Principles and the search for moral certainty

SOC.Sci. Med. Vol. 23, No. 5, pp. 461-468. 1986 Printed in Great Britain. All rights reserved

PRINCIPLES

Copyright

AND THE SEARCH LARRY R. CHURCHILL

Social and Administrative

FOR MORAL

02-7.9536;86 53.00 + 0.00 % 1986 Pqamon Journals Ltd

CERTAINTY

and Jo& JORGE SIMON

Medicine, University of North Carolina, Box 3, Wing D. Medical School 208H, Chapel Hill, NC 27514, U.S.A.

Abstract-In medical ethics, principles have an important but frequently overextended role. The need for exact answers and moral formulae sometimes leads to the misuse of principles, such that they usurp the central place of persons and become ends in themselves. The Baby Jane Doe case is discussed as a prominent instance of both the proper uses and abuses of principles. A more fitting role for principles is described and illustrated, stressing the use of principles as tools of moral discernment and the time-laden character of moral judgments. Key words-medical

ethics, principles, uncertainty, judgment

“We’re not just fighting for this baby but for the principle that every life is sacred [I]“. C. EVERETTKoop “It should be clear by now that what is needed in neonatal decision-making is precise articulation of agreed-upon principles and improved procedures for applying them to individual cases [2]“. GEORGEANNA~

It is generally accepted that principles represent the zenith of ethics and that appeal to principles is the central move in ethical reasoning. One well-known expression of these ideas is Henry Aiken’s depiction of levels of moral discourse. In .&ken’s scheme, value conflicts at the level of emotive expression or the level of moral rules are referred to the higher level of principles for resolution [3]. For example, ‘I hate abortion’ is an emotive expression; ‘Do not perform abortions’ expresses a moral rule; ‘The right of the fetus to life is more fundamental than the woman’s right to choose’ is one (but not the only) expression of the level of principles [4]. For Aiken, as for many contemporary philosophers, only principled discourse represents ethics in its true form, whereas responding on the basis of feelings or rules is inferior because of reliance on emotion or custom rather than a reasoning process. Much of our ordinary moral language seems to lend credence to Aiken’s hierarchy. We often talk of ‘acting on principle’ or of someone being a ‘person of principle’ as if this were the ultimate manifestation of morality, beyond which there can be no recourse. Or, in a more self-serving mode, we may have claimed we were acting ‘on principle’ meaning that we acted with consistency and integrity, while others were swayed to make compromises. In contrast to this tradition, some philosophers and theologians have argued for a more balanced

moral sensibility by return to an emphasis on virtue [5]. It may be that the reliance on principles in contemporary ethics has in fact restricted our ability to reason morally rather than enhanced it. But we will 461

argue that the problem does not lie in principles per se, but in their misuse. What is needed is not a replacement of principles with emotion or custom, or even re-emphasis on virtue, but a better understanding of the uses and limitations of principles. Our thesis is that the need for moral prescriptions in an uncertain world tempts us to manipulate principles to meet this need. The result is that both persons and decision-making processes are relegated to the background as the proper uses of principles are overlooked. We analyze the case of Baby Jane Doe to illustrate both proper uses and abuses. The judicious use of principles does not necessarily lead to right, or even exact, answers, but it does sharpen our perception and enhance moral dialogue. Finally, we argue that acknowledging a refined and more appropriate role for principles means we will have to forego the quest for certitude in ethics and make room for some uncertainty. Uncertainty and residual tension in moral judgments are not things we seek or relish, but they are unavoidable consequences of acknowledging that human moral agents are open beings whose lives are not finished products and whose judgments have an historical context. PRINCIPLES IN THE CASE OF BABY JANE DOE

Principles are, of course, of major importance in ethics. One of their general functions is to provide foundations for more specific, concrete rules and thus provide justification for actions. Principles as justification provide an answer to the question of why we think a particular decision to be right, good or appropriate. In order to illustrate this let us consider the case of Baby Jane Doe. It was in reference to this case that the U.S. Surgeon General, C. Everett Koop, was speaking when he declared, “we’re not just fighting for this baby, but for the principle that every life is sacred.” As we will argue later, Koop’s remarks constitute a misuse of principle and a distortion of moral reasoning. Baby Jane Doe was born October 11, 1983 at University Hospital, Stony Brook, Long Island, with severe handicaps: spina bifida, or an open spinal column; hydrocephalus,

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excess fluid on the brain; microcephaly. an unusually small head and brain. and an improperly formed brain stem [6]. Physicians judged that with conservative treatment she could live up to 2 years. With surgery she might live up to 20 years but would be paralyzed from the waist down and would have no awareness of her environment. After consultation with doctors, clergy, social workers and members of their family, the parents chose to forego surgery. Litigation was begun on October 16 by A. Lawrence Washburn, Jr, a Vermont attomev unrelated to the child or her family. By late October the ca;e had made its way to the New York State Court of Appeals, which refused to order surgery for the child and upheld the legality of the parents’ decision. In a judgment without comment on December 12, 1983, the U.S. Supreme Court let this decision stand. In a separate action the Federal Government brought suit against University Hospital on November 2, 1983 to examine the medical records of Baby Jane Doe to determine if there was discrimination because of handicap. This suit was pursuant to the Health and Human Services (HHS) Regulations which had previously notified U.S. hospitals that they risked losing federal funds if they withheld treatment or nourishment from handicapped infants. University Hospital had refused to relinquish the records, denying that HHS had any right of access. Federal District Court Judge Leonard Wexler ruled in favor of the hospital on November 16, 1983, and added that the decision of the parents to refuse consent to surgical procedures was “a reasonable one based on due consideration of medical options available and on a genuine concern for the best interests of the child.” In May of 1984 the Federal District Court of Southern New York ruled that the Federal ‘Baby Doe’ Regulations were invalid [7].

affective response and allows emotions to be felt without their becoming decisive. In addition, principles are thought to provide a common basis for adjudication of novel problems. Annas states this quite well: the basic task is to articulate principles upon which we can all agree, and then to refine the skills of their application. This will reduce ambiguity about how to approach novel situations and forestall the tendency for doctors or parents to rely exclusively on their private intuitions or apply provincial standards. Principles are the tools by which decision-makers seek to ensure consistent standards and strive for universalizability in actions, a norm which has dominated ethics since Kant [8]. The pediatrician, Norman Fost, writing about the dilemmas of caring for severely malformed infants, endorses a model of decision-making which relies on ‘generalizable principles’ precisely because this model will facilitate consistency [9]. Although consistency is generally a desirable characteristic of judgments, it is not the only, or even the first, measure of ethical decisions. Consistency can be a slippery criterion, since every case is unique in some respects. The need for consistency may lead to the obscuring of morally relevant differences, and a preoccupation with consistency can, at its worst, excuse us from looking closely and attending patiently to individuals. Seeking consistency above all else will cause us to focus on superficial aspects of troublesome situations, making the world seem more neat and manageable than it is. We may sometimes need to ask if we are seeking consistency or justice

The Baby Jane Doe case is a moral as well as a legal crucible for the testing of principles, and it is in this light that the moral reasoning of Dr Koop, the parents and Judge Wexler take on special interest. The mother of Baby Jane Doe, apparently speaking for both parents, said she opted against treatment of her daughter because even with treatment “she would always be an infant. . . and her overall condition would be pain.” Here the mother is invoking, among others, the principle of non-maleficence, that the treatment would be of no benefit and would inflict added suffering, a principle associated with the Hippocratic maxim primum non nocere-first, or above all, do no harm. It is, of course, very important to determine if the parents’ perception of their infant daughter’s potential is accurate and as well-informed as possible. We do not argue here that it was factually correct, but assuming it was, that their use of principle is morally sound. Used in this way, the appeal to principles does open onto discussion, for example, about meaning or measurement of harm, and encourages broader understanding of the actions taken. Judge Wexler in essence validated the parental decision. In saying he was satisfied that the best interests of the child were considered, he referred to another principle, beneficence. Such appeals to principles are altogether appropriate. Under conditions of stress we may be tempted to rely on our immediate reactions or to arrest our deliberations at the emotive level. In this way principles may help by appealing to the more rational side of the moral sensibility and serve as a check on knee-jerk responses to difficult situations. At its best, recourse to principles tempers our immediate

UOI.

Principles are doubtless important in any scheme of ethics. Our argument here is that their role must be carefully circumscribed. In many contemporary models of moral judgment the reliance on principles is too severe and they are asked to bear more weight than they can carry. Important aspects of principles are ignored by overemphasis on their justifying and consistency-seeking functions. When these functions are valued over all else the result is a hierarchy which detaches principles entirely from moral traditions, and even, in some cases, places principles over persons. PRINCIPLES

DISPLACING

PERSONS

It is precisely the importance of principles in ethical judgments which tempts their overextension, distortion and misuse. One distorted use of principles is based on the assumption that while moral customs are culture-bound and subjective, principles transcend particular societies and historical circumstances and are more objective. But this is true only so long as principles are viewed in isolation from actual events and in separation from the thinking of some moral agent [l 11. While principles may be thought of in the abstract as less culturally relative, their use is profoundly tied to time and context. We are not arguing here that some principles may not be normative across cultures, rather we are making a more practical point. Even granting a normative status for a principle, this principle will necessarily have different applications and meanings in differing contexts of use. Only as categorical abstractions can

Principles and the search for moral certainty principles be thought of as independent truths whose appeal is to a universal human rationality. In their

interpretation and use, principles become part of the histories and traditions of individuals and communities. Principles are also situation-specific, in the sense that they are appropriate in some settings, but not in others. For example, patient autonomy is an important ideal in the care of chronically ill persons, but it has a greatly diminished role in emergency care. The idea that principles are always more firm and objective than moral customs, transcending particulars of time and place, has led many to think of them as antecedent criteria for morality. When this occurs principles not only become the zenith of moral reasoning, they become ends in themselves. Principles cannot be put to work when they are deferred to as the high judge of our moral sensibilities. When a principle becomes a static shrine it creates a distorted ethic, one which displaces persons from the center of our concerns and puts adherence to the principle in their place. The statement of C. Everett Koop which opens the essay implies this sort of displacement. “We’re not just fighting for this baby,” he says, “but for the principle that every life is sacred”-as if fighting for an individual life was insufficient to explain his actions, and as if fighting for principle is an even higher form of moral undertaking than advocating for a person. When we are fighting for principles, it is impossible to use them as guides to direct our action. In such a scheme principles become intrinsic values to be protected rather than the means to respect and protect persons. Koop’s use of the principle of sacrality, his appeal to transcendent leverage in judgment, is brought at the price of relegating to the background precisely those persons in whose name this principle is evoked. It is not surprising that those at a distance from the decisions about severely malformed infants can feel most certain about what should be done and tout their principles as universal absolutes, for they are least in touch with the persons involved. From a distance, the concrete lives of people are blurred, and only the general issues, neatly packaged as choices between good and evil, remain in focus. Parents rightly fear that they and their children may be overlooked in the rush to locate and apply formal principles by those, like Koop, who aspire to moral certitude [12]. We are not claiming that Koop is unfamiliar with the general set of problems the Federal regulations addressed. His career as a pediatric surgeon makes him well acquainted with the suffering of children and their parents. It seems all the more odd, then, that he should seek to enact Procrustean regulations which ignore differences between and among cases in favor of standardization. It could be argued here that we have made a ‘straw man’ of Koop, interpreting his statement unsympathetically and out of context. More generous observers might argue that what looks like a fetish for the principle of sacrality is actually a strong (but not absolute) commitment to sacrality, coupled with a profound distrust of physicians and parents, a fear of the slippery slope and a willingness to err on the side of life. Koop might be willing even to concede our point, about the uses and abuses of principles, but be

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willing to accept the harms of a too zealous regard for life rather than tolerate what he perceives to be the widespread abuse of a system that allows case-bycase judgments. In support of a more sympathetic reading of Koop is his exclusion of cephalodymus and anencephalic infants from aggressive treatment as recorded in the President’s Commision Report, Deciding to Forego Lzj? -Sustaining Treatment [ 131. This sympathetic reading of Koop, however, is contradicted by the regulations he was instrumental in formulating, complete with investigatory squads to police those institutions which believe parents and doctors should have some say in these matters. But even if the more generous reading of Koop’s statement is the correct one, our critique still stands. His zeal for principle in fact keeps him from truly appreciating the harms his policies cause. Moreover, as we will argue later, every application of a moral principle is necessarily case-by-case. So unless principles are treated as laws, and thereby distorted, even a strong sacrality principle will not eliminate the need for judgments by persons who are close to the situation. The moral posturing which has attended the ‘Baby Doe’ Regulations over the past several years suggests that both persons and principles were abused. Persons were abused by being displaced from the central focus of deliberations, while principles, such as the sacrality of human life, were abused by our blind subservience to them. This use of principles is destructive to moral reasoning and to our sense of ourselves as moral agents since it encourages us to exchange ethical deliberation for moral dogma. The idea of principles as ends in themselves will tempt us to use principles as truncheons to club our moral opponents rather than as instruments for helping to sharpen our vision and more fully understand those who differ, who may see other principles at play. In summary, the devotion to principles involves an especially pernicious form of displacementdisplacement of our central concern in ethics away from the judgments of actual persons toward propositional truths, algorithmic formulae and automated processes. DOMINOES

The dependence on principles as universal absolutes also makes ethical thinking susceptible to the domino theory, sometimes called the slippery slope phenomenon. It goes something like this: “If it becomes accepted practice to terminate a severely handicapped infant’s life, where will the line be drawn-multihandicapped babies? blind babies? blue-eyed babies?” [14] The fallacy here is one of hasty generalization. It overlooks relevant differences between cases and situations, jumping from a single instance to general conclusions and assuming that unless principles are always rigidly adhered to they are of no use whatever. Like dominoes lined up in a row, the argument goes, if Baby Jane Doe is not treated, we will have no warrant to care for anyone. Or to change the metaphor, one step on the slippery slope and we are soon at the bottom. Of course not all appeals to a slippery slope or domino effect are bogus, as the domino effect may be either empirical or a conceptual claim. Empirically,

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some decisions may genuinely remove a necessary barrier and encourage widespread disregard for life. Our argument here concerns the preemptive use of the domino concept to blur differences and achieve a contrived uniformity which stunts our ability to see differences between cases. The domino scenario arises at all only because of the escalation of principles to the preeminent place in the moral sensibility, preempting and overshadowing all other dimensions of morality. Principles, when used in this dogmatic way, keep us from attending to the similarities and differences between cases and encourage an all-or-none sense of morality engendered by allegiance to a monolithic ideal. George Eliot, describing the plight of Maggie Tulliver in The Mill on the Floss, put it well: “. . . moral judgments must remain false and hollow unless they are checked and enlightened by a perpetual reference to the special circumstances that mark the individual lot [15].”

PRINCIPLES AS INSTRUMENTS THINKING AND SEEING

FOR

Ethical dominoes is a position most likely to be held by a moral agent who abuses principles. Principles are seen better as instruments for interpreting the moral facets of situations and as guides to action. The abuse of principles we refer to occurs when circumstances are shaped (and frequently distorted) to fit the favored principle. This thinking is from the principle, instead of using the principle as one instrument among others to think with. For example, the principle of sacrality of life can be made to gather and lump situations from first trimester abortion to withholding treatment or nutrition from those in chronic vegetative states. These may all be, in some sense, instances of violating the sacrality of life [16]. But in what sense? Upholding the sacrality of life tin take many forms. When the demands of care are beyond technical resources or human powers of endurance, sacrality of life can be acknowledged by letting life go. The alternative of prolonging dying or sustaining a life devoid of potential would be disrespectful of life. Moreover, the proposed Federal Regulations which claimed a right to protect life in the hospital while disclaiming any responsibility for the burdens of care later amounts to a policy of ‘some lives are sacred some of the time.’ Thinking from principles means entering situations of choice having determined in advance which principles to use. But this would be like a carpenter who approaches each task determined to use only a hammer. The resulting damage to tools, tasks and craftsmen is similar in each case. By contrast, using a principle as one instrument, among others, to think with is like a carpenter who comes to a task forearmed with a toolbox, prepared to survey the work and ready to employ what the job requires. A better use of principles is less as final legislators of our understanding and more as tools for guiding actions, like probes to find our way in a dimly lit room. Principles help us get our bearings in situations of moral perplexity. They are, in this regard, like compasses giving us direction, but rarely dictating a

and

Josf

JORGE SIM,&

single path or destination. For example, parents and pediatricians who employ the principle of the infant’s ‘best interest’ in cases like that of Baby Jane Doe soon discover that work of moral discernment only begins here. Apart from ruling out a few egregious wrongs, the most this principle can do is to orient us in a certain direction-to ask certain kinds of questions-rather than render specific and accurate predictions of an infant’s future well-being. Principles are not the measure of decisions but tools of exploration in the larger task of formulating the problem, delineating the values, adjudicating competing interests, etc. Principles by themselves never have the force of a proof, as in mathematics, but skillfully used they can be persuasive in guiding choices. Principles not only serve as instruments of thinking, they also present worlds in which certain choices appear as self-evidently right, or good. Principles shape and alter our perception of the world in which we choose, including who we understand ourselves to be, and what alternatives are appropriate to us. Principles are like paint brushes in the hands of the moral artist; they portray the moral landscape and set the contours of our choices, altering the world we see and in which we must act [17]. For example, the Golden Rule portrays a world in which one’s own self-regard and self-interest become the yardstick for measuring the imagined desire of another. The individual self occupies the foreground of this painting. Likewise, each of the principles of sacrality of life, parental autonomy or benefit to the infant engenders radically different notions of what is good or bad, such that both the description of the choices to be made as well as the choices themselves appear differently in each instance. For example, Koop’s sacrality of life principle would mandate aggressive treatment for Baby Jane Doe. In his vision of the world, parental concerns, harm to the family, social resources and even most quality of life indices for the infant herself are not significant parts of the picture. Painting with broad strokes, at a great distance from his subject, Koop’s portrait is unacceptable because it is inaccurate as a faithful rendering of multiple facets of the situation. What we know of Baby Jane Doe’s parents suggests a more realistic view in which more attention is given to detail and in which the infant’s well-being is steadily in focus. Thus, choosing a principle to act on is also choosing a way to think and a way to describe (and circumscribe) the context of action. Because this is the case, monolithic principles that aspire to universal validity are self-fulfilling. They value the world as they-portray it, without regard for alternative visions. Moral agents who rely on a single principle applied indiscriminately at a distance from the situation of choice are likely to be perceptually blind to critical factors. Their perceptions are rarely accurate and should not become normative. Statements like Koop’s serve as reminders that it is possible to hold and use sound ethical principles in an unsound way and thereby, ironically, to do harm to the community in whose name they are employed. The principle of the sacrality of life seems to function for many in our society as a free-floating omnibus norm, unanchored and thereby unresponsive to the specifics of any concrete situation. In such cases,

Principles and the search for moral certainty

become blunted and useless to speak to the needs of particular individuals. Principles as ways of seeing can ultimately blind us-their power to portray can become a power to obscure all else as well. Espousal of single principles will distort the moral landscape and make us conceptually handicapped. Only recourse to the texture of the lives of real people, in their concrete circumstances, will correct the oversimplified use of our moral resources. It is the effort to live out and embody our principles which will demonstrate their proper range of application. It may be objected that the refined role for principles which we recommend leads to moral relativism. By arguing that principles such as sacrality of life have limits, or are positively unhelpful in certain circumstances, it may be thought that we have foresaken sacrality of life altogether and invite double standards, expediency or even flagrant disregard for life. But the allegation of moral relativism simply misses the point. We do not reject principles out of hand; rather we argue for their rehabilitation and for greater precision in their use. Principles are too often employed in debates as unassailable absolutes. The alternative we argue for is not relativism but recognition of the fact that instruments of moral reasoning must be applied to situations of choice by judicious moral agents. The role of principles (as also of rules, customs, habits, hunches) in making choices is neither self-evident nor simple. Whatever relativism remains, having said this, is not a pernicious one that threatens all moral reasoning whatever, but the sort of relativism that relates principles to context and agents to actions in an integral rather than an accidental way. Some may object that to pay attention to context and differences among cases will take away from the radical reformative power of principles. For example, some may feel that the logical extension of our thinking is to make slavery right in some contexts and wrong in others, say, right in the antebellum South but wrong today. They would fear that the strong moral principle of liberty for all persons would be compromised by deference to context or tradition. Such an interpretation would be both faulty and misguided. Slavery was wrong in the 19th Century South and would be wrong now. The principle of liberty applies to both settings with equal force. Context does not make this principle wax or wane in intensity or validity. Our thesis about the need to contextualize principles is very different. There are situations in which liberty is not at issue and where to invoke it is to mislead and obfuscate our thinking. Principles must be judiciously applied and not forced into situations where they are not relevant. In the Baby Jane Doe case, it is not self-evident that sacrality of life is the primary operative principle to employ. Privacy or beneficence may be equally or more appropriate. And even if we concede that sacrality is the right (and only) principle, it simply does not follow automatically that respecting sacrality means giving maximal curative effort. While some practices are always wrong, it is not a monolithic and absolutist use of principles which guarantees that. It is rather a careful use of our moral principles

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reasoning in differing contexts that enables us to see that some acts (like slavery, or actively killing children) are reprehensible in all contexts. There is no more comfort here for the moral relativist than for the moral absolutist. In summary, we have used a variety of metaphors to elucidate the proper role of principles: carpentry tools, probes, compasses and paint brushes. Each of these are instruments to accomplish some task, but each can also be used inappropriately, for the wrong job, or in too wholesale a manner. All these notions imply skillful use. So substituting these metaphors for those of the formula, or the truncheon, will not, by itself, resolve the difficulty we are concerned with. But recognizing the instrumental character of principles does point to the heart of the issue, viz., how we understand ourselves as moral agents and why we are subsequently tempted to make principles absolute. It is to these matters that we now turn. CERTAINTY AND MORAL TENSION

The desire for objective and universal principles in ethics is part of the human need to think that we are good people who do the right thing, that is, to think of ourselves as righteous in a morally ambiguous world [18]. It is precisely this need that tempts us to oversimplify situations of choice and to espouse clear and singular action guides. Our need for security makes us vulnerable to absolutes and to manipulation by moral slogans, and keeps us hovering above real life with abstract principles made for a god. There are many advantages to an ethic of abstract principle. It is easy to know where one stands; ambiguity is reduced or eliminated. Moreover, this posture is efficient: novel situations can easily be assumed to be like previous ones; particulars and context do not have to be taken into account. Perhaps most importantly, adhering to principles makes us feel good about ourselves; it protects and co&-ms our self-image as good people. Yet ironically, the possession of such universally valid principles, were it possible, would not make us better people, but non-human. The human situation is irrevocably one of moral tension, and in two ways. First there is the tension, or pull between who we are and who we should be, between our lives as we know them and what we strive to become. All except those who believe they have arrived at, and are living out, ‘the truth,’ feel this tug. Even if the moral truth could be grasped and condensed into a maxim, we acknowledge the divergence between this grasp and the texture of our lives. Second, and more importantly, there is an inherent tension in the human situation due to the temporal structure of moral judgments. Such judgments are time-laden and thereby incur the same sort of partial, systematic opacity that characterizes our knowledge of any human activity. What Merleau-Ponty said of understanding our own history is also true of understanding our moral judgments. “My hold on the past and the future is precarious, and my possession of my own time is always postponed until a stage when I may fully understand it, yet this stage can never be reached, since it would be one more moment, bounded by

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the horizon of its future. and regaining in its turn further developments in order to be understood [19].” Moral judgments are precarious for the same reason. There is no fixed, final point when the moral fabric of life is still. We must, of course, make judgments at points in the temporal process, but the assumption that these times of judgment are final, or that in judging we are isolated and free of historical context is an error. Or, to make our pun more explicit, we might say that moral judgments are tense (strained, taut, anxious) because they are laden with tense (past, present, future) in a systematic way. Just as we never succeed in jumping onto the shadow of our own head, so in any given moral judgment we never quite succeed in encompassing the temporal place from which judgment is rendered. This requires another judgment, which itself has its horizons of time and its own contingencies of perspective [20]. This does not mean that there is no objectivity in ethics, no right or wrong, only that there is no transcendent finality of principle or perspective. Though we should seek, and are capable of, objectivity in ethics, it is an intersubjective objectivity, not an atemporal one. ;Moral judgments are just that, judgments-not guarantees of moral correctness or of personal righteousness. The ambiguity and lack of certainty occasioned by our temporal situation is what makes the human condition human (rather than god-like), and our recognition of this is what makes ethical reflection both possible and important. Hence, the answer is not different or better principles, or the pretense of universally valid judgments, or even an assertion that our need for moral certainty is not genuine, for it is. Rather what we need is an acknowledgement that even our most cherished principles have limits. We must acknowledge that uncertainty and the inevitability of some failure are part of the moral life. To acknowledge limits and ambiguity in moral judgments is not to embrace irrationality, or to suggest that reasoning has no place in moral decisions. The powers of reason to probe the moral sensibility are great; reason can ferret out assumptions, weigh competing values, clarify principles and even assess emotional responses to morally problematic situations. We assume that at least some moral uncertainty can be eliminated, and that much of it can be reduced in magnitude. But moral tension and ambiguity are inalienable dimensions of what it means to claim moral agency, to apply principles, to make moral judgments. Some problems seem to be beyond the powers of even our best efforts to resolve. Indeed, some medical problems such as the Baby Jane Doe case, appear to be genuinely intractable moral paradoxes [21]. They exhaust the limits of our analytic abilities; they defy an easy resolution; perhaps most importantly, they test the very intelligibility of our moral assumptions and thereby our moral security. They threaten our customary ways of acting, and by doing so, seem to threaten our moral vision of ourselves and others. This sort of moral tension does not occur because of the failure of principles but because of their limits. The residual uncertainty here reflects the fact that human moral concerns run beyond the capacity to

JORGE SIMON

simply ‘reason on principle’ and demand as thorough a process of perception and jud_ment as we are capable of. Such a process will have a place for principles, but not necessarily the preeminent place. The practice of medicine, like all moral activities. is ambiguous in this deep sense. But because it ventures to care for persons in distress and in exrremis-and because of its power-medicine reflects more clearly than other activities the boundaries and tensions of the human situation for the larger society it serves. For example, the oldest moral maxim of Western medicine is primum non nocere, yet physicians sometimes inflict suffering even in the name of altruism and with beneficient motivation [12]. Patients sometimes have adverse reactions to drugs, and procedures of diagnosis sometimes cause distress and even, rarely, disability. Professional advice and counseling sometimes lead patients away from help or toward self-destructive behavior. Efforts to rescue a malformed infant can result in avoidance and estrangement from family and even be merely deathdeferring, rather than life-prolonging. A surgical procedure designed to enhance an infant’s chances for survival may put the patient in intensive care. removed from family supports, in pain or obtunded for the duration of life. On occasion physicians are obliged to inflict suffering as the only known avenue to achieving a therapeutic good. Sometimes physicians and parents are involved in tragedy insofar as ‘the good’ for their children is, in irreducible ways, mysterious and beyond calculation. It seems this is the case with Baby Jane Doe. It is precisely in these cases that a discriminating use of principles is most needed. We do not intend, by evoking notions of ambiguity and uncertainty, to romanticize decisions, to excuse sloppy reasoning, or to enlist an easy pigeonhole for dealing with difficult problems. Acknowledging some uncertainty and residual tension in morals is not an excuse for mystifying moral analysis. The notion that if principles are not absolute then we are reduced to a mystifying, romantic (and totally subjective) view of ethics is frequently used by moral absolutists as a scare tactic: ‘it’s absolute principles or the moral abyss.’ The way out of this problem is through indicating, as we have done, that the choice is a false one, based on faulty concepts of human moral reasoning, and the role of principles within that reasoning. Ironically, the view of principles we have argued against in this essay suggests a romantic view of ethics which accepts principles uncritically and accords them a suprarational position in moral decisions. Our call for a judicious use of principles is in this sense, far from being romantic, actually more respectful of rational processes. Moral agents can avoid romanticism and overcome bias, not by positing the objectivity of principles, but by concerted efforts to expand their moral imagination and sharpen their reasoning processes. Our

point is that not even our best efforts will eliminate all ambiguity. Moral problems are not reducible to intellectual puzzles; they are not finally solved like algebraic problems or answered like empirical questions. They are rather lived through

and lived out in

conscious awareness of the suffering and hurt which

Principles and the search for moral certainty

so often accompany our best efforts to achieve good. Moral ambiguity is usually not eliminated from judgments but only better defined and localized. There are, of course, alternatives to acknowledging the limitations on human moral insights-ynicism, skepticism, ostrich-like optimism, blinding faith in limitless reason and technological rescue, or the moral certainty associated with the misuse of principles we have described. But in the end all of these are ways of denying our human condition, and of rejecting the necessity of making moral judgments, some of which will inevitably be wrong. At its best, a healthy respect for the multiple tensions of moral judgments will allow us to reaffirm a refined role for principles in a decision-making process, and give us the courage to be decisive without the pretense of being definitive [23]. CONCLUDING

REIMARKS

Our argument has been intended to indicate a refined role for principles as tools in the service of moral sensibility. Tools imply skillful users, and there is much to say about what would count as skillful use. Tools also imply appropriate contexts of useanother important dimension of judgments we do not discuss in detail here. Our main thesis is that we cannot escape recognition of our agency by trying to replace judgments with formulae. To acknowledge that principles are instruments is to see that they are always and only our tools, and we cannot make up for using them poorly by claiming that they have some special status in and of themselves [24]. Seasoned veterans of the medical ethics wars may feel that our conclusion is so obvious as to be a truism, hardly worth the time and energy invested here. We agree that our thesis is at least as old as Aristotle, who warned his readers not to seek more precision or certainty in practical affairs like ethics than the subject will allow [25]. All the same, we think it timely and fitting to be reminded of these matters, largely because our need for certainty and subsequent abuse of principles does tend to alienate moral judgment from us at a time when we most need to claim our agency unequivocally. We have also not indicated what we think should be done to and for Baby Jane Doe. Yet, to respond to this case with any greater degree of completeness presupposes both factual information and a privileged moral perspective we do not and cannot possess. It is precisely this presumption which has led others occasioned

astray in their search for certainty and the abuses we have argued against here.

Acknowledgemenrs-We gratefully acknowledge the careful reading and many helpful suggestions we received from Lawrence Thomas, John Churchill, Nancy King and an anonymous reviewer from Social Science and Medicine. REFERENCES I. The

New York Times, November 13, 1983. Koop, the

Surgeon General of the United States, was speaking in reference to the Baby Jane Doe Case. 2. Disconnecting the Baby Doe Hotline. Hasrings Center Rep. 13, 16, 1983. 3. Reason and Conducr. Knopf, New York, 1962.

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4. See Brody H. Ethical Decisions in Medicine. 2nd edn.

Little, Brown, Boston, 1981. Brody is one of many contemporary moral philosophers who lend general assent to Aiken’s hierarchy. A close look at almost any contemporary text in medical ethics will confirm the prevalence of this view of medical ethics. 5. See, for example, MacIntyre A. Afier Virtue. University of Notre Dame Press, Notre Dame. Indiana 1981. Toulmin S. The tyranny of principles. Husrings Cenrer Rev. 11. 1981: Becker L. The neglect of virtue. Erhics 85, ISiS; Hauerwas S. Vision and-Virtue. Fides~Claretian, Notre Dame, Indiana, 1974, or the seminal critique by Pincoffs E. Quandry ethics. Mind 80, 1971. May W. F. has suggested in a recent Soundings article that even when we do emphasize virtue we may do so in a “principle-oriented” way; see The virtues in a professional setting. Soundings 67, 247 1984. 6. All information and quotations concerning the Baby Jane Doe case were taken from The New York Times, November 13, November 20, December 13, 1983. 7. The story continues. Although the early HHS regulations have been ruled invalid, the most recent version of the regulations redefines child abuse to include withdrawal of nutritional or medically indicated treatment. Although most medical professional organizations consider this legislation better (or at least less harmful) than the original HHS rules, the revised rules still bespeak the sort of moral perspective this essay argues against. For an excellent analysis of the new rules see Rhoden N. K. and Arras J. D. Withholding treatment from Baby Doe: from discrimination to child abuse. Milbank Mem. Fund Quaff. 63, 18-51, 1985.

8. In his Foundations of the Metaphysics of Morals (1785) Kant said, “Act only according to that maxim by which you can at the same time will that it should become a universal law” (Translated by A. W. Beck). University of Chicago Press, Chicago, 1949. Unfortunately Kant’s Iirst formulation of his categorical imperative is giver more attention than his second one, which concerns treating persons as ends rather than only as means-a point we discuss later in this essay. 9. Counselinn families who have a child with severe congenital anomaly. Pediatrics 67, 321-329, 1981. 10. Cardinal Bemardin recently made good use of the notion of consistency, as consistent attention in policy, when he called for a ‘consistent ethic of life’ which would be concerned with nuclear war, poverty and the death oenaltv as well as abortion. The New York Times, December 7: 1983. 11. The principle of autonomy, for example, is highly prized by many in modem North American society. but not by all. Autonomy seems self-evidently right as a guiding norm for those who draw their moral sense of self from J. S. Mill, Locke or Jefferson; it is less so in communities influenced by Reformed Protestant traditions. such as Calvinism, and autonomy plays a negligible role in the moral reasoning of Jehovah’s Witnesses. The key for Witnesses seems to be, not autonomy, but Authorify, of Scripture and God, and obedience to those authorities is the nexus of Witnesses’ moral life, including refusal of blood. We also want to call attention, through this example, to the plurality of moral reasoning processes. Perhaps one mode of reasoning should be normative for all, but it is not self-evidently so. To assume that principles are the key to moral decisions, or more precisely, that autonomy will or should figure into every decision. is unwarranted. The burden of proof ties with those who would discredit Witnesses and others whose ways of thinking and choosing are eccentric to the majority. The study of ethics has too frequently ignored empirical studies of how persons actually reason in favor of theories about how persons ought to reason. How we

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LARRYR. CHURCHILLand Josf JORGES&N

ought to think morally cannot be realistically severed from how persons actually do think. Ethics is not, of course, reducible to empirical, sociological studies, but it has been a flaw of modem moral philosophies to assume that real choosing and specific choosers can be safely ignored. By contrast we find them theoretically relevant, though not determinative. 12. Lon Fuller argues that there are two principles of human association, one based on shared commitments, the other regulated by legal norms. The first is informal and relies on shared tacit values among intimates, while the latter is formal, rule-governed and tends toward legalism. See Fuller’s Two principles of human association. In Volunfnry Associurions (Edited by Pennock J. R. and Chapman J. W.), pp. 3-23. Atherton Press, New York, 1969. Sole reliance on principles easily reduces to formal and legalistic reasoning, thereby jeopardizing the more implicit values in which family life is grounded. 13. A report of the President’s Commission for the Study of

17.

18.

19. 20.

21.

Ethical Problems in Medicine and Biomedical and Behav iorul Research, pp. 219-220. U.S. Government Printing

22.

Office, Washington D.C., 1983. 14. Beraer A. When will we fullv accent our Babv Does? The-New York Times, November 13, 1983. . IS. Eliot G. The Miil on rhe Floss (1860), p. 628. Penguin Books, New York, 1979. 16. ‘Sacrality’ is a complex theological concept, and we do not discuss it fully here. In a strict sense, however, any absolute claim for the sacrality of human life is idolatrous, since the relativity of all rights and values is part of the radically monotheistic afhrmation that only God is absolute and is the center of all value. For a cogent

23. 24.

25.

statement of this position see Niebuhr H. R. Radicnf Monotheism and Western Culrure. Harper Bi Row, New York, 1943, pus&r. See Hauerwas S. Vision of Virrue. FidesClaretian, Notre Dame, Indiana, 1974. “. the moral life is best understood like an artist engaged in his skill than a critic making a judgment about the complete work.” p. 157. Cf. Hauerwas. Truthfulness and Tragedy, p. 207, note no. 3. University of Notre Dame Press, Notre Dame, Indiana, 1977. iMerleau-Ponty M. The Phenomenology of Perception, p. 346. Routledge & Kegan Paul, London, 1962. Ryle G. The Concept of Mind. Barnes & Noble, New York, 1949, makes a similar case about the ‘systematic elusiveness’ of the first-person pronoun ‘I’ (pp. 195-198). We have borrowed one of his examples in making our case here. See Geertz C. Religion as a cultural system. In The Interpretation of Cultures, p. 100. Basic Books, New York, 1973. For the emphasis and some of the phrasing of this section we are indebted to Harmon L. Smith. See Smith H. L. Who should decide: the case of Karen Quinlan. Christianity and Crisis 35, 321,1976. To say that principles are our tools does not, of course, mean that we create them, anymore than the carpenter creates his hammer. But like the carpenter, moral agents must apprentice themselves-and lay explicit claim to their personal agency in apprenticeship-in order to use their tools well. The Nicomncheun Ethics, Vol. I, 1094b, pp. 12-28. In The Basic Works of Aristorle (Edited by Richard McKeon), p. 936. Random House, New York, 1941.