EUROANESTHESIA 2007 Munich, Germany, 9-12 June 2007

EUROANESTHESIA 2007 Munich, Germany, 9-12 June 2007 WHERE DO THE PRINCIPLES OF BIOMEDICAL ETHICS COME FROM? 16RC1 ALEX CAHANA Postoperative and Interventional Pain Program, Department Anesthesiology, Pharmacology and Intensive Care University Hospitals of Geneva, Geneva, Switzerland Saturday Jun 9, 2007 15:00-15:45 Room 21 INTRODUCTION Philosophy must be understood backward but lived forward (Kierkegaard 1846, 1992vol 2:187) You will probably find few people who will argue that treating pain is wrong. However this is not the same as asking if treating pain is right, or is always treating pain always right? In order to make the right choice in various situations, where our moral intuition does not always provide adequate and coherent guidance, an understanding of the principles of bioethics is fundamental. You should treat others as you would like to be treated is an old and often useful saying; it allows us to tell moral right from wrong in many circumstances (e.g. preserve life and relieve pain in end-of-life care), but sometimes an act may be simultaneously morally right and wrong (e.g. abortion). So how can we really tell moral right from wrong? In order to answer this and subsequently perform good choices, a theoretical and systematic understanding of our moral life is necessary. Intuition simply does not suffice. If ethical theory provides consistency and rationality necessary for our moral judgment, a philosophical reflection on our moral life through the search of values and norms is needed. In these day-to-day dilemmas, choosing an ethical theory to apply and appropriately implement can be very difficult. Fortunately since 1979, Beauchamp and Childress textbook Principles of Biomedical Ethics serves us with coherent guidelines for practical judgments in medical moral dilemmas, by using four principles: respect of autonomy, non malfeasance, beneficence and justice. But where did these principles come from? Definitely these principles did not appear suddenly as spontaneous creation of the authors, but rather have been conceived from other ethical theories. In this paper we wish to present briefly seven theories which have affected our moral reasoning throughout times and which have, we believe, inspired at least partly the development of principle-based theory. This presentation must not be understood as an exhaustive historical review but rather as a rational reconstruction of conceptual nature. OBJECTIVISM VERSUS SUBJECTIVISM The debate whether morality is objective or subjective dates back to the ancient Greek, found in Plato s dialogues between his teacher Socrates and the Sophists, who were a group of thinkers who held that ethical argument is rather a matter of rhetoric and has nothing to do with true science. That morality is about persuading people to believe what you believe (dogma), rather than proving to them that the beliefs you hold are true (episteme). This dispute continues to date, where on one hand many hold that good, bad, right and wrong reflect opinion and desire (subjectivism), whereas others, like Socrates and Plato, think it reflects the objective nature of things (objectivism). Why is moral subjectivity so obvious? One of the reasons may be that in everyday life there are many conflicting moral opinions, that it is impossible to prove the superiority of one moral view over another; and that there are no observable moral facts. But although moral differences on abortion, euthanasia and capital punishment do exist, there is little moral disagreement on many other issues like slavery, child abuse and cheating at sport. It would be probably difficult to find someone who thinks that rape, murder and theft are good, and that honesty, loyalty and generosity are bad. In general moral problems can be analyzed in four separate attitudes: 1. Hard subjectivism: for every moral question there is never a right answer (Sophists) 2. Soft subjectivism: for many moral questions there are no right answers 3. Hard objectivism: for every moral question there is a right answer (Socrates and Plato) 4. Soft (or reasonable) objectivism: for many moral question there is a right answer Since moral questions pertain to norms and values on what values should a moral theory focus on? - 169 -

EGOISM For many of us the answer to this question would be: rich and famous. Albeit tempting as a response, it is logically incomplete since rich means to have money, and money within itself has only an instrumental, but not intrinsic value. Since money has no value in itself, it seems that the answer should be more like: a life which you are rich enough to do whatever you want and famous for achieving it. Thus the idea that the best life is one in which I ought to aim at getting what I want, is called egoism. The difference between egoism and selfishness is that selfishness is the tendency to seek and promote one s own comfort and satisfaction before that of anybody else. Selfish people always try to get the best seat or the largest slice of cake. By contrast egoism is the belief that I should do what only matters to me, which may include non-selfish acts, like working long hours or promoting my children s education or helping my best friends. This fundamental desire to fulfill personal needs as a centerpiece to a good life is know as rational egoism which recommends to always do whatever one wants, because the only good (that is moral ) reason to do something is because you want to do it. Rational egoism voiced mostly by 19th century German philosopher Friedrich Nietzsche, was in direct conflict with Judeo-Christian tradition of deny thy self. But the Judeo-Christian argument was mainly due to the confusion between the concept of desire (morally reprehensible longings and inclinations) and the concept of self-interest (things of vital importance to my well being). So when returning to the question what is the best sort of life to aim for, the egoist complete answer would be: a life which is in my best interests, interests which are not desires, which have an objective value and have a rational appeal. HEDONISM Since a good life is one in which one promotes its own interest and thus avoids human desires of dubious value, the question to be examined now is what is considered best interest? For the hedonists the answer is quite clear- pleasure. The main aim in life is the pursuit of pleasure and the avoidance of pain, so pleasure is what we ought to pursue and pain what we ought to avoid. The most known hedonists were the epicureans, named after the ancient Greek philosopher Epicure who viewed that life must strive at ataraxia and apathia that is tranquility of mind and health of body. Hence the importance of entertaining true opinions (false opinions, especially about God and soul will disturb our temper), to drink good wine, to be in good company and participate in a sophisticated culture. These pleasures are a natural good and are mild and gentle. Thus drunkenness, gluttony and vulgarity are not part of the hedonistic life since they induce pain and displeasure. If hedonism is a natural good, then we are to maximize pleasure and minimize pain in our lives as much as possible. This idea of maximizing the most pleasure for the greatest number possible was developed by 18th- 19th century English philosophers Jeremy Bentham and John Stuart Mill. Contrary to Bentham nevertheless, Mill distinguished between higher and lower pleasures as read in his famous dictum, I prefer to be a dis-satisfied Socrates, than a satisfied pig. Unfortunately Mill did not have a reliable method specifying how to discriminate higher and lower pleasures and thus his idea remained a relatively arbitrary stipulation (he proposed the criterion of the expert, i.e. of the person who knows both types of pleasure). Because all types of pleasures are not good and because there are other goods in life beyond pleasure, any moral theory to develop must include something more than just the promotion of pleasure. Aristotle, Plato s student, proposed that pleasure is indeed good, but it is not the highest good. In fact people seek pleasurable sensations, but only because of the happiness it comes along: we want to be happy, that is to flourish; when we succeed, we feel pleasure, but pleasure is only an accompanying good. So the life we seek is a pleasurable and happy life, but is it a good one? What constitutes a good and morally worthy life? VIRTUE THEORY For Aristotle it is not pleasure that is important as the hedonists claimed, but rather happiness (eudaimonia), and it is happiness which is of moral value. It is the happy life, which we must pursue and in order to obtain eudaimonia one must excel, seek wisdom and share this wisdom with others (friendship). But excellence (arete) is for Aristotle the same as virtue (a virtue is an excellence). So virtues such as practical wisdom (phronesis) and social skills (professionalism) are the supreme values that construct a worthy happy life. There are several manners to lead a virtuous life, because virtues are numerous; and more generally, a good life for a human being is not the same as a good life for a God or for non-human animals. In other words, good means not any good, but good-for-man. - 170 -

EXISTENTIALISM The question how shall I live is inescapably existential, because nothing determines its answer except ourselves, and this remains true even if we adopt a theological ethics (if we follow or try to follow God s commands) or any other objective moral doctrine. We alone are responsible for the decisions we make. Therefore existentialists, especially the 20th century French philosopher Jean Paul Sartre, emphasize that moral conduct is based on responsibility, liberty and autonomy. According to Sartre there are two modes of existence. One is being-in-itself, like trees and stones, versus one being-for-itself, aware of- or value for- themselves as human beings. Humans are special since this awareness of oneself and understanding of the world creates a moral obligation to live an authentic life authenticity is the fundamental value so that a worthy life is an authentic one, which in turn is not necessarily pleasant. So, what is important for existentialists is not what is chosen as a moral act, but rather the manner in which it is chosen. They call fleeing from painful moral decisions and giving oneself deterministic excuses bad faith, which suggests in turn that we are autonomous moral agents and that we alone, not God or nature, are responsible for our acts. It is wrong to think that one chooses pre-existing values from a catalogue, but rather the act of choice itself, in radical liberty, confers it value. Moreover, context is very important: ethical theory is something practical, within a social construct and is based on acting in good faith. The heart of existentialism is radical freedom in respect to moral norms, a freedom that we are condemned to. By our choice we define ourselves and we must assume full responsibility of these choices. These choices are difficult since it is easy to behave in bad faith, that is without being faithful to one s own liberty. For those who are skeptical with this concept of radical freedom but still want to take responsibility and liberty seriously, the question that arises is how do we make these right choices? What guides us into good faith? KANTIANISM For the 18th century German philosopher Immanuel Kant the answer was simple- reason. Since material benefits (goods that are of value for egoism and hedonism) or personal talents (important goods for virtue theory and existentialism) can be used well or badly, they cannot constitute the principle of moral good. Thus only reason can guide us into proper moral conduct, doing-the-right-thing. Among all moral theories it is probably that of Kant, which has most influenced principle-based theory of bioethics. For Kant the question of a good life is fraught with ambiguity. Do we mean the happiest life which makes it worthy or the worthiest life which makes us happy? In order to answer this Kant says that what matters from a moral point of view is not what we do, but what we intend to do and adds that our intentions (will) and actions should be tested in their ability to be applied everywhere by everybody (universalizability). In other words, people do what is right because it is right, regardless to whether it gives them or others pleasure (as it is the case with desires or inclinations). Desires and natural inclinations are a morally irrelevant and only good will count that is a will in conformity with universal rules. Kant referred these universal rules as categorical imperatives, which basically state that for pure practical reason one must act like this. Thus Kant s moral ought transcends desires and wants. We are not asking what will everyone do, but rather what if everyone was to do it? (i.e. lie, steal, cheat etc.). Kant puts his categorical imperative like this: I should never act in such a way that I could not also want that my maxim should be a universal law. More precisely, Kant believes that there is a unique categorical imperative: every rule of duty, i.e. maxim, if it is to be morally right, must be in accordance with this imperative that is with the requirement of universalizability. So, it is not possible to be caught in a real moral dilemma. But this imperative has a second reading, too: I should never act in such a way that I treat another person like a mere mean or instrument for the ends I pursue. It does not consist in a second new imperative; it expresses the same one, because nobody could rationally want to be treated like a mere mean. This second reading has a deep and central impact on our ethical and bioethical beliefs: everybody agrees now that it is forbidden to instrumentalize a human person, it is a violation of her dignity ( dignity is a concept whose modern roots are in the Kantian thought, too). The main problem however with Kantian law is that the moral emphasis is only on our intention and will to do our duty, without looking at the consequences of our acts. - 171 -

UTILITARIANISM If Kant s conception of best human life is that of moral duty, others criticized this concept as duty for the sake of duty and returned to the importance of giving place to a happy and fulfilling life. Thus we return to the idea of maximizing happiness and minimizing pain in the world, otherwise known as the greatest happiness principle. This principle, as mentioned, introduced by Jeremy Bentham and further developed by his compatriot John Stuart Mill, stated that my pleasures and pains are not to be regarded by me as anymore important than yours, when it comes to deciding what is right or wrong for me or anyone else. This of course ensures that utilitarianism is not a selfish doctrine: impartiality is for it a cardinal virtue. But utilitarianism is neither an altruistic theory where we put other s interest before our own (impartiality is not altruism; it is a kind of equality). On the contrary, individuals may suffer in the name of utility. In order to avoid unacceptable acts on individuals (for example to kill one to save many others) contemporary utilitarians also introduced an important distinction between act utilitarianism and rule utilitarianism, where the latter assures conduct most conducive to greatest happiness. Thus even in a context of where killing one to save many others would be an act utilitarianism, the rule precludes this because the consequences of a rule permitting the murder of an innocent for the greatest common good, would in fact decrease the greater happiness (nobody will be in security anymore). We see then that utilitarianism has a hedonic aspect to it, but more importantly a consequentialist feature, which puts it in direct opposition to Kant (which gives importance to duty for the duty s sake) and to existentialism (which prides in liberty). Thus in Kant s eyes the acts of Don Quixote (fighting mills) are morally worthy since his intentions (fight evil) are morally worthy, in Sartre s eyes these acts are morally worthy since Don Quixote is true to himself, whereas for the utilitarian, these acts are of no moral value since they are of no consequence. FINAL REMARKS: PRINCIPLE-BASED THEORY IN BIOETHICS- A POTPOURRI OF MORAL THEORIES So how do we decide what is right or wrong in face of a moral problem or dilemma? After this brief tour of various moral theories one can confidently identify the diverse influences of each one found in principlebased theory of bioethics, namely respect of autonomy, non-malfeasance, beneficence and justice. First soft or reasonable objectivism that states that for many moral question there is a right answer because for any moral question there might be a right answer, presents the interest in developing a systematic approach to deal with moral dilemmas and not to count upon a moral intuition alone. Egoism, different from selfishness, inspires the principle of beneficence in emphasizing that one s own desire (e.g. patient) is of moral value and merits to be the center of a good life. Hedonism, which replaces desires with maximizing pleasure and minimizing pain, reminds us that nonmalfeasance is an important principle to follow. Virtue theory, stating that a happy virtuous life is the most important value to attain, presents itself in the principles of bioethics as strive of doctors to promote good as a deontological obligation, as part of professional excellence. The radical freedom expressed in existentialism translates itself into the importance for the person, be she a doctor or a patient, to accept full responsibility for one s own decision. Kantianism is without doubt the greatest inspirer of the principle to respect of autonomy, but maybe more in words than in fact, because it defines autonomy as the capacity to give oneself moral rules (auto-nomoi); so, for him, it is only by applying categorical imperative, regardless to pleasure or consequence, that one expresses his dignity as a moral subject. So the autonomous person, if she is really autonomous, must choose under the constraint of the moral law. In bioethics, autonomy refers generally more to liberty (Locke and liberalism) and even sometimes to radical freedom (existentialism). Utilitarianism has influenced the principle of distributive justice and has defined guidelines for moral conduct within the social agreement. In summary we have tried to show that the four principles of bioethics have all been inspired from various moral theories. As our presentation is a conceptual reconstruction, it does not pretend full historical accuracy. Critiques say that ethical principlism is actually ethical fundamentalism and claims with good reason that other theories may have influenced bioethics as well (Hans Jonas ethics of responsibility, Carol Gilligan feminist ethics of care, Emmanuel Levinas ethics of alterity, to name a few). However we postulate that in order to understand well the strength and the limits of Beauchamp and Childress Principles of Biomedical Ethics, it is imperative to be aware of its vast and multiple origins. Once we master this we can try and answer more specifically, is treating pain the right thing to do. - 172 -

SUGGESTED READINGS: INTRODUCTION: Beauchamp TL, Childress JF. Principles of Biomedical ethics. Oxford University Press, 2001 OBJECTIVISM VS. SUBJECTIVISM Pappas N, Plato and the Republic. London, Routledge, 2003 EGOISM Young J, The death of God and the meaning of life. London and New York, Routledge, 2003 HEDONISM Gosling JCB. The Greeks on pleasure. Oxford, Clarendon press, 1982 VIRTUE THEORY Hughes G, Aristotle on Ethics. London and New York, Routledge, 2001 EXISTENTIALISM Howells C, The Cambridge Companion to Sartre. Cambridge University Press, 1992 KANTIANISM Stratton-Lake P, Kant, Duty and Moral worth, London and New York, Routledge, 2000 UTILITARIANISM Crisp R, Mill on Utilitarianism. London and New York, Routledge, 1997 CONTRACTUALISM Rawls J, A theory of Justice, Oxford University Press, 1973-173 -