the fundamental nature of being human. Drawing from fieldwork in Japan, Traphagan reveals a notably different sensibility, demonstrating how Japanese moral concepts and actions are based upon a deep awareness of the social embeddedness of people and an aesthetic sensitivity that emphasizes context and situation over universality in making moral evaluations of behavior. Traphagan develops data from Japan into a critical examination of how scholarly research in biomedical ethics, and ethics more generally, is conducted in North America. Arguing in a vein related to the emerging area of naturalized biomedical ethics, Traphagan proposes the creation of an empirically grounded study of moral behavior.

Chapter 1

Inventing Ethics

The common morality is the set of norms shared by all persons committed to morality…. The common morality is applicable to all persons in all places, and we rightly judge all human conduct by its standards … all persons committed to morality adhere to the standards we are calling the common morality.

—Beauchamp and Childress (2009:4–5)

1.1. The Problem of Common Morality

This book has been brewing in my head for more than twenty years, ever since I started graduate studies at Yale Divinity School focused on religious and social ethics. Throughout my time at Yale, I was constantly nagged by the feeling that the way in which religious and biomedical ethicists approach moral reasoning at American universities is flawed. I carried this impression with me to the University of Virginia, where I began a PhD in religious ethics, only to determine that I had no faith in the field, a realization that forced me to leave graduate school altogether for a few years. When I returned, I had concluded that what was missing in the approaches taken in much of the ethics world in general and the biomedical ethics world in particular was an awareness of, or even interest in, how ethics might be constructed in non-Western—and really non-Christian—societies. American ethicists in particular were, and are, concerned with what Aquinas wrote, or how to conceptualize the notion of supererogation in relation to Christian doctrine, or whether we can find a foundation for moral behavior in natural law as opposed to grounding ideas of right and wrong in calculations of utility. With a few important exceptions, ethicists in the United States, at least, rarely asked questions such as the following: Is the concept of natural law meaningful in all cultural contexts? Could natural law be relevant in one society, but not in another, and still be a useful basis for determining right and wrong? Can moral behavior be structured around something entirely unlike the Western emphasis on notions such as divine command or natural law? Could an ethical system be based on, say, aesthetic sensibility?

American biomedical ethicists tend to emphasize principles or fundamental features of the person that work from assumptions associated with Western liberal democracies, assumptions that structure how we think about moral decision making and the rights of individuals. It is assumed, for example, that concepts such as autonomy are features inherently related to individual selves (Levi 1999:34); far less frequently do ethicists explore the possibility that self is a cultural construct, and then ask how that might influence the notion or even meaningfulness of autonomy as a category of moral reasoning. One of the more profound problems of American biomedical ethics, as Long argues convincingly (2005:107), is that American bioethicists are inclined to draw on their own upbringing and socialization when thinking about the rights of persons and the relationship of individuals to others. As a result, there is a strong tendency to see autonomy as a natural state of being for any mature and capable human, and to assume that those who are incapacitated, particularly the mentally incapacitated, have or should have decreased capacity to act autonomously.

Intertwined with this faith in autonomy is an equivalent faith in the idea of Western rationality as an acultural and objective system of reasoning that provides a foundation for identifying if a person is capable of acting autonomously or whether a person has had the capacity to act autonomously somehow interrupted or eliminated through injury, illness, or simply having been born with a lower or different intellectual capacity in comparison to statistical norms. This notion of autonomy as foundational is widespread in Western philosophy and is well summed up in Kant's claim that autonomy represents “the basis of the dignity of human nature and of every rational nature” (2005:94), a notion that has continued to appear in the work of philosophers and theologians to the present day (cf. Pellegrino and Thomasma 1993). Thinking about, and rethinking, the relationship between autonomy and self is the central theme of this book; a theme that will involve questioning common assumptions about the nature of right and wrong and the possibilities for identifying anything we might call a “common morality” as it would apply to biomedical ethics (or any other application of moral concepts).

Indeed, when one does ask these types of questions, claims of a common morality like the one cited at the beginning of this book quickly become problematic. If moral principles are grounded on a set of assumptions about nature, culture, the structure and composition of human selves, as well as how people should conceptualize social interactions, responsibilities, and obligations different from those often assumed to be normal and natural by American and many other ethicists, then it is inherently difficult—most likely impossible—to arrive at any empirical basis for claiming a common morality. And it is imprudent to claim a common morality that is either overtly or tacitly derived from principles of behavior associated with one particular religious or cultural tradition. Common morality becomes a wish rather than a fact, its existence grounded in questionable intuitions about the world rather than empirical evidence and observation of the world. And intuition is insufficient as a basis for determining right and wrong, because intuition is deeply shaped by culture, thus people in different societies do not necessarily share intuitions.

Some scholars in the growing field of naturalized ethics have noted problems with the intuition-based approach to moral problem solving. These scholars have argued that reliance upon principles conceived as universal makes it very difficult to revise ethical ideas and beliefs in response to new and changing empirical understandings of both the biological and social aspects of human behavior (Walker 2009:3). The empirical issue of identifying the basis for a common morality is an important one, but an equally important question is whether or not we should even be directing our research efforts at finding, assuming, or addressing the notion of a common morality. My position is that little or nothing is to be gained in this endeavor and much lost, even brutalized, by trying to identify one set of moral principles by which all human conduct, even if limited to a specific area of ethical concern such as biomedicine, can or should be judged. Humans are simply too complex and human culture is too variegated for ethicists to work from the assumption that we can or should be building ethical propositions on the idea of either commonality or universality.

Even those elements that may appear common on the surface can display differences in meaning and interpretation at deeper levels. For example, for most Americans it would seem intuitively self-evident that killing or hastening the death of one's elder parents represents murder or neglect. However, Glascock has shown that there are preindustrial societies in which death-hastening practices have been normal when addressing perceived social problems such as unproductive or burdensome elders or deformed infants. Anthropologists in the mid-twentieth century observed skeletal evidence of practices among the Lau people of Polynesia in which feeble elders were abandoned at a lagoon where their lives would come to an end, and in other groups food denial or general denial of support was practiced, leading to death of elder family members deemed unproductive or too difficult to care for (Glascock 1990:47–48). These practices may seem wrong to most Americans or Christians who likely would define these acts as murder. However, murder itself is not easily defined. As Hauerwas points out in discussing Aristotle's comments on murder, “there is no in-principle answer” to what constitutes a particular murder, because “the ability to answer [the question of what constitutes murder] depends upon the tradition in which one has been trained” (in Berkman and Cartwright 2001:276). Although I doubt Hauerwas would take it this far, from my perspective the question is not whether killing is wrong, but whether or not a particular act of killing should be defined as murder and, then, how murder itself—understood as a form of unjustified killing—is defined in a particular cultural context. For those who accepted death hastening as an appropriate outcome for nonproductive elders, the specific practices were understood as natural and right among members of those societies, just as passive euthanasia is for many Americans today. Death-hastening practices in preindustrial societies represent an example in biomedical ethics where culture is a significant factor in understanding and analyzing the meanings of right and wrong and tests the notion of a common morality.

This book is intended as a work in the area of comparative biomedical ethics, a field that has emerged over the past ten to fifteen years and that, at its best, raises questions about how we can think about the nature of right and wrong in cross-cultural perspective. The emphasis on culture has a profound influence on how I view morality. It already should be clear that I view morality—like culture—not as an objective thing to be discovered through contemplation by intellectual elites who enjoy problem solving, nor is it something to be derived from the idiosyncratic intuitions of those intellectual elites (why do intellectuals assume that a steel worker or farmer is going to have the same intuitions they do, despite very different educations and experiences?). Rather, morality is a product of human invention and innovation that is practiced by individuals and groups in daily life. Moral principles are not given; they are created, enacted, and improvised upon by people engaged in contemplation and negotiation of the social relationships that generate cultural context. Ideas such as the Christian notion that “all humans are created for agapic love” (Jackson 2003:2) do not work in this formulation—humans are not the product of creation; they are the agents of creation. Therefore, although advocates for particular traditions such as theologians might hold cosmological commitments that define their range of possible moral thinking, scholars of comparative biomedical and religious ethics, like others engaged in cross-cultural research, cannot say anything final about the purpose for which humans were created because religions and mythologies vary significantly on that question. From a comparative ethical perspective, at the center of this creative process is an assumption that right and wrong are not ontological givens, but the shared products of human creativity and invention. To assume that humans and their moralities are products of a Creator is to disempower humanity and to deflect responsibility for our own actions and for our own moral creations—whether those creations are democracy or despotism, agape or murder.

When scholars such as Jackson proclaim culturally circumscribed virtues such as agape to be the foundation for equally culturally circumscribed concepts such as prudence, freedom, and justice, without which these concepts of the good would wither (2003:6), we run the risk of entering into a kind of philosophical or theological arrogance in which the foundational assumptions associated with one culture or one religious tradition are construed as being essential for the doing of good for all people, in all places, at all times. This type of approach, which is common in principlist forms of biomedical ethics and more generally in Christian ethics, has the unfortunate—and unintended—outcome of brutalizing the values of people living in societies that do not share assumptions and intuitions about the world—and about right and wrong—associated with these cultural, intellectual, philosophical, and theological traditions.

My goal in this book is to respond to this problem by exploring how the notion of autonomy might be conceptualized and employed in moral reasoning without an appeal to common or universal morality. More specifically, I am interested in imagining the possibility of biomedical ethics with its central tenet—autonomy—reconfigured. To some extent, this book can be situated within the framework of a naturalized approach to bioethics, although I am uncomfortable with the notion of “naturalized” largely because I am unclear on what constitutes natural within this area of reasoning; my own preference would be for a humanized, rather than naturalized, ethics in large part because ethics is a product of human thought and innovation. However, I agree with the claim among some who are proponents of naturalized bioethics that an important goal is to “push back against the … ethical abstractions and idealized assumptions [of contemporary biomedical ethics] with an empirically enriched understanding of how particular aspects of context matter morally, forcing the issue of what ethical ideals do (or even can) mean in practice” (Walker 2009:10). It is my position that one of the best sources of such empirically enriched understandings is ethnography, particularly ethnographic work within medical anthropology, that has for several decades developed a rich and complex inventory of data on variation in ideas about the nature of human bodies, selves, morality, health, and illness. This enormous data set has been largely untapped by biomedical ethicists. As I argue in the last chapter, there is a need for a merging of intellectual territory among medical anthropologists and biomedical ethicists to create an area of study that would involve not simply contemplating methods and ideas about moral decision making, but also would incorporate methodologies and practices related to gathering data about how people conceptualize right and wrong, health and illness. This book is intended as a step in that direction.

It should already be apparent to the reader, and I want to be very upfront about this point, that philosophically I align myself with the tradition of moral relativism; scholars such as David Wong are convincing in their assertions that we cannot identify a single true morality and that a relativist position allows for the possibility of reconciling features of human experience—our routine encounters with the empirical world—that set in contrast the seeming objective status of certain moral claims with the empirical fact that all claims of objective knowledge are mediated and interpreted and, thus, limited by subjective experience (Wong 1984:5). The argument I present here should be understood as fitting within the framework of moral particularism, a position that purports moral thought, judgment, and behavior does not presuppose, nor is it dependent upon, existence or creation of moral principles (Dancy 2004:18). My interest here is in understanding not a set of principles aimed at guiding what people should do, but at arguing that an understanding of the subtleties of moral decision making and behavior can move us away from the need to impose principles. As Dancy (2004:12) notes, “morality can get along perfectly well without principles.”

The problem of particularism versus generalism, or the debate between those who argue that principles are either evident in the world or, if not evident, at least a necessary fiction needed for the maintenance of social order, has very practical consequences. As Stout (1988:3) notes, humans living in different groups and societies do not share the same moral language. The consequences of our differences can be anything from intellectual debate to terrorism to total war. And yet despite our often vast differences in thinking about moral and immoral behavior and ideas, if we are to find a way to live peacefully, it is necessary to establish some common ground on which to assess what is right and what is wrong. On the surface, discovery or even invention of universal principles to guide moral action seems the best approach. I argue here that, in fact, the belief in universal principles aimed at guiding moral action—acceptance of the generalist agenda—is at the root of our problems. Moving away from an insistence on finding principles and accepting the idea of variability in moral thought and action may offer a way to translate and interpret variations in moral language, rather than to simply argue about whose language is correct and true. Although we can look for, and find, words and ideas that have relatively consistent moral significance across a variety of cultural contexts, we cannot identify a general or universal principle that can delimit the parameters of rightness or wrongness of actions for all people, places, and times in relation to that moral significance. For example, although abortion may be morally significant in many cultural contexts (and not in others), the moral response to abortion cannot be based upon a set of principles operating as a common morality because the nature of the moral significance in each context is variable.¹

My intellectual position is shaped by a further claim—one that is heavily influenced by my training and experience as an anthropologist—of cultural relativism. Although the notion of cultural relativism has certainly undergone significant critique (see Davis 2008), its application by anthropologists is often not well understood. Even otherwise eloquent and well-informed scholars sometimes make significant errors when representing cultural relativism. For example, Richard Dawkins (2006:319) describes what one would assume are cultural anthropologists as being “infected with ‘cultural relativism,’” and suggests that it is simply a form of quibbling by anthropologists (and others) over the meanings of words like “in” or “true” as they vary from one culture to another. As much as I admire Dawkins' work—and I think he has made some major contributions—he's clueless on this one.

Cultural relativism, as Geertz (2000) has pointed out, is not a position related to the value of a particular culture vis-à-vis other cultures, it is a viewpoint taken in trying to understand, evaluate, and analyze data collected about various cultures. Cultural relativism is a standpoint one takes in order to explore the enormous diversity of behaviors and beliefs among people in the world and to try, at least, to distance oneself from one's own assumptions about what is natural, given, and right. Cultural relativism does not demand giving up one's own beliefs; it simply asks the observer to try to make sense of the observed on its own terms and to bracket off his or her own cultural beliefs and values as much as possible while doing so. Nonetheless, the act of doing this often has the consequence of forcing anthropologists to shake their assumptions, which in turn impels us to question reductionist arguments about the nature of right and wrong, in which one attempts to situate morality aculturally and ahistorically, generati...