Rethinking Autonomy: A Critique of Principlism in Biomedical Ethics

Chapter 1 Inventing Ethics

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 1 2 Rethinking Autonomy 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 cen- 3 Inventing Ethics tral 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...