The cultural and philosophical foundations of normative medical ethics

Thirty years ago, the idea that culture and philosophy could provide a foundation for normative medical ethics was more easily entertained than it is today when the very notion of a norm, whether culturally, philosophically or ethically derived, is in itself a problem. In large measure this comes from our contemporary embrace of cultural and philosophical pluralism and an increasing tendency to exchange the difficult belief in abstract and universally applicable norms for the more accessible notion that ethical values are cultural and relative derivatives. Despite this, in the face of the unprecedented ethical dilemmas presented by modern medicine, we have attempted to apply traditional ethical norms and analysis to modern medicine to establish a consensus for its right practice. Unfortunately, the attempt has not been successful, so that wherever we turn we find that ethical problems in medicine remain intractable and unresolved. That, in turn, has prompted a certain scepticism about the efficacy of ethics in medicine. In order to understand why we have reached this impasse, it is essential to realize that we have seriously underestimated the way science and technology have informed and, as a consequence, transformed the practice of medicine. Contributing to this, our tendency to think of technology simply as a way of doing things has blinded us to the fact that it is more fundamentally a way of thinking, knowing and valuing. If this is the case, then science and technology as ends in themselves, not merely as means to an end, as a type of human thinking, understanding and valuing, will, I suggest, require a normative ethic derived and constructed differently in order to determine good science from bad science, morally speaking. And if we continue to work with an ethical analysis using norms derived from outside the process we will have nothing more to show for our efforts than a superficial exercise in ethics. As we take the measure of our technological power in so many arenas, including medicine, we have come to realize that ours is a civilization face to face with its own implications. Whether in the care of neonates, genetic engineering or organ transplantation, we realize that our capacity is such that it increases the moral density of everything we do. So unprecedented is this state of affairs that despite our best efforts, we have not been able to provide a satisfactory assessment of the moral density of medical science as we see it practised today. The only alternative in the face of this systematic failure is, I believe, an ethic for medicine derived from the activity of medicine itself, and understood as something medicine as a process gives shape to and needs unconditionally if it is to be practised ethically.