University of Notre Dame Press:  January 2000.  x + 214 pages.

Physicians in a large medical center in the United States once asked a fully competent immigrant what she preferred to have done about her illness. After thoroughly considering each of her alternatives, she freely made her choice. "O. K., that’s what we’ll do," the doctors agreed, thinking that the matter was settled. "Oh, no!" the patient exclaimed! "You asked me what I prefer, and I told you. But in my culture the men in the family are supposed to make such important decisions. Ask my husband and my sons; please do what they say!"

As this incident suggests, those who populate large medical centers are among the most diverse people on earth. Both the patients who frequent such institutions, and the professionals who serve them, represent every possible religion, race, nationality, culture, philosophy, gender, political preference, sexual orientation and economic class. As Harvey Cox wrote years ago, international airports parade human differences; however, at them we see only those who can afford to fly. Because large medical centers assist both the richest and the poorest, plus those who differ in every other way, they are microcosms of our world’s human diversity.

Deep moral differences surface with poignancy and sometimes pain in large medical centers. This is where conservative and liberal Christians sort out their views about abortion and euthanasia, where secular and Orthodox Jews decide how to define and determine death, where those who love technology and those who loathe it consider innovations such as in vitro fertilization and organ transplantation. It is also where practitioners of premodern, modern and postmodern medicine come to grips with each other as best they can. No wonder some refer to the tall structures of many large medical centers as bioethical "Towers of Babel," places where people with differing moral points of view find it difficult to communicate, particularly when debating controversial therapeutic options!

Bioethicists respond to this situation in two primary ways. Some try to overcome diversity by appealing to an ethical norm to which they believe all persons of sound mind ought to assent. Others, like H. Tristram Engelhardt, Jr. accept diversity as inescapable in public life and leave it to those who seem ethically odd to each other to resolve their differences however they choose, providing each decides with competency, freedom and knowledge. Within their various moral communities, however, people can draw upon a wider and deeper range of ethical guidelines, Engelhardt holds.

This book evaluates the methodological options in contemporary biomedical ethics and proposes an approach that falls between these extremes. It’s author, Kevin Wm. Wildes, S. J., studied with Engelhardt at Rice University and Baylor College of Medicine in Houston, Texas. He is now Associate Dean of Georgetown College at Georgetown University in Washington, D. C., where he also serves at the Kennedy Institute of Ethics.

Wildes contends that Engelhardt’s distinction between "moral strangers" and "moral friends" is helpful but incomplete. We need at least two other classifications, he writes, those of "moral enemies" and "moral acquaintances." "Moral enemies" are those who have so little in common that they greet each other as foes, if at all. "Moral acquaintances" have less in common than do "moral friends," but more than "moral strangers."

Although Wildes mentions the category of "moral enemies," his primary concern in this book is to explain and justify that of "moral acquaintances" on the basis of a communitarian view of the moral life. He presents the seven chapters of his argument in two clusters. Chapters one through four examine and assess the primary forms of bioethical reasoning today. Chapters five through seven outline his contributions. His work as a whole is thus both analytical and constructive.

Wildes begins the analytical portion of his presentation by highlighting the relationships between methodological pluralism in bioethics and ethical diversity in society at large in nations like the United States. He then examines selected representatives of the bioethical methods he calls "foundational." These include the utilitarianism of Peter Singer, the more Kantian approach of Alan Donagan, the natural law theories of John Finnis, Joseph M. Boyle and Germain Grisez, the contractarianism of Norman Daniels and Robert Veatch and the focus upon virtue theory in the writings of Edmund Pellegrino and David Thomasa.

These methods all assert the validity for every rational person of some basic norm by which ethical judgments can be made; however, they advance different accounts of what this norm ought to be and how particular ethical judgments ought to be made with it. 

In Wildes’ view, this rivalry is irresolvable in principle because there is no neutral place from which to choose the proper basic norm. Furthermore, even if granted its basic norm, none of these theories can yield concrete moral judgments without incorporating additional ethical content of some sort from somewhere else. Even if we agree that we should never treat humanity as a mere means, or that we should always do the greatest good for the greatest number, for instance, we must still recruit depictions of "humanity," "mere means," "good" and "greatest number" from places other than these basic norms. Therefore, Wildes writes, despite their many positive contributions, the inadequacies of foundational methods in bioethics are both formal and material.

Although he rarely uses the term, Wildes examines two "nonfoundational" approaches we usually think of as rivals: the principlism of Tom Beauchamp and James Childress and the casuistry of Albert Jonsen and Stephen Toulmin. Despite their differing emphases upon principles, in the first instance, and upon cases, in the second, these approaches are similar in that they propose an interactive, or dialectical, process through which we seek a reflective equilibrium on a case-by-case basis between an irreducible plurality of normative resources.

For Beauchamp and Childress, these primary normative resources are the equally binding principles of respect for autonomy, beneficence, nonmalificence and justice. For Jonsen and Toulmin, they are important cases that establish precedents in moral reasoning somewhat like previous court decisions do in case law. 

Wildes finds that principlism is unable to establish without arbitrariness the meaning, relationships and selection of its primary norms and that the common morality from which it draws these principles is complex, if not elusive or even illusory. For Jonsen and Toulmin, the casuistic reasoning of the High Middle ages provides a method that we can use in bioethics today. Yet that method was too embedded in the intellectual and cultural particularities of its time and place to be transferred with success to our very different context, Wildes writes.

Having argued that many foundational and nonfoundational methods in bioethics claim too much, one might expect that Wildes would then contend that Engelhardt’s emphasis upon the procedures of permission in public bioethics, and upon the richer normative resources available in only in specific moral communities, claims too little. He doesn’t. Instead Wildes weaves throughout his whole book his conviction that Engelhardt’s proceduralism exaggerates the degree to which various persons and groups within societies like the United States are ethically foreign too each other.

 Perhaps because some time ago Engelhardt  published The Foundations of Bioethics, a secular analysis and proposal, and only much more recently sent forth The Foundations for Christian Bioethics, a theologically informed one, Wildes does not probe the theoretical and practical relationships between Engelhardt’s two very different approaches.

Wildes’ constructive position begins by arguing that Engelhardt’s secular discussion accurately identifies the procedures of permission as the bioethical norm we should use where people differ deeply.  These articulate the overriding importance of competent, informed and voluntary consent in bioethical decision-making.  At this initial point, then, Wildes endorses and advances his mentor’s project. 

He goes on to argue, however, that even Engelhardt’s procedures of permission, lean and spare though they are, do not come to us culturally disembodied. Instead, like all other ethical norms, they are riveted to shared forms of communal life, as Ludwig Wittgenstein taught us to expect. In this case the pertinent shared form of life is the culture of nations like the United States.

Wildes also contends that this shared form of life possess a number of moral commitments that are richer than the procedures of permission. In an expression that might cause some to wince as though hearing an oxymoron, Wildes goes so far as to write of "the common morality of proceduralism."

Engelhardt proposes proceduralism precisely because he doubts the actuality in societies like the United States of a common morality! Wildes nevertheless identifies as evidence of a common morality a number of practices, plus their corresponding moral commitments, to which Engelhardt's procedures of permission are linked, in his view.

The custom of obtaining consent is among these practices, as are respect for the rule of law, limits upon the moral authority of government, and toleration as distinguished from acceptance. These are linked with broader cultural commitments to values and virtues such as freedom, honesty, trust, respect for persons, impartiality and fairness, cooperation, moral integrity, moral humility and peaceful methods of resolving conflicts. Because these flourish or languish in institutions and organizations as well as in individuals and smaller groups, bioethics should pay attention to social as well as personal and professional ethics, Wildes writes.

In what he calls "the geography of moral judgment," Wildes identifies several spots at which we can locate bioethical agreements and disagreements, as do earlier specifications of the so-called "levels" of ethical discourse. In his map, "object-level" judgments pertain to what should be done in particular times and places. "Justificatory judgments" identify the reasons, feelings, senses or values and so forth to which we appeal when making judgments about concrete thoughts, words and deeds. "Foundations judgments" pinpoint the even more general or basic warrants for the choices we make at the justificatory and object-level locations. 

Combining these options in various ways, Wildes identifies eight places at which bioethical decisions can converge or diverge, thereby alerting us to the likelihood that consensus at one place neither prescribes nor precludes agreement at the others. Keeping these locations in mind can help us avoid exaggerating the amount of agreement or disagreement in bioethics today, he argues.

Wildes does not take a further step the possibility of which intrigues me. As indicated, he argues that Engelhardt’s procedures of permission are ethically justified for secular bioethical decision-making in nations like the United States today. As also reported, he goes on to identify both the practices and the broader moral commitments to which these procedures are related in such societies. Having taken these two steps, Wildes might have used these richer resources to generate additional bioethical norms that would then supplement Engelhardt’s procedures of permission with which he began. 

Because he does not take this further step in this book, I hope that either Wildes or someone else eventually will give it a try. As I now envision it, this additional argument would be that, when we take into consideration the form of shared communal life to which they are related, Engelhardt’s procedures of permission lead us to other bioethical guidelines that are also binding in the same societies. That would be another volume!

Does this book succeed? If we keep in mind its focused agenda, I believe the answer to this question is "yes." In harmony with its communitarian loyalties, this volume does not thoroughly address what Wildes calls the "formal" question: Why should we accept as binding Engelhardt’s procedures of permission, along with the practices and broader moral commitments to which they are joined in societies like the United States? Yet we can say this about many communitarian theories of the moral life, not just this one.

Given the ethical resources of a particular community, some things can be established as right and others as wrong; however, whether we should reason from within that community is a question that is left largely unanswered, both in this book and in communitarian ethical theories more generally. 

As I understand it, however, Wildes’ purpose in this volume is not so much to debate this formal question as it is to address what he calls the material one. His aim is to demonstrate that Engelhardt’s procedures of permission provide more room for a common morality within societies like the United States than many think. He succeeds.

I believe that we all would do well to address the formal question more fully, however. Wildes rightly declares that there is no neutral spot from which to make choices among fundamentally different forms of shared communal life. He repeatedly claims that the Enlightenment, beginning in eighteenth century Europe,  failed in so far as it attempted to discover such a culturally unaffected location. 

True enough; nevertheless, there are vital differences in ethical reasoning between "neutral ground" and "common ground." Even though the first does not exist, the second may. Wildes establishes that, even within the severe constraints of the more secular of Engelhardt’s two approaches, we can find more ethical common ground within societies like the United States than many presume. It is at least possible that this is so globally as well. I think it likely.

Some of the endnotes in Wildes’ book detail his belief that deep moral differences reflect limitations in human knowledge, not the way things actually are. Yet it also appears that we humans are unlikely to outgrow these limitations entirely in the foreseeable future. Because I take this to be so, I doubt that we can anticipate an absolutely permanent and universally accepted answer to the formal ethical question soon enough to take seriously.

Yet we can make progress in this area of inquiry as in others. In the interest of doing so, I suggest that we consider adding the notion of "moral relatives" to those of "moral strangers," "moral friends," "moral enemies" and "moral acquaintances." Exploring this additional option would move us yet another step beyond the binary thinking that proceeds as though we are all either "moral friends" or "moral strangers," something Wildes’ book already accomplishes with its elaboration of the additional option of "moral acquaintances."

The notion of "moral relatives" also suggests that we may have much in common with those with whom we are not acquainted, whether directly in face-to-face encounters or indirectly through shared cultures. Relatives who meet for the first time are often surprised by how similar they are even though they have had no previous contact. Common virtues and values therefore do not always depend entirely upon direct or indirect acquaintance.

In addition, exploring the notion of "moral relatives" would encourage us to take as much ethical advantage as we now can of something we know to be so: all human beings are very much alike in their basic biological structures and needs, and upon these much else depends. In addition to these empirical similarities, comparable forms of basic moral reasoning are available to all people around the world. That some version of the "Golden Rule" can be found in many cultures is evidence of this.  These norms attest to the logical validity of treating equal persons in equal circumstances equally. 

Thus, whether we are talking about what David Hume called "matters of fact," or what he called "relationships of ideas," we have reason to be cautiously optimistic about finding at least some moral common ground among various societies as well as within them. In this book Wildes does not make this case. I think we should.

Engelhardt, Wildes and others recount the experiences of Captain James Cook throughout the Pacific Ocean in the eighteenth century as evidence of irresolvable cultural and ethical differences. As one who was reared in Hawaii, however, I offer my impression that Captain Cook and the islanders who killed him had more in common than we may suppose, and that an unusual series of miscalculations on his part probably contributed to his premature death at Kealakekua Bay.

Captain James Cook was one of humanity’s most accomplished navigators and most effective leaders and diplomats.  But like him, and perhaps even more like some of the less astute members of his crew, upon encountering another human culture, we often are first struck by how different things are. The longer we stay, however, and the more we come to understand the people and the society we are visiting, the more we realize how similar human beings all over the world actually are.

Stanley Hauerwas and Engelhardt often tell us that Texans are different.  Maybe so!  Yet even the citizens of the Lone Star State are human beings who are biologically related to all the rest of us!!  This is ethically pertinent!!!  

Does exploring the alternative of "moral relatives" open up the possibility of a natural law theory that can be inescapably binding upon all rational human beings and universally recognized as such? Because of the limitations in human understanding that we are not likely to overcome any time soon, I think not. Such theories today must make more humble and tentative claims than did many earlier ones. 

Nevertheless, whether we are acquainted with each other directly, indirectly or not at all, we human beings do have much in common and we have every prudential and ethical reason to make the most of our similarities. It is a sobering fact that the survival of our species may rest upon how successful we are in doing so.

H. Tristram Engelhardt, Jr. and Kevin Wm. Wildes, S. J.:  Thank you!