Dickenson raises
an uncomfortable question for medical ethics: is there really more of an
element of luck than we might care to acknowledge? Is it a real problem, or a
paradox in theory only? In a substantially revised and rewritten version of her
1991 book Moral Luck in Medical Ethics and Practical Politics she
considers some of the emerging ethical debates in more detail. In particular,
she includes new chapters on ethics in psychiatry, especially where the
assessment of risk and dangerousness is concerned, reproductive technology,
genetics and death and dying; all areas in which there have been major shifts
in what is medically possible and socially desirable, and, finally, attempts to
synthesise a mature feminism that has transcended its own crisis of faith and a
global ethic of responsible action. She also acknowledges, albeit only really
in the Preface, that the academic debate has been substantially shaped by
Ulrich Beck’s notion of The Risk Society.

She begins by
drawing out the inherent tension in the Kantian position that "the good
will is imperviously good" and that any ill-luck, any unfortunate
outcomes, are really neither here nor there in determining whether an act is
good or not. But, she maintains that moral luck is not just an issue for
Kantians. It poses considerable difficulties for virtue ethics and
consequentialism.

She first develops
a typology of luck, and distinguishes outcome luck encompassing "chance
luck" (where some sort of choice or gamble is made) and "brute
luck" (where no sense of choice is apparent, as in being hit by a falling
meteorite); "circumstantial luck" (including being lucky enough to
live in a country with clean water); "luck in character" (where some
people are simply lucky to be born with a sunny disposition, and their good
acts result from this). She then proceeds to outline some of the issues around
the paradox of luck in ethics, even considering whether it is a real problem at
all or just some clever word play by sophisticated nay-sayers. Her general
point here seems to be that it is a little of both. She states that we can
retain a notion of responsible agency (that is, that it cannot all come down to
luck), one that is not ultimately unsettled by moral luck, if we limit what
agents are responsible for. Thus, in the case of unfortunate outcomes to a
medical procedure the doctor is not responsible providing he has acted
correctly in informing the client of possible outcomes in obtaining informed
consent. Sometimes, it’s just the way it is.

She pursues
similar interrogations with regard to utilitarian outcomes, especially in
regard to remorse, death and dying and the withdrawal of life support, and,
interestingly in making psychiatric decisions about risk, deprivation of
liberty and forcible treatment. In this last example she again raises the issue
of responsibility and finds the absolute relativist position wanting. It really
is not enough to say that it is all in the chance allocation of genes and
social circumstances; there is always an element of personal responsibility.

It is, of course,
well travelled territory in psychiatry, but when Dickenson considers the moral
responsibility of the clinician who "gets it wrong" she is not so
much providing an "Oh, well. These things happen" excuse or
rationalisation. She is helping to develop a moral framework which counteracts
what she calls genetically normed or determined theories. For her, these are
not only "the counsel of despair" and as such an abrogation of
responsibility, they are philosophically incoherent. They want it both ways.

One of the most
engaging aspects of the book is her choice of case studies and examples. Wisely
avoiding any attempt to trump the classics she examines such diverse characters
as Anna Karenina (would a happy ending have changed it all?), Lady MacBeth
(responsibility and agency), Styron’s Sophie (would the life lived by her other
child made any difference?) and a number of real and imagined case histories,
Gaugin amongst them. Through this technique she engages us in the twisted, not
to say tortured paradoxes and contradictions, the if-onlies and the
how-could-I-have-knowns, the sense of fortune-tossed helplessness and the
lament of if-only-I-had-known-then-what-I-know-now.

All this makes for
a thought-provoking, but sympathetic and reassuring consideration. She makes a
significant contribution to a bedevilling problem, and adds new perspectives
that illuminate. In the final analysis, we may have to consider the observation
of that other noted philosopher of ethics and protofeminist, Mae West, that
"goodness had nothing to with it".

© 2003 Mark Welch 

Dr Mark Welch is currently a
Senior Lecturer and Postgraduate Coordinator in The School of
Nursing at the University of Canberra, Australia. His PhD investigated the
representation of madness in popular film, and his other research interests
include the mental health of refugees and victims of torture, and the history
of psychiatric epistemology.

Categories: Ethics