Escaping the Shadow
Authors: Lam Ryan 
Published: September 2022

Photo by Karl Raymund Catabas on Unsplash

The interests of patients at most levels of policymaking are represented by a disconnected patchwork of groups … “After Buddha was dead, they still showed his shadow in a cave for centuries – a tremendous, gruesome shadow. God is dead; but given the way people are, there may still for millennia be caves in which they show his shadow. – And we – we must still defeat his shadow as well!”
–  Friedrich Nietzsche[1]

INTRODUCTION
Friedrich Nietzsche famously declared that “God is dead!”[2] but lamented that his contemporaries remained living in the shadow of God. For Nietzsche, the morality of his time was still based in the Christian tradition, even though faith in God was waning. Bioethics lives under a similar shadow: the shadow of Enlightenment Era-rationalism. Bioethics curricula focus on principles derived from Kantian deontology and utilitarianism. The allure of maintaining a moral framework that provides a rational method that can be handily applied to any situation remains strong. The principlist approach advanced by Tom Beauchamp and James Childress is taught to nearly all medical students in the United States,[3] and is essentially the canonical ethical framework of bioethics. In this model, the principle of autonomy is Kantian in nature, and the principles of beneficence and non-maleficence are utilitarian in nature.[4] Moreover, the presented framework is an approach that, when applied rationally to any healthcare scenario, will yield an outcome “considered moral.”[5] This reflects a faulty conception of philosophy that plagues much of bioethics, wherein the only contribution of philosophy pertinent to bioethics is moral philosophy elucidated by European thinkers in the Enlightenment Era. The landscape of moral philosophy has evolved significantly from the 18th century. However, the bioethical world has not kept up with the philosophical world, remaining instead in the shadow of antiquated moral thinking. Also lacking in bioethics are other disciplines of philosophy, such as philosophy of language, existentialism, and aesthetics, which are often given no consideration at all. The inclusion of both modern moral philosophy and other philosophical fields is necessary if bioethics is to survive its transition into modernity.
l.     The Shadow of Enlightenment
Enlightenment Era philosophers such as Immanuel Kant argued that one need only employ reason to obtain knowledge; emotion bore no relevance when determining ethical behavior. Kant’s moral theories thus privileged a duty to act according to moral imperatives over feelings. Other Enlightenment Era philosophers such as John Locke developed systems that attempted to quantify human goods and human ills. This quantification potentially reduces human welfare and suffering to utility. Today, in the world of philosophy, such a “neutral analysis,” as Cora Diamond noted, is “dead or moribund.”[6] Bernard Williams remarked that such moral philosophy is “empty and boring,”[7] and G. E. M. Anscombe stated that it “no longer generally survives.”[8] And yet, just as the atheists in Nietzsche’s world dwelt in the moral code of a dead God, bioethicists still pursue a unified moral system that takes an input, applies some moral rules, and generates a moral outcome, like the four principles approach that Beauchamp and Childress laid out.[9]  Some detractors of principlism take issue with their approach for not being unified enough and want to replace it with a procedural framework that is even more systematic and complicated. They argue that the resulting moral framework would be a “comprehensive decision procedure for arriving at answers”[10] that retains the “impartiality that is an essential part of morality.”[11]
The shadow of rationalist morality has caused bioethical decision making to become detached and rigid when bioethics should concern itself with the humans whose lives it affects. A rational, divorced-from-emotion way of thinking ultimately fails to yield satisfactory results when decisions are made by and for emotional beings. Dr. Paul Farmer, among others, championed the idea that bioethics should be de-philosophized, as philosophy, cold and calculated, fails to adequately respond to the realities of those worst off.[12] Instead, Dr. Farmer emphasized the inclusion of the social sciences, like sociology and anthropology, in bioethics. Undoubtedly, Dr. Farmer was on the right track; bioethics should certainly engage directly with the people whom its decisions involve. If the narrow band of moral philosophy currently found in bioethics – that of stringent rationalism – were all that philosophy had to offer, I, too, would advocate for a de-philosophization.
Ludwig Wittgenstein notes that to attempt to capture the complexity of moral thinking in a manner that employs reason alone and casts aside emotion is a “hopeless task,” like reconstructing a sharp image “from a blurred one.”[13] Unfortunately, bioethics is mired in the remnants of this hopeless task. To Dr. Farmer, the dominant moral framework was too restrictive and was unresponsive to the social and humanitarian needs of those whom bioethics is meant to help. As such, he wished to free bioethics from the shadow of a morality derived from rationalist thinkers.
ll.     Beyond Rationalism
Like Nietzsche, who tried to resolve Europe’s post-religion vacuum by providing his society with a new way to live, Dr. Farmer wanted to replace the rationalist philosophy upon which bioethics was built with a “resocialization” of the field.[14] I agree with Dr. Farmer’s call for resocialization, as well as his denouncement of philosophy as it exists in bioethics. Evaluating risks and benefits along a predetermined array of moral principles is far too rigid and impersonal to guide what are often the most important decisions one will make. For Dr. Farmer, the most needed change was restoring the social element of bioethics. However, in advocating for this resocialization, Dr. Farmer casts philosophy as the antithesis of social science, noting that “few would regard philosophy … as a socializing discipline.”[15] I disagree. Rationalist moral philosophy may be lacking in socializing force, but there are other fields of philosophy that are responsive to our social reality. Rather than de-philosophizing bioethics, it makes more sense to replace the antisocial philosophies predominant in bioethics with prosocial philosophies better suited to it.
Of course, the contribution of philosophy to bioethics is more than moral theories from the Enlightenment Era. There are more recent philosophical contributions from outside the field of moral philosophy that have roused bioethical interest.  Jennifer Blumenthal-Barby, et al., argue for philosophy’s continued place in bioethics, citing Derek Parfit’s “non-identity problem,” which altered the landscape of reproductive ethics, and David Chalmers’ contributions to philosophy of consciousness, which have implications for the moral status of brain organoids.[16] Still, these are narrow applications of philosophy to highly specialized areas of bioethics, which not all bioethicists are inclined to delve into. Philosophy in bioethics should not be confined to niche applications in specialist fields but should influence all bioethical thought. Fortunately, there remains untapped a wealth of philosophical disciplines that pertains to exactly this.
Philosophy of language investigates the nature of meaning and understanding in communication, which is a necessary social action. Successfully deciphering and conveying moral values in discourse is a bioethicist’s bread and butter, as is resolving disagreements and reaching agreements. Indeed, it is often the case that miscommunication lies at the root of an impasse between a doctor and a patient. An understanding of the nature of the disagreement would help resolve the conflict, as different types of disagreements require different interventions for resolution. For instance, a “substantive disagreement,”[17] in which two parties use the same terms in the same ways and have a fundamental disagreement on which outcome is more desirable, can be resolved only if one party yields to the other. On the other hand, a “merely verbal dispute,”[18] in which two parties use the same terms to represent entirely different concepts and values, requires standardization of terminological usage for its resolution. As such, no one can overstate the moral importance of successful communication in bioethics, and an exploration of language itself would prove invaluable to a bioethicist’s training.
Existentialism is another subset of philosophy that acknowledges the social nature of human existence, noting that one’s being in the universe is concomitant with the existence of others sharing the same universe.[19] Thus, there is the recognition that whatever existence is, it is not complete without the existence of others. With this as a starting point, existentialists examined how to live meaningfully with others in this world. Since ethics crucially involves others, it is no surprise that existentialists pondered how to live moral lives. Existentialist conceptions of morality did not revolve around acting in accordance with a set of rules, but rather, recognized individual freedom in choosing how to act and emphasized acting authentically. In this vein, bioethicists should commit to doing what is right rather than committing to applying a set of principles. Existentialism, while part of the broader bioethics literature, is less common throughout bioethics curricula and deserves more prominence.
Martin Heidegger, for instance, emphasized the difference between two types of thinking: “calculative thinking” and “meditative thinking.” Heidegger characterizes calculative thinking as a computation, wherein from some given starting conditions “definite results”[20] are determined, and contrasts this with meditative thinking, which he describes as “thinking which contemplates the meaning which reigns in everything that is.”[21] Heidegger was critical of the pervasiveness of calculative thinking, seeing it as the “ground of thoughtlessness,”[22] in which we only relate to the world in a meaningless, mechanical way. This is the emphasized type of thinking in rationalist conceptions of morality popular in bioethics; from a set of starting conditions, a series of rules are applied, and a moral outcome is calculated. Such a technique, however, discounts the personal meaning individuals place on the aspects of their lives relevant to their decision making, as well as the meaning in committing to doing what is right. Under calculative thinking, such a commitment is reduced to rote rule-following. A turn to meditative thinking would ensure that bioethical decisions comport with living meaningful lives.
Even aesthetics, a discipline devoted to examining beauty and taste,[23] has a place in bioethics. Just as the viewing of a painting, the listening of a song, or the reading of a book elicits an effective response, hearing a patient’s story leaves an emotional imprint. The recounting of a traumatic moment imparts sadness, and a joyous occasion begets joy in the listener as well. As acknowledged in the field of everyday aesthetics, these aesthetic experiences often spur us to act:[24] The unsightly appearance of a polluted riverbank drives us to remove the trash; the presence of sorrow in one’s life drives us to ameliorate it. To be mindful of aesthetic experiences and allow them to affect us emotionally is paramount to the motivation of a bioethicist to serve the patient, not out of an obligation to a job description, but out of a desire to truly avail the patient of their anguish. For example, the new field of narrative medicine utilizes critical reading and literary techniques to train clinicians and bioethicists in emotional understanding and listening skills that stress the social aspects of medicine beyond rational analysis and decision making.
CONCLUSION
Dr. Farmer is absolutely correct; bioethics is in dire need of resocialization. It should not be the case that the justification for a moral action is essentially that “the rules say so,” or that simply by teaching such rules to medical students, the very act of making bioethical decisions that diverge from those determined by principles can be seen as an act of “bad faith … hubris or, worse, malpractice.”[25] As bioethicists are coming to realize, the rationalist philosophical traditions that bioethics was founded upon are past their expiry, and the time for change is now. Indeed, as Dr. Farmer urges, “socializing disciplines” like anthropology, history, political economy, and sociology are necessary to humanize the field of bioethics.[26] So too, however, can philosophy be a socializing discipline, if we know where to look.
Bioethics should evolve. Its new goal should be to focus on meaningful human relationships, and to phase out rigid, impersonal modes of moral thinking. The limited sampling of unsatisfying moral theories from hundreds of years ago leaves many bioethics students cold, and it is easy to see why bioethicists are ready to part ways with philosophy. I believe this is a move in the wrong direction; there is a place for philosophy in the future of bioethics. Just as bioethics needs a resocialization, it is also needs of a re-philosophization. These enrichments complement one another. There is more to bioethics than mechanically determining the right course of action in a healthcare setting. Bioethics engages with the most ancient of philosophical questions: questions of what makes human existence meaningful, what makes us who we are, how we want to relate to others, how and why we feel, what our place in the world is, how we can communicate what we think, and why our moral intuitions are so compelling. We would be remiss if we did not begin to investigate additional contributions to morality from a wider range of philosophies that try to provide answers to such questions, as they offer a richness to moral thinking that cannot be gleaned from traditional bioethical approaches alone.
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[1] Friedrich Wilhelm Nietzsche, The Gay Science: With a Prelude in German Rhymes and an Appendix of Songs, ed. Bernard Williams, Josefine Nauckhoff, and Adrian Del Caro, Cambridge Texts in the History of Philosophy (Cambridge, U.K. ; New York: Cambridge University Press, 2001), 109.
[2] Nietzsche, 120.
[3] Daniel C O’Brien, “Medical Ethics as Taught and as Practiced: Principlism, Narrative Ethics, and the Case of Living Donor Liver Transplantation,” The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine 47, no. 1 (February 1, 2022): 97, https://doi.org/10.1093/jmp/jhab039.
[4] K. D. Clouser and B. Gert, “A Critique of Principlism,” Journal of Medicine and Philosophy 15, no. 2 (April 1, 1990): 219–36, https://doi.org/10.1093/jmp/15.2.219.
[5] O’Brien, “Medical Ethics as Taught and as Practiced,” 97.
[6] Cora Diamond, “Having a Rough Story about What Moral Philosophy Is,” New Literary History 15, no. 1 (1983): 168, https://doi.org/10.2307/468998.
[7] Bernard Williams, Morality: An Introduction to Ethics, Canto ed (Cambridge ; New York: Cambridge University Press, 1993), xvii.
[8] G. E. M. Anscombe, “Modern Moral Philosophy,” Philosophy 33, no. 124 (January 1958): 1, https://doi.org/10.1017/S0031819100037943.
[9] Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 7th ed (New York: Oxford University Press, 2013), 13.
[10] Clouser and Gert, 233.
[11] Clouser and Gert, “A Critique of Principlism,” 235.
[12] Paul Farmer and Nicole Gastineau Campos, “Rethinking Medical Ethics: A View from Below,” Developing World Bioethics 4, no. 1 (May 2004): 17–41, https://doi.org/10.1111/j.1471-8731.2004.00065.x.
[13] Ludwig Wittgenstein, Philosophical Investigations, ed. Joachim Schulte, trans. P. M. S. Hacker, 4th edition (Chichester, West Sussex, U.K. ; Malden, MA: Wiley-Blackwell, 2009), 40.
[14] Farmer and Campos, “Rethinking Medical Ethics,” 20.
[15] Farmer and Campos, 20.
[16] Jennifer Blumenthal-Barby et al., “The Place of Philosophy in Bioethics Today,” The American Journal of Bioethics: AJOB, June 30, 2021, 3–5, https://doi.org/10.1080/15265161.2021.1940355.
[17] Brendan Balcerak Jackson, “Verbal Disputes and Substantiveness,” Erkenntnis 79, no. S1 (March 2014): 31–54, https://doi.org/10.1007/s10670-013-9444-5.
[18] C. S. I. Jenkins, “Merely Verbal Disputes,” Erkenntnis 79, no. 1 (March 1, 2014): 11–30, https://doi.org/10.1007/s10670-013-9443-6.
[19] Steven Crowell, “Existentialism,” in The Stanford Encyclopedia of Philosophy, ed. Edward N. Zalta, Summer 2020 (Metaphysics Research Lab, Stanford University, 2020), https://plato.stanford.edu/archives/sum2020/entries/existentialism/; Anita Avramides, “Other Minds,” in The Stanford Encyclopedia of Philosophy, ed. Edward N. Zalta, Winter 2020 (Metaphysics Research Lab, Stanford University, 2020), https://plato.stanford.edu/archives/win2020/entries/other-minds/.
[20] Martin Heidegger, Discourse on Thinking, Harper Torchbooks (New York, NY: Harper & Row, 1969), 46.
[21] Heidegger, 46.
[22] Heidegger, 45.
[23] Nick Zangwill, “Aesthetic Judgment,” in The Stanford Encyclopedia of Philosophy, ed. Edward N. Zalta, Winter 2021 (Metaphysics Research Lab, Stanford University, 2021), https://plato.stanford.edu/archives/win2021/entries/aesthetic-judgment/.
[24] Yuriko Saito, “Aesthetics of the Everyday,” in The Stanford Encyclopedia of Philosophy, ed. Edward N. Zalta, Spring 2021 (Metaphysics Research Lab, Stanford University, 2021), https://plato.stanford.edu/archives/spr2021/entries/aesthetics-of-everyday/.
[25] O’Brien, “Medical Ethics as Taught and as Practiced,” 112.
[26] Farmer and Campos, “Rethinking Medical Ethics,” 20.