* Should one focus on actions or character? The core difference between virtue theory (David Thomasma; Edmund Pellegrino) and other theories such as principlism (Beauchamp and DeGrazia), casuistry (Boyle) and Clouser/Gert’s “common morality” rests on this distinction. However, as the essays in this volume will make clear, one should be careful not to formulate these diverse theories in a way that makes the distinction too sharp. Virtue theorists recognize that a focus on character is not enough (Thomasma ), and other theorists recognize that virtue is important; for example, Boyle (p. 79) notes how the virtue of practical wisdom is needed for the subtle balancing involved in casuistical analysis (see also Beauchamp/DeGrazia, pp. 66-68; and Clouser/Gert). Aspects of feminist theory (esp. the ethics of care) are related to virtue theory, while others are more act- or system-oriented (Tong); and many narrative ethicists (e.g., Hauerwas and Pinchas, 1997; MacIntrye, 1984; see Nelson in this volume) are directly associated with virtue theory.
Should one focus on consequences or intrinsic features of an action? Much of the classic dispute between consequentialism (primarily with the variant of utilitarianism) and deontology can be understood in terms of this distinction. However, most bioethicists have eschewed single principle theories in favor of more complex, situated accounts. Where principles or rules are advocated, as in the theories of Beauchamp/DeGrazia and Clouser/Gert, more than one is put forward. Thus the classical dispute between utilitarians and deontologists is reconstructed in terms of balancing concerns associated with these traditions. In particular, principles of beneficence and nonmaleficence (among the principlists) or a rule not to harm (for Clouser/Gert) are put forward to capture the utilitarian concern about consequences, while a principle of autonomy or the rule to advance the norms that uphold society captures core deontological concerns. (Accounts of justice are more complex, with some more utilitarian and others more deontological.) It is worthwhile noting that a similar interest in integrating consequences with deontic constraints can be found in prominent casuistical (Boyle) and virtue oriented accounts (Pellegrino and Thomasma), as well. What used to be regarded as a dispute between theories is, for many bioethicists, a dispute about how best to balance the insights of both theories in the absence of a single, meta-principle or an algorithm for resolving the difference.
How are moral claims ultimately justified? Problems of justification in bioethical theory take several forms and occur at several levels. For example, in particular cases, a recommended course of action might be justified by appeal to principles, rules, or paradigm cases. There is debate about how effective such principles, rules, or cases are at justifying certain kinds of actions. At another level, a course of action that involves a balance between competing principles might be justified by a fuller account of the situation, which is relevant for the specification of principles, together with a reference to virtues associated with moral judgment (Boyle; Beauchamp and DeGrazia). At the broadest level, justification of the principles and the general theory might involve an appeal to “coherence” or the background “public morality” (Beauchamp and DeGrazia; Clouser and Gert) or, on different accounts, to natural law (Boyle) or a particular meta-narrative (Nelson).
How should one balance the need for situated deliberation against the threat of relativism? We live in a pluralistic society, with multiple cultures and beliefs informing ethical deliberation. As a result, there are often competing moral norms nested within competing traditions. An appreciation of diversity, and a recognition of the degree to which norms are culturally and historically situated, often comes into tension with the need for unambiguous norms that can mediate conflicting claims among these competing groups. And we often must act together for communal ends. How is such action guided? David Thomasma and Hilde Nelson explore these issues in depth, and they are also addressed by many of the other essays in this volume. Different bioethical theories struggle with these questions in different ways.
Should one preserve or critically transform the background moral system? The public and health care traditions that inform moral deliberations can have both positive and negative features, and bioethical theories will differ on what these are and the degree to which the background public system needs to be transformed. Some theories will see their primary role as clarifying and bringing to language this presupposed “common morality,” while others, such as feminism, will see their role as much more critical, calling into question not just the presupposed systems and norms, but even challenging the forms of ethical deliberation, seeing them as variants of a dominant group’s form of reflection. Tong nicely outlines, for example, how care-oriented feminists see traditional modes of moral reasoning, with their abstract, rule-oriented reflection as alienating womens’ more particularist, situated, care-oriented reasoning. Nelson similarly considers those who would look to more narrative-based ethical reflection as an alternative to the theoretical-juridical models.
Do the central norms of healthcare ethics arise out of the specific characteristics of its practice or are they applications of more general public norms? Edmund Pellegrino argues that bioethical norms should arise out of the realities of illness and medical practice; in particular, the healer’s response to the suffering patient. Through a phenomenology of the health care encounter, the physician-patient relation is made central, and norms are configured from there. By contrast, others see the norms in terms of a more general ethical theory.