LAURENCE B. McCULLOUGH AND ALBERT R. JONSEN

BIOETHICS EDUCATION: DIVERSITY AND CRITIQUE The papers in this number of the Journal of Medicine and Philosophy

I. SIX APPROACHES TO BIOETHICS EDUCATION

Alisa Carse provides a critique of the "justice orientation'', as it has now come to be known, namely, principle-based approaches to ethics generally and to bioethics, in particular. Based, in part, on the work of Carol Gilligan (1982) and, in part, on the work of feminist philosophers (of both genders), Professor Carse singles out as problematic (a) the centrality to the "moral point of view" of impartiality, (b) the "principle-driven and dispassionate" character of ethics, and (c) a paradigm of equality for all human relationships. Instead, she argues for a "care orientation" that emphasizes the particulars of experience and circumstance, engaged moral reasoning, and the recognition of disparities of power and possibilities in human relationships. On this basis she calls for a distinctive pedagogy for bioethics, one that goes beyond detached reflection to engaged, concerned action. The emphasis will seem unusual to some philosophers, but perhaps not to all and certainly not to clinicians, e.g., "personal skills and capacities that go with good caretaking", communication skills, the acceptance of ambivalence and uncertainty, taking social and political dimensions of the moral life - dimensions concerning the right and caring use of power - seriously, and the importance of

Laurence B. McCullough, Ph.D., Professor of Medicine and Medical Ethics, Baylor College of Medicine, Houston, Texas 77030, U.S.A. Albert R. Jonsen, Ph.D., Professor and Chairman, Department of Medical History and Ethics, School of Medicine, University of Washington, Seattle, Washington 98195, U.S.A. T\\e Journal of Medicine and Philosophy 16:1-4,1991. © 1991 Kluwer Academic Publishers. Printed in the Netherlands.

Downloaded from http://jmp.oxfordjournals.org/ at Lakehead University on March 18, 2015

concern bioethics education. Each author begins with an account of how bioethics should be understood and then identifies the major pedagogical implications of that account for college, university, or professional school teaching.

2

Laurence B. McCullough and Albert R. Jonsen

Downloaded from http://jmp.oxfordjournals.org/ at Lakehead University on March 18, 2015

locating bioethics teaching within the larger context of the other humanities disciplines, e.g., literature. John Arras centers his paper on a critique of recent work on casuistry (Jonsen and Toulmin, 1988) and the implications of that critique for bioethics teaching. Against the view that casuistry is reasoning by analogy from well-understood cases, without the benefit - or impediment - of ethical theory, Professor Arras argues that casuistry, if it is to work well, should not be understood as theory-minimal but, instead, as "theory-modest"; that is, to remedy the inherent shortcomings of a theory-minimal approach, casuistry requires some degree of theory, to guide and critically assess the decision making process of "triangulation" from familiar to increasingly less familiar cases. On this basis, some distinctive pedagogical implications come to the fore, including the importance of teaching from cases that are presented from the perspectives of all of the parties who are involved, in rich, murky detail. Teaching should promote suspicion of theory-minimal consensus - a risk of the approach to casuistry that Arras criticizes (an interesting implication for those of us in health professions education, where consensus plays so large a role in standards of care). Finally, teaching should aim to "unmask power" and confront it and its ethical dimensions as such. Stephen Wear accepts - indeed, insists on - the epistemological validity of the direct challenge from clinical experience to the bioethics of what he terms the "new ethos" of patient autonomy. His aim in advancing his critique of a dominant approach to bioethics is to make plain its risk of leaving health care professionals and patients alike with a nearly empty rhetoric of informed consent that at once demands too little and too much of both parties. Professor Wear argues for a more nuanced approach, one that takes seriously the clinically-informed continuum of what should be minimally required of both parties, what can be reasonably expected of them, and what can be hoped for from them. On this basis, he goes on to argue that bioethics must move beyond reflection to action. His remarks evoke the spirit of the earlier 'de Kamp Report7 (Culver et ah, 1985) but surely critical by implication - of its model of informed consent. Two main implications of this critique are worth noting here: (a) the need for "tougher" cases, presented as true to reality as possible, and discussed not just for content but for the actual care of the patient that should follow upon ethical reflection; and (b) the respon-

Bioethics Education: Diversity and Critique

3

Downloaded from http://jmp.oxfordjournals.org/ at Lakehead University on March 18, 2015

sibility of the bioethics teacher in the clinical setting to bring people from reflection to the willingness to act in an ethically informed fashion. Richard Wright identifies what he takes to be a fundamental confusion about bioethics that springs from a false dichotomy between (a) understanding bioethics as a field of philosophy, on the one hand, and (b) as a field of medicine - and the health care professions more generally, on the other. To remedy this problem he calls for a "construct" for bioethics that "informs the decisionmaking process and aids understanding the ethical components of that construct" (emphasis original). Professor Wright goes on to develop this construct on the basis of five components or "topics" of the decision making process. Two main pedagogical implications are worth underscoring: (a) the recursive nature of bioethics teaching, which should be seen as functioning on a constant feedback loop "from the problem back to and through the various components, as well as from one component to another"; and (b) teaching across the health care professions, e.g., teaching pharmacists' cases to medical students and vice versa, as a way to break down the professional insularity of bioethics that results from uncritically buying into the second of the two models that Professor Wright criticizes. Lachlan Forrow, Robert Arnold, and Joel Frader focus foursquare on teaching bioethics at the level of residency training of physicians. Their understanding of bioethics is that it should be theory-modest, to borrow Professor Arras' useful phrase, and that it should promote both serious reflection and ethically informed action. In this they follow the definition of clinical ethics offered by Jonsen, Siegler, and Winslade (1986), but not that more recently offered by others. (Miles et ah, 1989). Their strikingly clinical orientation is plain from their articulation of the goal of ethics teaching to resident physicians: "the development of professional competence in caring for patients", with ethical reflection and action understood as an indispensable element of that competence. Not surprisingly, their pedagogical concerns focus on the skills of ethical reflection and putting that reflection to work in the care of patients. Interestingly, Professors Forrow et ah, underscore the importance of teaching limits to one's skills in these areas, by emphasizing the skill of knowing when and how to seek ethics consultation in particularly difficult cases. Albert Jonsen's paper offers what might be termed a ' cultural

4

Laurence B. McCullough and Albert R. Jonsen

REFERENCES Culver, C.M., Clouser, K.D., Gert, B. et ah: 1985, 'Basic curricular goals in medical ethics', New England Journal of Medicine 312,253-256. Gilligan, C: 1982, In a Different Voice: Psychological Theory and Women's Development, Harvard University Press, Cambridge, Massachusetts. Jonsen, A.R., Siegler, M., and Winslade, W.: 1986, Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, Macmillan Publishing Co., New York, New York. Jonsen, A.R., and Toulmin, S.: 1988, The Abuse of Casuistry, University of California Press, Berkeley, California. Miles, S.H., Lane, L.W., Bickel, J. et al.\ 1989, 'Medical ethics education: Coming of age', Academic Medicine 64,705-714.

Downloaded from http://jmp.oxfordjournals.org/ at Lakehead University on March 18, 2015

critique' of bioethics by distinguishing its two main strands in the contemporary setting of the United States. The first he terms "moralism" the deep, well-established tendency for our culture to search for "clear, unambiguous moral principles" as guides for our social institutions. In this context, the beginning of bioethics in the United States more than two decades ago can be seen as springing from a moralism that "sought to bring the chaos of the new scientific medicine into the order of moral principle." This strand continues to have strong influence on the response to bioethical issues at the level of public policy. The second main strand concerns the shape that this response took in the academic literature. This strand, familiar to readers of this Journal, understands bioethics to be more concerned with method and more tolerant of ambiguity. Professor Jonsen draws some provocative pedagogical lessons from this cultural critique of bioethics, including a certain scepticism about the current emphasis on ethical principles, such as beneficence and justice, the risk of reinforcing moral relativism in our students, and the need for a more nuanced approach to teaching.

Bioethics education: diversity and critique.

McCullough and Jonsen introduce six papers in this issue of the Journal of Medicine and Philosophy concerning bioethics education. The authors present...
298KB Sizes 0 Downloads 0 Views