by Carl Elliott
Review by Christian Perring, Ph.D. on Nov 3rd 2000
One of the aims of philosophy and ethics, as normally conceived, is to be neutral and unbiased. Philosophers especially hope to achieve general truths. It is for other disciplines, such as psychology, sociology, and even novel writing to focus on the particular. Yet Carl Elliott is critical of much philosophy and medical ethics, and his book is unusual in its style, because he talks about his own life and his family. He tells of his experience and disenchantment with medical school, and his father's disappointment that two of his sons abandoned their plans to enter medicine. His discussion ranges over not just the familiar terrain of medical ethics, but also over novelists, sociology, anthropology, Wittgenstein, Aristotle, ordinary language philosophy, postmodernism, and modern cultural politics. More than that, his writing style is often casual, and he comes across as extremely personable. Elliott is a more interesting thinker than most professional medical ethicists, and I welcome this book.
One of the main themes of this book is that much of the debate in medical ethics is misguided, because it is based on a misunderstanding of the relation between morality and our practices. Elliott takes the later work of Ludwig Wittgenstein as an model, or at least an inspiration, for how to do philosophy the right way. Exactly what that way is when it comes to medical ethics isn't always so clear; much of Elliott's discussion consists in setting out common sense and making insightful comments about particular issues. Of course, it is not surprising that it is hard to briefly summarize a "general antitheory of bioethics"; indeed, such difficulty seems inherent in Elliott's project. It also makes your humble reviewer's task more challenging in explaining Elliott's approach. After reading through the book once, I found myself browsing through it in a very non-linear manner, reading passages here and there, asking myself, "so what exactly is his central idea?" I'm still unsure whether I have completely grasped it.
A Philosophical Disease addresses various ethical issues, such as the use of Prozac for enhancement, whether deafness is really a disability, the moral responsiblity of people with personality disorders, the ability of depressed people to give informed consent to test trials of new antidepressant drugs, and living heart transplants. Elliott makes many worthwhile points, even if often his conclusions are quite slight. For instance, in his chapter on enhancement and normality, he ends by saying that there are no rigid distinctions between disability and difference, or cure and enhancement, but that we must pay attention to our biological nature. Most readers probably acknowledged that much at the start of the chapter. I am not holding Elliott at fault here, since I doubt that we can make strong arguments for definitive solutions to such controversies. Indeed, I am sympathetic to Elliott's central starting point that we can't place much confidence in the "great philosophical theories," such as Kant's deontology, Mill's utilitarianism, or Aristotle's virtue ethics. Elliott is postmodernist enough to be suspicious of the "grand narratives" of modernism, and his tone is pleasingly tentative, with touches of irony and self-deprecation all the way through his book.
Elliott's ultimate aim in discussing these sorts of cases is as part of his philosophical examination of how to resolve ethical issues in the real world. He is interested in the methodology of bioethics, and he is unsatisfied with the way bioethics is normally carried on. There is some diversity in approaches of bioethics, but it is all too common to see someone trot out the four principles outlined by Beauchamp and Childress in their Principles of Biomedical Ethics. These principles, autonomy, beneficence, non-maleficence, and justice, are then applied to the problem at hand; the crank is turned and out pops the answer. But Elliott is also critical of the debate about other sorts of mainstream bioethical debates; for example that about the definition of personhood of fetuses. It seems to me that this is a critical sort of case for his argument (largely because it is here that I start to disagree with him), but it is precisely at such a point that the central message seems to lose focus.
The question at issue is how to go about resolving problems in medical ethics. Elliott is suspicious not just of grand theories, but apparently of all philosophical theorizing. But it is very hard to see why Elliott's alternative approach doesn't count as philosophical theorizing, or if he really rejects theorizing, then what alternative he is proposing. Take the case of the moral status of a fetus. Elliott says it is a mistake to think that we can rationally discover whether or not a fetus has the moral status of a person by inspecting our conception of a person, finding the necessary and sufficient criteria of personhood, and then seeing if a fetus meets those criteria. He says, But this is not the way our moral grammar works. In fact, just the opposite. Our moral attitudes are not grounded by a theory of persons; they are built into our language. Part of what we mean by the word "person" entails a certain moral attitude. I think Elliott is making two points here about personhood, one right, one wrong. He is very probably right that there is no simple single conception of a person implicit in our practices. Rather, there are many elements in the way we morally evaluate persons, and they may not even be consistent with each other. The different elements are morally loaded in different ways, and come with built-in moral assumptions. Thus there is no simple separation of fact and value in this case. But Elliott seems to draw an anti-theoretical conclusion from this, viz., that we don't have implicit theories of personhood loaded into our moral practices and that it is fruitless to examine and argue over which theories are rationally justifiable. He goes on to try to illustrate his claim in a way that highlights his error. He draws an analogy with the issue of how we should treat our friends -- and of course the nature of honesty, loyalty, and love are certainly profoundly topics. What if I know someone but I am not sure if that person qualifies as a friend? Taking a cue from the kind of reasoning the theoreticians of personhood use, my ethical task should be to set our criteria for friendship and see whether this person counts as a friend. The results of this list, and how this person matches up to it, will then tell me how to behave. Elliott says that simply imagining this method shows how wrong-headed an approach it is. But I fail to see the problem; it strikes me as an excellent suggestion for how to proceed if faced with a doubtful friendship. I would especially recommend it in the case of children and teenagers who very often are faced with uncertainty whether an acquaintance really counts as a friend. Some of the best philosophical debates I have had in my classes have been over the nature of friendship, and Aristotle's discussion is especially helpful. Similarly, it strikes me that the debate over the nature of personhood in bioethics is one of the richest and most important debates the discipline has produced.
This is not to say that producing lists of criteria for personhood or friendship is going to completely settle all the ethical questions associated with personhood or friendship. Of course the debate will proceed, and the moral assumptions of different sorts of analyses will be uncovered. But such theorizing and philosophizing is, as far as I can see, the best way to proceed. Indeed, in much of his discussion of cases of ethical problems in A Philosophical Disease, that is how Elliott himself proceeds. I conclude that Elliott is overplaying his hand; his conception of how we should go about doing philosophy, as embodied in his own practices rather than his theory, is not as anti-theoretical as he suggests.