Bioethics in a pluralistic world: Truth telling, informed consent, and euthanasia

I address a central problem in bioethics related to an assumption shared by both "principlists" and "casuists." In particular, I explore the problems of justification in pluralistic settings. While acknowledging the strengths of these approaches, I show how practitioners working with the casuistic and principlist methods tend to succumb to "the myth of the innocent eye." Both principlists and casuists place excessive reliance upon the conviction that there exists a shared, "common sensical" understanding of paradigmatic cases reflecting the existence of a common public moral discourse which enables the application of prima facie principles in a non-controversial manner. Principlists and casuists alike fail to address the significance of distinctive patterns of enculturation for the variable evaluation of what is regarded as "reasonable." In contrast, I argue that if serious attention is given to the existence of distinctive interpretive communities sculpted by particular variables such as religious background, historical moral traditions, and ethnicity, then the way in which "common sense" is construed, distinctions made, principles applied, and reasons provided will often vary. By considering the topics of truth telling within the context of cancer care in the United States, Japan, and Italy; informed consent practices in regions where individual autonomy is subordinate to community decisions, and indigenous accounts of healing challenge Western understandings of medical care and research; and euthanasia as understood by Roman Catholics, and members of numerous other religious groups in contrast to a number of humanists in the United States, I strive to show that diverse bodies of background, tacit knowledge play major roles in the distinctive interpretation of moral matters. These divergent interpretive traditions often guide moral reasoning in such a way that the standard methods in bioethics do not necessarily lead to shared understandings as to what constitutes just, reasonable practices and policies. By exploring these three topics, I reveal the significant challenges pluralistic settings pose to the "common sense" approaches to moral reasoning in bioethics developed by the principlists Tom Beauchamp and James Childress, and the casuists Albert Jonsen and Stephen Toulmin.