METHODS in MEDICAL ETHICS

Chapter 7

CASUISTRY AND CLINICAL ETHICS

Albert R. Jonsen

November 28, 2016

Presentation by Ellen Sunshine
 Albert R. Jonsen
Currently:
• Emeritus Professor of Ethics in Medicine, University of Washington School of
Medicine
• Co-Director, Program in Medicine and Human Values, California Pacific Medical
Center in San Francisco

Formerly:
• Chairman, Department of Medical History and Ethics, University of Washington
• Chief of the Division of Medical Ethics, School of Medicine, University of California
San Francisco
• President, University of San Francisco
• Contributed to the Belmont Report as member of the National Commission for the
Protection of Human Subjects of Biomedical and Behavioral Research
• Co-wrote The Abuse of Casuistry with Stephen Toulmin

And there’s always more to the story…

 INTRODUCTION
Definitions
• Clinical Ethics
The part of bioethics providing
a structured approach to the
identification, analysis, and
resolution of ethical problems
in clinical medicine (which is
“always about cases”)
• Casuistry
The ethical analysis of cases
Main Criticisms
• (1903) G.E. Moore Principia
Ethica: Casuistry doesn’t
base case reasoning on core
principles
• (1656-1657) Blaise Pascal
The Provincial Letters:
Casuistry leads to moral
relativism
 History of Casuist Analysis
• Aristotle, Roman Stoics, Cicero
• Christian Middle Ages
• 16th to 19th centuries – Roman Catholic and Anglican Theology
• 20th century – synonym for “overly clever, self-serving, relativistic
form of moral analysis”
• 1970s and 1980s – re-revaluation upon re-engagement of
bioethics with actual day-to-day medical ethics cases
• 1987 and onwards – attempt to ground casuist methodology to
“solid” moral reasoning

But this is only from philosophy’s perspective, not theology or

medicine.
“Medical ethicists have an intense interest in
theory and principle, but when they get down to
work, particularly as consultants in clinical
medicine, they perforce become casuists” (p.110)

But why?

Clinical medicine is always about cases; health

professionals are taught that each patient is unique
and his/her context deserves attention
The Method: But what is a case?

• A sphere of particular
(1) Discerning Topics
circumstances

(2) Weighing Principles • Cadere – to happen (the

involved instance of something
occurring)
(3) Employing
Analogical Reasoning • Capere – to hold (a way to sort
complex components to see
them distinctly)
 TOPICS
• Standard, common, invariant elements of some
enterprise or activity

1. Medical Indications – Medical facts, physical symptoms

2. Patient Preferences – wishes and choices about illness /
treatment / results

3. Quality of Life – physical, intellectual, affective, social states and

probability of interventions reaching those states

4. Contextual Features – social, organizational, administrative,

financial, legal that enhance or limit efficacy
 ETHICAL PRINCIPLES
• Moral dimensions of a case brought out by
facts and topics AND / OR which have weight
in themselves

1. Identify Principles – existing framework, such as Principlism,

or others

2. Weigh and Balance Principles – e.g. using Beauchamp

and Childress’ “composite theory” rather than single utilitarian principle

3. Form a “Considered Opinion”

A Scale
Circumstances Add
Weight… Patient
Pre
references
…But Principles also
have weight by Quality of Life
Qualittyy of Life
themselves
• Society cultivates ideas and Medical
values in intellectual, social,
Indications Medical
religious life Indications
• Critical reflection of scholars

Example: How to evaluate

research on children, the Beneficence Autonomy
“weight” of nonmaleficence vs.
“weight” of circumstances
 ANALOGICAL REASONING
• Finding firm ground for the moral authority of a proposed resolution of
the case (i.e. testing your conclusion)

1. Search for similar cases

2. Compare “contested case” (less clear how principle can be applied

within circumstances) with “uncontested case” (clear instances of
morally right/wrong action, where principles and circumstances are well-
aligned)

3. Reflect on similarities and differences between cases

The Casuist as art critic…is this painting from my attic worth anything? Is it a Van Gogh?
 THE CASE – Applying Casuistry
A man is brought into the Emergency Department bleeding severely. Doctors and
nurses recognize the need for a transfusion. The man is a Jehovah’s Witness and
refuses a transfusion. Is only using patient autonomy as basis for ethical decision
enough justification (for patient, patient’s family, fellow believers, health providers,
administrators, legal counsel, etc.)?

Medical facts, applicable policies /Collect Details & Discern Topics

laws, information
Questions and details arising from collection of facts
on family, the JW faith

Identify Principles & Weigh

Identify
Moral questions arising from situation Principles & Weigh
and other
Weigh based on patient views, other factors
principles

Analogical Reasoning
Identify paradigm case Compare & Contrast with our case
TOPICS – designate topics to sort circumstances, details, facts
Medical Indications Patient Preferences Quality of Life Contextual Factors
• Medical condition, causes, • No transfusion because of • Medical life or death • Father of young children
medical history, physical / religious faith • Spiritual life or death • Mission of ED
physiological status at • Hospital policy, state law
admission • Malpractice
• Tenets of religious faith
• Response of local
congregation

• How urgent is need for • How committed is patient to • Will patient view life after • Does law allow person to
transfusion? faith? transfusion with shame and refuse transfusion even at
• Did patient express regret for sinning, losing risk to life?
preference or the person respect as role model, • Will congregation ostracize
who brought him in? having caused others to sin? him or welcome him as
someone who was sinned
against?
ETHICAL PRINCIPLES – weigh principles within sphere of circumstances
Moral Questions: Can we let a person die if he can be saved by appropriate care? Are we responsible for harm if he dies? Can we leave
his children fatherless? Are we bound by a belief we don’t understand?

Weighing and Balancing: Autonomy – refuses transfusion, Beneficence – has to have transfusion to live. Equal, but if we add more
details: Does the patient even view life after transfusion as a benefit?

ANALOGICAL REASONING – compare similar cases

Is there a paradigm case which can reaffirm our conclusion?
 CRITIQUE OF CASUISTRY
• A smart enough person can make sharp distinctions and comparisons to justify something’s ethical nature.
(Blaise Pascal, The Provincial Letters) Response: This is a fault of how it’s done, not what it is. The
“untutored” human moral judgment process mirrors casuistic analysis.

• “a Study different from Ethics and one much less respectable, the study of Casuistry…(although Ethics
cannot be complete without it)…The defects of Casuistry are not defects of principle; no objection can be
taken to its aim and object. It has failed because…the casuist had been unable to distinguish, in the case
which he treats, those elements upon which their value depends”. (G.E. Moore, Principia Ethica) Response:
Jonsen is attempting to remedy this with the clinical ethics method, but also sorting into topics and
expanding on the process by weighing and balancing ethical principles.

• Is it ever possible to have a finite number of topics? They will always change. Response: Nothing is
permanent.

• How do we avoid sorting things into wrong topics, or bias, or account for different interpretations?
Response: Classical casuistry archived volumes of cases to account for discrepancies, and all cases were
open to challenges and criticisms.
 CRITIQUE OF CASUISTRY
• Can’t casuistry exist without ethical theory? If principles are open to revision in light of circumstances, how
will they not lose their power in moral discourse? Response: Failure to appreciate the weight of principles
allows good casuistry to collapse into situationism (the ethical doctrine that circumstances alone
determine the moral quality of decision and action). Casuistry is always tied to theory, in the same way
that ethical principles make use of casuistry (utilitarianism uses casuistry to determine how good is
maximized, Kantianism uses cases to illustrate application of categorical imperative). Casuistry only means
that it is not deduction from theory, but may use other methodology, such as reflective equilibrium.

• Casuists teach that ethical principles and theory emerge from cases. Response: Moral philosophy always
arises from contemplation of moral experience.

• When is a case clear enough to be a paradigm since there is no deductive reasoning? Which casuist’s case
becomes a paradigm? Response: Through examination and argument (such as the Karen Ann Quinlan
case), brings up intuitionism from moral psychology.

• Casuistry can’t respond to contemporary, controversial issues, such as animal research (DeGrazia and
Beauchamp). Response: Casuistry is a method, not the whole of moral philosophy. It can weigh principles
as they appear in a controversial issue, but how principles derive their weight is a question for broader
philosophical thought…
 CONCLUSION
So why do medical ethicists become casuists?

“Agents are compelled at every step to think out for themselves what the circumstances
demand, just as happens in the arts of medicine and navigation…Prudence is not concerned
with universals only; it must also take cognizance of particulars, because it is concerned with
conduct, and conduct has its sphere in particular circumstances” (Aristotle, Nichomachean
Ethics)

In defense of casuistry and clinical ethics:

• Only balancing principles is not a thorough enough justification; circumstances play a
valuable role (even if we reach same conclusion)
• Principles are “influenced” by cultural experiences (such as American individualism affecting
autonomy)
• Skeptics’ motives or perspectives should be considered when weighing their criticisms
• Respecting the “moral dimension of the mundane”, or the importance of the details of daily
life
• Fields of cognitive psychology and neuroscience are contributing to interest in casuistry
 Resources and Training
• Technique (as opposed to field of study)

• Acquired skills: scientific understanding of medical or clinical area;

communication to get idea of full situation and exchange facts / ideas; retain
and process different arguments, comfort in uncertainty; reflect on arguments
from outside world of ethics; understanding of theory, history, culture; read
and contribute to published case studies

• Intrinsic skills: virtuous; able to link cleverness to serious moral intent

• Reading: can choose among actual “high casuistry” texts from 1550-1650,
historical overviews of casuistry, criticisms, texts which illustrate casuistic
methodology, and recent bioethics textbooks / anthologies / journals which
are paying more attention to cases (with new attention to moral psychology)
 REFLECTION
• Casuistry in everyday life – situational
analogies are an ancient method of human
reasoning and are impossible to avoid

– I’m hungry, should I eat that mushroom?

– Used in common law
– Jonsen uses analogy to make argument for
analogy