Designing Practices, Institutions, and Processes

Ethics is embedded in the practices and institutions of society. Three examples illustrate the communal importance of ethical design. First is the distinction between Fights, Games, and Debates as successively more ethical and more intelligent institutional designs for handling conflict. The second is the Prisoner’s Dilemma in game theory, whose best solution is to step outside the game and change the surrounding institutional design. The third is an account of the ethical and effective institutional design solutions for various situations, especially of mediation for those that invoke the notion of ‘polycentric’ problems.

The Problems Resolved in a New Account of Reason

Deliberative judgment formation is a core human skill largely irreplaceable by rational formalisms. Judgment is rationally learnable and improvable like other skills, and well-designed deliberation is the foundation of non-formal rationality. It includes self-improvement by learning about our own norms and deliberative processes, exemplified in increasingly powerful scientific method, in the spread of institutional ethical resolution processes, and so on. There are four principal resources or means for the improvement of skilled judgment: observation, the use of both formal and non-formal reasoning procedures, constrained but creative construction, and systematic critical appraisal. These four bundles of processes are utilized by both individuals and, typically more powerfully, by communal groupings such as research teams. The bulk of the chapter is devoted to expositions of the four resources of non-formal reason and their strategic deployment in problem solving.

Designing Policies

Designing ethical policies is illustrated with two real examples. The first, allocating cadaver kidneys for transplantation, needs to develop a policy that satisfies the two conflicting fundamental values of equality and efficiency. Equality would require a lottery or a first-come, first-served policy. Efficiency would allocate kidneys to the candidates who would benefit the most. Because neither value may be dismissed, the values must be compromised. That compromise happens in two ways: by compromising the values of equality and efficiency within a policy at a time, and by cycling across policies over time, shifting the preference given to the two values back-and-forth. The second example is an illuminating account of how the National Institute for Health and Clinical Excellence in England and Wales designed a deliberative process for assessing the cost effectiveness of health care technologies.

Introduction

An example of real decision making is presented to illustrate two different accounts of rationality. Women who are at risk of having a child with a genetic condition must decide, after receiving genetic counselling, whether they will try to get pregnant. The genetic counsellors believe the women should use the principle of maximizing expected utility – multiply the probabilities of the outcomes (provided by geneticists) with the values of those outcomes (provided by each woman) and choose the option with the greatest expected utility. This principle manifests the formal rationality of moral philosophy. The women discarded it, however, because they knew that, regardless of the probability, they could have an affected child. Instead, they imagined scenarios of what it could be like living with an affected child to assess whether they could be able to live with their worst scenarios. The process of deliberation these women used to make their decisions is eminently rational, an exemplar of non-formal rationality. This book is about the rationality of deliberation and the judgments that result. The lesson is that we can only appreciate intelligent problem solving in ethics if we embrace a richer, more expansive conception of rational decision making.

Ethics as Design and Its Two Distinctive Methods

The new conception of rationality as non-formal reason is completed by an explanation of how design in engineering can be brought to the design of practical problems in ethics, from which the notion of ethics as design for flourishing is developed. The conventional notions of balancing and specification in applied ethics are rejected and replaced by two methods that use non-formal reason: fully engaged moral compromise and wide reflective equilibrium. A case depicts a disagreement between a nurse and a doctor in an intensive care unit that is resolved by a compromise that emanates from a process of deliberation among the staff. Reflective equilibrium was widely adopted into moral philosophy, and it quickly expanded into wide reflective equilibrium. Here it is further enhanced by adding the three features of liberation, extension, and enrichment. The upshot of these developments is a completed initial account of non-formal rationality with four resources, two specific methods, and a shift from principles to values.

The Process of Ethical Resolution: Using the Resources of Nonformal Reason

Real examples illustrate how the resources of non-formal reason are used practically. The first example is taken from an ethnographic study of children with leukemia. These children desperately wanted to know what was wrong with them, but their parents and the health care staff remained silent. The children used the four resources of non-formal reason to discover that they were dying. The other examples come from four cases that were presented in Chapter 2. The resources of non-formal reason were also used by Ms. B, Ms. F, K’Aila’s parents, and Mrs. Smith to illuminate their plights.

The Problems Generalized, Diagnosed, and Reframed in a New Account of Reason

The problematic features of moral issues revealed in Chapters 1 and 2 have exact counterparts in scientific research, where their appearance makes it clear that the problem is located in the common conception of formal reason, especially because logic currently underlies both ethics and science. To prepare for re-examining appropriate rational procedure, the received Western tradition of characterizing rationality formally is surveyed, and its limits are revealed. The natural framework for addressing these matters is a philosophical naturalism that recognizes that humans are fundamentally finite and fallible but have a powerful ability to learn and self-improve. This start re-focuses rationality on intelligent problem solving.

The Difficulties of Applied Ethics

A second kind of formal rationality, complementary to the maximizing expected utility in Chapter 1, is logical inference. In much of moral philosophy and in standard bioethics decision making is applied ethics. Moral theories are taken to be comprised of principles that are applied to the facts of cases to deduce conclusions about what ought to be done. The canonical depiction of bioethics, for instance, consists of the four principles of non-maleficence, beneficence, autonomy, and justice. The real examples in this chapter expose the many failings of that applied ethics. Most of the cases are about when to die and how to die, but the term ‘euthanasia’ is indeterminate. The crucial notion of ‘autonomy’ also is indeterminate. Both need to be clarified and specified. But how is this to be done? Similarly, when principles and rules conflict, as they often do, how is the one that prevails to be determined? There are no higher principles or rules that can be applied to get the right answer in any of these cases. More broadly, what makes a problem a moral problem, and what does being a moral problem mean? These issues require non-formal rational deliberation, not the formal rationality of deduction.

Designing Deliberation

Deliberation occurs when deliberate judgment has to be made. The best way to understand deliberation is by examining the operation of non-formal reason in examples of deliberation. Deliberation has been portrayed as an imaginative dramatic rehearsal. That is what the women in Chapter 1 did when deciding whether they would try to get pregnant. They imagined how their lives might be if they had a child with a genetic condition, and they examined their reactions. Telling, varying, and assessing narratives are other ways of deliberating. Deliberation often is shared, as in storytelling among occupational therapists and in conversing with a doctor or a clinical ethicist. Deliberation can also be institutionalized. A disagreement between doctors and nurses in an intensive care nursery emanates from their different professional training and their jobs. When participation is properly designed, deliberation can substantially reduce alienation by helping to reunite reason and motivation.