Casuistry and medical knowhow

Besides knowledge, medical expertise requires a good deal of 'know-how'. (28> Knowledge can be set out explicitly, as in textbooks, in codes, and in practice guidelines. Know-how is more implicit. It is a set of skills, built on experience, which (like non-medical skills such as recognizing a face or riding a bicycle) resist definition and yet are crucial to our expertise.

Casuistry exploits the know-how of ethical reasoning by tackling ethical problems not in terms of high-level theory or general principles but from the ground up, by considering particular cases. Faced with an ethically problematic case, casuistry involves one or both of the following:

• altering the case—varying the circumstances of the case to imagine situations in which it would be more obviously right or wrong to take a particular course;

• considering related cases—comparing the given case with a series of related cases in which, again, the ethical outcomes are clearer.

These two ways of thinking help to clarify our ethical intuitions by focusing on concrete details. Casuistry has a bad name in the history of ethics in that it is associated with bending principles to suit one's purposes! We owe its rehabilitation to two philosophers working in America, Albert Jonsen and Stephen Toulmin. (29) While serving on a Presidential Commission on bioethics, they observed that its members were usually able to agree on what ought to be done in a given case even though they often disagreed about why. The way to resolve ethical problems, they concluded, is not by referring to general principles but by considering particular cases.

Casuistry is driven by shared values. Its power as a method of ethical reasoning is in allowing us to access shared ethical intuitions, which, as part of the know-how of medical expertise, are often not fully explicit. This, however, is also its weakness. As the American philosopher, Loretta Kopelman, has pointed out, where values are not shared casuistry may be at best ineffective and at worst abusive. (39 But psychiatry, as we have seen, is characterized by diversity of values. The importance of casuistic reasoning in psychiatry is thus not to force agreement on ethical issues but to clarify the (often legitimate) value differences underlying dis agreement.

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