Is The Permission Possible As A Procedural Principle?

This dissertation aims to study the thoughts of Engelhardt, a renowned American Bioethicist, focusing on the key issue of his secular bioethics, the Principle of Permission. This dissertation will elaborate on the historical and cultural contexts of Engelhardt's Principle of Permission, tension of doctors' authority and patients' independent rights, the meaning, significance, and limitation of this Principle, and the possible application of this Principle in China. Such research is the first of its kind in the systematic research of Principle of Permission. The practical significance of this dissertation is to re-examine the current conditions and problems of informed consent in China in light of Principle of Permission and to give ethical guidance and suggestions to doctor-patient conflicts or disagreements in the pluralistic value context, in order to bring changes to the current situation, where Chinese medical techniques are conformed to the world while our bioethics are comparably weak. In terms of methodology, this dissertation uses literature research method and case-study method.In the1950s and1960s, with the development of advanced medical techniques, American traditional religious beliefs were challenged by secularism, doctors' authority was questioned (After the World War â…¡, inhumane human body experiments by deceiving or inducing experiment subjects were carried out in America.), movements to protect patients' rights were initiated, and plural cultural beliefs birthed in America. All these factors led people to concern and debate regarding bioethics. Facing various disagreements and disputes, many bioethicists have tried to build up a bioethics consensus with specific contents. Contrasted by mainline researches, American bioethics Engelhardt found a different approach. He proposed the Principle of Permission as a procedure bioethics consensus in light of the pluralistic context of many issues in bioethics and gave demonstration of a flexible solution to doctor-patient moral disputes. His research raised heated discussion among international bioethics field.In order to elaborate on the reasonableness of Engelhardt's Principle of Permission, the author starts with studying the historical and theorial contexts of Engelhardt's thoughts, namely post-modernity, moral plurality, limits of rationality, and the influence of classical liberalism. Influenced by these contexts, Engelhardt's bioethics has strong post-modern characteristics. He acknowledges his book Foundations of Bioethics as a post-modern work. With such an approach, Engelhardt sees moral pluralism as unavoidable in America. In his view, since different moral communities have different moral presuppositions and premises, disputes among moral strangers are endless. His concern with these differences is one major founding point for his procedure principle. Different from the practice of moral projects in Enlightenment, which is to solve moral differences by establishing objective and universally effective moral values, Engelhardt sees the moral project in Enlightenment as impossible in a cross-cultural setting since objective and universally moral values only exist in specific moral communities. He believes that "all human morals are concerned with freedom, equality, prosperity, and safety. This might become a fact. Nevertheless, according to how we judge and combine these relationships, an obviously different moral form will be established." As we can see, Engelhardt has been influenced by Maclntyre and post-modernism. Advocating prepositions of post-modern plurality, heterogeneity, and equality, he believes that rationality fails to prove the superiority of a certain moral value. Based on this understanding, Engelhardt claims that the solution of moral differences can only resort to persons participating in the debates. Human beings are the source of moral authority. We can conclude from this that Engelhardt is a bioethicist with classical liberalism complex, although he himself denies such identification. Engelhardt asserts that he has never advocated the absolute value of personal choices. We have to resort to human beings as the source of moral authority due to the fact that we have ceased to receive grace from God and the collapse of moral project in Enlightenment. According to him, freedom is only a priori condition of bioethics. Since objective and universally effective common moral understanding cannot be established, procedure agreement might be the path for solving moral disputes.The elaboration of the context of Engelhardt's thoughts and the analysis of his inclination provided the author a hermeneutical foundation for understanding Engelhardt's thought of game playing between doctors'authority and patients' autonomy. Engelhardt recognizes doctors' paternalism authority in certain circumstances, for instance, towards "incompetent individuals"(which includes two types:one being those who have never had action capacity, such as infants, babies, and people born with severe mental disabilities; the other being those who used to have action capacity but failed to indicate their desired treatment before they lost the capacity, for example, those adults who had not written a will in advance and became a vegetable or fell into a coma), patients who are competent but indicated or hinted their entrusting of decision to the doctors. The question now is this, what shall we do when moral disputes happen between a doctor and a competent patient? He gives four solutions: enforcement, one of the two parties in disputes changes his standpoint, perfect rational demonstration, and agreement (also called permission, do not do unto others what you don't want others do to you). As for the first approach, Engelhardt points out that because many people have noticed that knowledge is conditioned by its history and culture so any description of medical knowledge will be influenced by the history and culture of the communities that different scientists belong to. Therefore, we are not able to give a neutral, pure-descriptive illustration of any disease. Even though doctors could give what he thinks is the best and right medial strategy, the patient might not agree to it. Enforcement is impracticable because it is a typical ethical imperialism and a suppressive way without any reasoning. The second approach to doctor-patient conflicts is a bit complicated since situations in which doctor-patient conflicts are resolved because one of the disputing parties has given up his own stand do exist in reality. However, it is undeniable that it is unrealistic if we hope to solve all ethical disputes in this way, because history and reality have proved over and again that the major cultural traditions have not been integrated as one. Just as what Engelhardt says in the Introduction to his Foundations of Bioethics:in the20th century, some authoritarian political leaders tried to force one country into a single moral community. However, even after cruel suppression, plurality still exists as usual. So transiting from one moral community to another purely based on ones' consciousness is a very occasional phenomenon. The third approach is to solve doctor-patient conflicts through satisfactory rational reasoning. After the Enlightenment Moral Project has lost its validity, its impossibility becomes a self-evident fact. In view of this, only the fourth approach is applicable, that is to say that "agreement (permission)" is the best approach possible for solving moral disagreements.According to Engelhardt, the fulfillment of Principle of Permission is based on three conditions:its participants are self-conscious, rational, moral, and free "human beings;" they should belong to a certain moral community;"freedom and informed consent" are at core in the fulfillment of the Principle. Based on the above analysis, the author goes further to compare the Principle of Permission and Principle of Benevolence, Principle of Permission and Principle of Justice, and to establish the priority of Principle of Permission through demonstration. This in some degree has overcome the limitation of Four Principles of bioethics (beneficial or benevolent, no harming, respecting independence, and just).Engelhardt's Principle of Permission has caused heated debates in bioethics. The author sees the main value and significance of Principle of Permission as followings: first, Engelhardt has exceeded his Orthodox background and many communities and established a neutral moral framework, which is mutual respecting and equal negotiation. He set up the right moral proverb for moral strangers:do not do unto others what you don't want others do to you. This helps peaceful cooperation between universal moral strangers; second, Engelhardt is opposed to using the western moral value as a universal ethical value. He respects the cultural traditions of each country and nation. For him, universal morality is a strong concept in the west and is seen as the only absolute right one by some Europeans due to their influence by the Enlightenment. Opposite from them, Engelhardt believes that moral values of moral strangers could be influenced by dialogue, communication, and persuasion. Everyone should be tolerant of careful and rational decisions made by moral strangers; thirdly, Engelhardt's emphasis on Principle of Permission helps us to see the limitation of democratic systems by majority. Each individual should have the right of decision when it only involves major personal benefits and does not harm others or only cause harm in a trivial way. Of course, Principle of Permission is not perfect and cannot solve all bioethics problems. This does not hurt its values. The author believes that Engelhardt has give us a very satisfactory demonstration regarding moral disputes among moral strangers, which is the setting the limit of doctors' paternalism and authority of national health care policies.What influence could such Principle of Permission with a classical liberalism tendency bring to China? The author believes that this Principle has significance for us whether we see modern Chinese society as a highly authoritarian or a secular society that's walking towards plural values. First of all, with more and more overseas medical exchanges, medical cooperation will unavoidably face the dilemma of moral strangers. Possible moral disputes in such situations could be solved by using Principle of Permission. Secondly, since the reform of the medial system in1985, due to reasons like the scarcity of quality medical resources, rising of medical expenses, and market-oriented medical institutions, doctor-patient conflicts often take place and the doctor-patient relationship has deteriorated. It's pressing to establish harmonious doctor-patient relationship. In this background, if we are careless in bringing advanced medical techniques and clinical application, doctor-patient conflict will be aroused. Therefore, in areas of organ transplantation, assisted reproduction, and human body experiments, we need to respect, inform, communicate and understand well. This way the equal exchange between doctors and patients will be enhanced and trust between doctors and patients re-established.