Bioethics Consultation and First-Order Moral Reasoning: Leaving Philosophy at the Hospital Doors.

Barby-Blumenthal et al. (2022) argue that academic philosophy still has important contributions to make to bioethics. We agree with some and disagree with many of their claims. In this commentary, however, we address philosophy’s relationship with a specific branch of bioethics, namely clinical bioethics consultation (CBC), which the authors say little about. We agree with the authors that bioethics (including in the context of CBC) cannot rest on the rote application of pre-established theoretical work in ethics. Indeed, against the consensus among scholars at the recent conference the authors describe, we think this is as true of CBC as it is of the more abstruse issues the authors mention, such as the nature of consciousness, agency, and personal identity. In our view, CBC consisting of the mere application of prefab frameworks, such as the sacred “four principles” (Beauchamp and Childress 2019), is bad CBC. However, we also believe–in contrast to the authors’ claim that “people should view philosophers as a potential source of moral guidance on what the right (or wrong) thing to do is in a particular situation” (Blumenthal-Barby et al. 2022, 19)—that advanced training in philosophy has little relevance to CBC. This is because philosophical (and even moral-philosophical) expertise does not contribute to the knowledge and skills necessary to support clinicians in first-order moral reasoning. In our view, and consistent with established views in the field (e.g., ASBH 2011), the central aim of CBC is to support persons in the clinical environment as they engage in challenging instances of first-order moral reasoning. By "first-order moral reasoning" we mean the kind of moral reasoning that all persons unavoidably engage in throughout their daily lives as socially, professionally, legally, and politically situated moral agents. The term "first-order" distinguishes this form of moral reasoning from those that are, or contain elements of, reasoning about moral reasoning (i.e., secondor higher-order moral reasoning). Moral agents are faced with first-order questions like: should I euthanize my beloved companion animal now that she is gravely unwell? Should I speed in my car to get my child to the airport on time, so that he can visit his dying grandmother? Should I buy this t-shirt, given what I know about how this company produces its clothing? Should I tell Marcia that Tim has joined a known cult, despite the fact that doing so would violate Tim’s trust? First-order moral reasoning in the clinical setting is contextually different than that which occurs in other social and professional contexts, but it is first-order moral reasoning nonetheless. Moral questions in the clinical setting have no special philosophical salience or significance. They are rarely “general,” in the philosophical sense of that word; they do not concern the moral permissibility of broad categories of actions and they do not turn on metanormative or theoretical considerations about what makes actions right or wrong. Rather, they concern what ought to be done with respect to particular patients in particular contexts: should we discharge Mr. Holmes, despite his profound cognitive deficits and lack of suitable housing? Should I continue to offer dialysis to Ms. Ahmed, given her worsening condition and some of her utterances before she deteriorated? Who should make the decision for Ms. Bell about whether she will be admitted to a nursing home against her will? CBC is constituted by direct, case-level engagement by professional bioethicists with clinicians (and patients, families, surrogates, and so on) on questions such as these. CBC requires ethicists sometimes to guide or support the first-order moral reasoning of clinicians,