Society's Choices Social and Ethical Decision Making in Biomedicine (1995) / Chapter Skim
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The Value of Consensus
The Value of Consensus
Pages 241-260
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From page 241... ...
Or is preoccupation with consensus likely to obscure important differences, leading in many cases to recommendations so general or abstract as to be practically useless? These and related questions have assumed greater importance as governments and health care institutions turn to ad hoc or standing committees or commissions for guidance on perplexing bioethical issues.
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From page 242... ...
Issues likely to elicit complete consensus at the beginning of a group's deliberations are, as a result, not often addressed to ethics committees. Second, committee members usually represent differing social or ethical viewpoints or differing areas of biomedical, social scientific, or other types of expertise, or both.
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From page 243... ...
323.2 Consensus in societies acknowledging a plurality of conflicting comprehensive moral outlooks will often be overlapping. The wish for complete consensus on all moral issues is, as I will show below, utopian.
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From page 244... ...
. Among the issues addressed by this group of British physicians, lawyers, theologians, social scientists, and ordinary citizens, chaired by philosopher Mary Warnock, was the question of the permissibility of research using human embryos.
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From page 245... ...
Individual committee members may subsequently try to persuade those with whom they disagree of the superiority of their initial position with an aim to its eventually being reconsidered and endorsed by the group as a whole. Majonty Rule Occasionally a committee will be unable to reach complete or overlapping consensus on a particular issue or to devise a satisfactory compromise.
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From page 246... ...
Where a resort to vote-taking is a product of procedural consensus and represents procedural compromise, however, the outcome is endorsed by and attributable to the group as a whole. Following customary usage, I have to this point restricted the term "consensus" to pre- and postdeliberative complete consensus and overlapping consensus.
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From page 247... ...
By explicitly rejecting the concept of a right to health care, thus breaking with recent public discourse on this matter, the commission deprived those poorly served by the current health care system of a language with which to express their discontent. In so doing, the commission implicitly adopted a perspective that views social change as the consequence of the recognition of moral obligations by the socially powerful, rather than as a result of demands pressed from below as a matter of right (Bayer, 1984, p.
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From page 248... ...
In a revealing account of the complex workings of a hospital ethics committee, Ruth Macklin charts one group's struggle to reach consensus on a difficult philosophical question. Charged with developing policy for blood transfusions involving iehovah's Witnesses, the committee was unable to agree on guidelines for transfusing pregnant Witnesses.
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From page 249... ...
Our positions on particular issues are usually grounded in our comprehensive moral, religious, and philosophical outlooks and there is no single comprehensive outlook that should be embraced by all insofar as they are informed and rational. The comprehensive, identity-conferring outlooks that we bring to ethical reflection include a variety of conflicting, often equally reasonable, world views and ways of life.
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From page 250... ...
Though unable fully to determine our world views and ways of life, these well-grounded principles serve as important constraints on them.5 Each centers on a morally significant feature of human beings that cuts across social, cultural, national, religious, racial, and sexual differences: sentience (for the principle of utility) and the capacity for rational self-direction (for the Categorical Imperative)
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From page 251... ...
The problem is that there are a number of reasonable world views and ways of life that occasionally engender differing answers to moral questions, especially questions of biomedical ethics. This diversity of reasonable comprehensive moral outlooks, as Rawls points out, "is not a mere historical condition that may soon pass away; it is a permanent feature of the public culture of democracy" (Rawls, 1993, p.
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From page 252... ...
In some cases, advances in medical knowledge and technology create choices and possibilities so complex or radically new or unprecedented that neither particular world views and ways of life nor abstract general principles provide much in the way of firm or direct guidance. The questions, we know, are important, but we are not quite sure what to think or do about them.
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From page 253... ...
This agreement may take the form of complete consensus, overlapping consensus, compromise, or even consensus to endorse the outcome of a vote between two or more reasonable positions, each of which is regarded by everyone as superior to the group's coming to no agreement on the matter. A consensus meeting these conditions carries moral weight or adds normative significance to the group's recommendation because it respects both the depth of genuine uncertainty or the extent of reasonable disagreement on the matter and the need for informed, uncoerced agreement.
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From page 254... ...
An Illustration Consider, as an illustration, a statement of general principles for allocating transplantable organs and tissues developed by the 1991 Ethics Committee of the United Network on Organ Sharing (UNOS) (Ethics Committee, 1992~.6 The Ethics Committee identified three principles governing most allocation decisions: (1)
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From page 255... ...
Though the committee's compromise might be rejected as the best moral position by a number of individuals as individuals, it cannot, the Committee suggests, be reasonably rejected as a basis for public policy by individuals as citizens for whom informed, unforced reasonable agreement on such principles is of great importance.7 While a person may reasonably reject a policy that ignores or violates his or her personal moral position, he or she cannot reasonably reject a coherent policy that (1) acknowledges reasonable disagreement on the matter; (2)
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From page 256... ...
Yet it is one thing to urge that such groups be broadly constitutedhaving access to all relevant aspects of biomedical, social scientific, cultural/religious, legal, and bioethical expertise as well as knowledge of all reasonable ethical positions on matters that come before it and quite another to actually constitute such a committee while retaining workable size. There is no mechanism or formula for putting together an effective, broadly constituted bioethics committee or commission.
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From page 257... ...
The problem is aggravated by the fact that the complexity of modern medicine requires close cooperation among members of a health care team, patients, and patients' families who may, as individuals, have differing, but not unreasonable, positions on bioethical issues. The question, then, is whether it is possible to obtain unforced, informed agreement on ethical issues requiringjoint conduct among individuals who are either genuinely uncertain or committed to conflicting positions.
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From page 258... ...
Agreement may take the form of complete consensus, overlapping consensus, compromise, or endorsing the results of a vote. The ultimate test of such a recommendation is whether it is specific enough to be of practical value and, at the same time, unable to be reasonably rejected by the larger population as the basis for informed, uncoerced agreement (Benjamin, 1989,Scanlon, 1982~.
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From page 259... ...
Callahan, D.: 1992, "Ethics Committees and Social Issues: Potentials and Pitfalls," Cambridge Quarterly of Health Care Ethics 1, 5-10. Ethics Committee of the United Network on Organ Sharing: 1992, "General Principles for Allocating Human Organs and Tissues," Transplantation Proceedings 24: 2226-2235.
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From page 260... ...
Warnock, M.: 1985a, A Question of Life: The Warnock Report on Fertilisation and Embryology, Basil Blackwell, Oxford. Warnock, M.: 1985b, "Moral Thinking and Government Policy: The Warnock Committee on Human Embryology," Milbank Memorial Fund Quarterly 63: 50~22.
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