A Response to Keith on the

"Consequences of Reason"

D. Micah Hester, Ph.D.

Mercer University School of Medicine

SAAP Conference

March 9, 2002

As just mentioned by Heather Keith, there is a long history of abuse of, lack of concern for, and ethically problematic behavior towards developmentally disabled persons (a.k.a. the mentally retarded).  One of the most notorious incidents of the 20th century (brought to light by, of all people, Geraldo Rivera) was the use of mentally retarded, institutionalized children for research into hepatitis at the Willowbrook State School (NY) during the 1960s.  Poor treatment of these persons and other vulnerable populations (prisoners, the poor, institutionalized psychiatric patients, and so forth) in medical research eventually gave rise, in part, to the academic discipline now known as bioethics (a discipline in which I am currently employed).  Justification for use of these persons usually focused on some form of crass utilitarian calculation that not only divorced ends from means but devalued any sense we currently champion as "respect for persons."

It would seem at a glance that in the last 30-40 years, our moral climate has changed.  For example, medical research is now audited by Institutional Review Boards whose government appointed task is to protect persons from unethical research practices based on both federal guidelines (e.g., need for informed consent by the subject or by a legal proxy) and local community standards where federal guidelines are under determined.  In particular, it is commonly accepted that all research must only use subjects who have consented to be studied.  This requirement of consent, which has evolved from the Nuremberg Code, to the Code of Helsinki, to the Belmont Report, demands voluntary, informed consent free of coercive influences.  Thus, though such demands do not bar research of vulnerable populations entirely, any research proposed on such populations is difficult to justify and must obtain consent from the mentally retarded person herself or from her legal guardian.

Historically, informed consent has arisen from philosophically grounded pleas to respect persons and their autonomy.  Autonomy, in turn, is grounded in a classical Enlightenment concept of the self as a rational agent capable of legislating right and wrong, recognizing the good, and/or performing the duties of a rationally developed ethical life.  What Heather Keith’s paper has succeeded in doing is theoretically undermining Rationality as a basis for such an approach to ethics.  Her paper points out that the most an ethic like this can do for mentally retarded persons is protect them from overt harm—no small thing, but not enough.  Traditional Western moral philosophy, while quite successful in its negative strengths of delimiting why roughshod approaches to research must cease, in the end is incapable of any positive work that brings the mentally retarded into the community as participants in moral deliberation and consideration.  But while we might want to call this entire philosophical approach "liberating for some and dehumanizing to others," it is important to note that the liberating quality—that aspect of the philosophical approach that does liberate and protect—is not itself (as Heather implies).  As Dewey was excellent at pointing out, classical liberalism’s strengths should not be underestimated nor devalued, it simply didn’t have an account of the self that made it possible to go beyond the limits of an ethic of protection and consent—that is, an ethic of passive individuality.

Rather than praise our forefathers and –mothers in pragmatism for giving us a socially situated account of the self, a functional psychology that dovetails with an instrumentalist ethics which takes the continuum of means and ends seriously, that recognizes the complexity of experience and demands that we take seriously all factors and interests of a given situation (for Heather has done this admirably), I want to turn to two related problems that are unresolved at the end of Heather’s paper—the first being a particular instance of the second.

First, as an alternative to the Enlightenment scheme, Heather puts forth what she calls a pragmatist ethic that arises from such thinkers as Mead, Dewey, Addams and fits this with feminist approaches such as that of Nel Noddings’s "ethics of care."  While both pragmatists and feminists recognize the "sociality" of selves, the traditional scheme locates ethics in rationality and atomic individuality.  Caring for another in all her specific, culturally influenced, unique character—demanding, in turn, a moral sensitivity and affection—replaces universalizability of moral principles and decisions—divorced as they are from specific lived experience.  However, one problem that lingers at the end of this paper is whether Heather brought this home for us in a detailed enough way to show us exactly what her approach might mean for the mentally retarded.  Left primarily to the last two paragraphs of the paper, Heather’s comments on how pragmatism might help eliminate the problems left unresolved by traditional ethics seem to me too few to give us a clear method for ethical deliberation with mentally retarded persons.  For example, if Heather’s paradigm of what might be accomplished through this change of philosophy and perspective is the "People First" movement, then it is unclear what a pragmatic ethics gains us here.  Specifically, Heather says that the idea is to "work[s] toward goals such as equality, having a chance to speak up,… and to make decisions for themselves."  I truly believe this is all to the good, but the problem I see is that none of this necessitates a move away from a rationality-based ethic.  In fact, what such goals require is not that we must unavoidably rethink the ethical framework of the West but that we simply need to accept that the mentally retarded should be treated with the same respect for persons and autonomy as anyone else.  No one, at least in the contemporary debate, argues against the idea that to the degree that a fully capable adult can make decisions for herself, she should.  Nor does even an "extremist" like Peter Singer disagree with the position that if certain conditions (physical, mental, situational) affect decision-making, we must tread carefully, accepting as much decision-making (Singer says "interests") as there is.  For that matter, most would agree that we need to find alternative means when barriers to decision-making come our way.  In other words, though I agree with Heather’s philosophical approach, she has yet to show me how a pragmatic ethic of care does any real work in this case, for if our goal is to make sure that we recognize when a mentally retarded person can "make decisions for [herself]," the only means necessary to that end, it would seem, is a more detailed analysis of each individual person’s decision-making capacity when confronted with particular problems and questions.  If I am right about this, then it is not clear that rationality-based schemes are incapable of making such accommodations—even if most have not to this point.

But this specific problem, it seems to me, forces us to consider a more general one—viz., what good is this pragmatic account of ethics?  Now confessedly, Heather’s account is almost exactly my own account, an account I have given in lectures, essays, journal articles, and books for the past 5 years, and yet, it is not yet even clear to me what this pragmatic alternative to ethical theory actually does for us in practice.  The more I work in the clinic, the more I wonder what work my pragmatist training is doing that my colleagues trained in Kant aren’t able to do?  On a daily basis, in the face of a patient and/or health care professional, doesn’t an appeal to autonomy (taken as inclusively and pluralistically as you please) do all the work we need most of the time?  Doesn’t an appeal to rights and obligations in the legalistic and rationalist sense often just prove necessary and extremely useful?  Aren’t we concerned with this person, her problems, what she wants, what is best, and what is possible?  If so, how does pragmatism, in practice, help us answer these questions any better or worse than deontology or utilitarianism?  Maybe one answer is that in fact the practicing deontologist and utilitarian are really only doing pragmatism because there own rationalist schemes breakdown, and they (even if unwittingly and unrecognizably) end up doing what pragmatism has been talking about all along.  Furthermore, as Heather implies, it could be that this philosophical shift from autonomy & rationality to care & instrumentality does through the habits it engenders makes the pragmatist more sensitive, more open to differences of culture and experience.

Either way, I am pretty sure that all of this uncertainty is more my own failing than that of pragmatism itself, but increasingly I wonder.  What I am most sure of, however, is that Heather has the answers necessary to make my concerns fall away, so I turn it over to her and to your questions in order to squelch my fears and alleviate my stress.