Medicine-Based Values?

Toulmin's Diagnosis

In his classical article with the unforgettable title "How medicine saved the life of ethics" (Toulmin 1982), Stephen Toulmin claims that medicine saved ethics by giving the philosophers a positive reality check through medical challenges: (1) Ethics in medicine is a serious topic, not just something to discuss at seminars. If, for example, both A and B need treatment and there are only enough resources for one , the fundamental interests of these two people compete against each other. (2) In clinical medicine, the individual case might demand a different approach than that suggested by theory. Similarly, an ethicist who is confronted by a diversity of medical cases becomes aware of the fact that solutions drawn from ethical theory can be irrelevant in practice. (3) The moral philosopher has often focused on the individual and his or her universal commitments. The fact that ethical dilemmas can have deep roots in practical challenges and must be understood within a certain context has been "forgotten." (4) In clinically relevant ethics, it is important to find solutions that all involved parties find reasonable. This revitalizes central Aristotelian schools of thought on, for example, ethical judgment and situational understanding.

Today, there is a common understanding that in both the education of doctors and in the implementation of medical knowledge and technology there needs to be ethical guidelines and control. Toulmin wants us to see that the background for this agreement is multifaceted. It was not just the ethicists who saved the doctors. The doctors helped the ethicists to escape their academic isolation.

Ethics Committees

The establishment of ethics committees is perhaps the most interesting example of this. Here it is especially clear how ethical judgment establishes a basis for decision making: Each case presented to an ethics committee is special because one cannot reference decisions made in similar cases. At the same time, we are expected to handle similar cases equally. Consideration of the concrete, individual case must be balanced with the principle of similar treatment. Second, as a committee member, one must interpret and respect ethical principles that cannot be easily defined. Every principle must be interpreted and implemented within a specific and concrete context. Third, one must consider the law, but seen isolated, the implications of relevant rules can be difficult to determine. Fourth, the status of principles and rules are open for interpretation. The most important example of this is the Declaration of Helsinki, which was established through cooperation between the worlds' doctors unions. The strength and end result of such a document can be discussed. Fifth, multiple but partly conflicting juridical and ethical considerations can be relevant at the same time. An example: Decisions about confidentiality can prevent data gathering that is crucial in ensuring that a research project is scientifically acceptable. Two important ethical considerations are then put up against one another. As a sixth and final point, it can be mentioned that the ethics committee is expected to make a qualitative, scientific judgment. But what kind of quality judgment and how detailed it should be is up for discussion.

Two Definitions of Ethical Judgment

The fact that the committee must base their holistic decision on ethical judgment means that the committee, in an important sense of the word, stands freely: It can be difficult to refer to specific ethical rules or laws when making an external review of the committee's decision. Unless the committee has clearly not followed known principles and rules, then the committee is able to confront criticism by replying that the decision is based on holistic considerations, where many views have been taken into account. In this way, the usage of ethical judgment makes sure that the committee has freedom to act. The catch here is that the committee's responsibility becomes even more obvious. One cannot simply say that the decision is made based on rules and principles formulated by others, such as the state. The committee must, as a unit, be able to defend their decision.

The complexity of the work of the committee can, however, make it more tempting to think about ethics in...