A Theological Perspective on Principlist Bioethics
- ISBN: 9780190270148
- Published By: Oxford University Press
- Published: April 2019
The thesis of Nathan Carlin’s Pastoral Aesthetics: A Theological Perspective on Principlist Bioethics is, in part, that pastoral theology can redeem principlist bioethics. Principlism was popularized by Thomas Beauchamp and James Childress in Principles of Biomedical Ethics (Oxford University Press, 1979). Over the past 40 years, the four principles—autonomy, nonmaleficence, beneficence, and justice—have served health professionals around the world as an easily understood framework for bioethical decision-making. A victim of its own success, priciplism is widely derided and blamed by many academic bioethicists for all that is wrong with bioethics: too narrow, too Western, too simplistic, too programmatic. Not only is Carlin attempting to revive principlism, an out-of-vogue bioethical theory, but he proposes to do it with an eccentric theological ethic—pastoral theology—that hasn’t even been in vogue among theological bioethicists let alone among secular bioethicists.
Carlin situates his book in relation to three characteristics of bioethics scholarship. First, the occupation of the bioethical imagination by clones, cyborgs, CRISPR babies and xenotransplantation. Carlin resists the sensational and points his readers’ attention towards mundane bioethics: “the little ways individuals find themselves crushed by the forces of modern medicine” (12). The second is the secularization of bioethics. In the 1960s theologians helped shape bioethics, yet by the late 1970s theologically trained scholars began to “translate their insights regarding moral matters into a secular language” (4). This strategic secularization gave theological ethics wider reach, but by the 1990s and 2000s a more active secularization cast a suspicious eye on bioethicists drawing from religious or theological wells. The third involves the recent reopening of the medical door “for theological or religious perspectives in bioethics” (7). According to Carlin, this reopening was due to “postmodern, feminist, womanist and other contextual thinkers” challenging the claims of objectivity and neutrality made by secular bioethics. This is partly correct. A further aspect that Carlin only alludes to is the incorporation of spirituality into the therapeutic goals of modern medicine. More on this shortly.
Even with the door reopened to religious perspectives, Carlin aims to distinguish his approach from “theological bioethics,” which is developed out of Christian sources (e.g. scripture, doctrines, tradition, etc.) and then applied to cases (e.g. abortion, euthanasia, etc.). In contrast, Carlin develops a “pastoral aesthetics” that draws on pastoral theology and begins with human experience rather than a predefined doctrine. For Carlin, it is in the midst of human experience and in the tumult of life that we need to think bioethically and pastorally. Pastoral aesthetics offers a new way of looking at the principles, one that is informed by an “aesthetic sensibility that is theologically-informed, psychologically-sophisticated, therapeutically-oriented, and experientially-grounded” (13). Pastoral aesthetics, according to Carlin, broadens the bioethical imagination to appreciate the lived experience and social context of health and disease, joy and grief, life and death.
Images are central to Carlin’s pastoral theology, with each chapter of the book using a different image to create a dialogue with a bioethical principle. Carlin’s scheme also uses the language of centricity and eccentricity to describe the relationship between theory and practice, central and marginal, image and principle, and so on. For Carlin, the bioethical principle gives the centric perspective, while the image offers the eccentric viewpoint “at or from the margins” (31). The images of pastoral care that Carlin uses are the “living human document” (i.e. biography or lived experience) in relation to autonomy, the “circus clown” for nonmaleficence, the “diagnostician” for beneficence, and the “living human web” (i.e. social interconnectedness) for justice.
I will briefly focus on the clown, which Carlin conceives as a necessary part of a circus by occupying a boundary space between the crowd and the spectacle of the main event. Clowns serve to put the crowd at ease in the presence of dangerous feats and by deflating the bravado of stunt people (68). According to Carlin, a similar use of humor is needed in the healthcare setting. Carlin is not encouraging physicians to embrace this role; instead he suggests chaplains and bioethicists can be clowns by reimagining how danger and harm (i.e., nonmaleficence) are understood in medical spaces. In this way health professionals are given a new image or perspective that “can mitigate harm not by being humorous but by appreciating humor” (83) and thereby recalibrating expectations of death-defying heroic medicine.
This image of the chaplain or bioethicists as a clown on the periphery of the circus, is striking when placed in the context of less flattering metaphors used to describe bioethicists. Historian Charles Rosenberg suggested that bioethics is a parasite living off medicine as the host, while philosopher Carl Elliott described the bioethicist as the watchdog guarding the property of medicine from intruders. In these images the bioethicist’s capacity to critically transform medicine and address “the little ways individuals find themselves crushed by the forces of modern medicine” (12) is curtailed by their dependent position. Is the clown in a similar position of dependence? Do they risk being kicked out of the circus if their humor is too revealing or they don’t adhere to the commands of the ringmaster?
Carlin contends that pastoral aesthetics is a therapeutic, ethical, and critical position. Yet it is worth asking: can pastoral aesthetics be therapeutic and critical? When the pastoral theologian or chaplain is drawn into the therapeutic project, can they act as a “representative of the church and of Christ” (69) while also serving the patient, doctors, and the hospital? Perhaps. But as Jeffrey Bishop warns, the recent reopening of the medical door to religion is not without its risks. According to Bishop, a risk of “bringing religion and spirituality back into the clinic” is gutting the “very content of its metanarrative”—their moral and ontological commitments—in the service of the therapeutic industry and “biopsychosociospiritual governance” (“Biopsychosociospiritual medicine and other political schemes." Christian Bioethics, 2009).
Carlin argues that pastoral theology has a lot to offer bioethics and medical care. But what does pastoral theology risk if that offer is accepted? Will pastoral theology become another tool in the therapeutic arsenal of bio-psycho-social medicine? And who gets to define success in these encounters? Will the “clown” get evaluated based on key performance indicators and other bureaucratic measures? These questions are not intended to diminish the value of Carlin’s book but emerged from reading his rich account of the “ways religion can function in the complex lives and complicated contexts of individuals” (147). Hopefully it can provide some guidance for the clowns to juggle their way through bureaucratic audits and commercial imperatives, allowing them to help those crushed by modern medicine.
Christopher Mayes is a senior research fellow at the Institute for Citizenship and Globalisation, Deakin University.Christopher MayesDate Of Review:July 19, 2022