Abstract

In lieu of an abstract, here is a brief excerpt of the content:Bioethics Reconsidered: Theory and Method in a Post-Christian, Post-Modern AgeH. Tristram Engelhardt Jr. (bio)A candid assessment of the moral significance of our post-Christian, post-modern era calls for a reconsideration of the very project of bioethics. For many bioethicists, concerns for theory and method are secondary. 1 These scholars presuppose a common morality and a reasonable, overlapping consensus regarding [End Page 336] an appropriate polity. They assume as well that we, as humans, possess middle-level principles, casuistic capacities, and guiding intuitions that enable us, inter alia, to identify which allocations of health care are unfair, whether the purchase of organs from the poor is exploitative, and if physicians may require as a condition for treatment agreement on a professional standard for the disclosure of information in the acquisition of consent. In this account of bioethics, we are taken to share a content-full moral understanding. Theory may illuminate that understanding and method may resolve particular controversies, but neither is necessary to disclose the nature of the moral life in the domain of health care. The account presents us as bound by a content-full morality, about which we have pretheoretical knowledge and in terms of which we are able to reach appropriate decisions, even if we have competing theoretical understandings of that morality.This dominant account of bioethics has interesting similarities with Roman Catholic moral theology in assuming (1) the existence of a common canonical morality grounded in our nature, our sentiments, and/or our reason, as well as (2) the ability of reason, reflection, or analysis to disclose the substance of that morality. The difficulty is that there are diverse moral sentiments, sympathies, and visions. The depth of our disagreements can be gauged in our substantive disputes regarding abortion, physician-assisted suicide, and health care reform. Furthermore, no appeal to middle-level principles or to casuistry can bridge such differences when people really disagree. Such appeals only underscore what separates.Consider how an appeal to the principle of autonomy or justice in mediating disputes regarding the licensing of for-profit euthanatization services or the enactment of a health care proposal like that produced by the Clinton administration in 1993 (White House 1993) will only disclose how deep the disagreements are, if the disputants are a Rawlsian and a Nozickian (Rawls 1971, Nozick 1974). Or, consider an appeal to casuistry for the resolution of health care policy debates among parties, some of whom consider dumping and skimming to be morally exemplar acts of autonomy, frankness, and appropriate stewardship of resources (Engelhardt and Rie 1988), while the other parties regard them as exemplar acts of injustice. Such disputants will agree neither about the proper descriptions of the cases, nor about how to derive moral guidance from them, because they bring to the cases disparate moral senses and different understandings of moral rationality. In a world in which there are as many different accounts of fairness and justice as there are major religions, and where many may hold that exploiters are those who do not allow the poor to sell their organs to the rich, the presumption of a moral consensus or background morality (Bayertz 1994) serves more as an ideology than as a general authoritative moral disclosure. [End Page 337]In addition, it is not possible to choose among many 2 of the competing visions or accounts of justice, fairness, and appropriate behavior on the basis of sound rational argument. To choose authoritatively among competing content-full moralities or moral accounts, one must already have background moral guidance. If one is to choose the account that maximizes benefits over harms, one must be able to compare competing benefits. For example, in terms of consequences, one cannot compare liberty and equality outcomes without already knowing how to rank liberty and equality. One must already know the answer about which morality—e.g., the one that gives priority to liberty over equality, or the one that gives priority to equality over liberty—is authoritative. Nor will an appeal to preference satisfaction solve the difficulty of determining how to establish the canonical ethics and bioethics. One must first know how one should correct preferences, compare impassioned versus considered...