Albert R. Jonsen
One of the defining features of modern medical ethics is the presence of persons trained in the disciplines of moral philosophy and moral theology as participants in the conversation with health professionals, scientists, and legal scholars about moral questions in medicine and science. The philosophers and theologians naturally desired to bring to that conversation methods of analysis that are identified with their disciplines. When they entered the conversation, they quickly learned that in medical care the moral questions are stimulated by cases, particular instances in which actual persons are being treated in specific ways in definite circumstances. Scholars might have recalled the words of Aristotle, “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 1976, II, ii, 1104; IV, vii, 1141).
This intense concentration on the particulars of medical cases presented a problem for those trained in moral philosophy who worked on these issues in the early part of modern medical ethics. That discipline had, for many years, cultivated an approach to ethics that turned away from cases and toward theory. One of the seminal books of modern moral philosophy, G. E. Moore's Principia Ethica, opened with the assertion that there is “a study different from Ethics and one much less respectable, the study of Casuistry … (although Ethics cannot be complete without it).” He goes on, “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 cases which he treats, those elements upon which their value depends” (Moore 1903, 4-5). Many of Moore's predecessors in Continental and British moral philosophy had, since the late Renaissance and Enlightenment, reflected on the natural, psychological, and logical foundations of moral reasoning and constructed theories to ground the rationality (or in some instances the irrationality) of morality. After Moore, most moral philosophers in the English tradition turned their attention to the meaning of the peculiar vocabulary of moral discourse: What do words such as “right” and “good” mean, since they do not appear to refer to the objects of empirical perception? Casuistry, a “less respectable branch of moral philosophy” in Moore's words, was hardly noticed. Philosophers neither analyzed cases nor did they reflect, in anything but a