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02/20/2008 

Tishchenko P. D. Dimensions of Cultural Diversity of Medical Ethics

1. INTRODUCTION. ON A BROAD SENSE OF MORAL DIVERSITY IN HEALTH CARE

The title of my article carries a significant theoretical difficulty. In what sense can we speak about cultural diversity and "ethics"? In the work "Modernity – An Incomplete Project" Habermas recalls the idea of Max Weber fundamental to this topic who "characterised cultural modernity as the separation of substantive reason expressed in religion and metaphysics into three autonomous spheres. They are: science, morality, and art" (Habermas 1987: 148). That is why as soon as we start using the word "ethics" which from the time of Aristotle has meant a theoretical (secular) way of discriminating "good" and "evil", we are immediately in danger of losing "cultural diversity" as soon as other forms of moral evaluation are neglected.

For example, the Russian Orthodox Church was never interested in the development of "ethics" because rational principles, rules, imperatives or whatever could have only an instrumental role. The direct way to the idea of "the good" is belief. Meeting moral difficulties in medical practice (as well as in other areas of life) people should first of all recreate their authentic way of "being-in-the world" (their identity) in prayer, confession and communion. From the Church point of view without establishment of such a basic "pre-understanding" for any ethical understanding and judgement, nothing could be done properly. But for modernity such spiritual pre-understanding is a form of prejudices.


I think that the same could be said about the "moral identity" of believers in a significant number of other traditional and new religions. Such a position of resistance to the project of modernity in the area of morality is wrongly named "pre-modern" (as Habermas does) because a) their representatives are not going to become "modern"; and b) the Enlightenment idea that history progresses (develops) from a religious to a scientific world view has been falsified by history itself. This idea as such was and still is the way cultural diversity could be easily "coped with" (at this stage I prefer to use the Hegelian term "aufheben") and turned into a hierarchy of stages on a "ladder of development" from underdeveloped to developed forms. At the end of the 19th and beginning of the 20th centuries such arguments (proven by biomedical "objective knowledge") were used in most developed countries to justify of the natural rights of world domination that included the sense of intellectual and moral superiority. Similar ideas, of course in a much less aggressive form, exist in a number of ethical theories. As an example, I could mention Kohlbergvs theory of moral development used by Habermas in his version of discourse ethics. From this perspective: "... there is a universal valid form of rational moral thought process which all persons could articulate, assuming social and cultural conditions suitable to cognitive-moral stage development. We claim that ontogenesis towards this form of rational moral thinking occurs in all cultures in the same step wise, invariant stage sequence" (Kohlberg 1984: 286). The question is: to what extent is rational thinking is necessary for moral life, and to what extent it is sufficient.

The modern cultural situation puts the notion of the "development" of moral reason in question. The existing healthcare environment is a kind of a "summit" or "bazaar" of a great number of different modern and archaic practices from shamanism via psychoanalysis to gene therapy. As Ulrich Beck eloquently argues, this diversity is not a result of a lack of scientific knowledge, but of its most recent and advanced developments (Beck 2000). The existing deep crisis in the foundations of modern science (e.g. in theoretical physics and biology) has made scientists much more open minded to alternative worldviews than it was the case several decades ago. The same phenomenon is easy to recognise in the healthcare setting.

There is no hope today that education will protect against the influence of "prejudices", but rather makes people more sensitive to them. Daniel Callahan writes: "There is the remarkable popular interest in alternative and complimentary medicine, with evidence that nearly 40% of Americans turn to it for help not provided by a conventional medicine; and the more educated people are, the more they have use of it" (Callahan 2000: 679). Archaic and new alternative and complementary medicine retains its own type of healer-patient relations that could not, in principle, be morally ordered on the grounds of a Western type of ethics. For example, in most kinds of psychotherapy and healing practices "paternalism" (as a specific form of personal dependency) is not an external condition of relations with patients that could and should be morally meliorated. It is the internal structure of healing itself.

Let us summarize our introductory exploration. I am arguing that it is essential to speak in a broader sense about the diversity of moral perspectives in the area of healthcare. The problem of diversity of medical ethics is relevant only to a part of moral community, not to the whole of it. In this segment of the modern cultural environment the idea of "theory" presents the path for moral betterment. Meeting problems people should first try to grasp their nature theoretically and then act in accordance with this theoretical understanding. In a broad sense, the cultural diversity of moral stances incorporates the self-sufficient existence of those moral perspectives that simply do not need by virtue of their nature any theoretical account. This kind of diversity is present not only between countries, but also within all existing countries; it constitutes the specific feature of the cultural situation called by Ulrich Beck "other modernity". And what is most important, those parts that are "external" to ethics could not be situated on a ladder of development as "pre-modern" in relation to the central project of modernity where ethics is the way to distinguish between ideas of good and evil. Relations of different modes of moral life are not temporal, but spatial. They coexist beside each other and in competition with each other in the open space of modern societies.

In this article I am going to discuss first of all a proposal for coping with diversity in medical ethics that was offered by Tristram Engelhardt, Jr. in his "Foundations of Bioethics". Then, I am going to speak about cultural foundations of diversity in a broad sense. Afterwards I point out some examples for political diversity (most essentially in times of war and terrorism). I will finish with an evaluation of the specific role of public in competition of multiplicity of moral perspectives in health care.


2.  CONTENT-LESS THEORY AS THE RESPONSE ON THE CHALLENGE OF DIVERSITY

Diversity constitutes both the most specific fact or feature of modern ethical thinking in biomedicine (or bioethics), and a challenge to it. As H. T. Engelhardt, Jr. eloquently wrote: "[m]oral diversity is real. It is real in fact and in principle. Bioethics and healthcare policy have yet to take this diversity seriously" (1996: 3). Taking diversity seriously, Engelhardt diagnosed the danger: "... there is a swarm of alternative ethics ready to give rise to a babble of conflicting bioethics. This circumstance constitutes the foundational moral challenge of all healthcare policy. It brings the very field of bioethics into question" (1996: vii). Refusing both the nihilism of those who presume the impossibility of offering a generally accepted secular ethics, as well as those who dogmatically ignore the fact of diversity and try to create a content-full canonical moral theory for everybody, Engelhardt"... attempts instead to secure a content-less secular ethics. Given the limits of secular moral reasoning, all that is available is a mean (within certain constraints) of giving moral authority to common undertakings without establishing the moral worth on moral desirability of any particular choices" (ibid. viii).

The content-less way of doing ethics is a response to a paradoxical double attitude towards the phenomenon of diversity itself. We could fear it experiencing a kind of fundamental threat and a powerful motivation for any kind of thinking, including that in moral theory. And, we could also evaluate positively the threat to any attempt to find the foundation for morally right cooperation.

For Engelhardt, the first attitude towards the phenomenon of diversity is characteristic of the classical way of thinking and grounded both in the orthodox Judain-Christian tradition and philosophical traditions going back to Plato and Aristotle. To think means to grasp what is common in different things. The second perspective Engelhardt associates mostly with the negative historic experience of attempts to establish unified moral communities by brute force. "The great murderous endeavors of this century from Stalin and Hitler to the Gang of Four and Pol Pot have been born of attempts by force to make states single moral communities. Despite brutal repression, diversity remains" (ibid. 10). The historic account of the value of diversity does not mean for Engelhardt its' metaphysical reevaluation. Just to the contrary, for him the aim of content-less moral theory is to offer a "secular means for coming to terms with the chaos and diversity of postmodernity" (ibid. 10).

Such a theory for Engelhardt is the basic condition for peaceful collaboration between moral strangers in democratic societies. By understanding, his book provides "not simply a political theory, but an account of morality that should guide individuals when they meet as moral strangers to fashion healthcare policy. In the case that, when they so meet, they tend to collaborate in the realm of politics, through a res publica, a common thing that moral strangers of diverse moral community can share. Within that perspective nothing can contentfully be shared by all" (ibid. 10).

In this expressive passage we could notice two crucial issues for further exploration. First of all, we recognize the power and authority of the public, or res publica. But this recognition is far from being serious or consistent. The power of the public in itself is mere chaos for Engelhardt, or "a bubble of conflicting bioethics". That is why (this would be the second issue) his own mission as a professional in moral philosophy is to offer theoretically grounded "guidelines" that order chaos of public moral attitudes, making fruitful collaboration of strangers possible. But if any experts' idea or theory "should guide individuals" this would mean that individuals themselves are unable to self-organize or cooperate without the paternalistic guidance of an expert in philosophy. Individuals taken together are just inert chaotic masses. They need a prophet, a guru or a "father" to become a moral community.

In his introduction to "Meditations on First Philosophy" Descartes wrote that his mission is to convert those who do not believe in Gods existence using secular reasonable arguments. Engelhardt tries virtually the same -using reason to reestablish the unity of people left in chaos and estrangement after the loss of a common faith. Of course the difference is that Engelhardt offered only "empty", "formal" or "procedural" integration. But still this is an attempt to integrate others for their own good, but without any interest in their understanding of their own good, without the participation of those "others". It is a paradox of the founders of bioethics, that they questioned medical paternalism while staying firmly on the ground of moral paternalism.

As another example of this paradox, take this passage by Robert Veatch: "What we really have before us is a series of unsystematic, unreflective, ethical stances, or traditions. What we need is some ordering of that chaos we term a tradition, some systematic structuring of medical ethics so that physicians, other health professionals, government health planners, and consumers of medical care – all those who are important medical decision makers – can have some grasp of where they stand and why they may be in conflict with others with whom they interact" (Veatch 1981:5). The philosopher looks like a new Moses, through whose personal theoretical experience the internal order presents itself in "commandments" of principles and rules. The consequences of this inevitable characteristically philosophical thinking in medical ethics is to shift from anti-paternalism in relation to medical doctors to the paternalism of experts in moral theory which I have discussed elsewhere (Tishchenko 1998).

Here, I would like to pay attention to several other points. The position of a theoretical moral observer presented in "The Foundations" is outside the world of the moral community. It is reflected in introductory exploration, but has no role as a participant in the life of the "diverse moral community". To say more, this observer has no need of such participation. His reason is self-sufficient for a theoretical grasp of content-less moral "universals". And, what is important – it needs to be outside, distant in order to reflect on a priori conditions for the peaceful collaboration of "strangers" in the domain of "res publica".

But the public in itself is ignorant, uneducated in moral philosophy and that is why the chaos of public unsystematic stances could not be directly ordered by theoretical philosophical observations. Those results should be transformed into simple "guidelines" and invested in the fabric of communal life in the form of bureaucratic procedures. Just as Kant needed an enlightened monarch as a mediator between reason and society in general, the philosopher in medical ethics needs a bureaucracy for the implementation of constructed (or discovered) norms in the life of modern communities.

Not surprisingly Engelhardt's theory of moral strangers in bioethics was not shared by all in "res publica". Maybe this happened because his theory was not empty enough, and he had smuggled the content of the ideology of American liberalism into his supposedly content-less theory (Pellegrino 1998: 21). Anyway, the development of bioethics after the publishing of "The Foundations" has demonstrated that it is as impossible to discover content-less generally accepted ethics, as content-full ones. We witness a growing diversity of content-less or procedural accounts in medical ethics that leaves no hope for discovery of theory in this area. Does this mean our sliding into a bog of nihilism? Does "anything go" in moral life? Should we fear the fact of diversity and try to order the chaos? Or is it that this diversity is a direct result of the creativity of moral reason and we should wish it to "be fruitful and multiply ..."?

Let us stop at this point and return to the initial situation in order to make clear what is really at stake. First of all, it is a surprise that Engelhardt as a philosopher of the Hegelian brand is so swift to overlook the dialectical reflexive play of "form" and "content" inevitable in this situation. As already noted by a number of scholars the content of American liberalism is easily found in the foundations of Engelhardt's "content-less" theoretical structure of "guidelines" for moral strangers in democratic healthcare.

Second, Engelhardt's distinction between content-full ethics for "friends" and content-less ethics for moral "strangers" is based on their relation to the fact of diversity which could be refuted not only because of the impossibility of separating "form" from "content". Engelhardt also presumes that for a moral community of friends there is, in principle, the possibility of a common content-full theoretical ground. From the historical point of view this presumption is wrong – we cannot find any content-full theory that is more or less shared in any real "moral community of friends". As a matter of basic historic fact, there is no single "moral theory" among Muslims, Jews, Roman Catholics, Russian Orthodox, Marxists or others. Everywhere (of course in different proportions) we can easily find diversity of moral positions and perspectives. But absence of the theory does not mean chaos in moral life. This empirical (historical) argument moves us closer to a couple of essential philosophical questions.

Do we really need a theoretical ground for peaceful collaboration? Is diversity "the threat"? Of course, "every philosophy makes a practical and theoretical claim to totality and that not to make such a twofold claim is to be doing something which does not qualify as philosophy" (Spaemann in Habermas 1995:16). But the status of such claims could be different. It is reasonable to consider that any theoretical perspective is not a vision from "nowhere". It is always housed in an exact life-world, structured specifically from historical, cultural, ideological and personal perspectives. This makes diversity inevitable, and positions claims to totality in a kind of imaginary Utopia. In general any theory presents its own Utopian world. For example, the physical theoretical idea of an "ideal gas" marks a state of affairs that could never exist, but in spite of this (to some extent, because of this) is very fruitful for science and the further technological control of existing natural things and processes.

The difference between modern and classical moral philosophy (as well as the difference between modern and classical science) is in their different attitude to the question of the congruence of multiple theoretical (or "utopian") worlds and to the question of the observability of the observer.

After the Second World War in philosophy, and somewhat later in science, we witnessed a swift decline of interest in general theories. That means a decline in the desire to integrate a multiplicity of theoretical perspectives into one homogeneous world from one theoretical perspective. The situation is the same in physics, biology, medicine and philosophy. It is a new much more modest style of theoretical thinking that treats as essentially important claims to totality, but rejects "playing God" – this means, it rejects ambitions to speak for all from the position of an objective observer.

In modern medical ethics this modest style of theoretical exploration without the desire for theory is present in such influential trends as principlism, casuistry, the narrative approach, to some extent discourse ethics and some others. In different ways all of these theoretical perspectives share an understanding of modern medical ethics (bioethics) as predominantly an activity in a public forum. This means that the public cannot not be treated as a kind of chaotic mass that needs an expert to order its unsystematic moral vision. On the contrary, it holds as crucially important such things as moral common sense, morally structured in a narrative life-world, the heritage of communicative practices for the resolution of moral conflicts etc.

When neither the natural world nor the world of moral communities /resent in a diversity of theoretical perspectives, cannot be theoretically integrated into a single vision (and where there is no desire to do so), idea of common ground slides out of the "utopian worlds" of theoretical reason into empirical reality of the life world. I would like to agree with A. Johnsen that the beginning of bioethics can be traced to the establishment of the first ethics committees (Jonsen 2001).

Two existential discoveries of the limits to human reason were the creators of the first ethics committees. First of all, it was recognized that medical doctors do not have enough knowledge or experience to speak on behalf of their patients' good. Second, it was also recognized that there could be no expert in moral philosophy whose knowledge would be sufficient to clarify and resolve of moral problems in a healthcare setting. Of course moral experts were invited to participate in the common enterprise of evaluation and decision making, but (just like medical doctors) only on equal terms with lay people. To my mind, ethics committees are a kind of working model of a public forum of bioethics as part of a deliberative democracy. They present the pragmatic foundation, that in principle does not need theoretical guidelines for the common moral life of strangers, as well as friends. This does not mean that there is no need for moral experts' participation. It is always fruitful to give a theoretical discussion of the values that are involved and the procedures that should be used. But acceptance or rejection of any theoretical claim in public forum depends very little on theoretical perfection, but on other factors I discuss later.

Before doing this, I would like to explore some a priori cultural conditions for the integrated life of a modern moral community.

3.  CULTURE OF OTHER MODERNITY

Transformations of practices of biomedicine and discourses of medical ethics act in synergy with basic transformations of modern culture. They pump resources of new cultural impulses and give them back tremendous acceleration. In human beings they provokes new feelings of human power incorporated in biomedical technologies re-creating nature and a new experience of failure in the perceptual, imaginative and conceptual grasp of the nature of this human power. Human beings use this power in order to protect themselves against the threat of disease and other natural "enemies". But are we protected from misuse of this power?

For example, if one day genomics together with other biomedical sciences can fix "genes of death" in our bodies death would not disappear: it would be hidden, preserved and increased by genomics itself as the power of destruction localized in our "cultural genes" of freedom. Freedom of will is our basic cultural value as well as the cause of practices of transgression (including criminals, terrorists etc.). This failure reminds us to some extent of the truth of the Bible – the basic cause of death (as well as cultural progress, we could add) is our "sins" – the moral and ontological condition of human freedom. Humans may control nature, but who (if God is really dead) could control the "controllers"? Rethinking this question in the new cultural situation of biomedicine produces a new feeling of sublimity that retains the paradox of human power and ontological as well as existential weakness.

The feeling of sublime, presenting limits to human existence, shapes specifically the cultural play of a number of other existential feelings of which fear and hope are the most important. The specific design of this play in modern biomedicine was constituted in the 1960s by two great existential discoveries leading to the establishment of the ecological movement and of bioethics.

First of all, we consider the birth of the ecological movement. Somewhere in the seventeenth to eighteenth centuries in European culture the Christian idea of salvation was replaced by two initially separate ideas of health and freedom. This substitution and separation constituted the route to for scientifically oriented medical improvement and political action.

In the realm of biomedicine the basic threat to human identity was recognized in the external world of Nature, and the path to "salvation" was found in the scientifically designed technological control of external natural forces. Nature was blamed as the enemy and technology as the saviour. That is why the military metaphor was and is so popular in medicine, particularly in the ideology of the treatment of infection diseases and in political rhetoric (such as "war on cancer") and even in commercials ("Our soap kills all known germs!").

The ecological movement turned this linear existential orientation into a circular or paradoxical one. At the core of this existential shift was a fundamental discovery of a new threat to human existence. And what is crucial, it was found exactly where Western thinking was looking for "salvation" – in scientific and technological progress aiming at the conquest of Nature. We began to fear, but we did not give up these technological hopes. The desire of technologic control of natural forces is still the most powerful. But today it is balanced by the opposite desire to preserve Nature, to save it from human beings. The paradoxical play of existential feelings expressively illustrates the text of one advertisement for mineral water I found one day in my mail – "Natural spring water from Russian forests manufactured with the use of the most advanced Japanese technologies".

The diagnosis of the new existential threat was made by science itself; and what is wonderful is that the means of salvation from the new threat are designed by science as well in the growing industry of environmental control and protection as well as the manufacturing of "natural" products. Science has become threat and saviour in one, or as Ulrich Beck says – it has become "self-reflective", "self-doubting" and "self-limiting". The society that is growing on the new existential basis Beck calls the "risk society". The ecological shift has split scientific thinking into conflicting voices of scientific "truths", pro and contra exact technological innovations. Accompanied by the collapse of demarcationist programs in the philosophy of science (programs which attempted to establish a boundary between science and non-science) this shift legalized the multiplicity of truth-oriented scientific discourses. It made science more "open minded" not only in terms of intra-and inter-disciplinary differences inside science itself, but also in relation to non-scientific reasoning (religious, astrological, shamanic etc.). All of these different perspectives are today in permanent "dialogue" (Mikhail Bakhtin) in the evaluation of what is happening and in looking for prescriptions for what should we do in critical situations produced by technologic progress.

The transplantation of ecological thinking into biomedicine presumably happened after the thalidomide disaster (in which children were born without limbs to mothers who used the drug thalidomide during pregnancy), and transformed the pattern of relationships between science and practical medicine. For example, the "development time" for new drugs jumped from several weeks from the moment of synthesis of a new therapeutically active substance at the beginning of the 60s to around ten years by the beginning of the 1980s. "Development costs" escalated 20 times on more. The Safety, that is the prevention of the harmful effects of the "saviour" (the drug), had increasingly become the orientation of medical science (Le Fanu 1999: 247).

The second shift could be called "bioethical". It happened because of the intervention of multiple moral discourses into the area of medicine previously under the monopolized control of the scientifically oriented rationality of biomedical science and healthcare practice. The success of this intervention was predetermined by another existential "discovery", in the form of a number of public scandals involving biomedical research. The human body is not just an "object" of scientific research or medical treatment, but also the "flesh" of a specific person – its owner. That is why any action touching human flesh has an irreducible moral dimension that is largely invisible from the scientific point of view. This "blind spot" in scientific reason constituted a legitimate place for moral reason within modern biomedicine. At the same time, as its societal application to some extent, political practice has intruded into the world of biomedicine. Abortion, patients' rights, the rights of disabled people, cloning, genetic engineering, stem cell research – all of these and many other internal issues in biomedical science have become powerful motivations for political movements.

So the conflict of "truths" in the ecological shift was exacerbated by a conflict between scientific and moral reason in a bioethical shift. Not surprisingly, moral reason appeared in this "boxing ring" not as a unified agency but as an internally conflicted crowd of moral points of view, perspectives, values etc. This constellation of moral discourses inside biomedicine is usually called bioethics – the word initially created by Van Rensselaer Potter for the ecological obligations to the biosphere as a whole. I think that such a paradoxical existential play of desires, fears and hopes constitutes the basic structure of modern cultural identity – a specific rhythm of existential repetition. Modern progress in biotechnology offers "protection" from powerful external natural forces. Meanwhile, the ecological movement and bioethics provide complementary "protection" from the abuses and threats of biotechnology itself.

The cultural diversity of moral stances in healthcare depends deeply on the degree of appropriation by a moral community of the new existential rhythm of a risk society. For example, in Russia, as in other Third World countries, people are more or less informed about the ecological dangers or moral threats of biomedical technologies. But this information does not significantly influence their everyday behaviour because it does not touch the level of existential feelings. These feelings are still those characteristic of classical industrial society, with its predominant motivation of the conquest of Nature through technological control. The same kind of moral diversity may be found within all existing societies.

4. ETHOS OF WAR AND PEACEFUL MORAL COMMUNITY

The ethos of war constitutes a fundamental limit to the diversity of moral perspectives. Some differences cannot be tolerated. The limit of tolerance justifies and excuses both violence in relation to others and the limitation of democratic rights in relation to public.

Hegel was right to interpret war as an authentic and radical route to human self-understanding and self-development (but in contrast to Hegel, I would argue not necessarily progressive). At any rate warfare is a standard human "solution" to problems of cultural and political diversities. Whatever people we are, war is always with us and in us. In the short periods of peace, it is there potentially, and in most of human history , it is there in actuality. Of course, we differ very much in relation to the question of what kind of supreme value has to be threatened in order to provoke the move from potential to actual war-identity. For some people in some historic periods financial interests are enough (such as the "Opium wars" of China in the 19th century), for others it is national interests (like Russia in Chechnya), racial (Germany in the Second World War), ethnic (the Middle East today), class values (USSR), the values of the "modern liberal market democracy" and "universal values of human rights" (the case of Kosovo), or the fear of global terrorism (the case of Iraq). It makes a difference, but offers no option to which modern societies can be without self-identity of war.

Moral principles for the evaluation of human actions in a state of war could be called an "ethos of war". An ethos of war presumes the basic demarcation among "we" (allies) and "they" (enemies). The moral metaphor of a pirates' ship is relevant to this difference (at least until the middle of the 20th century). The Ten Commandments are used only by the internal circle of those who are on board of our ship. Others are outside the moral community of humanity. We are "the people" and they are "beasts" to be exterminated if they threaten us, and to be used "as means only" for achieving the great ends of the war (like the thousands of innocent lives in Hiroshima). In the second part of the 20th century this idea was meliorated by a number of international laws and conventions on the moral standards of warfare. But still, the difference in value between "we" and "they" is dramatic. It constitutes the difference between "medical ethics for us" and "medical ethics for them" in the time of war. The Iraq war gives a lot of examples of priority setting in the distribution of scare health care resources. First it was necessary according to the ethos of war for alliance troops to save oil fields (so valuable to "us") and only last hospitals (desperately needed for "them"). Specific moral problems and values of the ethos of war could also be found in the methods of provision of medical help in zones of catastrophes, areas of mass destruction, or after the terrorist use of chemical or biological weapons.

Biomedical professionals participate in war in different ways. Special problems are associated with their activity in the development of chemical, nuclear and bio-weapons. Hidden in secret labs and protected by the prioritisation of "national interests" this area of biomedical science is beyond public control. Evidence of violations of human rights could be found throughout. Justification for all such violations is based on the idea of legitimate sacrifice of human lives and private values on the alter of national interests (or another supreme value) in a state of war.

"One part of the war machine conscripted a soldier, another part conscripted a human subject, and the same principle held for both. In effect, wartime promoted teleological as opposed to deontological ethics; "the greatest good for the greatest number" was the most compelling precept to justify sending some men to be killed so that others might live. The same ethics seemed to justify using institutionalised retarded or mentally ill persons in human research" (Rothman 1995: 2252). The Nuremberg code and the Helsinki Declaration (1964) were attempts to "turn the table" and to make values of peaceful community higher than those of ethos of war. One of the basic principles of "ethos of peaceful community" is just the reversal of the principle of legitimate sacrifice. It goes: "Every biomedical research project involving human subjects should be preceded by careful assessment of predictable risks in comparison with foreseeable benefits to the subject or to others. Concern for the interests of the subject must always prevail over the interests of science and society" (World Medical Association 2000,1964).

In official self-consciousness of modern societies this move was successful, but the ethos of war survived in the depth of military structures and after "September 11" was resurrected. As an example, we could mention existing international situation concerning the control of development of new methods of biological warfare. In 1972 the Convention on the Prohibition of the Development, Production and Stocking of Bacteriological (Biological) and Toxin Weapons and on their Destruction (BTWC) was signed by a majority of countries. An application to this protocol a "Verification Protocol" that aimed to establish effective regime of inspections was in preparation for a couple of decades after this. But it was "suspended in November 2001 when the United States declared that they would not support nor permit the conclusion of a binding multilateral verification agreement. Among the reasons that US officials cited for the refusal was that the US believes that other countries are cheating and that the US should not be subject to the same standards as the rest of the world, and that the intellectual property of the US biotechnology industry would be put at risk by spying inspectors" (Sunshine Project 2002: 21).

The argument of "spying inspectors" echoes the same argument heard from Soviet military authorities, Saddam Hussein, authorities of Northern Korea and others belonging to the so called "axis of evil". It is based on the ethos of war. It protects development of biomedical research in the area not only from spying enemies, but also from own public control of moral and ecologic standards at use. What ever good ends and justifiable reasons has the unleashed "war against terrorism" – it inevitably expands the area of biomedical research and medical practices that are bound by the ethos of war with all negative consequences for the basic values of international peaceful moral community.

From the perspective of a peaceful moral community war is an extraordinary event. It is a transgression of moral order, its' justifiable or unjustifiable violation. From Hegelian point of view that has significant reasons – it is the way that a new world order is born. Both evaluations have their own justice and power. It is impossible to neglect or prefer either of them.

I consider the ethos of war as an external boundary for the ethos of a peaceful moral community. I now finish with an evaluation of the specific role of public in a peaceful moral community, in competition of multiplicity of moral perspectives in health care.

 
5. THEATRE OF BIOETHICS AND SPECIFIC ROLE OF PUBLIC

Presented in a huge number of scientific and public discussions bioethical deliberation looks like a "theatre" that, from my point of view, has its own cultural role. From the perspective of classical philosophy Engelhardt was right to call it "... a babble of conflicting bioethics" (Engelhardt 1996: vi).

I think, keeping in mind Bakhtin's vision of thinking as dialogue, that the conflict of "babbling bioethics" is a precondition for the existence of the bioethics we have today and its most characteristic feature – the dialogical way of reasoning. The word "babble" is instructive, reminding us of some specific points in the history of European culture that help to illuminate the phenomenon of diversity of moral perspectives and the role of the public, putting the "res" (power) of the public in a new light.

According to the Oxford dictionary, – to babble means to speak incoherently, indistinctly or foolishly. I would like to remind you of the time of the Renaissance, when the "fool" had become a popular figure in scientific and philosophical writings. To mention two of the most significant examples: Erasmus Desiderius' (1466-1536) "In Praise of Folly" appealed to the wisdom of "babbling" in order to undermine scholastic teaching and to free space for a new image of Man in the Universe. In Galileo Galilei's (1564— 1642) "Dialogue Concerning the Two World Systems", one of the first roles is "a Simple Man" (Symplitchio), – a lay man or "a man from a street" whose everyday wisdom helps Galileo to dispute Aristotles' ontology.

At the very beginning of the New Era we could see "open-minded" science in permanent dialogue with the "public" – the community of ignorant people. For example, Robert Hooke, who developed the basic methodological principles of scientific research for the London Royal Society, insisted that knowledge should be developed to the extent that scientists could demonstrate truth in public. And public demonstrations of scientific experiments were a routine activity of the society at the very beginning of its life.

At the same time we could see the development of similar phenomena in medicine in the "anatomic theatre"; The famous frontispiece of Vesalius' "De Fabrica Human Corporis" shows a scene from an anatomic "performance". Among the spectators we can recognize many leading thinkers and political leaders of the time, including Martin Luther. What was the role of those "fools" – people ignorant of anatomy, crowded around Vesalius? What was his role? He was not their teacher and they were not his students. Both parts participate in the magic of the anatomic theatre. The role of Vesalius was to dissect decomposing disfigured flesh to recreate in the imagination of the spectators the young flourishing athletic body, constructed in accordance with the Pythagorean concept of ideal proportions.

I suppose that the role of the spectators was that of a jury in court hearings. Vesalius like an expert witness attested to the new truth of human nature. His attestation competed with the attestation of a rival theatre that of the Church. And those ignorant in anatomy, the "fools", were to decide which attestation was more persuasive and which less in this historic case of Vesalius contra Galen (the Church). So, the babbling of fools (the public) pronounced a verdict on conflicting expert attestations in ongoing court hearings of history.

I will insist that the same kind of "bubble" constitutes the heart of bioethics as specific intellectual activity. To some extent this issue is acknowledged in the so со called "week principle of publicity" (Henry S. Richardson). In bioethics justification must be offered in terms of reasons that may be publicly stated. The need for "profanation" of professional knowledge of scientific truth or moral goodness is the same as it was in the epoch of Renaissance – the conflict of truths and conflicting ideas of good could be solved only in public "court hearings" (at any rate in civilized manner).

If to change slightly one of Paul Ricoeur sayings – conflict of truths is a goad that sends "experts" to a court of appeal – to make attestations in front of jury composed of lay people (public). In such attestations rival experts (e.g. scientists and moral philosophers) could not appeal to jury knowledge of foundations of the truth or the good they are presenting. They should turn reasoning out of "depth" of knowledge onto "surface" of narratives of public presentations. Due to Paul Ricoeur narration is the "summit" of scientific (description) and moral (prescriptive) reasons. They could meet each other and be in conflict only on the surface of life stories. "The actions figured by narrative fictions are complex ones, rich in anticipation of an ethical nature. Telling a story, we observed, is deploying am imaginary space for thought experiments in which moral judgment operates in a hypothetical mode" (1992:107).

In this sense attestation of rival moral and scientific "experts" in bioethics in front of public ("jury") is basically a storytelling – an imaginary thought experiments in which expert constructs a version of a "life plan" – how life would change for good or for bad if proposed ideas (new norms or new methods of treatment) would be accepted by the "jury". In order to disapprove this "dramatic" attestation rival experts should create their own imaginary versions of life stories – possible changes (surely negative) in life of lay people. In other words – bioethics looks like a kind of a competition of storytellers or tragic poets in antic theatre. Public (spectators) is the agency that grants gifts (awards) of recognition to those whose "stories" mostly fit their internal moral predispositions. It is the way of permanent co-evolution of public moral identity and ideology of biotechnological progress.

If to put this idea in other words – "bioethical theatre" presents a specific form of cultural selection of competing for survival multiplicity of moral values, stiles of life, and world visions, and on the other hand, – multiplicity of biotechnological projects of solution of human problems. This way humanity achieves contingent, open to reappraisal normative structures that order and stabilize the stream of scientific progress in biomedicine.

6.        CONCLUSION

Moral diversity in health care setting is a symptom of reintegration of three previously separated forms of human reason – science, morality and sense of beauty (working in the theatre of bioethics) into a new structural unity of forming risk society. At the same time this new structural unity opens space for participation of cultural projects independent from the project of Modernity.


References

 
Beck, U. Risk Society. Towards An Other Modernity. [Russian translation] Moscow: Progress-Tradition, 2000.

Callahan, D. "Judging the Future: Whose Fait Will It Be." The Journal of Medicine and Philosophy 2000, 25, 3, 679ff.

Engelhardt, H.T. Jr. The Foundations of Bioethics. New York, Oxford: Oxford University Press, 1996, 2nd edition.

Habermas, J. "Modernity – An Incomplete Project." In Interpretive Social Science. A Second Look. P. Rabinow and W.M. Sullivan (eds.). Univ. of California Press, 1987.

Jonsen, A.R. Paper presented at the Euresco-conference "Bioethics – an interdisciplinary challenge and a cultural project. 8-13. Sept. 2001, Davos, Switzerland.

Kohlberg, L. The Psychology of Moral Development. San Francisco, 1984.

Le Fanu, J. The Rise and Tall of Modern Medicine. London: Little Brown Company, 1999.

Pellegrino, E.D. and Thomasma, D.C. For the Patient's Good. Restoration of Beneficence in Health Care. New York, Oxford: Oxford University Press, 1998.

Ricoeur, P. Oneself as Another. Paris, 1992.

Rothman, D.J. "Research, Human: Historical Aspects." In Encyclopedia of Bioethics, Revised Edition. W.Th. Reich (ed.). New York: Macmillan Library Reference, Simon and Schuster Macmillan, 1995.

Spaemann is quoted from Habermas, J. Moral Consciousness and Communicative Action. Translated by C. Lenhardt and S.W. Nicholsen. Cambridge, Massachusetts: The MIT Press, 1995.

Sunshine Project. An Introduction to Biological Weapons, their Prohibition, and the Relationship to Biosafety. Third World Network, 2002.

Tishchenko, P. "The Goals of Moral Reflection." In Advances in Bioethics. M. Evans (ed.). JAI Press INC., 1998, v. 4, 51-64.

Veatch, R.M. A Theory of Medical Ethics. New York: Basic Books, Inc. Publishers, 1981.

World Medical Association. Declaration of Helsinki. Ethical Principles for Medical Research Involving Human Subjects (1964), Adopted by 52nd WMA General Assembly, Edinburgh, Scotland, October 2000.

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