Clinical decision-making: the case against the new casuistry.

That advances in the biological sciences coupled with progress in medical technology have had and continue to have profound effects on both ends of the spectrum of life is fantastically clear. It is safe to say with some confidence that medical advances have put both medical professionals and those patients and families that may be the recipients of recent biomedical gains in the position of making decisions that range over bringing about life, sustaining life, and terminating life.1Despite this wealth of medical knowledge and the concomitant advances in medical technology that continue to come our way at groundbreaking speed, decisions regarding how to employ or whether or not to employ such knowledge and technology to actual medical situations/cases has proven to be a notoriously difficult task. The moral status of many of the decisions made by medical practitioners, employing various sorts of medical technology at all regions of the spectrum of life, has come under a great deal of scrutiny in the last thirty years. More specifically, it is the moral reasoning of medical practitioners in medical settings that has been "under the moral microscope" as a result of the decisions that have been and continue to be made in the wake of our current frenzy of scientific and medical headwayToday, three broad procedures or methodologies are being employed by bioethicists and clinicians to address the many complex medical decisions that are now part of our "brave new world." First, there is the theory school of medical ethics. Those who pledge allegiance to this camp apply general moral theories (e.g., utilitarianism, contractarianism, virtue ethics, deontology, etc.) to the specific problems that have emerged as a result of the advances made in medical and biological research (e.g., organ transplantation, gene manipulation, fetal tissue research, euthanasia, abortion, etc.). The second method for resolving decisions in clinical settings is the principle approach. Those who embrace this method eschew the difficulties associated with constructing a moral edifice, but move directly to a set of principles (e.g., autonomy/self-rule, beneficence, justice, rights, nonmaleficence, probity, etc.) that are applied to particular biomedical cases. Then, justification is given as to why a particular subset of these principles and the corresponding weight and hierarchy attached to each principle within a chosen subset is appropriate to the case at hand.2 The third methodology, which is comprised of a few variations, is what is called the case-based or casuistic method of moral decision-making in medical settings.3 Adherents of this practice insist that both of the first two methods, the theory approach and the principle approach, are not at all efficacious (by themselves) in resolving concrete problems in clinical settings. Rather, casuists declare firmly that the only way to resolve the complex issues in medical settings is to focus simply on the actual details of specific cases and then determine what to do in the given cases.This essay will focus on the casuistic approach. To make this inquiry tractable, after providing a brief historical backdrop for this discussion, I will provide an account of a version of casuistry offered by Jonsen and Toulmin (hereafter JT). Next, I will provide some of the central criticisms of this approach that would appear to render it rather moribund. I will then explain and evaluate Carson Strong's recent attempt to defend theJT strategy. My analysis will reveal that Strong's defense of theJT version of casuistry is not nearly as puissant as he purports.4 The upshot, which includes two overlooked criticisms, will make clear that JT's version of casuistry is inadequate as a serious methodological framework from which to make difficult decisions in clinical settings.Historical BackgroundIt is no secret that moral theorists disagree vehemently as to what constitutes the correct framework from which to evaluate what kinds of acts are good and what kinds of acts are bad. …