Still saving the life of ethics.

Still Saving the Life of Ethics Back when medicine was saving the life of ethics and offering refuge to moral philosophers, who brought with them their exotic languages and customs (but alas no cuisine), and ethics committees across the land were gathering around insensate patients, incanting words like deontology, teleology, beneficence, autonomy, and paternalism, the textbooks were of the trickle-down variety, presenting lofty moral principles as decision-making guides for resolving specific dilemmas in the clinical setting. Fine examples of such books continue to be issued and reissued, but as James Childress acknowledges: The difficult question is not whether to invoke or apply principles and rules but rather which rules and principles should be adopted, how they should be interpreted, how much weight and strength they should be accorded, which have priority in a conflict, and in what relations and situations they apply. (In Robert M. Veatch, ed., Cross Cultural Perspectives in Medical Ethics: Readings. Boston: Jones and Bartlett, 1989.) One recent book starts at the bottom, at the case level, and therefore is no less than revolutionary: Albert R. Jonsen and Stephen Toulmin's Abuse of Casuistry (Berkeley and Los Angeles: University of California Press, 1988). Its title seems designed to send it slipping into obscurity--which would be a shame, I think, because the book provides a kind of basic science for practitioners of clinical ethics. Elegantly written and scholarly, it traces casuistry from its rise in classical Greco-Roman times through several centuries of Christianity to its corruption and dishonor under the scornful gaze of Pascal in the seventeenth century. Casuistry, in the authors' words, is: the analysis of moral issues, using procedures of reasoning based on paradigms and analogies, leading to the formulation of expert opinions about the existence and stringency of particular moral obligations, framed in terms of rules or maxims that are general but not universal or invariable, since they hold good with certainty only in the typical conditions of the agent and circumstances of action. They trace this form of practical reasoning (phronesis) to Aristotle, who believed that "ethics deals with a multitude of particular concrete situations, which are themselves so variable that they resist all attempts to generalize about them in universal terms." It is similar to the reasoning of the Talmud, case law, and general medical decisionmaking, which is why it serves clinical ethics so well. In matters of putting off and bringing on death, the most important recent publication took place not in a medical or ethical journal but in the record of the United States Supreme Court, when it decided the Cruzan case. Although legal scholars are giddy about the Court's discovery of a Constitutional right to refuse medical attention even where it could prolong or save one's life, the discovery is less significant to physicians and patients, since the right has been confirmed again and again in courts and legislatures around the country and endorsed by authoritative medical societies. The damage the Court has done in Cruzan is to allow states to impose "clear and convincing" standards that in my view could be impossible to meet even with duly executed living wills. For example, Mary O'Connor, a New York hospital worker, repeatedly told friends and family that she would not want to be kept alive by medical interventions if she were in a helpless condition similar to those which she witnessed daily. But her statements were deemed by the court to be unclear and unconvincing because she did not predict her own circumstances with sufficient exactitude. If a medically experienced person cannot find words that meet the clear and convincing standard, who can? …