Bioethics: metaphysics or pragmatics?

When we deal with fundamental issues in bioethics, are we concerned with the metaphysical or the pragmatic? Answering this question is of great importance because the choice between two quite different understandings of bioethics depends upon it. Is bioethics a sort of casuistry, a kind of reflection whose principal purpose is to suppport and inform legislative processes and public discussions on urgent scientific and medical problems? Or is it an intellectual investigation within the speculative core of moral philosophy?

I myself opt for the pragmatic interpretation and programme. The theoretical aspirations of bioethics should be limited, precisely so that the those who deal with these issues can acquire increased political influence. My argument is quite simple: ‘Hard’ practical philosophy- which is to say classical ethics and politics rooted in the traditional philosophical literature from Socrates to Hegel-cannot provide us with conclusions, or even discussions, that have both these features: they consonant with the original theories of great philosophers while the same time enabling us to pass from general theory to detailed practical problems, which, in the end has to be the true focus of bioethics. It follows that we have a choice: either we pursue the practical, and make conventional, essentially idle references to classical thought about morality, references which do no more than ornament the popular, easy-to-understand arguments that are typical in bioethical discourse at large; or, we sharply differentiate speculative philosophical ethics from practical legal and political argument, and make the latter constitute the intellectual background to bioethics, thereby increasing its relevance and competence.

My own preference, to repeat, is the second-a self-imposed limitation on the theoretical aspirations of bioethics based upon the belief, first that bioethics cannot catch up with the speculative advances of general ethics (advances which are due precisely to its lack of practical relevance) and second, that there is an urgent social need for effective intellectual support, both for legislative processes and public discussions in the field of medical and ecological practice.

This general thesis can best be illustrated by three examples. Each of them concentrates on a classical issue in medical or environmental ethics. In each case I shall assemble evidence of two different sorts of associated thinking. First, I shall list some associated classical concepts, and other bits and pieces of philosophical teachings, which really do come into play in a properly speculative inquiry. Secondly, I shall list the contemporaneously relevant and socially important practical questions, points and issues, that are, and should be, taken into consideration when we place the practical and political aspects of the problem at the forefront. The purpose of this contrast is to demonstrate just how every different the philosophical and the practical questions are, the first being essentially metaphysical, and the other wholly pragmatic. My strategy is to let these differences speak for themselves, rather than complicate them with too many comments. As a philosopher in the continental, speculative tradition, I stand firmly by the importance of the sort of thinking that is to be found in the works of Aristotle, Aquinas, Kant or Hegel. At the same time, taking into account the relevance of the issues and their very great social importance - a relevance and an importance which bioethical issues certainly have-I am ready to give up my metaphysical inclinations, and to accept the self-limitation of reason on political (which is to say practical) grounds.

The examples I cite show two things. It is impossible to move from an empirical consideration of case-based instances to metaphysical theses underlying them by means of some sort of inductive procedure. At the same time, it is quite unfeasible to attempt some sort of deduction which starts from metaphysical theses and derives detailed conclusions for empirical or case-based applications. (The only extensive project of this type which aims to derive the practical from the metaphysical-namely the concept of natural law-encounters well known difficulties.) Moreover, empirical discourse is a sort of betrayal in relation to the declared objectives of metaphysics. Speculative philosophy rejects all pragmatically motivated elasticity in relation to the principles it forulates and adopts; it accepts no political (democratic) circumstances as a justification the divergence of law based on political decision from the moral law directly understood. The practical underlying rule of all other thought and deliberation-bonum faciendum, malum vitandum (do the good, avoid the evil)-justifies no metaphysical limitations or waivers. Similarly -from the strictly empirical viewpoint-such values as “the experience of a good life” or “personal satisfaction” have no relation to the classic metaphysical ideas of virtue and wisdom as the essence of happiness. As a result, all empirically formulated issues of practical philosophy are reduced to abstract metaphysical conceptions, which are merely supplemented with examples and illustrative cases; the possibilty of ‘applying’ these conceptions is nothing more than an assertion. In short, it is difficult to discern any logical link between practical metaphysics (philosophical ethics) and the empirical-and-legal case-based discourse.

1.1 The speculative context that surrounds this issue includes the following elements:

A. Self-determination: The sovereignty and internal freedom of the individual; the self-determination of a rational being; the fact that an individual always belongs to some community.

B. Responsibility: The responsibility of the individual for his or her own life and the individual's power over that life (suicide as an absolute power over the self in opposition to the prerogatives of God as Creator).

C. Life as the greatest good for a human being, versus quality of life.

D. The nature of death and the immortality of the soul.

E. Suffering, its reality and unreality.

1.2 The historical context of the issue must refer to:

Stoic doctrine and its criticism in Christian ethics;

Secular and theological doctrines of natural law;

the history of arguments related to immortality of soul (from Plato, through Augustinus, up to the systems of XVII century);

the history of the problem of death and suicide-from Stoic, through the Christian (mainly Thomistic) ethics, up to existentialism;

the question of the liberty and sovereignty of an individual:-from Socrates, through disputes on predestination and grace, up to voluntarianism of Fichte or Schopenhauer, as well as the theory of liberty in Hegel and the concept of the free spirit in Nietzsche.

1.3 By contrast, the pragmatic requirements for resolving the problem of euthanasia are as follows:

Defining the difference between assisted suicide and mercy killing.

Defining the difference between an act of euthanasia and a rational withdrawal of life-supporting therapy of terminally ill persons.

Determining the conditions of the mental ‘fitness’ of the ill person and hence the validity of his/her demand for euthanasia.

Determining the economic costs and medical demands generated by life-supporting therapy of the terminally ill people.

Considering the danger of inducing terminally ill people to demand euthanasia and the possibilities or reducing this danger.

Estimating the the danger of criminal abuse of euthanasia procedures and ways of eliminating it.

Deciding whether the above questions can be resolved clearly enough to enable the state to legalise euthanasia and to maintain control over it.

Weighing the possible inability of the state to enforce positive legal regulation against the freedom of the individual in matters of euthanasia.

1.4. The conceptual discrepancy between the first list (the philosophical perspective) and the second (the legal/pragmatic approach) is brought out even more starkly if we juxtapose the basic problems generated by both. Among many other issues, a basic problem in the speculative context is the dilemma between the freedom of individual human beings and the obligations of usch beings to their Creator. If God exists and indeed demands an exclusive right over life and death, then, of course, human claims to sovereign power over body and life must give way to the holy power of the Creator. The question is whether God exists and whether He actually forbids all support and acceleration of the unavoidable moment of death. In fact, we face here the issue of the existence of God and the foundations of faith in His revelation.

By contrast, in the pragmatic field, the main dilemma relates to the right of the state to regulate acts of euthanasia, and if it has this right, whether such regulations ought to be restrictive or liberal in relation to the practices concerned. The intellectual difficulties connected with this dilemma consist in the (relative) arbitrariness of the definitions that are needed if detailed legal regulations are to be formulated, e.g. the definition of mental competence, of the difference between euthanasia and failure to undertake the palliative therapy.

In both spheres of discourse, we encounter a similar obstacle - the need to arrive at a conclusion despite undetermination and hence an unavoidable element of arbitrariness. In the former case, the underermination generates an arbitrariness with respect to belief or disbelief in the existence of God and the sense of His revelation; in the latter case, it is the arbitrariness of efficient definitions of certain types of behaviour. No general methodology exists for dealing with this unavoidable arbitrariness. Nor is there any strategy for “accommodating” the arbitrariness within the scope of rational procedures. The very essence of arbitrariness relies on free selection between options - each arbitrary choice is legitimised exclusively on the basis of individual terms whether practical or theoretical. Typically, the following moves are suggested as possible bridges between the strictly philosophical and the practical. The first chooses faith, and on this basis decrees ideologically (so to speak) that the state must forbid euthanasia independently of any difficulties related to the formulation of law in this field. The other, declines the theological choice, and relying on agnosticism grants individuals an absolute liberty with respect to euthanasia, and thus avoids the need for legal definition that the prohibition euthanasia would require. This second approach may be the more plausible, yet it does not actually mean that liberal philosophical theory is providing justification via practical application. This is often assumed to be the case in liberal discourse, but it is an invalid inference. The assumption that “we do not know and shall never know the answer to problems of life, death, freedom and divine law” does not lead logically to the statement: “let everyone decide in his/her own conscience, and the state stay away from the issue, since no rational foundations exist to formulate laws in this field.” In any situation where a given practical problem must be solved this is true, and so uncertainty cannot be a good ground on which to deprive the state of its decision-making rights. In short, discussion over basic philosophical aspects of freedom, natural law, etc. cannot lead to demonstrable solutions, and from the viewpoint of the practical legislative process, the adoption of any particular philosophical position relies basically on accepting certain arbitrary elements, i.e. some authoritarian intellectual influence. In effect, the discussion of practical legal solutions becomes ideological, even if the philosophy is deep and creative, when not ossified an ideological decree believed to be relevant to practical discussion.

2.1 From a purely philosophical point of view, this issue involves consideration of the following problems:

Animal souls and animal subjectivity; the ability of animals to experience physical and psychological pain.

Analogies between animals and humans as a basis for solidarity with and compassion for animals.

The moral value of corporeality and of the sensual and emotional life.

Nature as a substantial good giving rise to an obligation to respect it.

The good of the species vs the good of an animal individual.

Human animality as an integral moment of humanity.

The possibility of possessing rights by non-rational beings.

2.2 The historical context of the issue must refer to:

Classical theories of animal souls in Aristotle and Middle Ages;

Theological discourse related to the power of man over the nature-in Catholicism and Protestantism;

The theology of the body;

Modern traditions of mechanistic and behavioral approach to animality; naturalistic and behavioristic psychology of man;

German vitalism (for instance Nietzsche), French vitalism (for instance Bergson);

The phenomenology of corporeality (Merleau-Ponty);

Economic, structuralist and semiotic conceptions of corporeality (from Spinoza and Leibniz to Marx, Freud, Foucault and Deleuze).

2.3 From the pragmatic point of view, however, bioethics faces the following tasks in relation to the rights of animals:

Defining the balance betweenthe economic interests of human beings and the duty to limit the suffering of animals.

Determining which experiments on animals are ‘necessary’, and by what standards they must meet.

Defining the obligations of both the human race and of political states to animal species and goods of nature.

Reconciling human territorial claims with the needs of animal species.

Defining the obligations that from the domestication of animal species and individuals as well as the legal balance between the prevention of cruelty to animals and the pursuit of human freedom

2.4. The scope for speculative or philosophical discussion on the issue of animal animals seems more promising, because the issues are more confined. If it is debatable just to what extent the psychological life of animals is similar to the human psyche, it is not difficult to prove that humans are responsible for animals to some degree, and thus that animals are entitled to some legal protection. On the other hand, since it has to be accepted that animals are not human beings, they do not enjoy full rights. These general philsophical statements cannot simply be translated into the practical sphere. They are meaningful, interesting and important, but such is the nature of speculative thought that it leads to meaningful concepts (some legal protection, for example), not to precise measurements or other empirical definitions. However, the formulation of applicable laws pertaining to the rights of animals does require precise specification if it is to accomplish the practical application of legal imperatives with respect to the rights of animals. But it cannot reasonably be expected that philosophical speculations about animal rights, even if they are meaningful, interesting and important, are in any way helpful in this

3.1 In terms of speculative philosophy, with respect to this issue the following topics are relevant:

The nature of the state and, consequently, the mutual commitments of state and citizens.

The superiority of the state as a common good versus its subordination to the freedom of the individual.

The nature of responsibility: the responsibility of the community for the individual, and responsibility of an individual for the community and for him or herself.

The nature of health, and the right to self-determination with respect to our own bodies.

The legitimation of the political acts of the state with respect to public health.

3.2 The historical teachings relevant to this issue are:

Classical theories of state and power in Plato, Aristotle, Aquinas, Locke, Hobbes, Kant, Hegel;

Authoritarian and liberal conceptions of state;

Socialist ideas of social protection and distributive.

3.3 From the pragmatic point of view, the topic gives the following issues:

Defining state policies in the area of public health and determining the sources of their financing.

Determining both levels and areas of public responsibilities for health (state, community, self-aid societies, charity institutions),

Determining the division of responsibility for public health between public entities and private arrangements (insurances).

Determining the line of demarcation between basic and non-basic medical services, and thus defining the extent of the right to health care.

Arriving at a balance between individual-oriented and society-directed activities of the state in public health;

Formulating epidemiological and health care strategies and determining the financial priorities of the state with respect to them.

Resolving conflicts between expensive or in other ways exclusive medical services and preventive or epidemiological activities in public health and the ways of resolving them.

Drawing the line between political propaganda and health education programme.

3.4. The issue of the state’s responsibilites in the area of public health uncovers a an area in which liberal-based political programmes differ radically from other political programmes that rely on the classical foundations of political philosophy. The strictly liberal position denies the state any overriding rights in relation to individuals, rights that are essential in rival authoritarian or paternalistic political concepts. The liberal state also eschews any right to control the human body, a right often assumed in other historic political systems, as is illustrated where suicide is a criminal act. In the liberal state everyone is his/her own master, and in consequence public authorities are expected to fulfil administrative asks and objectives assigned to them, and public officers are “hired” (or elected) for this purpose.

At first sight then, it might appear that liberal political philosophy can supply arguments against extensive state activity in the sphere of public health and individual well-being. However, a closer analysis shows that it is not the case, since under the democratic process the libral theory envisages, society may assign to public authorities the objectives of public health care. Conversely, all the “paternalistic” philosophies, though they might seems to recommend a public health policy based on moral and ideological motivation, as in the case of the rights of animals are unable to generate the sort of detailed guidelines which alone could be helpful in building actual systems of public health, which is the practical essence of the problem.

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I hope that the above examples of three different bioethics issues show clearly that the chances of substantial, and not merely rhetorical reference to the great themes and historical figures in the Western philosophical tradition in the discussion and resolution of a practical, social problem-oriented bioethic, are slim. There is simply no continuity of thought between the metaphysical issues of speculative ethics and the practical issues of a politically useful bioethics. Moreover, however unsatisfactory this may be, it is the general nature of philosophy which explains this fact.