Those of you who are hostile to strident utilitarianism should, perhaps, look away now. Jonathan Baron's utilitarianism is of a particularly strident sort. He would put it in place of  the current norm of open and covert appeals to intuitions within bioethics. That is to say, he is not really against bioethics as such, but only the way in which it is currently conducted. It is taken to involve messy forms of deliberation without any adequate justification of the decisions that result. This is not something that I would dispute, at least as far as the messiness goes, but the reader may wonder (that is to say I wonder) whether the toleration of such mess is not sometimes morally preferable to any available means of simplification. (However tempting the latter may be.)

In place of intuitions, Baron wants to put evaluation by appeal to what can be quantified and hence compared. We may not think that this will leave us with much but Baron is able to cover genetic modification, questions of life and death, consent, drug research and a good deal else, albeit each topic is quickly glossed rather than explored in depth. This is not a fault, just a sacrifice of detail to show breadth of applicability. Baron's concern is to show the in principle usefulness of quantitative methods, he is not trying to do everything in just over 200 pages. Quantification take place in the context of 'utilitarian decision analysis'. (Here's the technical bit, and again the squeamish may wish to look away.) To make some decision we ask (i) what would be the worst that could happen if we do x and things go wrong? And we ask (ii) what is the worst case scenario of we fail to do x? This is a combination of questions that is more familiar in the following form: what could happen if you operate? And what could happen if you don't operate?

By comparing the relative harmfulness of these two scenarios we get a measure of the required degree of probability that a favourable outcome can be secured. If, for example, the potential harm of an operation vastly outweighs the potential harm of doing nothing then the probability of success needs to be pretty close to 1 (i.e. 100%). (That's the technical bit over.)

To give persuasive force to his position Baron opens with an appeal to the case of Jesse Gelsinger. Jesse died at the age of 18. He had a mild form of a rare metabolic disorder that is life-threatening only for infants and not for adults. He didn't die from the disorder, he died from the experimental treatment. He allowed a medical team to try out an experimental therapy that went badly wrong. Research activities on human subjects in part of the hospital were suspended, inquiries were made, rules were tightened.

Although Gelsinger had no need for the therapy, he was asked for consent because it was politically unacceptable to try he therapy out on infants even though in severe cases of the disorder the infants would die anyway and the therapy might (only might) have improved their survival chances. Experimenting on babies is a touchy subject. We like consent, and infants cannot give it, nor is parental consent always an obviously suitable substitute. Readers are not-too-covertly invited to consider that Gelsinger died of misplaced and muddled intuitions of a familiar sort. Other interpretations of what went wrong are possible.

It is also far from obvious that Baron is consistent in appealing to the reader's intuitions in this way (even covertly) given that messy appeals to intuitions (covert and overt) are to be purged. On the plus side, Baron anticipates the charge that at some point he must  be drawing upon his own ideas of what is intuitively appealing. On the minus side, he doesn't give much of a response to this charge, noting only that the intuitions that he does appeal to (if he appeals to any) are of a different sort. This may be true, but the reader is owed an explanation of why the differences in question are relevant to decision making.

Be that as it may, once his own utilitarian intuitions are up and running Baron's approach is able to show its strengths. In particular, he is able to use decision analysis to good effect by making the abstract utilitarian concern for maximization into something far more action guiding than is usually the case. This is a major plus in favour of his approach and advocates of utilitarianism may feel that it is a step in the right direction. However, this association of decision analysis and utilitarianism comes at a price. Both of them quantify, and what they quantify is utility. But utilitarianism can and often does take account of the utility of actions or rules for lots of different people or indeed for everyone. This is the very thing that tends to make it impractical, it requires interpersonal comparisons and does so on an unworkable scale.

Although decision analysis is utilitarian in inspiration, it is characteristically a localised approach used by individuals or groups of individuals to determine what is best for themselves. It has a narrower and more workable focus of attention. Fusing the two works strongly for utilitarianisms benefit but to he detriment of the localized focus of decision analysis. In spite of his opening appeal to the Gelsinger case and the need to allow parents to consent on behalf of infants, fusion of these approaches (at least as it is effected by Baron) involves pushing the decision-making process upwards. It is moved away from patients and relatives who would just not be competent to take into account the fullest range of relevant considerations. What we are left with is a familiar model of deliberative expertise, albeit coupled with consultation of patients and relatives about ends and not means. Although this presupposes a very strong separation of ends/means reasoning, it does at least allows for some consultation about the former, even if it rules out any robust conception of choice. In this respect, Baron's approach can looks a little more liberal than it is. Consultation is not based upon respect for persons but is a way of finding out the desires whose satisfaction is to be maximised given the assumption that individuals will be the best authorities on what they themselves want. This is a claim with a fairly long pedigree and some big questions to answer. It requires something akin to a transparent self with privileged (best) access to its own mental states and a willingness to be candid about just what they are. These are rather a large assumptions and not the only large assumptions that the reader is asked to make. Those with an appetite for utilitarianism and an aversion to mess may find this a valuable, if at times overly-condensed  text. Others may see more problems than plausible solutions.

© 2006 Tony Milligan

Tony Milligan completed his doctorate on Iris Murdoch at Glasgow University where he currently tutors in philosophy. He also teaches philosophy with the Lifelong Learning Centre at the University of Strathclyde.

Categories: Ethics, Philosophical