Abstract
Philosophers and other specialists are increasingly called upon to offer insight and guidance for complex moral decisions, whether as ethics committee members or as ethics consultants. The practice of ethics consultation is especially prominent in health care facilities, and there is growing professional interest in academic programs and fellowships designed to develop skills in assisting with moral decision-making. This phenomenon has raised questions among both academics and medical professionals about the nature and plausibility of anyone’s possessing such a skill, particularly, whether ethics professionals should be regarded as other specialists, as experts who can offer authoritative advice. In this introduction, we explain some of the basic concepts related to moral expertise and review the central debates over its nature, plausibility, scope, and implications, for both theoretical bioethics and clinical practice.
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Notes
- 1.
Some scholars attempt to maintain a distinction between morality and ethics, but here we follow the majority of academic philosophers in using them interchangeably to refer to the study of the related concepts of good, bad, right, wrong, permissible, impermissible, and obligatory.
- 2.
Richard Zaner expresses the timidity many ethicists feel embarking upon the task of ethics consulting: “[M]any of us felt acutely out of place and recoiled in shock and dismay” (1988: 5). Giles Scofield excoriates the notion, arguing that “medical ethics consultants neither know nor agree on what they do for a living, much less what one needs to know and what skills one needs to do whatever it is they do for a living (2008: 96). And Julia Driver notes that this sentiment extends fairly widely, since most of us are even more willing to accept aesthetics experts than ethics experts, “displayed by a willingness to be guided by the advice of art critics as to what movie we ought to see, and what art exhibit is the most worthwhile” (2006: 619).
- 3.
Joint Commission (1992). The Joint Commission is the independent, not-for-profit accrediting body for hospitals in the United States (formerly known as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)).
- 4.
Fox et al. (2007). Fox, et al. estimate that every hospital over 400 beds has an ethics consultation service, but there are concerns with their sampling methods, and there is disagreement over how broadly they construe “consultation service.”
- 5.
Döries and Hespe-Jungesblut (2007).
- 6.
UK Clinical Ethics Network (2011).
- 7.
Heraclitus: Fragments, Fr. 108. T. M. Robinson, trans.
- 8.
- 9.
See Khan (2005: 49–51).
- 10.
For more on the history of this debate, see the first seven chapters of Rasmussen (2005), which include discussions of Socrates, Aristotle, David Hume, J. S. Mill, Josiah Royce, John Dewey, and G. E. Moore.
- 11.
Or that we at least have well-justified beliefs about the morally preferable thing to do.
- 12.
See Wolff (1970) and Zagzebski (2012). Some scholars, like Immanuel Kant and J. S. Mill, can be interpreted as defending the idea that part of what makes your knowledge of morality knowledge (in a strong sense) is that it is a result of reflecting on your own decision-making process. In other words, it is a function of your autonomy as a rational agent. Mill writes, “If a person possesses any tolerable amount of common sense and experience, his own mode of laying out his existence is the best, not because it is the best in itself, but because it is his own mode” (2002: 69). Of course, even Kant doesn’t rule out the possibility of checking your reasoning against the informed opinion of others. See Zagzebski (2012: 23–26) for an excellent discussion of how Kant regards testimony in his Anthropology
- 13.
Locke (1979).
- 14.
Ayer (1954).
- 15.
- 16.
Broad (1952: 244).
- 17.
- 18.
- 19.
To be sure, each of these has moral implications. The point is to simply highlight that neither laws nor institutional policies are, in themselves, moral statements, even if motivated by moral concerns with moral implications for care. For instance, a federal law requiring that all new employees have the legal right to work in the country is not itself a moral requirement. Similarly, an institutional policy that all team members wash their hands has clear moral implications, but not every instance in which that policy is violated is a moral infraction.
- 20.
See MacIntyre (1988) for the influence of different accounts of rationality on decision-making.
- 21.
Aulisio (2003: 5)
- 22.
Many of the items on this list come from Aulisio (ibid.).
- 23.
Stolper et al. (2010: 151).
- 24.
Exceptions include Hopkins (2007) and Priaulx, et al. (2014).
- 25.
- 26.
The term “epistemic” refers to concepts associated with knowledge or justified belief. A person’s “epistemic community” is the group of people closest to the person in terms of what they are interested in knowing, how questions are framed about that subject, and the relevant evidence and strategies for answering those questions. For instance, the international community of scientists would be members of a chemist’s epistemic community.
- 27.
Burch (1974) puts this point eloquently: “In the typical moral problem, the ethically relevant features are tricky to specify and extremely difficult to weigh with respect to one another. Moreover, there is no given short-list of possible actions to be decided upon; instead there looms before the person deciding what do to an open field of infinitely diverse actions, shading into one another in countless, different ways. To be or not to be is hardly ever the moral question, but rather when, where, how, for whom, how much, and in what respect to be or not to be. A moral problem calls not for a mechanical response, but rather for a creative act” (655).
- 28.
The brackets in this paragraph replace masculine pronouns with plural pronouns.
- 29.
- 30.
Julia Driver offers a humorous example: “Satan could well be an example of a being with superior moral knowledge, but it would be unwise to defer to Satan’s judgment on what to do. I might be confident in his ability to know, but not confident in his accurate transmission of that knowledge, because I view him to be deceitful” (2006: 630).
- 31.
Dale Miller (2005) notes that some, like J.S. Mill, hold that there is no “intrinsic connection between moral beliefs/knowledge and moral motivation” (a view known as moral externalism), which means that knowing the right thing to do does not entail that one will feel any motivation to act on that belief. “This implies that while those with greater moral expertise might be able to lay claim to greater moral knowledge, … it would be a mistake to assume that they are automatically more virtuous…than anyone else” (83).
- 32.
Widdershoven and Molewijk (2010).
- 33.
1970: 6. George Agich (1995: 274) calls this the “command-obedience” model of authority, which is grounded in political structures. He contrasts this with “social role authority,” according to which someone accepts a person’s testimony based on a set of complex, informal social relationships. For example, “a teacher does not order students, except when he behaves as a disciplinarian and then does so as a school official in charge of conduct. Teaching as such involves complex processes of communication that bind student and teacher into an authority relationship where teaching and learning occur. A scientist interacting with peers might rightly take their word on a particular scientific point over that of a layman. Such trust is based not simply on other scientists’ power or position, though that might to some degree contribute to the initial acceptance, but also on their common commitment to methods of work and modes of demonstration” (276). In subsequent paragraphs, we call social role authority “epistemic authority.”
- 34.
Zagzebski draws heavily from Joseph Raz’s (1986) account of authority, but for simplicity we will focus on Zagzebski here.
- 35.
Zagzebski, 107.
- 36.
In a suggestive study that Zagzebski cites by Mlodinow (2008), when animals discern that one choice is better a majority of the time, they choose that option every time. And thus, they choose the better choice most of the time; they are outcome-maximizers. Humans, on the other hand, are probability-matchers. If a choice is better about 75% of the time, humans will choose that option about 75% of the time, making it very likely that they will almost always choose the better option less than 75% of the time. (Zagzebski, 2012: 115)
- 37.
110–111. By “conscientious reflection” Zagzebski means, “[u]sing our faculties to the best of our ability in order to get the truth” (2012: 48).
- 38.
(2018: 234).
- 39.
Ibid., p. 235, italics hers.
- 40.
Ibid., pp. 238ff.
- 41.
Ibid., p. 239.
- 42.
Ibid.
- 43.
Ibid.
- 44.
Whether the person is in a better position to know the time (instead of merely having a justified belief about the time) is a more complicated question, leading to questions about the reliability of watches, the proper functioning of that person’s watch, etc.
- 45.
See Elizabeth Fricker (2006).
- 46.
- 47.
It is controversial whether patient authority is plausibly regarded as “expertise.” Given that any particular medical condition involves extensive subject matter outside the patient’s competence, we have categorized this authority as situational with respect to evidence only the patient could have.
- 48.
His famous defense of this is in Groundwork for the Metaphysics of Morals (1785/1997).
- 49.
- 50.
See also David Adams, this volume (Chap. 12).
- 51.
Martin Hoffman (2012) draws a distinction between “ethics expertise” and “genuine moral expertise,” arguing that, while moral philosophers might be competent to apply moral concepts to complex situations, it is a mistake to think that it gives them privileged access to “esoteric moral knowledge (304–306). This suggests that ethics experts might be trusted for their epistemic virtues even if they cannot dispense moral truths.
- 52.
Gesang’s conclusion depends on adopting what he calls the “coherence theory of moral justification,” which he contrasts with the “deductive theory.” We won’t rehearse these details here but will simply note that whether one adopts the coherence theory affects the plausibility of Gesang’s conclusion. See Cowley (2012) for a critique of Gesang.
- 53.
Rasmussen (2005). Rasmussen (2011) distinguishes between “ethics expertise” and “moral expertise” as a heuristic to help distinguish the sorts of epistemic authority CECs might possess. Though there is no widely accepted account of the sorts of recommendations that ethicists can make, one may think that CECs can make decisive recommendations that effectively and objectively resolve moral dispute (what she calls “moral expertise”). She argues that this is not the sort of expertise a CEC could plausibly have, and argues, instead, that they have “ethics expertise,” the authority to offer “non-normatively binding recommendations grounded in a pervasive ethos or practice within a particular context” (650).
- 54.
There are some organizations and professional groups for clinical ethics consultants in other geographic regions. For example, the Canadian Bioethics Society holds an annual conference and offers some resources for ethics consultants.
- 55.
There are exceptions to this. For instance, many committees also engage in reviews of previous cases for purposes of education and quality improvement.
- 56.
Cf. Stolper, et al. (2010).
- 57.
- 58.
For a brief explanation of how disagreement can affect beliefs about morality generally, see Jonathan Matheson (2015: 4–5).
- 59.
Ben Cross (2016) defends this strong version of the argument from disagreement, concluding that the fact that reputable moral philosophers disagree about certain moral claims implies that we should place no degree of trust in either of them regarding those claims.
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Watson, J.C., Guidry-Grimes, L.K. (2018). Introduction. In: Watson, J., Guidry-Grimes, L. (eds) Moral Expertise. Philosophy and Medicine, vol 129. Springer, Cham. https://doi.org/10.1007/978-3-319-92759-6_1
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