The Value of Consensus

MARTIN BENJAMIN, Ph.D.

Professor of Philosophy, Michigan State University

In 1988, a group of 33 physicians, bioethicists, and medical economists from ten different countries met at Lawrence University in Appleton, Wisconsin, to formulate guidelines for stopping medical treatment. Apart from minority dissents on two matters of detail, the guidelines were endorsed by the group as a whole and subsequently published as "The Appleton Consensus: Suggested International Guidelines for Decisions to Forego Medical Treatment" (Stanley et al., 1989). What, if anything, is added to the value of such guidelines by the inclusion of "consensus" in the title? Does consensus give special credence or authority to this and similar outcomes of group deliberation? Should members of such groups be encouraged to strive for consensus? Or is preoccupation with consensus likely to obscure important differences, leading in many cases to recommendations so general or abstract as to be practically useless?

These and related questions have assumed greater importance as governments and health care institutions turn to ad hoc or standing committees or commissions for guidance on perplexing bioethical issues. In what follows I examine the nature, value, and limits of consensus in bioethics. I begin by identifying different types of consensus and their relations to notions like compromise and majority rule. I turn then to a variety of normative and methodological issues that must be addressed by ethics committees and commissions as they consider whether, and if so to what extent, their deliberations should be directed by a search for consensus.



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Society's Choices: Social and Ethical Decision Making in Biomedicine The Value of Consensus MARTIN BENJAMIN, Ph.D. Professor of Philosophy, Michigan State University In 1988, a group of 33 physicians, bioethicists, and medical economists from ten different countries met at Lawrence University in Appleton, Wisconsin, to formulate guidelines for stopping medical treatment. Apart from minority dissents on two matters of detail, the guidelines were endorsed by the group as a whole and subsequently published as "The Appleton Consensus: Suggested International Guidelines for Decisions to Forego Medical Treatment" (Stanley et al., 1989). What, if anything, is added to the value of such guidelines by the inclusion of "consensus" in the title? Does consensus give special credence or authority to this and similar outcomes of group deliberation? Should members of such groups be encouraged to strive for consensus? Or is preoccupation with consensus likely to obscure important differences, leading in many cases to recommendations so general or abstract as to be practically useless? These and related questions have assumed greater importance as governments and health care institutions turn to ad hoc or standing committees or commissions for guidance on perplexing bioethical issues. In what follows I examine the nature, value, and limits of consensus in bioethics. I begin by identifying different types of consensus and their relations to notions like compromise and majority rule. I turn then to a variety of normative and methodological issues that must be addressed by ethics committees and commissions as they consider whether, and if so to what extent, their deliberations should be directed by a search for consensus.

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Society's Choices: Social and Ethical Decision Making in Biomedicine FORMS OF AGREEMENT Agreement among members of bioethics committees and commissions may take a number of forms. At one end of the spectrum is full agreement on both the substance of a recommendation and its supporting arguments. At the other is vote-taking and the group's endorsing the will of the majority. In between are ''overlapping consensus" and compromise. Complete Consensus A consensus is, most generally, an agreement-a collective unanimous opinion-among a number of persons. If, for example, members of an ethics committee immediately agree on a recommendation and its supporting values or principles, consensus is predeliberatively complete. The entire position-argument and conclusion-of each member is, at the outset, congruent with that of the others. Predeliberative complete consensus will, for two reasons, be uncommon. First, questions directed to such committees are usually contested. Ethics commissions or committees are created when the larger group they represent must speak with one voice on complex ethical questions to which members or clients of these groups give uncertain or conflicting answers. Issues likely to elicit complete consensus at the beginning of a group's deliberations are, as a result, not often addressed to ethics committees. Second, committee members usually represent differing social or ethical viewpoints or differing areas of biomedical, social scientific, or other types of expertise, or both. It is, in part, the diverse and representative composition of such committees that lends special authority to whatever agreement emerges from their deliberations. At the same time, this diversity is unlikely to produce predeliberative complete consensus. Yet if complete consensus rarely emerges at the beginning of a group's deliberations, it will, more often, develop toward the end. Consider, for example, questions so novel or puzzling that committee members have, at the outset, no firm positions on them. "This is not to say," as Jonathan Moreno puts it, "that they come with no views or principles in relation to the matter at hand, but rather that they do not hold them in such esteem that they are prepared to insist that their essence be represented in the solution" (Moreno, 1990a, p. 43). Here, open-minded, informed, mutually respectful, give-and-take discussion aimed at well-grounded agreement may produce convergence on both reasons and conclusion-complete consensus. Still, such consensus will not be frequent. Committee members often bring differing moral outlooks or principles to the deliberations that affect their reasoning or conclusions. Moreover, individuals representing differ-

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Society's Choices: Social and Ethical Decision Making in Biomedicine ing areas of expertise are likely to emphasize different aspects of complex, multidimensional questions in their thinking, leading to differing arguments, if not differing conclusions. If, however, committee members agree in their conclusions, but come to these conclusions in different ways, the result may still be consensus, though not complete consensus. Overlapping Consensus The term "overlapping consensus" has been coined by political philosopher John Rawls to characterize agreement on basic principles of justice among individuals embracing a plurality of different, occasionally conflicting, comprehensive moral, religious, and philosophical outlooks (Rawls, 1993, pp. 15, 133-72). As different premises may lead to the same conclusion, different comprehensive outlooks, Rawls argues, may support the same conception of social justice. There is, in this event, overlap among those parts of different individuals' comprehensive moral, religious, and philosophical views that include a particular conception of social justice, but not among their moral, religious, and philosophical views as a whole. Thus, for example, one person may situate his or her support of a particular conception of justice within certain religious convictions, while another may find a place for the very same conception within either Kant's or Mill's comprehensive (secular) moral theory (Rawls, 1993, p. 145). Agreement among members of an ethics committee or commission may also be a type of overlapping consensus. Individuals arguing from different moral, religious, philosophical, and empirical premises may nonetheless reach the same conclusion with respect to positions or policies in bioethics.1 Stephen Toulmin observed this sort of consensus in his role as a staff member with the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. Although commissioners were usually in agreement about their recommendations-"even about quite detailed recommendations"-the consensus did not, Toulmin writes, extend to the arguments or principles supporting these recommendations: When the eleven individual commissioners asked themselves what "principles" underlay and supposedly justified their adhesion to the consensus, each of them answered in his or her own way: the Catholics appealed to Catholic principles, the humanists to humanist principles, and so on. They could agree; they could agree what they were agreeing about; but, apparently, they could not agree why they agreed about it [Toulmin, 1981, p. 32].2 Consensus in societies acknowledging a plurality of conflicting comprehensive moral outlooks will often be overlapping. The wish for complete consensus on all moral issues is, as I will show below, utopian. I want

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Society's Choices: Social and Ethical Decision Making in Biomedicine now to compare consensus-complete and overlapping-with compromise and (what may be construed as a special kind of compromise) majority rule. Compromise Compromise bears more than a superficial resemblance to consensus, but it is also importantly different. Central to compromise is the idea of mutual concession for mutual gain. Consider, in this connection, the deliberations and conclusions of the Warnock Committee of Inquiry into Human Fertilization and Embryology (Warnock, 1985b). Among the issues addressed by this group of British physicians, lawyers, theologians, social scientists, and ordinary citizens, chaired by philosopher Mary Warnock, was the question of the permissibility of research using human embryos. Moral opinion on this matter was at the time (and still is) deeply divided. At the root of the controversy are opposing views of the moral status of the embryo. Those who believe that human life protected by laws against murder begins at conception consider the embryo to have the same status as an adult human being, and are thus strongly opposed to any research of this kind. Those who regard the moral status of the human embryo as significantly lower than that of an adult are heavily influenced by the undeniable utilitarian advantages of such research with respect to inquiries into infertility, miscarriage, congenital defects, and related matters. The Warnock Committee was charged with making a recommendation at the national level on this highly controversial question. Although moral views on this matter were divided, a policy embodied in law would necessarily be singular and binding on all. The most basic recommendation of the majority of the committee's members on the question of embryo research seems to have been a compromise between the two polar positions. Such research would be permitted, but only for up to 14 days from fertilization. It would, after this, be categorically forbidden. As Warnock puts it, in the end the Inquiry felt bound to argue, partly on Utilitarian grounds, that the benefits that had come in the past from research using human embryos were so great (and were likely to be even greater in the future), that such research had to be permitted; but that it should be permitted only at the very earliest stage of the development of the embryo [Warnock, 1985a, p. 517]. Thus, each polar position to the disagreement (that representing an extreme conservative or "pro-life" view of the moral standing of the embryo, and that representing a considerably more liberal, or utilitarian, view) received part, but not all, of what it was after. Members of the committee holding either of these positions who nonetheless agreed to the compro-

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Society's Choices: Social and Ethical Decision Making in Biomedicine mise must be presumed, for one reason or another, to have valued the committee's speaking with one voice on this matter more than they valued the committee's endorsing their own view at the price of continued impasse. Compromise in this and similar situations resembles consensus insofar as the group speaks with one voice in making and supporting a particular recommendation.3 There is consensus, in these circumstances, on what position ought to be adopted by the group. Compromise differs from consensus, however, insofar as those supporting the compromise retain personal moral views that are more or less at odds with the position they endorse in their roles as committee members.4 Each party to the compromise makes concessions for the sake of agreement on a single recommendation that seems to have some independent validity and to capture as much of one polar position as it does of the other. The matter is not, however, fully settled; there is no closure, no final harmony, no complete or overlapping consensus. Moral compromise is not, strictly speaking, resolution. It makes the best of what contending parties regard as a bad situation. Individual committee members may subsequently try to persuade those with whom they disagree of the superiority of their initial position with an aim to its eventually being reconsidered and endorsed by the group as a whole. Majority Rule Occasionally a committee will be unable to reach complete or overlapping consensus on a particular issue or to devise a satisfactory compromise. Still, each member may believe that the group's making either of two recommendations on the issue would be better than its making no recommendation at all. In this event a consensus may emerge from taking a vote between the two alternatives, then endorsing, as a committee, the recommendation receiving a majority of votes. A resort to majority rule under such circumstances includes elements of both consensus and compromise. There is, first, consensus on the procedure to be followed in determining the group's substantive position-what we might call procedural-as opposed to substantive, consensus. Second, agreeing to abide by the outcome of this procedure is a type of compromise. A committee member favoring position A over position B would rather have the entire committee recommend A on its merits. But since this will not occur and efforts to find a compromise position between A and B have been unsuccessful, the committee member agrees to the vote because he or she believes the possibility of B's winning a majority of votes and becoming the committee's recommendation is from an ethical point of view better than the committee's remaining deadlocked. If those favor-

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Society's Choices: Social and Ethical Decision Making in Biomedicine ing position B follow mutatis mutandis the same chain of reasoning, the result may be characterized as a procedural, as opposed to a substantive, compromise. Though less desirable than substantive consensus or substantive compromise, employment of majority rule under such circumstances is fair to all committee members. What would be unfair, however, is resorting to vote-taking without the consent of all committee members and then attributing the results to the committee as a whole. A majority position, under such conditions, is attributable only to those who voted for that position, and not to those who were opposed to settling the matter by vote-taking. Where a resort to vote-taking is a product of procedural consensus and represents procedural compromise, however, the outcome is endorsed by and attributable to the group as a whole. Following customary usage, I have to this point restricted the term consensus" to pre- and postdeliberative complete consensus and overlapping consensus. But because both compromise and majority rule contain elements of consensus and are sometimes employed by ethics committees and commissions, I consider them as forms of consensus in what follows. STRATEGIC CONSIDERATIONS Arguments for consensus may be either strategic or normative. Strategic considerations emphasize the instrumental value of consensus. The principal value of consensus is, on this view, its contribution to obtaining external acceptance and implementation of a group's recommendations. Normative arguments center on a more direct connection between consensus and moral rightness; consensus is regarded as adding substantive value or weight to the recommendations of an ethics committee or commission. I discuss strategic considerations in this section and normative considerations in the next. In an article describing and defending the structure and operation of the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Commission Chairman Morris B. Abram and attorney Susan M. Wolf emphasize the practical importance of virtual unanimity or consensus among the commission's members: A Commission such as this one has only the power of persuasion. A group performing ethical analysis with no coercive powers cannot be persuasive without internal agreement. Unlike a court or legislature, which is structured to have effect as long as a majority agrees, a commission requires agreement that is as close to unanimity as possible, to have any effect at all. Without such virtual unanimity, the commission members simply voice possible arguments; with it the commission can persuade. The commission method thus forces the commissioners to find areas of common accord [Abram and Wolf, 1984, p. 629].

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Society's Choices: Social and Ethical Decision Making in Biomedicine The provisions governing membership on the commission, Abram and Wolf add, mandated that commissioners have diverse backgrounds and represent a variety of ethical viewpoints. Though making agreement more difficult to achieve, this same diversity contributes to the persuasive power of any consensus emerging from such a group. The more dissimilar their backgrounds and viewpoints, the more likely it is that positions on which they achieve consensus (or even well-grounded compromise) will be endorsed by legislators and public. Yet stressing consensus for strategic reasons may weaken the substantive power or coherence of a group's recommendations. Consider, for example, criticisms of the President's Commission's volume on access to health care. Ronald Bayer, in a well-documented review of the commission's deliberations on this matter, identifies and sharply criticizes the "kinds of compromises that were necessary to bring the Commission's work [on this topic] to a successful conclusion" (Bayer, 1984, p. 314). Agreement between the commission's staff, who favored the language of rights, and most commissioners and the staffs executive director, who did not, required replacing the notion of a right to health care with the weaker notion of a societal obligation to provide access to care. This was, to Bayer's mind, an unfortunate concession. "The concept of positive or social welfare rights," he argues, has emerged in recent American history as the most potent political language for those seeking to make claims against a nonegalitarian social structure. By explicitly rejecting the concept of a right to health care, thus breaking with recent public discourse on this matter, the commission deprived those poorly served by the current health care system of a language with which to express their discontent. In so doing, the commission implicitly adopted a perspective that views social change as the consequence of the recognition of moral obligations by the socially powerful, rather than as a result of demands pressed from below as a matter of right (Bayer, 1984, p. 320). This charge has been echoed by John Arras, who argues that the commission's "retreat from the right to health care" represents "a significant retrenchment of our public commitment to provide health care for the needy" (Arras, 1984, p. 322). In a different but related vein, Baruch Brody criticizes the commission's work on access to health care for failing to come to grips with underlying philosophical questions about distributive justice. "The Commission," he maintains, "needed to delve more deeply into the philosophical issues in order to show the extent to which we lack an appropriate social policy about access because we lack a social consensus about distributive justice" (Brody, 1989, p. 376f). A number of deep and divisive philosophical questions were papered over in the interests of maintaining a strategic consensus. Yet this served no purpose and may even have hampered subsequent

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Society's Choices: Social and Ethical Decision Making in Biomedicine efforts to address the important underlying questions. "By failing to delve into the philosophical problems about justice in the allocation of resources," Brody concludes, the Commission failed to provide a coherent approach to the difficult problems of securing access to health care. It would have done better, I submit, to be more philosophical, to present a series of alternative theories of justice and their implications, and to call upon society to make some choice among them [Brody, 1989, p. 383]. Where deep philosophical differences underlie conflicts about policy, a committee or commission does better to identify these differences and urge further reflection than to obscure them with a shallow strategic consensus on what proves to be an empty or incoherent substantive recommendation. In a revealing account of the complex workings of a hospital ethics committee, Ruth Macklin charts one group's struggle to reach consensus on a difficult philosophical question. Charged with developing policy for blood transfusions involving Jehovah's Witnesses, the committee was unable to agree on guidelines for transfusing pregnant Witnesses. The issue was whether these patients should have the same right to refuse lifesaving transfusions as other adult Jehovah's Witnesses. On the one hand, some members of the committee believed that pregnant Witnesses should have the same rights to control their bodies as other Jehovah's Witnesses. On the other hand, some physicians maintained that the presence of what they considered a "second patient"-the fetus-would not permit them to accede in good conscience to any refusal of a lifesaving transfusion by a pregnant Witness. After two years of deliberation and numerous reversals of position, the committee eventually determined that it could not reach a consensus on specific guidelines for pregnant Witnesses. "Reluctantly," Macklin reports, ''the committee adopted the suggestion that it not even attempt to dictate a policy but limit its task to describing the competing principles, leaving the decision-making process to the patient and clinician" (Macklin, 1988, p. 20). NORMATIVE CONSIDERATIONS Abram and Wolf do not ask whether consensus can have normative as well as strategic or persuasive value. Does consensus add moral weight to a position in bioethics? Philosophers have long argued that the mere fact of agreement does not make a position morally right (Moreno, 1990b). Still consensus may, in some circumstances and under some conditions, contribute to the normative significance of a group's recommendations. To show how this is so I must say something about (1) the nature and extent of

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Society's Choices: Social and Ethical Decision Making in Biomedicine moral pluralism; (2) the distinction between rationality and reasonableness; (3) the extent to which questions of biomedical ethics generate genuine uncertainty or reasonable disagreement; (4) the importance of agreement, both in health care institutions and in national policy, on some of these questions; and (5) the likelihood that informed, unforced agreement on a particular issue or policy among members of a conscientious, well constituted ethics committee or commission will respect, if not incorporate, all reasonable positions on the matter. Moral Pluralism Moral pluralism, as I use the term here, is the view that moral disagreement cannot be eliminated by appeals to abstract impersonal principles. Our positions on particular issues are usually grounded in our comprehensive moral, religious, and philosophical outlooks and there is no single comprehensive outlook that should be embraced by all insofar as they are informed and rational. The comprehensive, identity-conferring outlooks that we bring to ethical reflection include a variety of conflicting, often equally reasonable, world views and ways of life. A world view is a complex, often unarticulated (and perhaps not fully articulable) set of deeply held and highly cherished beliefs about the nature and organization of the universe and one's place in it. Normative as well as descriptive-comprised of interlocking general beliefs about knowledge, reality, and value-a world view so pervades and conditions our everyday thinking that it is largely unnoticed (Luker, 1984, p. 158). Among the elements of a world view are one's deepest convictions about: (a) God that is, whether there is a God and, if so, God's nature; (b) the nature and purpose (if any) of the universe and human life; (c) the nature, justification, and extent of human knowledge; (d) the nature of human beings (including, for example, their capacities for free will, goodness, compassion, selfishness, and, in certain world views, sin and redemption); (e) the best way(s) to structure human relationships (including sexual and familial relationships, friendship, political institutions, and obligations to strangers); (f) the nature and status of morality, especially injunctions and principles having to do with the taking of life, the nature of equality, respect for liberty, and so on; and (g) the moral standing of nonhuman animals and the intrinsic value (if any) of the natural environment. A world view, as this list suggests, may be theistic or entirely nontheistic. Closely related to a particular world view is a corresponding way of life. "Ways of life," writes Stuart Hampshire, "are coherent totalities of customs, attitudes, beliefs, institutions, which are interconnected and mutually dependent in patterns that are sometimes evident and sometimes subtle and concealed." Ways of life include "repeated patterns of behavior, . . .

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Society's Choices: Social and Ethical Decision Making in Biomedicine admired ideal types of men and women, standards of taste, family relationships, styles of education and upbringing, religious practices and other dominant concerns" (Hampshire, 1983, p. 5). A person's world view and way of life are dynamically interrelated. A world view helps to structure a way of life; a way of life presupposes and embodies a particular world view. Deep changes in one are likely to occasion related changes in the other. A distinctive and easily recognized world view and way of life is that of the Amish. Most world views and ways of life are, however, more difficult to delineate in rapidly changing complex societies like ours which permit, if not encourage, the exercise of individual choice. A complex amalgam of a wide variety of beliefs, attitudes, values, ideals, and practices, a contemporary world view and way of life is often highly customized. This is not, however, to say that these more individualized world views and ways of life are less significant to those who identify with them than a distinctively Amish world view and way of life is to those who identify with it. A world view and way of life gives shape and meaning to a person's life, providing the basis for his or her identity and integrity as a moral being. World views and ways of life come into conflict because they are, for the most part, based on local and particular, rather than more general and universal, aspects of human life. Their perspectives are historically conditioned, contingent, and sometimes fiercely personal and parochial. Loyalties to particular institutions, practices, projects, and persons are often regarded as essential to one's way of life; they constitute much of one's identity and set one off from others as a particular person. Not all world views and ways of life are, however, worthy of respect. A world view and way of life may be criticized for inconsistency or instability, or for clearly and systematically violating the principle of utility or the second formulation of Kant's Categorical Imperative ("So act as to treat humanity, whether in thine own person or in that of any other, in every case as an end withal, never as a means only"). Though unable fully to determine our world views and ways of life, these well-grounded principles serve as important constraints on them.5 Each centers on a morally significant feature of human beings that cuts across social, cultural, national, religious, racial, and sexual differences: sentience (for the principle of utility) and the capacity for rational self-direction (for the Categorical Imperative). World views and ways of life systematically indifferent to or contemptuous of the principle of utility or the Categorical Imperative must be rejected (or at least constrained) regardless of their historical roots or their importance to the identities of those holding them. It is thus that world views and ways of life endorsing what clearly amounts to wanton cruelty and neglect, human sacrifice, and slavery are widely and rightly condemned. Campaigns to reform world views and ways of life incorporating more subtle violations of these principles are now being undertaken.

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Society's Choices: Social and Ethical Decision Making in Biomedicine Some—for example, those that have added "racism" and "sexism" to our vocabularies-have already achieved a measure of success. Others-for example, those attempting to raise our consciousness about homophobia and speciesism-still have a long way to go. But the general point remains: World views and ways of life that clearly and systematically violate these more abstract and general principles are unreasonable and may be restricted. A world view and way of life is reasonable to the extent that it satisfies well-grounded, widely shared standards and principles of reason. The problem is that there are a number of reasonable world views and ways of life that occasionally engender differing answers to moral questions, especially questions of biomedical ethics. This diversity of reasonable comprehensive moral outlooks, as Rawls points out, "is not a mere historical condition that may soon pass away; it is a permanent feature of the public culture of democracy" (Rawls, 1993, p. 36). So long as people enjoy a certain amount of liberty of thought and action they will embrace a variety of reasonable world views and ways of life that will occasionally yield conflicting answers to moral questions. Agreement by all on a single world view and way of life can be maintained, as Rawls adds, only by "the oppressive use of state power" (Rawls, 1993, p. 37). Rationality and Reasonableness Rationality is, for the most part, an intellectual virtue having to do with the selection and pursuit of the most effective means to a set of carefully selected ends. "I behave irrationally," W. M. Sibley writes, when I do not bother to ascertain the true nature of the ends I set myself; or when I heedlessly sacrifice one end to a second, which when attained I find to be of less worth to me than the first would have been; or when I select unrealistic means; or when, having reached a rational enough decision, I fail to implement that decision in practice [Sibley, 1953, p. 556]. One's ends as a rational agent need not, however, be egoistic. Consider, for example, a paternalistic physician whose world view and way of life places a premium on improving other people's health and saving their lives. Insofar as this physician is rational he will do what he can to pursue this end. But he is not, simply as a rational agent, required to give equal respect and concern to the conflicting reasonable ends of his patients. Rationality requires that the physician take his patients' ends into account only insofar as doing so is instrumentally necessary for effectively furthering those of his ends (which incorporate, in this instance, his conception of their welfare) that may be distinct from or opposed to theirs. If, therefore, the physician's obtaining consent to what he regards as beneficial treatment from a competent adult patient requires that he deceive the patient

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Society's Choices: Social and Ethical Decision Making in Biomedicine and he knows he can get away with it, the physician will, insofar as he is rational, be deceptive. Reasonableness, on the other hand, requires giving equal or fair consideration to the reasonable ends or viewpoints of others for their own sakes. A person can therefore be rational without being reasonable, as shown by the example of the paternalistic physician. Reasonableness is a moral virtue, not simply an intellectual one. To be reasonable is to seek reasons for one's conduct that respect the reasonable ends and points of view of those affected by it. It is therefore, in the light of moral pluralism, unreasonable to suppose that there is one and only one right answer to all moral questions. Insofar as I acknowledge that a disagreement between another person and myself is rooted in a conflict between reasonable world views and ways of life and I am committed to respecting the (reasonable) ends and points of view of others, I must admit that abstract, impersonal reason cannot, at least at this point, provide a resolution (Benjamin, 1990a, Ch. 4). Bioethical Questions Questions of biomedical ethics place unusual strain on our moral frameworks and traditions. In some cases, advances in medical knowledge and technology create choices and possibilities so complex or radically new or unprecedented that neither particular world views and ways of life nor abstract general principles provide much in the way of firm or direct guidance. The questions, we know, are important, but we are not quite sure what to think or do about them. We feel a need to learn more about the complex clinical, scientific, social, and ethical aspects of them before coming to a decision. In other cases, these new choices and possibilities-especially those involving procreation, childbirth, child rearing, the nature of the family, and the termination of life-elicit clear and firm responses rooted in different world views and ways of life. Not only do we have ethical positions on these choices and possibilities, but they are deeply held and identity conferring. Yet they conflict with ethical positions rooted in other (reasonable) world views and ways of life that we cannot, insofar as we are reasonable, simply dismiss. Although we are clear about what we, as individuals, believe to be right, we are not quite sure what should be done by a health care team, a hospital, or a society when those directly affected hold conflicting, yet not unreasonable, positions. Need for Agreement It is the need for some sort of agreement or consensus in the light of the genuine uncertainty and reasonable disagreement characteristic of

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Society's Choices: Social and Ethical Decision Making in Biomedicine many questions in biomedical ethics that has prompted the development of ethics committees and commissions. The complexity of modern medicine often requires the close cooperation among members of a health care team, patients, and patients' families. Though some of these individuals may, at least initially, be uncertain about or hold conflicting positions on bioethical issues, they often need to agree on a single treatment plan. Respect for reasonable moral differences requires that this agreement be informed and uncoerced rather than imposed by deception or force by those with a monopoly on power. If parties to a particular conflict are unable to come to such an agreement by themselves, they may seek assistance from an institutional ethics committee. The same is true of questions of hospital or national policy. Though different individuals and organizations may, for example, have conflicting, reasonable views on how transplantable organs ought to be allocated in the United States, a national system requires agreement on a single set of principles and criteria binding on all. Here, too, respect for reasonable moral differences requires that this agreement be informed and uncoerced rather than imposed by force or deception. Value of Consensus Suppose we find ourselves in a situation requiring a single policy on a complex bioethical question characterized by genuine uncertainty or reasonable disagreement. A committee or commission is constituted to examine the situation and recommend a policy. The committee members represent or have access to all relevant aspects of biomedical, social scientific, cultural-religious, legal, and bioethical expertise on the matter, with emphasis on patient-citizen viewpoints. The group makes a concerted effort to identify all reasonable positions on the issue and to give them fair consideration. Moreover, no committee member or coalition of committee members is able to dominate the group's information-gathering, deliberation, or decision-making. Finally, after considering all actual or imagined reasonable arguments and positions on the matter, the group comes to an informed, uncoerced agreement on what, for institutional or social purposes, is regarded by each member as the best answer to the question. This agreement may take the form of complete consensus, overlapping consensus, compromise, or even consensus to endorse the outcome of a vote between two or more reasonable positions, each of which is regarded by everyone as superior to the group's coming to no agreement on the matter. A consensus meeting these conditions carries moral weight or adds normative significance to the group's recommendation because it respects both the depth of genuine uncertainty or the extent of reasonable disagreement on the matter and the need for informed, uncoerced agreement. This is

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Society's Choices: Social and Ethical Decision Making in Biomedicine not to say that the recommendation must be accepted without question. Yet the burden is on those who disagree to show why, for purposes of reasonable agreement in a pluralistic society, it is defective. An Illustration Consider, as an illustration, a statement of general principles for allocating transplantable organs and tissues developed by the 1991 Ethics Committee of the United Network on Organ Sharing (UNOS) (Ethics Committee, 1992).6 The Ethics Committee identified three principles governing most allocation decisions: (1) Utility (interpreted as net medical benefit); (2) justice (requiring fair or equitable treatment to all those awaiting organs); and (3) autonomy (respecting informed, self-directing patient choice, even if this does not in certain instances maximize utility or promote equitable distribution). The group then acknowledged possible conflicts between the three principles and addressed means of resolving them. One strategy is to establish a fixed ranking of the principles-to prioritize or lexically order them in some way-and to always follow this ranking. One might, for example, propose that autonomy is prior to and, in cases of conflict, overrides justice; and that justice is similarly prior to and, in cases of conflict, overrides utility. This was, however, rejected as overly rigid. Whatever ranking one established ahead of time, it is always possible to imagine situations in which the consequences of adhering to it would be unacceptable. A second strategy is to address conflicts case by case, appealing to moral intuition. The problem with this is that people's intuitions differ widely on these matters, resulting in deadlock or a lack of uniformity from one transplant center to another and within centers from one person to another. A third strategy, which the committee endorsed, is to acknowledge the complexity of the situation and seek some sort of compromise or accommodation among the three principles. With regard to conflicts between utility and justice, for example, the committee states: While [individual] members of the Committee hold diverging positions regarding the ethically correct relations between utility and justice, a consensus has been reached for purposes of policy relative to organ and tissue allocation: utility . . . and justice (or fairness in distribution) should be given equal status. This means that it is unacceptable for an allocation policy to single-mindedly strive to maximize aggregate medical good without any consideration of justice in distribution or for a policy to be single-minded about promoting justice at the expense of the overall (medical) good [Ethics Committee, 1992, p. 2229, emphasis added]. In cases of conflict, the committee proposed, justice and utility require equal consideration:

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Society's Choices: Social and Ethical Decision Making in Biomedicine We make this proposal fully realizing that it may not square with the personal morality of many people. Some would insist on higher priority for utility; others for equity. In fact, whole classes of people might be so inclined invariably to favor one of these principles or the other. The fact that one group would give very heavy weight to one or the other of the principles cannot, for public policy purposes, settle the matter. Inasmuch as: (1) neither side can provide conclusive arguments for its position; (2) each side can provide plausible arguments for its position; and (3) ours is a pluralistic society in which individual views cover the entire spectrum from pure utilitarianism to extreme egalitarianism, we believe that giving equal consideration to each is a fair and workable compromise [Ethics Committee, 1992, p. 2230, emphasis added]. Apart from minor differences in wording, this line of reasoning closely resembles the one developed in this section. Though the committee's compromise might be rejected as the best moral position by a number of individuals as individuals, it cannot, the Committee suggests, be reasonably rejected as a basis for public policy by individuals as citizens for whom informed, unforced reasonable agreement on such principles is of great importance.7 While a person may reasonably reject a policy that ignores or violates his or her personal moral position, he or she cannot reasonably reject a coherent policy that (1) acknowledges reasonable disagreement on the matter; (2) incorporates important elements of his or her personal moral position; and (3) respects as many different reasonable positions as any workable alternative. Finally, we should note that this Committee, like the hospital ethics committee described above by Macklin, was unwilling to reach consensus at any cost. The subcommittee drafting the initial document could not, for example, agree on whether (carefully screened, abstinent) alcoholic endstage liver disease patients should be able to compete equally with nonalcoholic patients for access to the limited supply of transplantable livers. After considerable discussion and a 3-2 straw vote, subcommittee members concluded they could not, in good conscience, answer this question as a group. The final document states that "the Ethics Committee has not at this time reached a single position regarding the nonpunitive use of this factor [organ-damaging patterns of behavior] in allocation of organs" and then identifies arguments for and against the alternatives (Ethics Committee, 1992, p. 2234). PROBLEMS AND LIMITS A consensus among members of an ethics committee or commission may be questioned in a number of ways. Doubts may be raised about a particular group's composition, its deliberations, and its substantive recommendations.

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Society's Choices: Social and Ethical Decision Making in Biomedicine Composition Recall the "Appleton Consensus" (Stanley et al., 1989). One might reasonably ask whether a group consisting only of physicians, bioethicists, and economists has given adequate consideration to all relevant, reasonable views on questions of foregoing medical treatment. Were, for example, the possibly differing, reasonable viewpoints of patient-citizens, nurses, and allied health professionals given the same weight as those of the committee members? Were the committee members aware of, and capable of adequately representing, these other viewpoints? Consensus among members of a bioethics committee or commission has normative significance only if the group is broadly constituted. The group forming the Appleton Consensus, though it may in fact have identified and considered all reasonable positions, appears to fall short on this ground. Yet it is one thing to urge that such groups be broadly constituted having access to all relevant aspects of biomedical, social scientific, cultural/religious, legal, and bioethical expertise as well as knowledge of all reasonable ethical positions on matters that come before it-and quite another to actually constitute such a committee while retaining workable size. There is no mechanism or formula for putting together an effective, broadly constituted bioethics committee or commission. If, however, we are to attribute normative significance to any consensus it may reach, we must pay careful attention to the breadth of its membership (Fleetwood et al., 1989; Lo, 1987). Deliberations The deliberations of well-informed, broadly constituted committees or commissions may go wrong in a number of ways. First, such groups may be co-opted to serve the partisan interests of those who appoint them (Callahan, 1992). Second, the view of powerful or charismatic chairpersons, individual members, or subgroups may be given more weight than they deserve. Third, pressure to reach agreement may lead to avoiding controversial issues, underestimating risks and objections, ignoring unpopular or powerless viewpoints, failing to consider alternatives, failing to seek additional information, uncritically accepting secondhand information, or failing to exercise sufficient imagination or ingenuity in building consensus or devising compromise (Lo, 1987, p. 48). A problem endemic to committee deliberations is "groupthink," defined by Irving L. Janis as "a mode of thinking that people engage in when they are deeply involved in a cohesive in-group, when the members' strivings for unanimity override their motivation to realistically appraise alternative courses of action" (Janis, 1972, p. 9).

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Society's Choices: Social and Ethical Decision Making in Biomedicine To be forewarned of these and other pitfalls of group dynamics is, however, to be forearmed. "Ethics committees that recognize the dangers of groupthink can," as Lo points out, "take steps to avoid them": First, committees can guard against premature agreement. The chairperson may explicitly ask that doubts and objections be expressed or may appoint members to make the case against the majority. Second, committees can scrutinize any secondhand information they receive ... Third, the committee can look for innovative ways to settle disputes [Lo, 1987, p. 48]. Recommendations That a broadly constituted, well-informed ethics committee or commission has reached consensus on a particular recommendation is reason for giving serious, but not uncritical, attention to it. The presumption is that such multidisciplinary groups have examined all aspects of a bioethical question characterized by genuine uncertainty or reasonable disagreement and, after considering all reasonable alternatives, conscientiously come to informed, unforced agreement on the best position for institutional or social purposes. This is, however, only a presumption. Given the many ways in which a group's deliberations can go wrong, a morally autonomous individual must critically examine the group's reasoning before endorsing its conclusions. CONCLUSION Advances in medical knowledge and technology together with moral pluralism create a variety of bioethical questions about which we are genuinely uncertain or deeply divided. The problem is aggravated by the fact that the complexity of modern medicine requires close cooperation among members of a health care team, patients, and patients' families who may, as individuals, have differing, but not unreasonable, positions on bioethical issues. The question, then, is whether it is possible to obtain unforced, informed agreement on ethical issues requiring joint conduct among individuals who are either genuinely uncertain or committed to conflicting positions. The same is true, at the policy level, for hospitals and other health care institutions and for society as a whole. In response, governments and health care institutions have turned for guidance to various more or less broadly constituted, multidisciplinary committees or commissions. At their best, such groups represent or have access to all relevant expert knowledge and moral perspectives. They strive to identify all reasonable moral positions and give them fair consideration. Avoiding "groupthink" and related pitfalls, the committee or commission

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Society's Choices: Social and Ethical Decision Making in Biomedicine may then come to informed, uncoerced agreement on what, for institutional or social purposes, is regarded by each member as the best (or most reasonable) answer to a certain question. Agreement may take the form of complete consensus, overlapping consensus, compromise, or endorsing the results of a vote. The ultimate test of such a recommendation is whether it is specific enough to be of practical value and, at the same time, unable to be reasonably rejected by the larger population as the basis for informed, uncoerced agreement (Benjamin, 1989, Scanlon, 1982). These conditions, as indicated above, cannot always be satisfied. In such cases committees or commissions do better to identify difficulties and problems than to paper them over (Brody, 1989; Fleetwood et al., 1989; Macklin, 1988). In other cases, however, the deliberations and recommendations of a well-constituted ethics committee or commission may be able to meet these conditions. Both the Warnock Committee's recommendation on embryo research (Warnock, 1985b) and the UNOS Ethics Committee's recommendation on principles for organ allocation (Ethics Committee, 1992) seem to me to be sufficiently specific and, given the need for broad societal agreement, difficult for anyone to reasonably reject. These groups succeed, in part, because they explicitly acknowledge various conflicting positions, together with the need for reasonable agreement (Warnock, 1985a; Ethics Committee, 1992). More important than a committee's achieving consensus among its members is its ability to stimulate and guide the development of an informed, uncoerced agreement in the larger society. Broadly constituted groups that aim at this end may not always reach consensus. But when they do, it is more likely to be of genuine value. NOTES 1.   This should not be unfamiliar to bioethicists who can often construct both utilitarian and Kantian arguments for the same conclusion. 2.   Toulmin himself might be reluctant to characterize such situations in terms of ''overlapping consensus" or different principles leading to the same conclusion. He is prompted to question the value of principles in ethical reasoning: "So, by the end of my tenure with the Commission I had begun to suspect that the point of 'appealing to principles' was something quite else: not to give particular ethical judgments a more solid foundation, but rather to square the collective ethical conclusions of the Commission as a whole with each individual commissioner's other nonethical commitments." 3.   There were, however, dissenters and a minority report on this issue in the case of the Warnock Committee. 4.   The discrepancy between an individual's personal moral position and the compromise position he or she endorses as a member of the committee raises questions of personal integrity. I cannot pursue these questions here. Elsewhere I have argued that compromise may, in such circumstances, be integrity-preserving (Benjamin, 1990a, 1990b). 5.   One must distinguish between the principle of utility and the Categorical Imperative, on the one hand, and utilitarianism and Kantianism, on the other. The principle of utility

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Society's Choices: Social and Ethical Decision Making in Biomedicine     and some form of the Categorical Imperative are likely to be part of any reasonable, comprehensive moral outlook. Utilitarianism and Kantianism, however, are particular comprehensive outlooks that derive or subordinate all other ethical considerations to the principle of utility and the Categorical Imperative, respectively. 6.   "Members of the committee were purposely selected to represent diverse fields of expertise and varying perspectives. Physicians, ethicists, clergy, lawyers, transplant coordinators, nurses, patients, and individuals from other fields are included on the committee" (1991 Ethics Committee, 1992, p. 2226). I was a member of this committee. 7.   This formulation draws on the contractualist criterion of moral justification developed by T. M. Scanlon (Scanlon, 1982). REFERENCES Abram, M. B., and Wolf, S. M.: 1984, "Public Involvement in Medical Ethics," New England Journal of Medicine 310, 627-32. Arras, J. D.: 1984, "Retreat from the Right to Health Care: The President's Commission and Access to Health Care," Cardozo Law Review 6, 321-45. Bayer, R.: 1984, "Ethics, Politics, and Access to Health Care," Cardozo Law Review 6, 303-20. Benjamin, M.: 1989, "Value Conflicts in Organ Allocation," Transplantation Proceedings, 21, 3378-79. Benjamin, M.: 1990a, Splitting the Difference: Compromise and Integrity in Ethics and Politics, University Press of Kansas, Lawrence, Kansas. Benjamin, M.: 1990b, "Philosophical Integrity and Policy Development in Bioethics, "Journal of Medicine and Philosophy 15: 375-89. Brody, B. A.: 1989, "The President's Commission: The Need to be More Philosophical," Journal of Medicine and Philosophy 14: 369-83. Callahan, D.: 1992, "Ethics Committees and Social Issues: Potentials and Pitfalls," Cambridge Quarterly of Health Care Ethics 1, 5-10. Ethics Committee of the United Network on Organ Sharing: 1992, "General Principles for Allocating Human Organs and Tissues," Transplantation Proceedings 24: 2226-2235. Fleetwood, J.E., Arnold, R.M., Baron, R.J.: 1989, "Giving Answers or Raising Questions?: The Problematic Role of Institutional Ethics Committees," Journal of Medical Ethics 15: 137-42. Hampshire, S.: 1983, Morality and Conflict, Harvard University Press, Cambridge, MA. Janis, Irving L.: 1972, Victims of Groupthink, Houghton Mifflin, Boston. Lo, B.: 1987, "Behind Closed Doors: Promises and Pitfalls of Ethics Committees," New England Journal of Medicine 317: 46-50. Luker, K.: 1984, Abortion and the Politics of Motherhood, University of California Press, Berkeley and Los Angeles. Macklin, R.: 1988, "The Inner Workings of an Ethics Committee: Latest Battle over Jehovah's Witnesses," Hastings Center Report 18: 15-20. Moreno, J.D.: 1990a, "What Means This Consensus? Ethics Committees and the Philosophic Tradition," Journal of Clinical Ethics 1: 38-43. Moreno, J.D.: 1990b, "Getting to 'Maybe'," Bioethics Books 2: 41-43. Rawls, J.: 1993, Political Liberalism, Columbia University Press, New York. Scanlon, T.M.: 1982, "Contractualism and Utilitarianism," in Sen, A. and Williams, B.: 1982, Utilitarianism and Beyond, Cambridge University Press, Cambridge. Sibley, W.M.: 1953, "The Rational Versus the Reasonable," Philosophical Review 62: 554-60. Stanley, J.M. and 32 others: 1989, "The Appleton Consensus: Suggested International Guidelines for Decisions to Forego Medical Treatment," Journal of Medical Ethics 15: 129-36.

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Society's Choices: Social and Ethical Decision Making in Biomedicine Toulmin, S.E.: 1981, "The Tyranny of Principles," Hastings Center Report 11:31-39. Warnock, M.: 1985a, A Question of Life: The Warnock Report on Fertilisation and Embryology, Basil Blackwell, Oxford. Warnock, M.: 1985b, "Moral Thinking and Government Policy: The Warnock Committee on Human Embryology," Milbank Memorial Fund Quarterly 63: 504-22.