Integration or Application?

The notion of integration refers to a close “interaction between moral theory and empirical data” (p. 57) and intensive cooperation between “ethicists and descriptive scientists” (p. 55).²

This methodological approach is thus specifically directed toward interdisciplinary cooperation where empirical data and the particularities of social practices are at the center of the investigation. Rather than coming from the outside equipped with readymade moral principles, integrated empirical ethics teases out and makes explicit “the normative knowledge embodied in practice” (p. 73).³ Hence the rules that result from the integration approach are said to provide good guidelines for practice because they are rooted in it. On this view, it appears that moral philosophy should primarily analyze practical experience without distancing itself from it and thus threatening to distort the subject matter.

The Integration thesis is largely motivated by the criticism of the prevailing view that the role of moral philosophy in bioethics is characterized by application of abstract theories or normative principles to the subject matter.⁴

In contrast, sociology and law emphasize the analysis of social norms, as reflected in acts, regulations, policies, practices, and people's views. As a consequence, the “external” critical normative perspective of philosophy tends to clash with the “internal” and descriptive analysis of law and sociology. But in particular, the argument goes, the application of theory and principles stands in tension with the scientific or social practice itself that is the subject of investigation. A common criticism goes like this: “Because of an inadequate understanding of practice, it is rather inattentive to the particularities of the practical setting. Moral theories and principles are necessarily abstract, and therefore fail to take account of the sometimes idiosyncratic reality of clinical work and the actual experiences of practitioners.”⁵

Although the integration view implies an important criticism of many texts that have been written in the field of biomedical ethics, it does not, in my experience, correctly identify the typical role of moral philosophy in interdisciplinary research. Surely, both moral theories and principles do play a role in the critical analysis of the subject matter, but they are usually not externally “applied” to it. Many bioethical projects are carried out without explicitly introducing ethical theories, and people adhering to different theories seem to be able to analyze the issues without being entangled in them. Moreover, the Integration thesis clearly exaggerates the role of “abstract moral principles” in bioethics. Heuristic moral principles certainly can inform moral reasoning, help identify relevant features of situations, and enlighten decisions, but only if they do not stand in the way of thinking. Matti Häyry put it succinctly: “Bioethical principles should be employed to promote discussion, not to suppress it” and “it does not really matter where they came from, if they can be used to promote sensible bioethical discussion”.⁶

Accepted Norms and Reasoned Principles

Obviously, attentiveness to experience, practice, and context is crucial to a successful moral analysis, and I welcome attempts to reconsider bioethics in order to strengthen these factors. However, I sense in the Integration thesis a problematic view about the role of moral philosophy in interdisciplinary research. Paradoxically, the normative force of the thesis is too strong, the moral imperative of being guided by the accepted praxis is too restrictive. As a consequence, the Integration thesis encounters a similar problem as is central to the critique of the adherents of application: that its emphasis on abstract theory and principles stands in the way of fruitful analysis of practice. My criticism of the Integration thesis is that its theoretical emphasis on the role of moral reflection in interdisciplinary research may preclude a fruitful analysis of practice, not because of alienating distance from practice, but rather because of a suffocating closeness to it.

Although the thesis starts out by sensibly emphasizing practice and experience, it soon slides into a debatable normative position toward the primacy of accepted norms over reasoned principles. Accepting that “normativity is the primary function of ethical theory,” Lieke van der Scheer and Guy Widdershoven argue, for instance, that the roots of this normativity are to be sought in “experience,” within actual “morality” and not “ethics” as a theoretical effort of reasoning and justification.⁷

Not surprisingly, the Aristotelian notion of phronésis is taken as an example of the way in which moral philosophy should proceed in an integrative approach to bioethics. In the dominating spirit of neo-Aristotelianism, phronésis is primarily seen as ethos-oriented reflection and less as logos-enlightened deliberation. But it is far from obvious to me that a contemporary phrónimos would practice moral reflection as it is described in the idea of “integrated empirical ethics.” Neo-Aristotelians do not seem to realize that our moral predicament is post-Kantian. This, however, must be recognized in a contemporary account of phronésis. Phronésis is an intellectual virtue that not only finds the particular fitting thing to do within a situation but does so in virtue of practical reasoning about what is generally right.

For a neo-Aristotelian in a post-Kantian world, I see no compelling reason why practical deliberation should not be informed by critical moral principles. In light of the context of our contemporary ethical life, which is shot through with universal rights and principles, I do not see that as a viable option. Of course, neo-Aristotelians can choose to lean toward what Schnädelbach has called “the ideology of phronesis,” which systematically weakens all validity claims in favor of lived praxis.⁸

But in so doing they put up a false dichotomy between assertion of principles on the one hand and the sense for the situation on the other hand. This interpretation ignores the emphasis that Aristotle places on use of “the right reason” and implies discursive capacities that are procedural rather than substantive.⁹ The practically wise man in contemporary society will judge the relative significance of specific situations in light of general moral principles. As Aristotle writes in the Politics, “the power of speech is intended to set forth the expedient and inexpedient, and therefore likewise the just and the unjust.”¹⁰

We exercise the power of speech in “sensible bioethical discussion” that should not have any a priori theoretical restrictions other than what is required by its inherent rationality and good scientific practice. Free moral thinking must not be told to respect the existing norms because such thinking inevitably implies that the reasons for the normative claims made must stand to scrutiny. That is the nature of an examination of validity claims. Just as empirical science must critically examine truth claims, so ethics needs to critically scrutinize claims to rightness that are embodied in law and local standards, in actual ethical views or an established social consensus. It is necessary to understand the normativity that resides in the social context, but it is never sufficient to conclude moral reasoning.

I agree that the norms for reflection should be found in actual practice, but the reasoning about their validity should not be limited by the normative implications of an established practice. “The meaning which practitioners give to their situation and the reasons they have for their actions” are certainly relevant issues for ethical analysis and so is “search for actions and guidelines which occurs in dialogue with practice” but these are far from exhausting its functions.¹¹

A key factor in a successful moral analysis of a particular practice is an attempt to analyze the foundations of the factually accepted. The question is not only what is in fact accepted but also why it is accepted and whether it is worthy of recognition?¹²

If we put this in the language of hermeneutics, which is often used by integrationists, the task is not only to understand participants' own normative understanding and actual policies—the so-called hermeneutics of faith—but also to examine how they are formed by power and special interests—sometimes referred to as hermeneutics of suspicion.¹³

Moreover, both these hermeneutic tasks can be better served by sociology than ethics, and the uniquely moral task is the third one, namely, whether the participants' own normative understanding stands to reason. It is elementary for moral analysis that the fact that people accept something or that it has been enacted in law or declarations does not imply that there are good reasons for accepting it. This is the main reason why moral analysis must not be too close to the practice itself, however contextually sensitive and participating it wants to be, because reflective distancing is the precondition for a fruitful moral investigation.

An Example

The “search for rules and guidelines” is said to be “the most important work in integrated empirical ethics.”¹⁴

Although its defenders have doubts about its universal usefulness, they see it as a “tool that may be used especially in dealing with new problems for which a community … has not as yet developed rules, principles or virtues.”¹⁵ I believe, to the contrary, that the shortcomings of the Integration thesis are perhaps most obvious when the subject matter is in the making as in the ethical analysis of genetic databases. Let us take the example of the issue of consent for participation in such databases as resources for research. Although the search for guidelines has been a strong motivating factor for ethical research of databases, it requires primarily a careful analysis of the key concepts of the practice under scrutiny. This implies that the notion of consent be thoroughly analyzed as a moral concept and its function and limits in the ethics of research elaborated. It is important to ask what kind of consent is suitable in the new environment of human genetic databases, where it is difficult to see future use of data and samples at the time of collection.

If we consider briefly the case of the Icelandic Health Sector Database, the law simply states: “A patient may request at any time that information on him/her not be entered onto the health-sector database.”¹⁶

This has been referred to as an opt-out clause and is often regarded as presumed consent. The staunchest critics of the database project have argued that this is a violation of research ethics and insist on obtaining informed consent. Others argue that although the opt-out clause is not sufficient to protect the interests of participants, the traditional requirement of informed consent is not suitable for this case and alternative conceptions of explicit consent have been proposed.¹⁷ Moreover, there are differences over the question of whether the strong support of the Icelandic people for the database project counts as informed communal consent or not,¹⁸ and also how much weight popular support for a project should have in arguments concerning individual consent for participation in research.

It further complicates the question of consent that is obtained for the processing of medical information into the database that the license to run the Icelandic database was granted to a private company. This means that data that have been collected in the context of communal healthcare are moved into a commercialized private sphere—that is, handed over to a third party that is not involved in the patients' care. This transfer of data out of the ethos of mutual advantage and trust implied in communal medicine makes the question of consent even more pressing and complicated.

As can be seen from this example, various aims are implied in a bioethical examination of a fundamental concept in database research.¹⁹

The Integration thesis would presumably emphasize ways to elicit the moral knowledge embedded in scientific practice and in the ordinary moral consciousness. To do that, people can be asked in empirical surveys about their views toward consent procedures for participation in human genetic databases and in database research. Laws and regulations about consent can be mapped and different legal approaches compared and interpreted. Lessons can be drawn from traditional research ethics as it has been applied to the storage and use of data for research. These and other empirical analyses would certainly be important ingredients for moral reflection.

In the case of population genetic databases,²⁰

however, the empirical “building blocks” are not well substantiated, partly due to a lack of experience in the field and partly due to the complexities of the subject matter. There is no experience of databases of this type; we are entering a new era of multifaceted commercialized databases that have been enabled by an enormous growth in genetics in combination with advanced computer technology. As a consequence, the “traditional research ethos” is in a state of upheaval and we are facing new challenges. Also, some empirical evidence is unusually problematic because the views people express are rarely based on good information about these complex issues and they are also largely influenced by “genetic ideology,” which requires careful scrutiny. Analysis of mundane moral reasoning and ordinary moral consciousness will never reach the depth necessary for unveiling the powers at work in this context.

Complementarity

I have argued that the Integration thesis does not provide good enough food for sensible interdisciplinary thought and bioethical discussion. Another view that has emerged in the debate about the role of moral philosophy in interdisciplinary research, the Complementarity thesis, seems to be more promising. According to this thesis, the role of legal theory, moral philosophy, and sociology could all “be said to involve conceptual analysis and critique of arguments.”²¹

The notion of complementarity implies that the disciplines in fruitful interdisciplinary research are “working alongside each other, sometimes asking different questions and always looking at the same topic in a distinctive way from within their own discipline.”²² I take this to mean that the disciplines should make use of any theories or principles that are useful for the task at hand and may further understanding, interpretation, and explanation of it.

The primary roles of moral philosophy are, if I take this view further, a critical and clarifying analysis of concepts, arguments, and subject matters, as well as an examination of existing or proposed norms and guidelines. The implications of philosophical arguments, which often stem from sheer conceptual dissatisfaction, are particularly important in this context. It has been argued, for instance, that “the standard account of genetic discrimination” is inadequate and must be rejected.²³

It is important to bear in mind that the standard view informs both empirical data and existing normative frameworks. And if there is a sensible reception of thinking in the “real world,” this philosophical argument could change both. Neither practical experience nor application of principles could have brought forth this type of argument. Only good thinking.

According to the Complementarity thesis, sociological, legal, and philosophical reasoning complement each other in their joint, yet different critical thinking about the subject matter. This may be rather vague, but I regard that as a good thing because it neither prescribes what are the appropriate normative tools of moral reflection nor does it attempt to restrict its normative power. As a consequence, it delineates a way to avoid both the alienating (and often rootless) distance of a principled application and the overly involved (and sometimes spiritless) analysis of what goes on in practice. The main point is that each discipline and each participant does what he or she does best, exercise the inherent critical thinking of scientific endeavour to the utmost in a free pursuit of what they see as most important for understanding the subject matter. This is an exercise in academic freedom or freedom of research that is ruled only by the power of the best arguments and the requirements of the subject matter.

In conclusion, it seems to me that the Complementarity thesis points to an appropriate description of interdisciplinary discourse and sensible ethical discussion. The response to the Greyhound syndrome, therefore, is not less thinking, but pervasive critical thinking among all partners in interdisciplinary research.