Moral Epistemology

THOMAS NAGEL, Ph.D.

Professor of Philosophy and Law, New York University

If our interest is the public evaluation and control of advances in biomedicine or other technologies, the problem of moral knowledge has to be closely connected with the conditions of political legitimacy. The issue is not just, "What are the grounds and methods of moral thought in general?" but "What methods can be used to justify conclusions that are fit to serve as the basis for public policy and public restraint?" There may be grounds of moral belief which can serve legitimately as a basis for personal conduct, but which it would be inappropriate to rely on in justifying the actions of official bodies, taken in the name of a public which comprises a wide range of conviction.

I shall return to this point later. But for most of this discussion I won't distinguish between the morality of public and of private choice, but will talk about the foundations of moral judgment in general. Because of the essentially public concerns which prompt the discussion, however, I shall leave aside the morality of individual virtue, which may have some bearing on the conduct of particular public officials but has little to do with technology assessment.

Epistemology, or the theory of knowledge, is a function of the subject matter. How to arrive at conclusions, how to justify or criticize them, and the pitfalls along the way, all depend on what kind of thing you are trying to make up your mind about. So the first question to answer is: What is morality about-what kind of thing is a moral belief? What is it, in other words, that moral epistemology must investigate our knowledge of?

The minimal answer has two elements: (1) Moral conclusions are



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Society's Choices: Social and Ethical Decision Making in Biomedicine Moral Epistemology THOMAS NAGEL, Ph.D. Professor of Philosophy and Law, New York University If our interest is the public evaluation and control of advances in biomedicine or other technologies, the problem of moral knowledge has to be closely connected with the conditions of political legitimacy. The issue is not just, "What are the grounds and methods of moral thought in general?" but "What methods can be used to justify conclusions that are fit to serve as the basis for public policy and public restraint?" There may be grounds of moral belief which can serve legitimately as a basis for personal conduct, but which it would be inappropriate to rely on in justifying the actions of official bodies, taken in the name of a public which comprises a wide range of conviction. I shall return to this point later. But for most of this discussion I won't distinguish between the morality of public and of private choice, but will talk about the foundations of moral judgment in general. Because of the essentially public concerns which prompt the discussion, however, I shall leave aside the morality of individual virtue, which may have some bearing on the conduct of particular public officials but has little to do with technology assessment. Epistemology, or the theory of knowledge, is a function of the subject matter. How to arrive at conclusions, how to justify or criticize them, and the pitfalls along the way, all depend on what kind of thing you are trying to make up your mind about. So the first question to answer is: What is morality about-what kind of thing is a moral belief? What is it, in other words, that moral epistemology must investigate our knowledge of? The minimal answer has two elements: (1) Moral conclusions are

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Society's Choices: Social and Ethical Decision Making in Biomedicine practical, which means that they are about what to do rather than about what is the case (even though they may be based partly on what is the case); (2) they are not merely individual but represent a possible area of interpersonal agreement. The most general concept of morality, shared by those who may differ widely about its substantive content or foundation, refers to standards of individual or collective conduct which permit people to agree in the determination of what ought to be done in a given case or under given circumstances. There is difference of opinion over how wide the range of possible agreement should be-whether morality should seek answers that permit convergence only among members of a particular community or culture, or among all human beings or even all rational beings (a class which could in principle include nonhumans). But however we answer that question, the main point is that such standards, if they exist, are supposed to give the same result whoever in the moral community is trying to answer the question. If you are trying to decide what to do, and if there is a moral answer to the question of what you ought to do, that answer should be available not just to you but to anyone else informed about your situation. It should be independent of the point of view of the individual making the judgment, and in that sense objective. If such an answer is available, it should permit you to justify your conduct not only to yourself but to others. So the search for moral knowledge is the search for a basis for objective judgments about what people ought to do-judgments on which they can agree and which allow them to offer justifications to one another for their conduct. Such justifications will have to appeal to something independent of the differences in point of view that ordinarily divide us, and that are generally so important in motivating our actions-something we can rely on in common. What this is, or whether such a thing can be found at all, is the central issue of ethical theory. But most theorists would recognize, as characteristic of morality, the aim of convergence by individuals with diverse and conflicting points of view on standards of conduct and choice which all can see as justified. Morality, if there is such a thing, requires us to transcend in the practical domain our individual perspectives, and by means of this collective transcendence to converge on a common standpoint of evaluation. It aims to supply a framework of potential agreement or harmony within which the remaining differences can operate without doing harm. There is in this sense a loose analogy between the aims of moral and of factual knowledge: Both are concerned with convergence on results all parties can recognize as correct, and both require transcendence of a purely personal point of view to one that is more shareable and objective. But the convergence sought by moral thought is practical and motivational, whereas the convergence sought by factual and scientific thought is conver-

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Society's Choices: Social and Ethical Decision Making in Biomedicine gence of belief-convergence on a true account of how things are, or a common picture of the world. The pursuit of moral knowledge, therefore, must proceed by the development of our motives and practices, not of our beliefs and descriptions. Because our personal desires are so individual and conflicts of interest and attitude are often so severe, the question whether moral objectivity is possible is more serious than the comparable question about other fields. Nonevaluative subjects like mathematics, science, and history don't provide models for a conception of moral knowledge: In trying to determine how to live together, we are not talking about abstract timeless structures or about the observable external world. To reach a common standpoint that is practical rather than merely theoretical, as morality requires, we must modify our motives and attitudes by some process of coordination that is suited for the purpose. The first step, common to many moral theories, is to put yourself in other people's shoes, with sufficient imagination to be fairly sure that you understand their point of view and their preferences, experiences, and interests. An appreciation of the antecedent divergence that creates the conflicts to which morality seeks a solution is essential in pursuing convergence. The other effect of putting yourself in other people's shoes is to induce the sort of impartiality and escape from egocentricity which is needed to reach a common standpoint. Whatever the moral solution, it should have an appeal that is the same for everyone, even if it also impinges unequally on their nonmoral interests. But to get further, we have to decide what to do with all these points of view, how to generate some kind of unity out of them. And to say any more than this about moral epistemology, we must move to the level of substantive moral argument. The methods of thought in this field, as in others, are revealed in the way one thinks about particular hypotheses. It is no more possible here than elsewhere to specify a pure, content-free method that can be used mechanically to produce results. If we look instead at the disagreements among leading theories of moral justification, and the way in which criticism of general principles can emerge from particular counterinstances or counterarguments, we will get a better picture of the process. I am going to begin by tracing the disagreements among several representative theories of how this is to be done-theories which have made an enduring contribution to our understanding of moral knowledge, even if none of them captures the whole truth about it. Each of them offers a different account of the basis of convergence, as follows: collective self-interest (Hobbes), natural rights (Locke), general benevolence (Hume), and universalizability (Kant).1 Though they are associated with classic authors, each of these approaches has its contemporary representatives. The Hobbesian approach to moral argument is motivationally the sim-

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Society's Choices: Social and Ethical Decision Making in Biomedicine plest. It assumes that the motives which produce conflict, notably self-interest and the desire to survive, must also be relied on to resolve those conflicts, because no other motives of comparable power are available to override them. Hobbes therefore identified the content of morality with those rules of conduct that it would be in everyone's interest for everyone to follow. He also recognized, however, that this by itself was not sufficient to give any individual a self-interested reason to follow those rules himself. (In effect, Hobbes was the first thinker to describe the prisoner's dilemma.) To bring collective self-interest into accord with individual self-interest, thereby making its achievement motivationally possible, it was necessary to change the external circumstances by setting up an enforcer of the moral rules, the sovereign. Only in that way would it become safe for individuals to adhere to the rules that each of them has a reason to want everyone to adhere to. According to Hobbes, the realization of morality, though not its content, depends on political institutions. However, the important point for our purposes is that Hobbes thought moral discovery did not depend on any modification of human motives. Rather, the convergence on common standards of conduct characteristic of morality was the result of social and psychological theory, on the basis of a single principle of motivation. The problem was, how to create the conditions of convergence and harmony on the basis of the most reliable motive, self-interest. The reasoning to that end was essentially instrumental: An analysis of human interactions and conditions of trust and distrust suggests a method of overcoming the destructive effects of self-interest and fear not by altering human motives, but only by changing the means of their expression. We are not, on this theory, led to accept moral constraints on our conduct by a concern for the good of others. While Hobbes's recognition of the gap between individual and collective self-interest, and his proposal for closing it, are among the most important insights of moral and political theory, his conception of the motivational basis of ethics seems too narrow. Intuitively, there seems to be some reason to refrain from harming others which derives from their interests, and not just from your own. When Locke tries to express this recognition, he appeals both to the Golden Rule and to the equality of mankind in the sight of God; but the idea can be understood in completely secular terms-indeed in terms of the imaginative step already mentioned, of putting yourself in other people's shoes. The most basic moral argument, "How would you like it if someone did that to you?" can be given either a Hobbesian or a Locke an interpretation. In the former sense, it is an appeal to self-interest, through an implied reference to general practices and conventions whose imposition would serve everyone's interest, yours included. In the latter sense, it is a direct invitation to imagine the situation from the point of view of the

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Society's Choices: Social and Ethical Decision Making in Biomedicine other, in order to induce a recognition that what happens to him matters in itself, and should matter not only to him but to you. Thus it is designed to evoke motives which are in a broad sense altruistic or other-regarding. This is an example of the sort of appeal to intuition that is as indispensable in moral thinking as appeals to observation are in empirical thinking, and appeals to self-evidence in logical thinking. Moral intuitions are not infallible, but they provide the only data we have to support or discredit general hypotheses. Some moral intuitions can be explained away as illusions or prejudices, but even then the alternative is generally supported by other intuitions, at some level. In the case of Locke, the anti-Hobbesian intuitions are not limited to a general consideration for the interests of others, but take the form of a system of equal natural rights, essentially rights against interference, which are said to constrain us in our dealings with others even in the absence of a legal enforcement system. This type of conception has been very prominent in subsequent moral and political theory. The idea is that morality requires us to accord everyone an equal status in some sense-the same status we claim for ourselves in their treatment of us-and that this status should be defined as a kind of inviolability. Each of us is protected by a moral boundary which accords us a degree of freedom to act in pursuit of our personal aims without interference by others, provided what we do does not violate the identical boundary protecting anyone else. While there has been much disagreement over what should be included in this category of equal rights, as a form of moral thought it continues to be very much alive. However, it has also provoked an equally important reaction, the tradition of utilitarianism, stemming from the work of Hume. Rights are supposed by Locke to be natural and morally basic. That is, they are not merely legal or conventional creations which serve an instrumental purpose. This contrasts with Hobbes, who had held that property rights, for example, serve the common interest but are brought into existence only with the creation of the state; Locke believed that property rights were prepolitical. Hume, by contrast with both of them, held that the motivational foundation of morality was a single sentiment of impartial benevolence, or concern for people's well-being, but that it did not express itself directly in the recognition of equal rights. Rather, rights of property, obligations of contract and promise, and other strict moral boundaries are in his view conventions-sometimes legally enforced-which are justified by the contribution of their strict application to the overall or general welfare of persons living under them: justified, in other words, by their utility. So Hume differs from Hobbes in believing that morality can rely on a motive other than self-interest-a motive of benevolence that arises when we view the lives of all persons, ourselves included, from a detached and

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Society's Choices: Social and Ethical Decision Making in Biomedicine sympathetic perspective. But he differs from Locke in believing that this is the only fundamental moral principle, and that all others, specifically the various individual rights, are derived from it. The sole criterion of the correct moral rules, on this view, is whether they promote utility or the general welfare of all persons added together. (Note, this is different from the Hobbesian standard of the common interest, or the simultaneous interest of each person taken separately.) This position is known as rule-utilitarianism, and it holds that while some moral assessments of policies and actions depend on their direct contribution to overall utility, many of the most important assessments are indirect-placing an act like respect for property or contract under a rule or convention that serves utility not act by act, but only as a whole. The controversy between natural rights theory and rule-utilitarianism illustrates an important type of theoretical controversy in ethics. The disputants may agree roughly in their substantive moral judgments of central cases, but they disagree over what is fundamental and what derivative: They disagree, in other words, about the correct moral explanation of those substantive intuitions in which they agree. And this may in turn be connected with disagreements about less obvious substantive questions, which will be decided differently by the extension of different justificatory principles. For example, the answer to the question of how much discretion people should have over the use and disposition of their property will depend significantly on whether property rights are, as Locke thought, an aspect of a natural right to equal liberty, or, as Hume thought, a set of conventions designed to promote security, stable long-term expectations, and the general welfare-in which case their appropriate scope will vary with contingent circumstances. In its development by Bentham and Mill2 and later writers utilitarianism became the clearest example of a moral theory based on only a single purely moral intuition, with everything else following from it with the help of nonmoral, factual premises. The moral principle at the top is that the only measure of good is the sum of the welfare of individuals, and the only measure of right is how effectively an act or policy contributes to that good. Determining how we should live, how societies should be organized, and what laws and policies they should adopt is then entirely a matter of instrumental reasoning about what will maximize expected utility (the utility of the possible results combined in proportion to their relative probabilities). Many moral theorists are drawn to this structural feature of utilitarianism. It seems cleaner and more reliable to depend on a single, simple principle that seems intuitively certain, rather than having to rely on moral intuition over and over again in judging different principles and different choices. With a single principle like the principle of utility, one can derive

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Society's Choices: Social and Ethical Decision Making in Biomedicine results using only the data of empirical natural and social science, plus quantitative calculation. The application of morality to life is thus provided with a well-defined method, often called cost-benefit analysis, and the only remaining uncertainties or vaguenesses are factual. Most of moral epistemology becomes factual epistemology. However, this outlook attracts strong resistance from those who believe that moral thought is far more complex and autonomous, and that the structure of values and moral requirements is normative throughout, rather than just consisting of the deductive and empirical consequences of a single normative premise. According to this alternative view, morality is general in the sense that its reasons treat like cases alike, and morally relevant differences must be found to justify treating different cases differently-but this generality cannot be captured in a single, simple principle. Probably the most important representative of this position is Kant, in spite of his claim to be able to derive all of morality from a single principle, the Categorical Imperative. What makes the Categorical Imperative logically different from the principle of utility is that it cannot be applied without substantive evaluative judgment all along the way to the conclusion, whereas the principle of utility requires only factual and mathematical judgment for its application. Kant formulates the Categorical Imperative in more than one way, but the most famous version is the principle of universalizability-that one should govern one's own conduct only on principles that one could will to be universal laws applying to everyone. The derivation of particular moral conclusions from this formula is anything but straightforward, and the words ''could will" conceal a demand for further normative judgment. In contemporary theory, this approach is usually identified with a contractarian method of resolving the conflicting interests and values of different individuals. The method has something in common with traditional social contract theory, but it attempts to place the different points of view to be combined on a footing of greater equality, by making the contract a hypothetical rather than an actual one, to avoid the influence on its outcome of differences in power or threat advantage. What equally situated individuals would agree to or converge on as a common standard is offered as a justification for accepting it as morally correct.3 But here again, the process of justification seems normative "all the way down." This raises a particularly vexed issue in moral theory: whether the reliance on evaluative or normative judgment in deriving particular moral conclusions from general moral principles makes the whole process circular and the system empty. Rawls, who is a contemporary representative of the Kantian tradition, has defended the method of moral complexity under the heading of "reflective equilibrium."4 We suppose that our moral sense is the imperfect apprehension of a complex structure of principles

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Society's Choices: Social and Ethical Decision Making in Biomedicine and justificatory reasons, and we try to refine our understanding of this structure by exercising moral intuition both at the level of plausible general principles and at the level of particular substantive judgments of action or policy. We proceed by trying through mutual adjustment to produce the best fit between persuasive principles, plausible specific consequences that follow from them, and general theoretical accounts of the overall structure and motivational foundation of moral constraints. The reasoning is moral at every point, but the partial independence of the points creates a kind of check, and the possibility of confirmation, disconfirmation, and revision. Apart from method, the opposition between the Kantian and utilitarian traditions is also one over the right way to count everyone equally in moral thought. Utilitarians count everyone equally by counting everyone's welfare impartially as a contribution to the total, whose maximization then serves as the criterion for all other moral requirements. According to utilitarianism, therefore, all other forms of equality (of rights, opportunities, status, or resources) are morally favored only if they serve as instrumental means to the maximization of that total. According to the Kantian tradition (which in this respect has something in common with Locke), there are independent values of equality, not derivative from the maximization of utility, which in fact limit the way it is permissible to treat people even in order to advance the general welfare. Certain rights to equal treatment, equal liberty, equal inviolability, and equal opportunity are not, in other words, merely instrumental to the promotion of the good, but are morally basic. This is a very deep disagreement about the form of equal regard for everyone that underlies morality. The issue is whether certain minimal protections for each individual have a privileged position which cannot be overridden by a greater aggregate balance of benefits to numbers of other individuals. There is no reason a priori to think that counting people's interests equally as input to the total is the only adequate form of moral respect. Obviously the issue is not going to be easy to resolve. It can be understood in broader perspective as the opposition between two conceptions or models of impartiality: the model of collective sympathy and the model of individual identification. If one wishes to give substance to the idea of impartial respect for everyone, which is the essence of an ethical system, two psychological models offer themselves. The first is that of an impartial sympathetic spectator, who cares equally about the happiness and unhappiness, fulfillment and frustration, of all persons. The solution to a typical moral problem in which individual interests conflict would then be the one this spectator would be motivated to choose by his sympathy for all the affected parties. Such a method of decision tends toward maximizing the total balance of happiness over unhappiness; so the sympathetic spectator model has a

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Society's Choices: Social and Ethical Decision Making in Biomedicine natural association with utilitarianism, which accords to everyone equal status as a potential contributor to that total-but not equality in the outcome, as such. The second psychological model of impartiality does not employ a spectator at all, but imagines someone who instead of remaining outside, identifies himself with each of the persons whose conflicts give rise to the moral problem-as if each person's interests and attitudes were his own, but separately. This model of simultaneous multiple identification is much harder to imagine,5 but the point of the method is to discourage the kind of blending together of everyone's happiness and unhappiness that is encouraged by the sympathetic spectator model. If one identifies separately with each individual, those interests cannot be so easily combined. This is an attempt to build the distinction between different persons more deeply into the interpretation of impartiality from the start. It calls for an alternative method of dealing with conflicts of interest and of combining advantages and disadvantages to yield a solution. The method suggested by this model, as an alternative to maximizing the aggregate total welfare, is that of a system of priorities. To express one's identification with each individual, one tries to identify an order of priority among needs, interests, benefits, and harms, and meets higher priority needs before less urgent ones in case of conflict-even if more people would receive the lower priority benefit. This different method of according people equal respect requires us to focus on urgent matters of survival and basic capacities for a minimally decent life before going on to the provision of benefits higher on the scale of well-being. That will mean resisting the method of aggregation which allows the accumulated weight of sheer numbers of better-off people to override the more urgent needs of a minority. (An example would be the costly provision of education, assistance, and access to the handicapped, which is hard to justify in utilitarian terms.) Similar reasoning may assign priority to the protection of certain basic individual rights, whose violation can't then be justified by appeals to the general welfare. The present state of moral controversy reveals a high level of uncertainty about both methods and conclusions, but at the same time there is clearly a lot of value in the three primary standards I have described: common interest, overall utility, and equal rights. On some questions these standards will give the same answer: All of them justify the most obvious rules against killing, assault, coercion, theft, and breach of promise, and all of them are plausible justifications for the evaluation of policies, even if none of them can be the whole truth. It is also important that all of them try to count everyone the same, in the evaluation of policies and measures, even though the way interests are counted and combined is different from one method to the other.

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Society's Choices: Social and Ethical Decision Making in Biomedicine For an individual or a group wishing to justify policy in the public forum, it would be a mistake to think there was some standpoint of pure moral epistemology, above the level of moral disagreement, from which that can be done. One cannot, in other words, move to a domain outside of moral controversy to find objective grounds for settling it. However general the principles one appeals to, the arguments must be substantive, for that is where the problems arise and where their solutions have to be found. In this respect morality is no different from anything else. There is no abstract rule for discovering the right answer to every historical, medical, or economic question either: If there are objective justifications in those fields, they show themselves at the level of substantive argument, where alternatives are proposed and evidence is evaluated. I have described some methods of moral thought which to one degree or another carry conviction, but those engaged in a task like technology assessment have to actually employ such arguments, and make first-order judgments as to their relative cogency when they yield conflicting results. In the exercise of public responsibility, those judgments cannot be merely personal, but must attempt to express a moral outlook that the public in whose name the decision is being taken can reasonably be expected to adopt, in light of the reasons offered. This doesn't mean that the acceptable justifications have to be discovered by surveys of antecedent moral opinion, since carefully reasoned decisions about public questions should attempt to supply the grounds for their own acceptance. But it does mean that new decisions should aim to cohere with a publicly available moral understanding, and to form part of its natural evolution. In this respect the task has something in common with that of a court deciding a difficult and morally loaded case. It is not easy to identify a public moral philosophy for the United States, since we are such a pluralistic society. However, I think it is safe to say that the quasi-consensus is not Hobbesian, and not utilitarian either. Rather it is a qualified priority view, in which (1) the guarantee to everyone of certain individual rights against interference (justified partly but not entirely on rule-utilitarian grounds) limits the methods that can be used to pursue the general welfare; (2) there is also a prioritized understanding of welfare itself, with (3) greatest importance being assigned, from the point of view of public policy, to things that are in everyone's interest, like defense, security, and the environment (a Hobbesian element), and (4) also increasingly to the most basic or urgent human needs; (5) above that level a utilitarian standard is supposed to be roughly approximated by the balancing of interests in democratic politics, though of course the system doesn't often work as it should. But the identification of standards and arguments has to be carried out, in good faith, by those who make decisions and offer reasons for them. It is only by actual argument that we can

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Society's Choices: Social and Ethical Decision Making in Biomedicine find objective standards, whether we are talking about ethics, biology, or anything else. In dealing with controversial cases, there is no substitute for the familiar process of formulating general hypotheses and testing them by the credibility of their implications in other cases where intuitions may be clearer. If two people disagree about the right thing to do in a particular situation, they should be able to find reasons for their different opinions, and those reasons will reveal principles which in turn imply other decisions in other cases, permitting the justifications to be compared. Of course the whole system of justification is quite involved, and various principles may interact, but progress can often be made on this basis-at least to produce greater understanding of the grounds of disagreement, if not to resolve it finally. Even if morality is ultimately to be based on a single axiom like the principle of utility, the defense of that claim must involve more than an appeal to the self-evidence of the principle: It must be shown by detailed argument and consideration of actual and hypothetical cases to provide the best way of justifying the moral conclusions that, on reflection, prove most convincing. This doesn't mean a moral theory has to preserve the intuitions we start out with, only that if it does not, it must genuinely persuade us of something else. That is not a matter merely of drawing logical consequences from a formula, but of changing our values and motives. As regards the motivational and attitudinal developments involved in moral thought, there are two ways of interpreting the process, as we have already seen. According to the conception common to Hobbes and the utilitarians, the basic motive stays the same-self-interest or benevolence and the details of morality are developed by attaching that motive to different policies, institutions, and courses of action, on the basis of information about what will actually promote either the common interest or the aggregate general welfare. According to the other conception, characteristic of the modern Kantian tradition, moral thought involves the development of more complex, morally influenced motives, as our sense of what is and is not a sufficient reason for action is altered by changing conceptions of equity, fairness, responsibility, cruelty, desert, and so forth. On either conception, the aim of moral thought is to discover justifications which can produce convergence in what people find acceptable in one another's conduct. Often it will involve breaking a fairly wide existing consensus on the way to finding a new, firmer foundation for agreement. The aim of convergence has nothing essentially conservative about it. Accepted orthodoxies cannot so easily be overthrown in ethics, as in science, by the discovery of new empirical evidence, but they can be overthrown by new arguments and new appeals to the moral imagination-as has hap-

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Society's Choices: Social and Ethical Decision Making in Biomedicine pened conspicuously in the recognition of traditional social inequalities as morally arbitrary. Let me close by commenting on two related issues, the question of expertise and the place of moral considerations in political decision. The first issue naturally arises in connection with anything like technology assessment, because scientific expertise is indispensable with regard to the facts, the risks, and probabilities, and often there is no way of making the full grounds of such expert judgments generally accessible. Only someone with years of training and experience can evaluate them, and others, including politicians and most of the affected public,just have to try to find grounds for deciding whom to believe. Even where specialists disagree about the likely effects of an advance, those charged with public decisions can't really expect to arrive at an independent view of their own. By contrast, there is much less room for expertise with regard to the moral and evaluative aspects of policy. Moral judgments are everyone's job, and while some people are better at them than others, the reasons behind them ought to be made available, for the purposes of public choice, in a way that those responsible, and eventually the public at large, can find directly persuasive. Moral grounds for public decisions, unlike scientific grounds, should be at least potentially part of public rather than expert knowledge. As I said earlier, this doesn't mean that they have to be familiar in advance; but if they break new ground, they should nevertheless aspire to offer reasons which can command assent not only from specialists-even if those who spend more of their time thinking about these things may be better able to come up with plausible proposals. Morality's ambition is, or at least ought to be, to provide a system of conduct under which everyone can live, with a sense of mutual justifiability. This follows from the conditions of political legitimacy: We do not live in a theocracy, where some people are thought to have a privileged and direct line to the moral truth. That brings me to the second issue, which was also mentioned at the start of our discussion: the modification of moral argument for political purposes. In a democracy, the aim of procedures of decision should be to secure results that can be acknowledged as legitimate by as wide a portion of the citizenry as possible. Even those who personally disagree with a result, or whose interests are harmed by it, should ideally be able to recognize as legitimate the methods by which their preferences and opinions were overruled by others. This means that in a democratic polity, there may have to be some restriction on the types of moral grounds on which it is legitimate to base policy decisions. Those that are too particular to be generally authorized may have to give way to more public grounds. Our society is not only democratic but richly pluralistic. Many different religions and systems of ultimate value coexist here, and it is important to their coexistence that they be able to find terms for living side by side,

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Society's Choices: Social and Ethical Decision Making in Biomedicine and dealing with potential conflicts, that do not require them to convert one another. The cost of conflict resolution and cooperation cannot be the total elimination of disagreement. It may therefore often turn out that principles of conduct that serve as moral justifications within a community of belief or practice are not suited to serve that role for political or policy decisions made in the name of the society as a whole. This is conspicuously true of moral requirements rooted in a specific religious faith, but it may also apply more widely. It can affect not only the rules of conduct one accepts, but also the correct measure of individual well-being for the purpose of calculating benefit, harm, and overall utility. For example, the fact that someone cares more about spending money on a religious pilgrimage than on basic medical care may provide a good reason for that person to decide how to use his own resources, but it is a poor reason for a program of public assistance to support his religious rather than his medical expenditures-because the value of medical treatment can command public recognition and the religious claim cannot. While someone's preferences are ordinarily a good basis for deciding what is better or worse for him, a less individual standard of value may be needed for purposes of public justification.6 The pluralism of our culture requires that public choices be made on a leaner and more universalistic basis than private ones. The extent to which universality is itself a necessary aim of moral theory is a matter of controversy. There are those who believe that the ambition of traditional theories to search for the correct principles for persons as such is misplaced-even if that is not an inappropriate aim for mathematics and science. I am not sympathetic with this view, but even if one thinks that morality is by its nature more local than logical or factual thought, the ambition of universality at least within the community concerned with the decisions-the community in whose name they are taken, if not all those affected-follows from the function of moral argument in supporting convergence and mutually acceptable standards of justification. To go beyond this would involve deeper epistemological questions which cannot be adequately treated in a discussion of this sort. I would say only that although the aim of moral thought is to provide a basis for agreement, the bare empirical appeal to community consensus where it exists is never in itself a moral argument. It can serve only as the starting point for the examination, and criticism or endorsement, of the reasons underlying that consensus. NOTES 1.   Thomas Hobbes, Leviathan (1651); John Locke, Second Treatise of Government (1690); David Hume, Enquiry Concerning the Principles of Morals (1751); Immanuel Kant, Foundations of the Metaphysics of Morals (1785).

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Society's Choices: Social and Ethical Decision Making in Biomedicine 2.   Jeremy Bentham, An Introduction to the Principles of Morals and Legislation (1788); John Stuart Mill, Utilitarianism (1863). 3.   See John Rawls, A Theory of Justice (Harvard University Press, 1971); T. M. Scanlon, "Contractualism and Utilitarianism," in Amartya Sen and Bernard Williams, eds., Utilitarianism and Beyond (Cambridge University Press, 1982). 4.   Rawls, op. cit. 5.   Something corresponding to it has been proposed by Rawls in his hypothetical social contract model called the Original Position. 6.   See T. M. Scanlon, "Preference and Urgency," Journal of Philosophy, Vol. 72, 1975.