Justifying Bioethical Case Decisions: Reflective Equilibrium and Mid-Level Moral Principles

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Bioethics is a practical enterprise intended to produce morally acceptable solutions to clinical case problems. Although answers can be derived from deductivist or principle-driven methods of deliberation, these solutions may be too abstract to be accepted as appropriate to the circumstances, clinically effective, or suitable to those stakeholders affected by the decision. Furthermore, it has proven difficult to identify the best moral principle to apply to each case, because of the variation in detail and nuance impacting each situation.

In this dissertation, I exemplify the difficulty in practical bioethics deliberations by presenting in detail the activities of a practicing ethics committee, working at the clinical level of private medical practice in the field of assisted reproductive medicine. In descriptions of over forty cases, I show the difficulty this committee faced in solving routine cases and even more when attempting to solve the novel cases that arise with some frequency in this unique field.

This research leads me to recommend a more procedural approach, based on the process of reflective equilibrium described by John Rawls, but supplemented by the contractualist version put forth by T. M. Scanlon. In this deliberative process, a wide variety of factors are considered: moral theory, particular details, paradigm cases, information from policy boards or professional organizations, diverse points of view, and public input. From this style of reasoning, useful mid-level principles can emerge, providing justification for bioethical solutions and encouraging consensus, which can also play a legitimizing role in decision-making.

I conclude that this inclusive kind of deliberation is more likely to occur at the level of the professional organization or the national commission, where broad diversity in participation and information, as well as public input, can take place. Decisions or principles achieved from this wider level of discourse will be more legitimate and can then be used to guide ethics committee members functioning at the private level.