Review by Denise Cooper-Clarke, February 2022.
Ethical Basics for the Caring Professions: Knowledge and Skills for Thoughtful Practice
by Graeme R. McLean
London and New York: Routledge, 2021
ISBN 9781032009582, 240 pages, 1st edition, paperback
AUD$69.99
Professional ethics may be conceptualised in two quite different ways. It may be understood as an exercise in the application of general ethical theory (ies) to the particular issues which arise in that profession. Alternatively, clinical medicine, nursing, social work, and so on may be understood to generate their own “internal” morality: a complex of professional role-generated norms and commitments, which arise from the nature of that activity with particular and characteristic ends. The latter understanding may be derived from virtue ethics, specifically the work of Alasdair MacIntyre on moral practices. This kind of understanding might provide doctors, for example, with particular reasons for believing that killing their patients is wrong for doctors, apart from any general considerations of the wrongness of killing.
Graeme McLean’s book is based primarily on the first approach. He writes as a philosopher (he is Adjunct Research Fellow in Philosophy at Charles Sturt University, and an ISCAST Fellow), albeit one with experience in teaching healthcare students and who incorporates the insights and perspectives of healthcare professionals. His premise is that philosophy helps us to think critically and that “academic philosophers offer very helpful answers to some of those difficult questions (about how we ought to act)” (p. ix). But right up front he also recognises the objection the reader will undoubtedly raise, namely that philosophers themselves disagree about the answers to some of the most difficult questions in healthcare.
Nevertheless, he is confident that philosophy offers helpful tools for critical reasoning that all can and should employ. This is one of the book’s strengths. McLean discusses the basic tools of logic by which one can determine if an argument is first, valid, and second, sound. He goes on to a technical discussion of types of argument and objections to them. Throughout, he uses examples from the philosophical literature on abortion. I wondered if it would have been better to choose a less controversial and emotive topic if he wanted the reader to engage in cool reasoning. Further, very few healthcare professionals actually perform or are involved in abortions and so a decision about its morality is not relevant to most healthcare professionals qua healthcare professionals.
McLean says that one way to assess a premise of an argument is through considering the consequences if it were true. If the consequences are judged “false” or “unacceptable” then “the view cannot be right” (p. 38). But false or unacceptable to whom? Assessments may vary. But McLean believes in many cases there will be agreement, based on what he has stated explicitly is his own starting point for ethical reflection—that ordinary people possess some “common moral sense.” But how far this will get us in seemingly intractable debates is questionable, as he himself admits in the book’s later chapters, where he says this intractability arises from different fundamental convictions or worldviews.
McLean uses the “four principles” approach of Beauchamp and Childress (principlism) to examine a series of case studies in medicine and social work. This is another very helpful section and could be used as a basis for group discussion. Given a general audience with, presumably, a wide range of worldviews, including religious commitments or lack of them, this approach is reasonable, as—although among academic bioethicists its inadequacies are widely recognised—no alternative has captured widespread acceptance.
One of these inadequacies is that it requires to be supplemented with virtues. Indeed, McLean acknowledges what many bioethicists seem to ignore, that most “hard” cases are not hard because it is difficult to know what is right to do, but because it is hard to do what is right. What is required, he says, is a commitment to the principles—what I would call virtue, the qualities of character that motivate one to do the right thing.
Another limitation acknowledged by the author is that the principles (as Beauchamp and Childress themselves acknowledge) often need to be balanced against each other, but themselves provide no guidance as to how they should be balanced. This will depend on the circumstances of individual cases.
But there is another limitation of the four principles approach that McLean does not mention. There is an inherent inconsistency between the claims that such a morality is, on the one hand, shared by all reasonable persons—a matter of “common” sense—and, on the other, based on conventions and traditions. The particular tradition in which principlism arose was U.S. individualism, and it does not always travel well beyond this context. One way to make the four principles less culture-specific is to regard them simply as a framework or initial mapping for approaching individual cases. This is how McLean uses them. But then it is apparent that their content (specification) must come from elsewhere. As must the basis for balancing the principles. One needs a thicker concept of the good than the principles provide, in order to apply them.
In Western liberal individualist societies, that reject the promotion of a “thick” concept of the good, inevitably the principle of respect for patient autonomy becomes dominant. There is no account of the good to give content to beneficence other than the patient’s own conception of the good for him or her. But then it seems we have lost altogether any sense of the healthcare professional as a moral agent. Rather they become technicians or “service providers” implementing the patient’s wishes. The patient or client becomes a consumer. Healthcare becomes “values free.” We have moved a long way from the idea of professional ethics with distinctive values and codes of conduct.
Clearly McLean does not advocate this view. He speaks of the distinctive features of professional ethics and the traditional definition of a profession that involves particular standards of conduct. And he speaks of the power imbalance in the relationship between a health professional and their patient/client that involves the need for trust. In the discussion of euthanasia, he refers to the duty of care which overrides even a patient’s expressed wish to be assisted to die.
Ethical Basics for the Health Professions deals much more sympathetically with a religious worldview and a religious, specifically Judeo-Christian, understanding of ethics than most standard bioethics texts. There are substantial sections outlining this view and specifically its understanding of the human person in the discussion of antenatal screening for foetal abnormalities. It is contrasted with a utilitarian view exemplified by Jonathan Glover and Peter Singer. The book closes with a challenge: “What kind of carer will you be?”
I would recommend this book, especially for Christian healthcare students and practitioners.
Review by Tom Slater, November 2022
Ethical Basics for the Caring Professions: Knowledge and Skills for Thoughtful Practice
by Graeme R. McLean
London and New York: Routledge, 2021
ISBN 9781032009582, 240 pages, 1st edition, paperback
AUD$69.99
A layperson’s view
It seems almost impertinent to offer some additional observations on Graeme McLean’s Ethical Basics for the Caring Professions, following a more technical earlier review by Denise Cooper-Clarke. I do so only to add some special emphases concerning the accessibility and relevance of the book to the “ordinary” layperson like me.
While Denise does indeed recommend the book, “especially for Christian healthcare students and practitioners,” I thought that perhaps her high-level analysis with reference to wider philosophical considerations might nevertheless deter a potential reader, for whom the book would be entirely appropriate. I am sure the book would be helpful to many people who, by force of circumstance, are confronted with the same (and indeed other) ethical issues and would benefit greatly from the tools for thinking about them which the book offers. The author’s own words in a footnote on the last page seem to agree: “As is my strategy throughout this book, I am not trying to provide a scholarly overview of the topic, but rather to expose and discuss the basic questions that I believe the caring professions need to face.” [author italics]
The issues McLean engages with go to the heart of what it means to be a society that values people, and cares for them accordingly.
It is not sufficient justification to do something to, or even for someone, medically, psychologically or otherwise, just because we can. McLean calls into question some of the justifications which are currently offered for practices which, even if legal, should be profoundly disturbing to a person of good conscience, let alone a person of Christian faith. The end alone doesn’t justify the means.
At this point, perhaps I should declare a personal interest. I was privileged to proofread the manuscript, not primarily as a long-time friend of the author, in which description I unashamedly rejoice, but as someone who might to some extent represent the intended readers—people of average intelligence, and without finely honed logical skills, many of whom are nevertheless faced in the workplace sometimes with profound ethical issues which they can’t avoid, and with which they need help. That is to say, I could hope to act as a sort of litmus test of what would be clear to such people, and what might be clearer if it were stated differently. I have no vested interest, but only the desire that people in the caring professions, as well as carers and citizens in general, should be strongly encouraged to read it.
For me, an outstanding feature of the book is that I could follow the argument! Indeed, I was engrossed by it, even though I am not a health practitioner, but simply a Christian wanting to think straight about such things. Indeed, in this case the issues have profound implications both for the health professionals and for those they care for. And not just professionals either, but ordinary people who may be faced with decisions on behalf of family members who may not be able to speak for themselves, as well as pastors and teachers to whom people look for wisdom in such things.
It was no surprise that I found the book thoroughly accessible, since Graeme has demonstrated a life-long gift as a brilliant teacher and communicator—an ability that manifested itself in earlier years as he held senior secondary students at summer camps engrossed in dialogical teaching about Christian beliefs, and as a tutor at Monash University. In his subsequent teaching career he received awards as the outstanding teacher at not one but two universities (the University of the Witwatersrand in South Africa in 1997 and Charles Sturt University in 2008), as well being recognised by the Australian Learning and Teaching Council in 2009 for his “outstanding contribution to student learning.” I cite these things briefly not to give him an unnecessary or gratuitous compliment, but simply to underline the point once again that the “ordinary” reader can expect to get value from this important book.
Whether oral or written, Graeme’s teaching is characterised by laser-like clarity, thoroughness and passion, as well as patience and empathy. This book is no exception, but rather a shining example of those characteristics. It is in two sections. The first section has five chapters which set out an invaluable framework for thinking straight—logically—about truth claims in general, and ethical issues in particular. The second section applies this way of thinking to the issues of euthanasia (Chap. 6) and disability, screening, and the value of human life (Chap. 7).
No dry academic tome, it is liberally sprinkled with examples and stories that illustrate the argument at every turn. Indeed, it is at times entertaining, as the author exposes one fallacy or another, or comments on experiences with students, with dry wit. And finally, those who enjoy good writing will not be disappointed. But that’s the icing on the cake.
Some time ago I was talking to a friend who is now retired after a very distinguished medical career, and who has been actively studying the spread of “voluntary assisted dying” (VAD) worldwide. I was talking hopefully about the potential contribution of this book to the debate, once it was published. He was pessimistic at two points: first, that the horse has bolted as far as legislating for VAD goes in many jurisdictions; and second, that most medicos “don’t want to think” about such issues, either because they are too busy, or because it is too hard.
One hopes, rather forlornly, that he is too pessimistic. But be that as it may, this is a book which could strengthen the confidence of Christian medicos in the respectability and relevance of theistic beliefs, and reward countless others of us who just worry about societal trends without being sure how to think straight and think Christianly about them.
Finally, though, it needs to be emphasized that this is not a book that belongs mainly on the desks of Christian people. It is a conspicuous example of argument which stands up in any arena on its own merits, even as (and partly because) it neither hides theistic assumptions, nor zealously promotes them. I am excited, though not in the least surprised, that it has found a world-class publisher, and hope that it will be read by many “ordinary Christians,” and perhaps even lead others to seriously reconsider the idea that “the fear of the Lord is the beginning of wisdom.”