Tishchenko P. D. The Goals of Moral Reflection
In attempting to impose order on the moral relationships in medical practice, medical ethics is in danger of suppressing the authentic values of practitioners and patients alike. Moreover medical ethics can be paternalistic, first inciting a perceived need for "professional" frameworks of moral analysis then supplying such frameworks without regard for their effects on actual practice, such as a dependence on the explanatory rhetoric of medical ethical analysis, ironically based on a highly artificial notion of "autonomy," and on the reduction of personal moral deliberation to the mere following of protocols and the filling out of forms. The adversarial nature of the autonomy models creates adversaries in need of "help," namely the services provided by medical ethicists; the obvious danger is that medical ethics becomes self-serving. Moreover, the replacement of genuine moral reflection by procedures and protocols finally paralyzes people's capacity for moral thought. Moral life requires the personal facing of genuine difficulty, disorder, and uncertainty. The more important goals of moral reflection are not so much (ready-made) answers to moral problems as the development of authentic moral character. Medical ethics is in danger of obstructing these more important goals.
The whole business of moral reasoning rests on the simple presupposition that without it people couldn't properly distinguish what is right (good) and what is wrong (evil) for them. That is why the first and the most important role of moral reflections is to make visible that moral order which in everyday life is hidden in the uneducated obscurity and uncertainty of ordinary language in use.
Visualization of this moral order is a precondition for the improvement of human relations in general and in particular areas of social life. For example, modern bioethics is trying to do this job in the field of health care. It tries to make clear the existing relations between moral subjects and to improve them by means of orderly moral reasoning. The danger is that in doing this, moral theory or theorizing presumes some values of its own as supreme, and that it underestimates traditional values and norms that are embedded in the professional skills and the practical knowledge of lay people, embedded in their everyday experience. Consider this eloquent 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, P. 5).
This feeling of superiority over some supposedly correct account of where "they" (other people) "stand" puts moral philosophers (here and henceforward I mean those moral philosophers who are engaged in bioethics) in the same dubious paternalistic position of that "expert" authority they meant to have unmasked and condemned in the traditional moral stance of medical professionals. We (moral philosophers or bioethicists) are making the same mistake as our intended clients, the traditional medical doctors. Many such doctors supposed they knew better what was good for their patients than did the patients themselves, because of the special professional knowledge and experience they have. But Evans rightly detects the same false supposition on the part of some philosophers: "They hope...that moral judgments about...patients' treatment will follow as conclusions from their own, less subjective or otherwise suspect, method. I do not share their hope; moreover I think it dangerous.... Those who debate publicly in health care ethics are sometimes mistakenly thought to have special authority to pronounce on moral matters" (Evans, 1996, P. 24). Moral philosophers have done a good job to the extent that they have helped medical doctors to consider the limited nature of their activity, and to be more self-critical in their professional performance. Philosophers have shown that medical knowledge is laden with doctors' personal and corporate interests. But now it is time for us moral philosophers to consider the paradoxical effects of our actions, their "altered nature," to use a term of Hans Jonas. At the same time I do not think that it is possible to overcome what we might call this "moral paternalism" in the same way as that in which bioethics deals with medical paternalism.
It is hard to imagine an ethics of "doing ethics" or of bioethics. The attempt puts us into a vicious circle; the ethics of doing ethics will itself need a further ethics of doing ethics of doing ethics, and so on. But some attempt at philosophical self-reflection, with regard to the cultural and social limits upon professional "moral upgrading" of human situations in general and in health care in particular ought to be worthwhile. In this chapter I am going to offer a critical philosophical investigation of the limits of moral reasoning and its goals. Moral reasoning aims to make things better, but like all other human actions it is a practical intervention in the human situation, and as such it may have harmful or injurious results as well. The possibility of harming or injuring others entails a specific net of duties on the part of professionals toward their clients. "If I injure someone it is generally held that I have a duty to make amends, to help the injured party. This acquired duty to help in a specific case is quite different in character from the general duty people have to help injured people," observes Veatch (1981, P. 84). I think that a recognition of the sort of injuries we moral philosophers could inflict upon our clients also calls forth a critical awareness of the limited, finite nature of what is honorable in our professional activities.
I. INJURING AS A PRECONDITION OF HELP
Moral philosophers traditionally presuppose that their goal as members of a specific professional group is to help physicians and patients to solve the moral problems that they meet in their professional encounters. But an obvious question is to what extent our clients really have such problems and really want professional philosophers to help them. When I began to establish bioethics in Russia five years ago the first thing I recognized was that our "clients" (be they physicians or patients) simply didn't have moral problems of the kind that I might have helped to "treat" using bioethical technicalities like the principle of informed consent, or a right to die, or whatever. People didn't bother about such things. That is why as an enthusiastic "bioethicist" the first thing I succeeded in doing (together with my friends and colleagues) was to threaten the self-confidence of medical professionals and patients alike, imposing on them a feeling of guilt for the actual or potential harm they could do, and a feeling of powerlessness to distinguish between right and wrong in medical practice without my professional help. The more they felt guilty and disabled, the more they needed my help. The more my clients needed my help, the more I would benefit supporting myself in the tough Russian economic climate through my provision of a high-quality "ethical care." Like surgeons we violently and painfully intervene in the natural order in health care, trying to make things better, or at least more ordered. But strangely enough, and in contrast with surgeons, we do not stop to consider that our interventions could have any negative side effects.
In my experience this professional activity was a violent intervention into the way that Russian people (and no doubt people in other countries) use their everyday language to express what is happening to them as physicians and patients. To put the point somewhat graphically, we injected our professional language into the body of everyday medical talk like viruses inject their genetic materials into the fabric of living cells. Applying theoretically derived standards of rational certainty, we made the everyday language of health care seem vague and uncertain. Having established this uncertainty we could then offer our help in making human relations more clear and ordered! For centuries physicians and patients knew who they were, where they stood, and what kinds of relationships they had. This knowledge was self-evident. It was embedded in patterns of ordinary language and learned by individuals in the same way that they learn all the other practical skills of everyday life. But bioethics then "discovered" in the physician-patient relation hidden and usually unseen conflicts between these two moral agents (physician and patient), thus displaying the danger of abuses of medical professional power. As soon as the "real" structure of human relations in health care was observed and theoretically clarified, and the danger was localized, bioethics could offer its professional treatment—the autonomy model of physician-patient relations.
Now I do not wish to paint too uniformly black a picture. I do believe that the implementation of this model in the clinical research and medical practice settings changed them for the better in many cases. A theoretical, artificial, moral order can and does help to protect both patients' and physicians' rights, their moral and physical integrity. As Thomasma has observed:
Obviously, the strength of this model lies in its stress on adult decisional capacity and the corresponding protection from the harms of medical technology. Most often these harms are described during the process of interventions during critical, chronic, and dying periods. But the model can also be applied very helpfully to everyday encounters in the clinical setting, by far the more frequent type of interactions in healthcare (Thomasma, 1992, P. 16).
But this moral protection can have a significant side effect which we should consider seriously; along with the idea of autonomy, we also inject into the body of the physician-patient relations an all-penetrating virus of suspicion that stimulates patients to view the medical profession as a potential, or actual source of harm. Although it is very easy to release this virus, controlling it is difficult. An uncomfortable feature of this for me personally is that, as public suspicion of the medical profession is aroused and patients' fears of possible iatrogenic harms are heightened, professional bioethicists (such as myself) will benefit through being presented as the protectors of patients' rights. I am sure that there are many situations in clinical settings where an application of the autonomy model is helpful. But I want to emphasise that there is always the price of this side effect of our professional help. Fears and suspicions of iatrogenic harms work in bioethics like viral vectors. They are the means by which artificial (and hence "foreign") ethical concepts are introduced into everyday language, ostensibly for the improvement of human conditions, but at the price of injuring mutual trust between the parties concerned. We should always balance the harms and benefits of our professional moral interventions. Moral regulation and mutual mistrust both come in the same package. In the environmental and technological context, Hans Jonas thought that a "heuristic of fear" should form the basis for the future moral theory.
Consequently, an imaginative "heuristic of fear," replacing the former projections of hope, must tell us what is possibly at stake and what we must beware of. The magnitude of those stakes, taken together with the insufficiency of our predictive knowledge, leads to the pragmatic rule to give the prophecy of doom priority to the prophecy of bliss (Jonas, 1984, P. x).
In fact a heuristic of fear is already the most powerful technology of modern bioethics in its interventions into public discourse. That is why Jonas's proposals for future moral theory sound equally like methodological considerations of what we are doing each day in the field of health care ethics.
As long as the danger is unknown, we do not know what to preserve and why. Knowledge of this comes, against all logic and method, from the perception of what to avoid....Because this is the way we are made: the perception of malum is infinitely easier to us than the perception of bonum; it is more direct, more compelling, less given to difference of opinion, of taste, and most of all, obtruding itself without our looking for it (Jonas, 1984, P. 27).
The improvement of human relations in health care (as well as in other fields of social relations) goes hand in hand with helping people to visualize new dangers they have not experienced before. In their turn new dangers transform the most basic patterns of human identity. At the beginning of this century Sigmund Freud encouraged people to visualize the danger of repressive pathogenic authority on the part of a child's father. This visualization constituted and legitimized psychoanalysis as a popular therapy and a treatment of human suffering. Modern bioethics has visualized another, distinct danger at the very beginning of existence of each individual—a conflict of rights and interests between a child (a fetus) and her mother. In this case the mother of the child is seen as the first danger for her existence. Complementary to this, the existence of the child is interpreted as a threat and a danger to the mother's self-determination. This version of what one ought to avoid and what one ought to fear cuts across all our everyday experience of what childhood or motherhood is and should be about. It sounds ridiculous and artificial. It splits organic unity, based on the mutual love of a child and her mother, into an almost violent confrontation between individuals whose true identity is somehow recognized only in acts of self-determination. This moral separation and alienation of children (fetuses) from their mothers turns out to be the precondition of a supposed moral orderliness presented in the language of human rights — women's rights of choice and fetuses' rights to life.
I think that this alienation of mothers and fetuses, and this injection of a sense of mutual danger and fear, are significant injuries caused by our theoretical moral reflections. Have we a moral right intentionally to inflict these injuries? I think in fact we do indeed have such a right. But the right is limited by those cases where the pain and harms arising from our treatment will be less than the pain and harms we are going to prevent. Particularly is this true in the case of abortions and the new reproductive technologies where the separation of fetuses and mothers is already determined in mothers' or third parties' intentions. At best, moral reflection here can do no more than try to impose order upon human relations that are already disintegrated by women's desire for self-determination supported by new developments in biomedical technologies. In other cases I believe we have no right to intrude with our artificial language of human rights into the ordinary language of everyday relations, where the wisdom of a traditional commonsense understanding of childhood and motherhood is retained.
A lack of systematic ethical order in the minds of interacting physicians, patients, and family members is not sufficient justification for the imposition of an "ethical treatment": moral order (orderliness) is not good in itself. We have no empirical evidence to say that morally and rationally ordered interactions in all cases are better than a "chaos" of feelings and unreflective stances of partners linked by mutual love and respect. In any case, no one ought to imagine that moral philosophers (who of all groups might be supposed to have the most systematic and self-reflective knowledge of moral principles) are the most high-minded people, or that their way of moral life has any superiority over the way of life of lay-people uneducated in formal ethics. That is why we should always try to localize the area of our theoretical moral interventions, in order to minimize the harms we might ourselves inflict.
If this is done responsibly, then perhaps the recognition of specific injuries which moral philosophers might inflict does itself constitute a specific ground for the legitimization of moral philosophy into a "true profession," in the sense of responsibly exercising that precise form of social power which is called "pastoral" by Michel Foucault.
II. ETHICS AS A PASTORAL POWER
To say that one of the goals of moral reflection is to produce a specific kind of social power and domination is to contradict one of the tenets of mainstream moral philosophy. Most moral philosophers are confident (indeed, proud) that through the protection of self-determination they help people to escape subordinate positions in a hierarchical social system. For example, bioethics is meant to have given patients knowledge and social techniques (like the mechanisms of informed consent) to resist paternalistic domination by medical professionals in the clinical and scientific setting. It is meant to have helped them put their relations with physicians under their own rational control. In a manner close to, but not identical with, the work of Michel Foucault I would like to show that the well-meaning assistance of moral philosophers in the protection of human liberties carries a specific price people will have to pay in the form of a new dependency and subordination. I do not here mean to unmask some hidden selfish interest on the part of moral philosophers (including myself) in having domination over others, nor do I mean to humble and to devalue our professional treatment of human situations. I have a different aim, namely to offer a more critical reflection on the finitude of moral reasoning, and to increase our critical sensitivity to the possibility of those harms we might inflict in our well-meaning exercise of a social power. The stimulation of fears of new dangers and suspicions regarding the activity of medical professionals are important mechanisms in the proliferation of this "pastoral power" of moral philosophers in the health care setting.
Another possible harm, and one that needs more attention in understanding how our professional power is exercised, lies in bringing about a kind of moral disability. Usually moral reflections are supposed to mirror human actions in a language that makes them clear in the light of a theoretically ordered dichotomy between good and evil or right and wrong. The Western philosophical tradition tries to organize such reflections into a kind of a moral theory. Philosophers perform this task, perhaps keeping in mind the paradigmatic example of scientists. Scientists aim to make nature clear for the purposes of human reason, discovering and grasping in a form of a theory the natural order of things. And this making the natural order clear is the means by which people put natural things under their own control and use, for instance in industrial technologies. But in order to establish their freedom over external natural forces, people put themselves into a position of dependency upon science (which is regarded as the source of truth in modern communities). Thus, people disvalue and falsify their own common sense and everyday knowledge in relation to scientific truth. Through education and mass media they are trained to feel themselves disabled from having their own access to this truth (i.e., an access independent from science itself). In other words, the exercise of self-determination over the natural world, so crucial for justifying the authenticity of the civilized "self of human beings, is based on obedience to science. The paternalistic position of medical doctors is grounded in their privileged access to this true knowledge. In much the same way, moral philosophers may be tempted to hope to discover and to present in a theoretical form some authentic moral order for human communities. They attempt to make this order clear by means of systematic professional theoretical reflection. The discovery of a moral order would help people to resolve the moral difficulties they have, and would put human interactions under rational control based on a system of values and principles.
But now we meet the same dialectics of power and knowledge as in the case of the application of scientific truth. In order to overcome an external dependency upon medical professionals, patients risk putting themselves into an equivalent paternalistic dependency upon moral philosophers who are authorized to speak for the true (or a true) moral order of human relations. And (wonder of wonders) the reward for this obedience is the same, that is, access to the technologies designed to help people to establish control over external forces—in this case in the form of other persons. The numerous codes and guidelines, which rapidly multiply the formal human relationships to be found in health care and other areas of life, are a kind of moral technology. The instruments of this technology are usually based on precise ethical principles and are produced by people with professional expertise in this field. As soon as a guideline or a code is produced it appears ready to be applied by other professionals and laypeople for the prevention and resolution of their problems without any appreciation of the laws or principles they represent. These codes and guidelines could be used instrumentally in the same way that most of us use computers, cars, or other physical tools without bothering about the natural laws on which they are based. For example, the design and realization of informed consent forms for research subjects needs a lot of professional moral consideration. But as soon as these forms are available, the whole moral business is turned into the paperwork of correct filling out of forms. It becomes a matter of indifference whether researchers know something or nothing about the principle of autonomy, or the principle of beneficence. All they need is to follow guidelines on how to fill out the informed consent forms which are authorized by the institution where they conduct their research. In the fabric of modern social life, moral reason is becoming a real social power through the incorporation of its intellectual commodities into schemes of bureaucratic administration. Moral ordering is turning into another form of administrative regulation, control, and supervision. Daniel Callahan writes:
The most obvious trend is that there will be more and more external regulation and bureaucracy. It is certainly not likely that those administering or working in hospitals are going to find themselves freer in the years ahead to make decisions as they see fit. Rather, given the large number of changes taking place, coupled with the fact that in this country we appear to prefer solving many of our problems through bureaucratic systems, guidelines, and regulations, it seems inevitable that this is going to be an increasing part of hospital life (Callahan, 1992, P. 5).
Moral regulations and policies amalgamate into the machinery of modern medicalized social power (or bio-power in the terminology of Michel Foucault) constituting its most significant new dimension. Foucault had limited his analyses of the construction and control of moral subjects to what he called the "technologies of confession." Bioethics has implemented a significantly new and different technology of the creation, recognition, and control of subjects that is mainly based on the idea of self-determination.
The autonomous agent is one who is self-directed, rather than one who obeys the command of others. These descriptions of autonomy all presuppose the existence of authentic self, a self that can be distinguished from the reigning influences of other persons or alien motives (Macklin, 1982, P. 57).
Bioethics gives people knowledge—what counts as the problem in their relations with health care professionals, what kind of dangers to fear, what it means to have an "authentic self," what it is to distinguish this self from the "reigning influences" of others, and what will count as an appropriate resolution of patients' struggle for freedom and self-determination. Moral reflections establish a general matrix for the recognition, conceptualization, and technical "solution" of human problems in the biomedical setting. It differs from the traditional confessional technology of moral control. If the technology of confession tries to control some "internal" content of moral subjects, modern bioethics offers a way of recognizing and controlling external conditions for the performance of acts of self-determination in which we can discern ideas of an "authentic self—ideas, of course, imposed by moral philosophers upon the public mentality.
Virtue ethics is an attractive exception to this tendency. But I think that it is much less influential in the biomedical setting because it is much more difficult to turn it into a kind of bureaucratic technology of control and administration. Mainstream bioethics is busy with the production of moral technologies to suit consumers in governmental and medical bodies. For example, if you would like your research in bioethics to be funded by a governmental body (such as the National Institutes of Health in the United States) it will be good for you to promise to prepare guidelines or proposals for future guidelines for the solution of those burning human problems which are the objects of your professional diagnostics and treatment. The pastoral power of experts in moral philosophy thus becomes incorporated into the power of modern biomedicine (or, as Dreyfus and Rabinov term it, "bio-power"), and possesses all its characteristic features:
Bio-power spread under the banner of making people healthy and protecting them. When there was a resistance or failure to achieve its stated aims, this was construed as further proof of the need to reinforce and extend the power of the experts. A technical matrix was established. By definition, there ought to be a way of solving any technical problem. Once the matrix was established, the spread of bio-power was assured, for there was nothing else to appeal to; any other standards could be shown to be abnormal or to present merely technical problems. We are promised normalization and happiness through science and law. When they fail, this only justifies the need for more of the same (Dreyfus & Rabinov, 1983, P. 196).
Moral reflections aimed at improving human relations in health care significantly reinforce the legal and scientific power of normalization. They structure a possible field of action (confrontations or cooperations) for patients, physicians, and others involved in health care relations. Differentiating among the various interacting agents is the most important vehicle for the enlargement of the pastoral power of moral philosophy. As I have already observed, the autonomy model (so popular in bioethics) is based on the recognition and stigmatization of physicians as a potential source of danger for patients. It is a significant act of discrimination, produced by experts in moral philosophy, which bestows upon physicians a feeling of the collective guilt of offenders and upon patients a feeling of the collective innocence of victims. It turns cooperation into conflict and imposes the language of conflict upon the world of therapeutic relationships—a world previously conceived in the language of compassion, mercy, and beneficence.
As examples of such social discrimination consider the following two titles of recent books, namely Enemies of Patients (Macklin, 1993) and Exploring the Gene Myth: How Genetic Information is Produced and Manipulated by Scientists, Physicians, Employers, Insurance Companies, and Law Enforcers (Hubbard & Wald, 1993). I doubt the prudence and wisdom of such labeling and stigmatization. We should be careful not to turn our social environment into a battlefield of the Hobbesian "war of all against all" as soon as each of us is able to exercise professional power over others. Even street beggars, in trying to manipulate and to milk our feelings of compassion, are exercising a certain kind of professional power. I think we should take a lesson from modern environmental ethics where it has been recognized that nature with its reigning external forces is not the enemy of human beings. In our attempts to combat this "enemy" and to put it under our rational control through industrial technologies we have put ourselves in danger of physical extermination. It was possible for environmentalists to revise the status of "the external" (in the form of nature) from enemy to partner. Why is it difficult for professionals in moral philosophy to recognize that what is external for the authentic self, that is other persons, are not enemies too?
My own answer to this question is that it is difficult because the alienation of partners in social interactions, into conflicting groups of "enemies" that endanger each other, is a precondition for the professional help of bioethicists. If such a danger is not diagnosed and localized by professionals, and if it is not recognized by clients, then there will be no grounds for demand and no need for professional help. Moral philosophers engaged in bioethics earn our living by the provision of ethical help. Like any normal social agents we are interested in expanding the market for our professional expert services. If we are not critically aware of this interest, we are always in danger of confusing the common good (as observed from the position of an objective observer) with our own personal interests, and of aggravating existing dangers or even of creating new ones as objects for our professional treatment.
I am sure that our professional duty and responsibility is to avoid generalizing those of our intellectual models which rest upon identifying grounds for mistrust. In order to minimize the harms of our professional interventions into human relations we should always prefer when possible the language of partnership and democratic collaboration to that of civil warfare. "First of all do no harm" is a good regulative principle, not only for doctors but also for us bioethicists. If we can resolve a problem using only the common sense of everyday language we should do this without the intrusion of artificial terms from moral theory. Theoretical ordering is not good in itself. Only if common sense fails have we a professional right or duty to intervene, and even then we must choose less harmful tools. For example, a good alternative (when possible) to the militarized technological language of the autonomy model could be the language of "beneficence-in-trust" of virtue ethics (Pellegrino & Thomasma, 1988). If the preexisting moral situation in a particular area of society is as a matter of fact more hostile, and if people are already significantly alienated from each other, then perhaps we have a right and a social duty to use stronger "remedies" like the autonomy model; but we should always keep in mind its possible side effects.
At the same time perhaps our preferences for the use of militarized language in our professional activities shows our own dependency on a more general social and cultural context. Moral reflections are basically a public use of human reason. That is why they are heavily dependent on whatever kind of medium binds isolated individuals into a historically precise society, or "public." Two centuries ago Kant could easily think about the public use of human reason taking for granted the transparency of the social medium binding autonomous agents into a community which understood and shared universal reasons. Today, by contrast, we are confronted with an opaque mass media, which has its own internal interests and requirements for "publicizing," that is for making ideas open to the public. I agree with Lewontin that these requirements can produce a significant distortion of scientific knowledge, and I would add that the same happens when moral ideas are transformed by the mass media for public consumption. For ideas in order to be published and to have a good press, or to become "good television," they must be turned into simple and entertaining narratives, into "dramatic theories" (Lewontin, 1992). Fears, suspicions, and dangers are very attractive and useful for turning careful and accurate moral reflection into entertaining and profitable showbiz.
It is very difficult to publicize a balanced opinion that considers the complexity of life and the uncertainty of moral knowledge, that doesn't discriminate people into groups of enemies, and that doesn't offer simple solutions. For example, when my colleague Yudin and I tried to organize in Moscow a public discussion on the moral problems of transplantation technology we met a significant reluctance on the part of medical doctors to participate. Our first guess was that they were afraid to endanger their financial interests by exposing them to the public gaze. But we were right only partially. They were also afraid of the manner in which this "gaze" prefers to see everything. We understood this better when we took some prepared materials for this discussion to the editor of one of the "intellectual" daily papers in Moscow. He swiftly looked through our papers and said, "There is nothing to publish, guys. Bring me something about a murder of donors, the theft of kidneys, or fraudulent medical doctors and you'll be in the paper the next morning!" We had written about the problems of partnership between the public and medical doctors in the transplant setting. But he wanted us to look for the patients' enemies, and in fact (though perhaps it was not his intention) to use the same language of "enemies of the people" that was used in our country in the time of Stalin's Great Terror. Terrors, fears, blood, or violence—the stuff of raw emotions—attract people and unite them as a solid group of consumers of the attractions of the modern mass media. This is how we as the contemporary public are made—to paraphrase the remark of Hans Jonas quoted earlier. Ironically, we find ourselves in a circle of mutual dependency. In order, as "experts in moral orderliness," to exercise our professional power over the public we too must obey the requirements that this public imposes on us as a condition of their consuming our intellectual commodities. That is why, when thinking about the goals of moral reasoning, we should always give critical consideration to the way everyday language becomes distorted and acquires, embedded within it, the coercive influences of modern publicity.
III. 'BACK TO THE ROUGH GROUND!"
The goal of ethical reflection is to help people with their moral difficulties. The view that we have been criticizing interprets this as offering an easy life provided that "clients" follow guidelines which have been designed by moral experts. But in such cases the burden of a personal decision has been substituted by a comprehensive technological and often bureaucratic solution. For example, serious moral problems concerning the use of human subjects in experimentation are often substituted in medical scientific practice by the mechanisms of informed consent. These mechanisms shift the main attention from the personal moral choices of researchers to their accurate filling out of consent forms. Thus, a researcher could suppose that he or she is morally right not because of the difficult personal, "internal," work of moral decision making, but simply because of the formal correctness of his or her paperwork. Of course, the proper implementation of such procedures as those of informed consent is extremely important (particularly in Russia) from the point of view of improving the mechanisms of civil administration in biomedical science. But this should not be treated as a final solution of the moral problems at stake. Indeed, this mechanical moral facilitation, like other forms of technology, can bring about an atrophy of its clients' own moral capacities. As I have already said, this disability on the part of such clients to solve moral problems themselves is the precondition for their need of the "expert" help of professional bioethicists. A certain amount of our professional help arises in direct proportion to the corresponding degree of this disability on the part of our clients, whether it arises naturally or is artifically inflicted.
Let us imagine (as a thought experiment) that the whole area of health care is comprehensively covered by robust moral guidelines that solve all the moral problems we could think of. The goal of moral reflection in this area will have been achieved. But, as a side effect, this causes a total paralysis of the moral capacities of medical professionals—their complete moral disability inside a complete, morally well-ordered social system. Therefore, paradoxical though it sounds, in order to safeguard the moral capacities of our clients we (bioethicists) should always keep our interventions within the status of unfinished projects, not only de facto, but in principle. Moral problems are truly moral when they have no final solution, and when they resist any easy decision making based on the mindless application of ethical "technologies" such as principles, rules, guidelines, and so on.
It strikes me that the temptation of easy ethical solutions has something in common with the physicist's notion of "ideal movement" without friction. Paragraph 107 of Wittgenstein's Philosophical Investigations will be a proper warning in such a case:
The more narrowly we examine actual language, the sharper becomes the conflict between it and our requirement. (For the crystalline purity of logic was, of course, not a result of investigation: it was a requirement.) The conflict becomes intolerable; the requirement is now in danger of becoming empty. We have got onto slippery ice where there is no friction and so in a certain sense the conditions are ideal, but also, because of that, we are unable to walk. We want to walk: so we need friction. Back to the rough ground!
If we want to walk in the world of human relations we should reconsider in a positive way a meaning of "friction" for us—of chaos, uncertainty, disorder, difficulties, and so on. We need this "friction" in order to perform as human beings, just as climbers need rocks. Perhaps the goal of moral reflection is, ultimately, a rational moral order rather in the way that reaching the top of a mountain will be the goal for a climber. But a climber needs the intervening rocks in order to be a climber. If we intervened (for instance, with a helicopter) to transport the climber to her goal, the toughest peak of the highest mountain, we would have made her life as a climber meaningless. In the same way moral human beings need the resistance of moral problems in order not to lose their moral identity. This marks the limit of our professional help of moral bettering through moral orderliness. And in practice, for example when teaching students, the first thing most of us do is to make their moral awareness not easier but more difficult, initially by showing that moral problems have no single good or easy solution. We teach our students that each "technology" of ethical orderliness could be opposed by another one with different moral priorities. Once they become rationally aware that they can have no false promise of easy automatic ethical solutions, no hope that someone might deputize for them in making "the right decision," then they are in the right position to act as morally mature agents. This critical recognition, of the final nature of the moral reasoning which we use in our professional activity as moral philosophers specializing in bioethics, should become a constituent of our professional virtue. We should treat the goals of moral reflection as a kind of regulative requirement for localized interventions, limited in power and prone to being "altered in nature" like all other human actions.
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