Methods in Medical Ethics

Second Edition

Jeremy Sugarman, Daniel P. Sulmasy, Jeremy Sugarman, Daniel P. Sulmasy

• Publisher: Georgetown University Press
• Year: 2010
• ISBN:
  9781589016231
• Edition: 2
• Topic: Medicina
• Subtopic: Etica in medicina

Medical ethics draws upon methods from a wide array of disciplines, including anthropology, economics, epidemiology, health services research, history, law, medicine, nursing, philosophy, psychology, sociology, and theology.

In this influential book, outstanding scholars in medical ethics bring these many methods together in one place to be systematically described, critiqued, and challenged. Newly revised and updated chapters in this second edition include philosophy, religion and theology, virtue and professionalism, casuistry and clinical ethics, law, history, qualitative research, ethnography, quantitative surveys, experimental methods, and economics and decision science. This second edition also includes new chapters on literature and sociology, as well as a second chapter on philosophy which expands the range of philosophical methods discussed to include gender ethics, communitarianism, and discourse ethics. In each of these chapters, contributors provide descriptions of the methods, critiques, and notes on resources and training.

Methods in Medical Ethics is a valuable resource for scholars, teachers, editors, and students in any of the disciplines that have contributed to the field. As a textbook and reference for graduate students and scholars in medical ethics, it offers a rich understanding of the complexities involved in the rigorous investigation of moral questions in medical practice and research.

PART I

Overview

CHAPTER 1

The Many Methods of Medical Ethics

(Or, Thirteen Ways of Looking at a Blackbird)

DANIEL P. SULMASY AND JEREMY SUGARMAN

The range of scholarship falling under the umbrella of medical ethics is astounding. For instance, the disciplines of anthropology, economics, epidemiology, health services research, history, law, literature, medicine, nursing, philosophy, social psychology, sociology, and theology all have scholars working in the field of medical ethics. Some employ unique methods. Others use similar methods but have different theoretical orientations. However, it is not always clear whether, or how appropriately, work done in many of these disciplines is considered scholarship in medical ethics. Neither is it always clear how these methods and disciplines relate to each other. In this chapter we provide a general orientation to the scope of these many methods and offer what we take to be proper interdisciplinary relationships in medical ethics.

Types of Ethical Inquiry

Philosophers hold that there are three basic types of ethical inquiry: normative ethics, metaethics, and descriptive ethics (Frankena 1973). Normative ethics is the branch of philosophical or theological inquiry that sets out to give answers to the following questions: What ought to be done? What ought not to be done? What kinds of persons ought we strive to become? Normative ethics sets out to answer these questions in a systematic, critical fashion, and to justify the answers that are offered. In medical ethics normative ethics is concerned with arguments about such topics as the morality of physician-assisted suicide or whether it is morally proper to clone human beings.

Metaethics is the branch of philosophy that investigates the meaning of moral terms, the logic and linguistics of moral reasoning, and the fundamental questions of moral ontology, epistemology, and justification. It is the most abstract type of ethical inquiry but one vital to normative investigations. Whether or not it is explicitly acknowledged, all normative inquiry rests upon a fundamental stance regarding metaethical questions. Metaethics asks, What does “right” mean? What does “ought” mean? What is implied by saying “I ought to do X?” Is morality objective or subjective? Are there any moral truths that transcend particular cultures? If so, how does one know what these truths are? Positions regarding all of these questions lurk below the surface of most normative ethical discussions, whether in general normative ethics or in medical ethics. Sometimes it is only possible to understand the grounds upon which people disagree by investigating questions at this level of abstraction. In many cases, however, there is enough general agreement that normative inquiry can proceed without explicitly engaging metaethical questions.

Descriptive ethics does not directly engage questions of what one ought to do or the proper use of ethical terms. Descriptive ethics asks empirical questions such as, How do people think they ought to act in this particular situation of normative concern? What facts are relevant to this normative ethical inquiry? How do people actually behave in this particular circumstance of ethical concern? In medical ethics the literature is replete with descriptive ethics studies, such as surveys concerning what patients and doctors think about the morality of late-term abortions, about attitudes toward completing advance directives, or about perceptions concerning the risk of being tested for BRCA1/2 (breast and ovarian cancer susceptibility genes).

While all these types of ethical inquiry are important, normative ethics seems to be at the core of ethical inquiry. This is not to suggest that normative ethics is more intellectual or more worthwhile than other disciplines. Rather, we suggest that while the other types of ethical inquiry are inherently interesting, they are most important, meaningful, and useful because of the normative questions that are at stake. One asks, “What does the word ‘ought’ mean?” because it is very interesting and important to know what one ought to do. In general one is fundamentally interested in knowing what percentage of the population thinks something ought to be done in particular circumstances or how people actually behave in such circumstances, if it is interesting and important to know how one ought to behave in such circumstances. It is relatively uninteresting to ask, “How often should men shine their shoes?” It is much more interesting to know how a physician ought to respond when a patient asks, “Doctor, will you help me die?”

Yet, even if normative ethics is at the core of scholarship in ethics, all these types of research are interesting and important. The methods employed to answer the three types of questions necessarily differ, but each contributes something. They all help to fill in the outlines of ethical inquiry. This can be metaphorically illustrated by the Wallace Stevens poem “Thirteen Ways of Looking at a Blackbird” (1951). Stevens’s poem masterfully captures both the complexity and the advantages of looking at anything from a multiplicity of perspectives. Medical ethics is like this poem. Each of the thirteen stanzas of the poem illustrates a view of the blackbird. Each view tells us something about the viewer as well as something about the blackbird. No single view tells us what a blackbird is. But in sum, at the end of the poem, the reader has a better sense of the blackbird. That sense is ineluctably incomplete. But it is ever richer and fuller after thirteen views. As Stevens writes:

The blackbird whirled in the autumn winds.
It was a small part of the pantomime.

So it is, we suggest, with medical ethics. Neither the methods employed by philosophy nor theology nor anthropology nor history nor law nor any other methods that contribute to scholarship in medical ethics describe the blackbird called medical ethics in its entirety. But by examining a moral question from the vantage point of several different methods, one gains a richer understanding of that moral question and a better grasp of an answer. Under ideal circumstances, each method of medical ethics contributes something that is of importance for scholars who employ other methods to investigate the same questions. Each method looks at the blackbird from a different perspective. And ultimately, in health care, such research is vital not only to scholars, but above all to those practicing the healing professions. After all, medical ethics is, in large part, about what these people ought to do. And what these people do obviously has profound implications for individuals when they are sick.

One Field, Many Disciplines, Many Methods

Is medical ethics a discipline in its own right? Jonsen (1998) has suggested that in a simple sense it is, but in the strictest sense it is not. Some might suggest that medical ethics is now really a single, unified discipline in which any scholar can employ any of the methods described in this book to address the question at hand, jettisoning the disciplinary boundaries and theoretical assumptions that otherwise keep these disciplines from communicating with each other. Witness, for example, the growth of graduate programs that offer degrees in “bioethics.” Others might suggest that the scholarly product would be better if each discipline were to use the methods proper to that discipline to practice medical ethics without ever bothering to examine how other disciplines examine questions in medical ethics, even if these other disciplines employ the same methods. The result is confusion over what medical ethics scholarship really is, or ought to be.

We would like to bring further conceptual clarity to this discussion by carefully distinguishing between field, discipline, and method. Borrowing from the Oxford English Dictionary, we define a field of inquiry as a subject matter or set of phenomena or questions addressed by a scholar or scholars. By contrast we define a discipline as a department of learning or knowledge, a community of scholars who share common assumptions about training, modes of inquiry, the kind of knowledge that is sought, and the boundaries of the subject matter proper to the discipline. Finally, we define a method as a systematic procedure, technique, or mode of inquiry that is employed in examining research questions.

We take the view that medical ethics is a single field of inquiry of great interest to many disciplines rather than a discipline in its own right. What medical ethicists share is a common subject matter, not a common disciplinary mode of investigating that subject. Their common subject matter is the normative aspect of health care. This is the medical ethicists’ blackbird. It is their field. However, they view it through the eyes of a wide variety of disciplines. These disciplines employ a wide variety of methods, some shared by several disciplines and some unique to a particular discipline. Medical ethics is one field that embraces a variety of disciplines and methods. Thus, one conducts research in medical ethics as a philosopher or as a health services researcher or as a historian. One can certainly be cross-trained in more than one of these disciplines. But the quality of scholarship, in our view, will generally be best when investigators have a disciplinary home base. This will ensure a firm understanding of the assumptions and the limitations of the methods proper to these disciplines, as well as ensuring rigor and appropriate peer review of the research.

Childress (2007) has criticized our argument that all the various types of scholarship in this field can properly be called medical ethics. Childress would limit the use of the term to describing normative work, and the methods of medical ethics to the philosophical and theological methods described in chapters 3 through 7 in this book. In a certain sense the use of a term such as “medical ethics” is stipulative, and one can stipulate that it cover whatever set of studies one wishes. Narrowing the use of the term “medical ethics” to normative work alone, however, seems to deny the reality of the rich, complex, and multidisciplinary field that medical ethics has become. Many of the scholars whose work is described in this book, while using the techniques of nonnormative disciplines, describe themselves as medical ethicists. Many have worked as part of multidisciplinary teams, informing theory with data and orienting descriptive studies to help find solutions to knotty normative questions. What else should all this research be called? “Sociological studies contributing in a descriptive and cooperative way to the normative work of real medical ethics”? It seems simpler and truer to reality to call it all medical ethics. Further, a narrow approach, such as the one proposed by Childress, flies in the face of the standard division we have outlined between metaethics, normative ethics, and descriptive ethics, a description of the types of ethical inquiry that Childress has espoused in every edition of the famous textbook that he coauthored with Beauchamp (Beauchamp and Childress 2009, 2).

We agree with Childress that the normative questions are central, but if it is standard usage to call all this work forms of ethical investigation, and those who use these various methods are in serious dialogue with one another, sometimes even collaborating as part of the same multidisciplinary team, then it is unclear what is gained by restricting the use of the term to normative methods. While not denying the primacy of the normative, medical ethics has become an extraordinarily multidisciplinary field.

Medical Ethics as an Interdisciplinary Field

Multidisciplinarity, however, is not interdisciplinarity. Although there is constant chatter about interdisciplinary research on university campuses, medical ethics is a field of inquiry with enormous potential to make that chatter real. Normative questions, as stated above, are inherently interesting. These questions are of interest to scholars in many disciplines. Sadly, however, what often seems to be missing is genuine interchange between these scholars. For example, the eyes of a lawyer or philosopher often glaze over when someone describes the statistical methods used in a research project about informed consent. Or a health services researcher can be overheard muttering something about “fluff” when a theologian begins to expatiate about the relationship between the concepts of dignity and justice in health care. In this book we hope to move beyond these stereotypes. We realize that we cannot make a casuist into a decision-scientist in a few pages. However, part of what we hope to make possible for medical ethicists is enough of a rudimentary understanding of the other disciplines in the field to help facilitate a richer, genuinely interdisciplinary conversation in medical ethics.

If we are correct in our contention that medical ethics is an interdisciplinary field, then it is incumbent upon us to suggest how these various disciplines and methods should relate to one another. The focus of this discussion will be on the relationship between normative and descriptive methods. Alth...