REVIEW BY JAN C. HELLER, PhD
Practical Decision Making in Health Care Ethics: Cases and Concepts
Raymond J. Devettere
Georgetown University Press, Washington, DC,
1995, 512 pp., $59.95 (hardcover), $25.95 (softcover)
In Practical Decision Making in Health Care Ethics: Cases and Concepts, Raymond J. Devettere offers a compelling and well-written introduction to healthcare ethics. Devettere intends the book to be read as an alternative to the various obligation-based, principles-oriented approaches that have dominated the field of healthcare ethics since the publication of the Belmont Report in 1978. Thus, in contrast to obligation or duty, his approach is based in virtue, which he understands as a unity of feeling, habit, and behavior that is teleologically oriented toward the creation of a "good life." In contrast to reasoning based on moral principles to determine what action an agent is required or forbidden to do, Devettere uses a traditional notion of prudence to guide agents in their decision making.
As Devettere notes, the alternative he proposes is not new; rather, it represents a selective retrieval of the approach to ethics first developed by Aristotle and later elaborated on by Thomas Aquinas. Of the approaches now competing for ascendancy in healthcare ethics, Devettere believes that Aristotle and Aquinas's approach best captures his conviction that "ethics is more about the habits, feelings, and behaviors that we need to cultivate and practice in order to live well than it is about our obligations; more about flourishing in life than about duties" (p. xv). The book is not offered as a proof of the superiority of this approach, or even as an adequate explanation of it, but as a demonstration that such a retrieval is theoretically possible and practically useful in contemporary healthcare settings.
To the extent that Devettere tries to justify his approach, he does so in part by observing that it can answer a question that contemporary approaches to ethics seemingly cannot answer, namely, why one should be moral. In Devettere's view, one should be moral for self-interested reasons; that is, because this is how one will most likely flourish as a human being. Indeed, he notes, all humans seek this flourishing naturally. However, self-interest in the sense Devettere is using it need not be narrowly interpreted as selfishness or egoism. Insofar as he construes human flourishing in interpersonal and social terms, his approach opens to other-centered virtues. Nevertheless, in contrast to the impartial perspectives required by many contemporary approaches to ethics, it is always appropriate in Devettere's approach to be concerned with my good and the good of those with whom I enjoy what philosophers call "special relations." The implication of this concern could be significant in some cases, for it could imply that it is permissible to treat my patient differently than I would treat your patient. The special relation that exists between me and my patient might, for example, recast certain allocation choices when resources are scarce, as in transplant medicine.
Devettere also justifies his approach by delimiting the certainty that properly can be expected of any ethical decision. This explains his use of the term "practical" in the book's title, and it signals his concern that we reason about morality on the basis of prudence. Prudence, or practical reasoning, is focused on everyday concerns, and especially on the contingent state of affairs that will exist only if agents choose to bring them into existence. It is contrasted to the theoretical rationality available in other domains of human knowing, which gives agents a far more certain tool for knowing. However uncertain, as a way of reasoning, prudence seeks a mean between extremes or, as the author calls it, the most "reasonable" alternative. This mean is demonstrated again and again in Devettere's casuistry, as he reviews no fewer than 53 separate cases.
Devettere's extensive review of cases illustrates the interpretive power of the approach and educates the reader concerning historically important cases that helped shape the field. As suggested by its subtitle, the book is essentially divided into two parts. Chapters 5 through 15 review these important cases, while chapters 1 through 4 review the basic concepts and terminology of his approach. Devettere's discussion of each case follows a two-stage format. Stage one, called "situational awareness," identifies the case's relevant facts and values, inquiring about what is happening, who the decision makers are, what options--both good and bad--are available to agents, and what circumstances they need to consider. The second stage, called "prudential reasoning," considers each agent's options from his or her perspective and asks what he or she can reasonably do to live well in light of the circumstances presented by the case. When these considerations lead agents to conflicting conclusions, as they often do, Devettere relies on the concepts outlined in chapters 1 through 4 to determine which agent's perspective reasonably should take precedence and which action should finally be pursued.
Of the concepts used in Devettere's approach to healthcare ethics, I found his discussion of common ethical distinctions in chapter 3 to be one of the most interesting, as well as one of the most potentially controversial, chapters in the book. What Devettere terms "misleading" distinctions include actions and omissions, withdrawing and withholding treatment, intentionally causing death and letting die, paternalism and autonomy, ordinary and extraordinary means of preserving life, futile and effective treatment, direct and indirect results, and immoral and intrinsically immoral actions. What he calls "helpful" distinctions include reasonable and unreasonable, prudence and judgement, descriptive and evaluative language, and bad and immoral.
The author's development of these distinctions reveals that he is philosophically adept and possesses an intimate knowledge of theological ethics. Informed Roman Catholic readers will recognize that many of these distinctions were originally developed by Catholic moral theologians. Devettere summarizes their history and development in short, to-the-point discussions that students will find quite useful. Some readers will take issue with Devettere's understanding of some of these distinctions. For example, he contends that the concept of "intrinsically evil" actions is incoherent. This implies that what is traditionally called "direct" abortion could be morally justified in certain cases; indeed, his distinction between bad and immoral implies that no action is ruled out of bounds morally simply because it produces bad effects. This said, it should also be noted that Devettere argues generally for what most would regard as rather conservative positions on many of the controversial issues in contemporary healthcare ethics--revealing again his penchant for seeking the mean.
We might want to ask to what extent Devettere is successful in making good his claim to give us an alternative approach to healthcare ethics. Although there are clearly many affinities between the various components of his approach, there are no necessary relations between them. That is, there are no necessary relations between a virtue-based approach to ethics, a commitment to prudential reasoning, and a preference for casuistry, even though it is true historically that these components are often found together. Each could be, and is, incorporated into obligation-based, principles-oriented approaches to ethics. So, while Devettere acknowledges these theoretical possibilities, I am not entirely clear what it means to claim that his is an alternative approach. Is Devettere's approach different in kind from other approaches, or is it merely different in degree or emphasis? Moreover, what is at stake in such a determination, especially when many so-called principlists might agree with much of his casuistry, albeit for different reasons?
We might also want to ask particular questions about the various components of Devettere's approach. For example, we might ask him to elaborate on his understanding of the good life. He seems to understand the term functionally. This allows him to claim that all humans seek it. But Devettere is aware that individuals routinely seek substantive goods that conflict with what he seems to regard as good. This possibility is seen in his occasional use of the term "truly good." It seems he is operating with some notion of what counts as a truly good life, and it would be helpful for the reader to know what it is and how he defends it. Also, while I find myself persuaded by much of his casuistry, I wonder how it might fare if we asked him to consider less personal, more far-reaching cases, such as those involving the effects of medical research on future generations or on large populations that are currently living. In such cases, I suspect Devettere's emphasis on the agent's perspective and on special relations will prove problematic.
These critical concerns notwithstanding, this carefully crafted and well-researched book amply demonstrates the author's experience in various healthcare settings and his knowledge of the relevant philosophical and religious sources in ethics. My only quibble with the book's format is that it has no footnotes; instead, it has a brief review of sources at the end of each chapter. This makes the text easier to read, but also more difficult for students to track down the sources of specific facts and arguments.
Undergraduate students and the interested public will find the book's language accessible and easy to read. With the book's helpful glossary and indexes, busy medical professionals will find it a ready source of information on, and discussion of, the difficult cases they encounter. And, although the book is not intended for the specialist in ethics, graduate students and professional ethicists will find it a valuable addition to their libraries, not only for having so many important cases in one place (the book is worth owning just for this), but also for being one of the finest examples of healthcare casuistry now in print.
Jan C. Heller, PhD
Director, Center for Ethics in Health Care
Saint Joseph's Health System
Atlanta