University of St. Thomas



Tom Tomlinson, “Casuistry in Medical Ethics”

Questions to Guide Your Reading

1. Introduction

1. According to the author, casuistry’s appeal to those who deal with medical ethics has two sources? What are they?

* (1) Reactions against principle-based approaches to ethical problems; and (2) the practical and pedagogical centrality of the “case” in medical ethics

2. Reactions Against Principle-Based Approaches

2. According to the author, there are roughly four sorts of criticisms directed against the application of general ethical principles to the problems encountered in medical ethics. What are they?

* (1) Without benefit of a single, defensible, overarching moral principle (highly unlikely), appeals to principles will, in genuinely hard cases, always lead to moral conflicts among competing principles; a conflict which is irresolvable in terms of the principles themselves.

* (2) Even when we operate within the scope of a single moral principle, all we have teo work with is a truism which is too abstract to generate any unequivocal conclusion about any specific circumstance. The question remains about how to apply the general principle to specific cases.

* (3) The idea that our commonly accepted ethical principles are the wholly sufficient grounds of moral justification ignores the likelihood that they are (or might be) based in “local” history and custom, and subject to distortions. [Ashley mentions both of these problems.]

* (4) Finally, unlike scientific theories, ethical theories which systematize intuited considered judgments don’t tell us anything we don’t already know, and therefore have no real explanatory or justificatory power. The notion is that “It would be wrong to leap over the table now and strangle you” carries more moral conviction than “Do not kill.” (Wrong.)

3. The Practical and Pedagogical Centrality of the Case

3. According to the author, if appeals to moral principles are abandoned completely, then moral skepticism and moral relativism are likely to follow. Why is this a problem? Why are skepticism and relativism easier in moral philosophy than in real life?

* In real life, one has to actually make decisions which are justifiable to oneself and which can survive scrutiny by others. (Thus the practical centrality of the case.)

4. Why is “casuistry,” basing our reasoning on cases rather than in general principles, likely to be attractive to persons in medical ethics?

* Because case-based approaches are simply the way medical ethics is taught. (But it’s also the way business is taught, and it hasn’t always been great there.)

4. Casuistry to the Rescue?

5. How does the author define casuistry?

* It is not merely the give-and-take of reasoned moral argument, nor the use of paradigm cases as a testing ground for the refinement of moral principles or theories.

* More precisely: “the interpretation of moral issues, using procedures of reasoning based on paradigms and analogies, leading to the formulation of expert opinion 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 the circumstances of action.

6. As an illustration of casuistry in action, the author sets forth the case of a pregnant woman who is a Jehovah’s Witness refusing a blood transfusion. They subsequently take up the case of a man who was a Jehovah’s Witness and thus refused a blood transfusion. First, does it trouble you that the results are different: the man gets the transfusion but the woman doesn’t? And second, does the “case based” approach seem to suffer from some of the same problems that the principle-based approach was criticized for above?

5. The Argument for Casuistry

7. According to the author, what are the problems associated with judging the morality of a case based on “analogy” with a paradigm case or “pattern recognition”?

6. Historical Interlude

8. The author gives the example of a priest named John Ward who, during the period in English history when you would be executed for being a priest in England, made use of the “casuistical” practice of “mental reservation.” When asked whether he was a priest, he answered, “no,” but by that he meant he was not a priest of Apollo. And when he was asked whether he had crossed the sea (priests often were smuggled into the country from France), he answered, “no,” but by that he meant he had not crossed the Indian sea. What would your judgment be of this use of casuistry? Would your judgment be that Fr. John Ward had violated the commandment against “bearing false witness”? Or did he manage to act in accord with it in this particular instance?

9. The basic issue here seems to be the problems that can arise with “absolutist moral systems.” Such problems really can arise. I don’t want to deny the potential problems. But there are a number of different ways of responding to the problems. One would be simply to “bite the bullet,” so to speak, and admit that sometimes upholding one’s basic moral obligations may involve sacrifice. Another would be to say that, yes, we need prudence in applying the basic principles to specific cases, and thus we need room for maneuver, but that we can’t base our principles only on the results we want to get. And of course the third would be to say that our principles should be tailored to the results we intuitively think we should be getting in this or that individual case. Which of these three would you prefer and why?

7. Problems and Limits of Modern Casuistry

10. What are the four problems or limits with modern casuistry the author identifies in this section?

* (1) First the appeal to paradigm cases assumes that th proper ones have been selected for comparison, and in any contentious ethical questions, where there are competing ethical considerations or “maxims,” there will also be alternative sets of paradigm cases tow hcih analogies can be drawn. There is still a need to decide from the very outset which of the two paradigmatic types is more compelling.

* (2) It is not obvious how casuistry is any more articulate than a rule-based approach in explaining the connection between rules, principles, or maxims, on the one hand, and specific moral judgments on the other.

* (3) In its reliance on settled convictions about paradigm cases, casuistry runs the danger of uncritical conventionalism and conservatism. It provides no way by which the settled paradigm themselves might be challenged. It is not more historically self-conscious than more “theoretical” approaches.

* (4) Finally, in its reliance on the paradigm case and argument by analogy, casuistry provides no avenue for other, indispensable types or moral argument, especially appeals to consequences.

8. An Example: Jonsen’s Casuistical Analysis of the “Case of Debbie”

11. I am not interested for our purposes that you recall all the details of the debates surrounding the “Case of Debbie.” What I’m more interested in for our purposes is simply that you get a sense of what a casuistical debate would be like. So, can you describe what a debate using the casuistical approach is like? (You should be able to, especially because the writing assignment for today depends upon your being able to describe it succinctly.)

9. What Can Be Salvaged?

12. Since I assigned this article simply to give you a sense of what casuistry is and how one uses it to approach moral questions, I’m not so interested that you take away anything in particular from this section. It might be worth noting, however, the author’s two main contentions. The first is that casuistry doesn’t seem to offer much benefit over principle-based approaches. (Others would undoubtedly agree with him and would have their own counter-arguments, but it’s simply worth noting that this is his position.) The second contention — under the heading “What Can Be Salvaged?” — is that it’s important to know all the details of a case: not merely the physical, medical details, but also the relevant details about persons and relationships. Later in the semester, we’re going to be talking about the virtue of prudence, and you’ll want to keep all these sorts of details in mind. We’ll want to ask whether developing the virtue of prudence might not involve precisely this ability to discern and give appropriate weight to all the details relevant to a specific circumstance. It may be that applying a general principle to a specific case is less a “one-size-fits-all” sort of situation and more like applying the general principles of geometry and engineering to specific buildings. You can’t simply use the exact same measurements for every building, because different buildings are different, and even with the same type of building, one might be built on a hill, another on a flat surface, another on swampy ground, another on rocky ground. But by the same token, you can’t violate the basic principles of geometry and engineering or else the building will fall down.

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