does teachingby cases mislead morality?christophermiles coope 47 coat pocket. his coat is hangingin...

Journal ofMedical Ethics, 1996; 22: 46-52

Teaching medical ethics

Does teaching by cases mislead us aboutmorality?Christopher Miles Coope University of Leeds

AbstractThose who teach or are taught medical ethics with aheavy reliance on case studies should be warned first ofall that the practice tends to exaggerate the degree towhich morality is controversial. Secondly, they ought torealise that it is often quite unclear what problems countas moral problems. Thirdly, they will need to bear inmind that there may be - and presumably are - limits towhat we may regard as open to discussion. It would bequite superficial to assume that ethics teachers, goingalong with what is generally accepted by their colleaguesin this matter, would never tempt students to disregardthese limits.

Medical ethics will often be taught by a considera-tion of case-studies. We are all familiar with whatgoes on. The student will be taken on a ward-roundof curious examples, which at least pretend to bedrawn from actual cases, in order as it were to givehim or her experience on the job: the job of moraljudgment. He will not come unprepared to the task,for there will have been some introductory materialoffering various 'moral theories' (bundled up liketools in a tool-box), but he will - I suspect - notcome very well prepared either (1). I have certaindisquiets about this way of proceeding which I wantto share with you.

Nothing that I say is meant to suggest that theemployment of case-studies is out of place inteaching ethics. Even Jesus taught in parables (2). Itis perhaps better to teach in this way than dependupon the uncertainties, absurdities even, of what iscalled moral theory. And I shall myself make acertain use of the case-study method in putting myargument.

First of all, we should ask ourselves whether thecontinued use of controversial examples serves toexaggerate the extent to which morality, as distinctfrom moral theory, is controversial. By way ofbalance, it would be useful to take examples of what

Key wordsCase studies; teaching ethics; consequentialism; moraltheory.

we suppose (some philosophers apart) to be quiteuncontroversial wrong-doings: killing a patient inorder to provide useful organs for other patients,kidnapping a more or less rational adult patient off thestreet and administering much needed therapy againsthis will, telling straightforward lies to the local author-ity in order to improve one's services - that sort ofthing - and then raise the question why these actions arewrong. It is very easy to give unsatisfactory answers(3). In this way, as indeed in regard to so many of oureveryday 'non-moral' beliefs, we can come to under-stand better what we already know. One might followRichard Hare's terminology here, and talk of 'twolevels' (4): a level at which we know (quite often) whatwe must or may do, and a level at which we seek tounderstand the musts and mays in question.(Naturally, a claim to know that a doctor should notbe killing his patients to provide organs, etc, leaves usopen to the familiar charge of 'simplistic commonsense intuitionism'; but if we do not pretend tosupport our convictions by appeal to uncannyIntuitive Powers, powers of Moral Cognition,possessed either by ourselves or by some moralmajority, the force of such a charge is none tooclear.)

This effort at understanding should be put along-side our study of cases. For if our deeper under-standing of the moral truisms we fitfully live by isfaulty or inadequate, it is hard to see how a con-sideration of difficult cases will help us. This betterunderstanding might even be a precondition fordealing with the cases. (Insofar that is to say as theycan be dealt with at all, for we should alwaysremember that the concepts we employ, suchas 'harm', 'intention', 'human good', 'injustice','murder', 'consequence', etc, all have vague bound-aries, and hence might give rise to many problemcases that have no solutions.) Of course, if a case isnot difficult the teacher might use it simply as a test.For example, the following case study, which ispossibly corrupting, could be offered to a child:

Case study one: The needed bun: You are hungry. Inthe shop window there is a lovely cream bun costing10 pence. Your classmate James has 10 pence in his

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Christopher Miles Coope 47

coat pocket. His coat is hanging in the corridor. Noone is looking. What do you do now?

But if the person setting the problem does not knowthe answer, or even how to search for it, it becomesa little unclear what the case study, as teachingmaterial, is intended to achieve.

So there is this reason for disquiet. However,there are two further reasons which require moreextended discussion. Basically, I want to suggest thatthe case-study method may encourage us to ask ques-tions that should not be asked. I think I can see thisencouragement in the teaching at which I have beenpresent, and I don't suppose that my experience hasbeen in the least unusual. What I offer here is merelya caution. I do not propose to discuss whether twoper cent or 92 per cent of our students are misled inthe ways I suggest. One can usefully warn that stonesare slippery without knowing how many people haveactually slipped on them.

I have suggested that our practice of appealing tocase studies may invite us to ask questions that weshould not be asking. There are two quite differentdangers here. Some questions do not arise. Otherquestions ought not to arise. I shall deal with eachkind of danger in turn.My first worry can be brought out with the aid of

the following case study, based on a real lifeexample. (I have altered the details to preserveanonymity.)

Case study two: Slippers in the kitchen: You are sittingat home by the kitchen table. You have your slipperson. There is a newspaper at your elbow. You havenot written to any ofyour aunts that day. It is raining-and Tuesday. What ought you to do?

Of course one would be rather surprised to be askedto consider such a case. But can we be so very surethat cases of this undiscussable kind are not in factput before our students? The question: 'What oughtyou to do?' is clearly foolish in this context, aseveryone will see at once. Why? People will agree thatthe question is foolish, but they may not agree ontheir reason. Is the question foolish simply because wehave not been given enough detail?

Straightforward utilitarianismLet us first make a passing nod in the direction ofstraightforward utilitarianism. Any straightforwardutilitarian, as I use the phrase, will think that one hasa duty to maximise something, such as happiness,pleasure, preference satisfaction, respect for rights,average utility, or whatever (maybe a combination ofvarious ingredients: a little happiness here, toppedup with rights-respecting there, and so on). Such aperson will not of course be able to answer our case-study question from his simple utilitarian perspec-tive. He would need much more information! In fact

one would not expect him to take much interest incase studies, for would he not always want to knowmore? And even those more moderate individualswho think we ought always to be producing a 'satis-factory amount' of some good would be in trouble.But I do not want to dwell on these difficulties, for itis hard to believe that there are any real utilitarians ofany of these simple kinds, as opposed to the nominalutilitarians one meets in the classroom who are nodoubt as plentiful as nominal members of theChurch of England, and of course blackberries (5).However, I think that our case-study question wouldalso be found unsatisfactory by ordinary reflectivepeople quite unacquainted with utilitarianism orwith any other -ism for that matter. Why?

Perpetually directiveDoesn't the case-study method here presuppose orsuggest that morality is perpetually directive - thathowever hard it might be for us to find, there isalways such a thing as The Moral Thing To Do? Orperhaps a disjunction of several trivially distinctMoral Things (like setting off with this foot or withthat)? Or, if it is supposed that there are 'moraldilemmas', where anything one might do would havewhat would be called a 'moral cost', doesn't thecase-study method rather take for granted that therewould at least be The Right Wrong Thing To Do?True enough, one might need more information - asindeed the utilitarian mentioned in our last para-graph would have insisted, there being hardly anylimit to the information he would need. Butwould more information always make a difference?Suppose, for example, we were to add to our casestudy the item that someone on the other side of thetown would be cheered up by a visit? Would the moralmust then come into the picture? I think not.One way, an exceedingly common way, of

thinking of morality is to regard it as a set ofboundary injunctions. We would be thinking here ofthe morality which divides actions into the 'all right'and the wrong, the permissible and the forbidden, orof the requirements of justice (where this is notthought of as an exclusively distributive matter, buthas to do with what is owed to others). It is of courseabsurd to object to a morality of boundaries, of rules,as if it were old-fashioned, a mere hangover from theJewish roots of our civilisation, something onlysuitable for children. The morality of boundariescannot, to be sure, be the whole story; but it is moreof the story than is commonly supposed. Accordingto this account, there would be such a thing as moralfreedom, within these limits - so it is a view ofmorality that one might expect to appeal to liberals.Contrast the popular academic idea that one has ageneral obligation to satisfy preferences. Here onewould be entirely hemmed in by obligations. If onewere sitting in the kitchen in one's slippers andwould like a cup of coffee, then prima facie one



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48 Teaching medical ethics: Does teaching by cases mislead us about morality?

would have an obligation to put the kettle on. Thedifficulty would be to move from one's prima facieobligations, so easy in many cases to discern, to TheRight Thing To Do all things considered.

Morality certainly does set boundaries: one mustnot kill, steal, lie, etc. (Of course, I state theseinjunctions in a simple way, as a kind of shorthand,suitable for the most elementary instruction;everyone recognises that the moral teachings inquestion might be quite complex.) Many of theseinjunctions are naturally thought of as negative, andthat is why the word boundary is perhaps appropri-ate. Given these boundaries, we might take thequestion, 'What ought you to do?', to be asking'What ought you NOT to do? Presumably thequestion in Case Study One above was asked in thisspirit. Not all the injunctions, however, are negative.Thus one would have actively to care for an infantjust discovered on one's lonely doorstep on awinter's night. This would be so, even if the infanthad been left by a malicious individual wishing toimpose a duty of care. And here one would cross aforbidden boundary by 'doing nothing', by shrug-ging one's shoulders with the thought, it's no businessof mine.Now it would be indeed hard to think of a situa-

tion in which one was unable, if so minded, to crossat least one of these boundaries. For we live, forexample, under the boundary-injunction not toindulge in certain uncharitable thoughts. And this isa boundary that is always within reach. So of course,if asked What is The Moral Thing To Do, whilesitting by the fireside with one's slippers on, etc, onecan always say: 'Don't Cross The Boundaries!' (Inthis sense of course, morality will be perpetuallydirective.) But this is not answering the question inthe spirit in which it is asked, and it is the questionasked in this spirit that needs to be rejected. There isoften nothing that could be called the moral thing todo, just as there would be nothing that could becalled the amusing or the surprising or the politething to do. Imagine yourself talking to a friend in apub. Now, what is the action that politeness demands?The question might well have no application.Politeness, at best, would simply rule out certainthings. (I say 'at best' because someone mightsuppose that among close friends, at ease with oneanother, there is no such thing as politeness orimpoliteness.)

Incompatible aimsIn the same way as there is often no such thing as theright thing to do, there will often be no such thing,where people have incompatible aims, as thesolution which justice demands. One is perhapsinclined to suppose that any such difference in whatis wanted could be put to an arbitrator, an arbitratorwho would not merely be supposed to patch up acompromise that might be acceptable, with luck, to

the parties, but who would consult what justicerequires, the idea being that this outcome could,given sufficient knowledge, be worked out, or at leastsettled by some procedure known to be called for,such as the tossing of a coin. But what makes ussuppose that justice has this comprehensive scope?Justice might, in many cases, simply rule out certainways of settling things, such as killing and lying.Now I said that there is more to morality than

keeping the right side of the boundaries. There arevirtues other than justice. But perhaps these can onlybe exercised in appropriate circumstances. Onecannot be patient if one is not being kept waiting.One cannot exercise courage if there is nothingfearful that needs to be faced. But is this true of allthe virtues? Is there not always the possibility of akindly action? These tend, we shall suppose, (withMill let us say) to be among those admirable actionsthat are not obligatory. Now consider one of theseactions. It might be writing to an aunt. Would it betrue that one ought to do just that? It is easy to seethat the answer is no, not only because one wrotejust yesterday, but because there might be otherequally admirable but incompatible actions, and onemight choose to do one of those instead. It wouldhardly be sensible to attempt to write out a long dis-junction of admirable possibilities. But can we saythat one ought to do at least one of these actions?(or, supposing that somehow there is only one,would it follow that one ought to do it?) The troublehere is to understand this ought. We would not meanthat the action is obligatory - we ruled this out whenwe set up the example. Nor do we mean that theaction is advisable in some way. The question,'What ought I to do?', seems to lack sense.

SensitivityIt can be difficult for us to appreciate this point, forwe are all so afraid of being accused of insensitivity.Like the princess, we want to be able to feel the peaof duty through all those mattresses. If we can't, weinvent. Nothing easier. What should one do in thatkitchen? One must take the tea to the neighbours, post theslippers to Oxfam, and jolly well settle down to thoseletters, that's what! Of course, one is not reallyexpected to do anything about it. Sensitivity, here, isall.Now it might be thought that no one teaching

moral philosophy by the use of case studies couldseriously offer examples of the slippers in the kitchenvariety. But I suspect, by listening in to such instruc-tion, that this can happen. Of course, the unsatisfac-toriness is concealed. Here are a couple of examplesmore or less copied out of Ethics and the HealthServices Manager (6).

Case study three: The wrong dose: A staff nurse hasgiven a baby double the normal dose of a drug. Thebaby had a slight reaction but has now recovered.



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The clinical nurse manager feels that the nurseshould be suspended from duty and reported to theUnited Kingdom Central Council for Nursing,Midwifery and Health Visiting (UKCC).As the unit general manager, what advice would you

give?

Case study four: Incident in the outpatients department:A sister in the outpatients department reports that apatient asked to speak to her confidentially yesterdayabout an incident the patient says happened to himlast time he visited outpatients. He was seen at theend of the session, which overran. The consultanthad assured the nurse on the clinic that this was asimple follow-up and added that she was happy tosee the patient on her own. The patient now alleges,some weeks later, that the consultant sexuallyassaulted him. He does not wish to make trouble,however, and does not want the matter to go further;he just thought the sister should know. The consul-tant is very senior and highly respected, and thesister has worked with her for years.

Sister tells you this: as unit general manager what doyou do now?

It will be noted that in both these cases a definiteanswer is sought: what to do. It is not simply amatter of what is ruled out. I am not saying thatthese cases are obviously parallel to slippers in thekitchen - only that they might seem on reflection tobe so, and that the possibility should be considered.To be sure, a health services manager might have todeal with eventualities like these, and it might verywell be useful in the training of managers to considera range of case studies of this kind. Similarly, politi-cians might have to have training in how to deal withawkward questions asked on doorsteps while can-vassing, or addressed to them by TV interviewers: acertain tact would clearly be needed. But whatmakes us suppose that there is something calledmorality that can provide solutions, or sort thingsout, as distinct from laying down those boundaries?We might answer that morality encourages us, ifthat's the word, to be fairly considerate, where this isnot thought of as a strict matter of duty. And ofcourse a manager is morally obliged to be reasonablyattentive to the duties that he has assumed and forwhich he is paid. It is this background of obligationbound up with the manager's role that makes ussuppose that these case studies are radically differentfrom slippers in the kitchen. If cases like these arise, heshould take thought and not simply reach for his golfclubs. He is morally obliged to take stock; it doesnot, however, follow that the problem itself isusefully thought of as a moral one, or that profes-sional ethicists ought to be called in to give adviceand to help to detect The Right Things To Do.Difficult choices, where the outcome might seriouslyaffect other people, are not always thought of asmoral problems. If a man cannot decide whether to

marry Betty or Hettie the last thing he might need isa marital moralist.

So the first consideration when presented with acase study is this: one should ask whether it presents amoral issue at all. It is important to ask this question,even if we cannot always expect the answer to bevery clear-cut, as morality must be a pretty vagueconcept. If we do not attend to this matter we shallfind ourselves involved in very tedious discussions.People will be put off medical ethics altogether, savethose with an abnormal appetite for uplift. Whatpractical problems count as moral problems - orperhaps better, as issues of justice, or of obligation -is a question we need to consider. We live in an eraof rising expectations. We expect more and morefrom morality, and the 'ethicists' who are supposedto know about it. We shall find ourselves invited todiscuss Investment Ethics, Culinary Ethics, LeisureEthics, Chiropody Ethics, Ballroom Dancing Ethics,etc, all with their attendant case studies. There willsoon be journals devoted to such topics. All this tothe delight of the modem commercial universitywhich cannot see the good for the fees (7).

Second cautionI turn now to the second caution I wish to make inregard to the case-study method of moral education.My argument so far has amounted to a complaintthat morality was being taken too seriously; for theidea that there is always something that is demandedof one is surely inspired by over-earnestness. I nowwant to suggest that in some of our discussions ofcase studies, morality is not being taken seriouslyenough. It is perhaps the very extravagance of themorality of perpetual injunction that makes usinsensitive to the injunctions that really matter.Once again, I shall make up an example, this timesomewhat more elaborate, to bring out the point. Inits form it closely resembles case-study questions thatI have actually heard discussed, and I also suspectthat in its matter it is not a wholly unreasonableparody.You are to imagine that you are a student at a

well-known Central European university in thenineteen-thirties. Your amiable and impressiveteacher of philosophy has conscientiously preparedsome materials for you. They comprise the usualtour through moral theories, and some case studies,among which you will find the following.

Case-study five: Responsible treatment of the insane: Asthe head of a psychiatric hospital, you have to decidewhat is to happen to three of your patients, Herr X,Herr Y, and Frau Z. All are due for termination.The facts. There are three methods of terminationavailable. The first is painless, but causes convul-sions, and this is very distressing for the nursingstaff. The second is also painless, and death ispeaceful. But the body is rendered useless for



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research purposes. The third method is really quiteuncomfortable for the patient, but fortunately doesnot have to take place when there are nurses present.This method allows valuable experimental work tobe undertaken, both before and after death, workthat is expected to be of considerable benefit to otherpatients. Note that the first method is twice asexpensive to use as either of the other two. Herr Xhas expressed a strong preference to be terminatedby the second method. When the matter is put toFrau Z she just giggles. (We cannot get through toHerr Y at all.)Questions: 1. Which method should you choose?; 2.Would it be wrong to discriminate between thesepatients?; 3. Would it make any difference if a largenumber of patients were to be terminated, andresources were scarce?Break up into groups offour. You have ten minutes inwhich to come up with an answer.

Once again we would be rather surprised tobe offered this case to consider. (Perhaps we areconfident that teaching materials of this kind willnever be distributed in our classes. I think, forreasons I shall explain, that this confidence ismisplaced. I invented this example before havingread Michael Burleigh's instructive Death andDeliverance, 'Euthanasia' in Germany 1900-1945 (8).(We should remember that the doctors in Germanywere so often quite ordinary civilised people, livingby the standards of their time.) If we were offeredsuch a case to consider, we would, I assume, simplytear up the paper and walk out - if that is to say wehad the proper courage: after all, we might beembarrassed about appearing to make a fuss, orappearing 'extreme'. We would tear up the paper incontempt because we would suppose that certainpossibilities - one ought rather to call them 'tempta-tions' - were not to be weighed and considered.

But doesn't the case-study method rather pre-suppose that any course of action is at least open todiscussion, if only to be rejected? True enough, adevotee of the case-study method, tolerantly andrationally willing to weigh any issue put in front ofhim, might himself find fault with Responsible treat-ment of the insane - on the ground that the questionsasked were too restricted. He might say that the firstquestion should have read: 'Which method, if any,should you choose?' But this I suggest is not enough.It is surely part of the virtue of justice that certain pos-sibilities should be off the agenda. People sometimesreject a proposal by saying "I won't hear of it!' Thisriposte is often unthinkingly made or light-hearted,but used in eamest, it captures very well what justicesometimes requires of us. We might not all agreeexactly when we are 'not to hear' of a certain possi-bility, and there will be borderline cases where wemight anxiously suspect that we ought not to be con-sidering what is on offer, but I dare say we would allconfidently include Responsible treatment of the insane.

Note that I am not saying that we should refuse todiscuss this sort of case in any way at all. I am in factdiscussing it right now. And of course there is a needto discuss why it is wrong to terminate our psychi-atric patients. As I said at the beginning, it is import-ant to seek to understand better what we know.Tearing up the paper is not an invitation to stopthinking. But we should not be prepared seriously toconsider certain possibilities put to us, and weshould not by our participation in such discussionsgive the impression that we go along with the seriousconsideration of such possibilities. Such a refusalneed not of course be made in a spirit of self-right-eousness. For that would indicate a pride that noneof us can afford.

Nothing depends here on my particular example.It would be beside the point to say for example thatthe author of this paper simply has a hang-up aboutthe killing of psychiatric patients, that he dislikes thissort of thing. If there are some kinds of action,perhaps not including the one I suggested, whichshould not be put before us as options, then ourstudents should be made aware of the fact. Theyshould be aware of their right, indeed their duty, toobject to the proceedings and to refuse to partici-pate. To consider whether to X, even in hypotheticalcircumstances, is after all an action. As an action it isopen to moral appraisal; and it might turn out to bebad. A student, unimpressed with the fact that acase study had the official blessing of the courseinstructor, and who was prepared to stand out fromthe crowd and say 'This is just not something I amwilling to discuss, and I suggest you do not discuss iteither' should, I think, earn our respect, even if inthe particular case he seemed to us to have shownbad judgment. In my experience, students seemquite unmindful that such an issue might arise.

UnreasonablenessWe will perhaps be asked whether someone whoteaches or praises this kind of intolerance might notbe inviting unreasonableness and ill-will. Well,intolerance certainly has its dangers. But so too does'a little learning' - though we all have to start bylearning a little. (As for much learning it makes aman mad, or so they say.) What kind of moral edu-cation is safe? Is it safe for example to teach a criticalattitude? Teach someone to be critical and goodnessknows what he might do, to his detriment and toours. Is it safe to teach kindness? Teach a man to bekind and he might think it necessary to be cruel.Sometimes one simply has to live with dangers, aswhen one drives a car or walks across the road.

If asked why it is necessary to take this line - andthere must be some reason - we would perhaps saysomething like this: that it is important not only toavoid certain actions, but also to avoid certain invita-tions to action. Someone who works in a bankshould not allow himself to dream of what he might



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do with the money. He should not dwell on thewhat-ifs. 'What if I were in desperate need ...'.'What ifmy aunt was in desperate need ...?' 'What ifit were someone else's aunt ...?' 'What if there werea hundred needy aunts, and the bank had treated merather badly ... ?' I do not mean to suggest, nor do Ibelieve, that property rights are sacred in the face ofneed. But a bank employee is in a position of trust,unlike a hungry man walking beside a field ofturnips. Doctors who are in charge of the weak andvulnerable have a special duty not to so much asdream of harming them, even in the interests of'good causes'. Nor should they get themselves usedto the idea of harming them by considering invita-tions to harm incorporated in case studies. Nor,where trust is so important and yet so fragile, shouldthey become involved in earnest discussions aboutwhether a lie might not be for the best in a certainsituation - a situation devised especially to make a liea tempting option. (We might make the sameremarks about the police. We ought not to encour-age the trainee policemen in our charge to considercase studies in which they are offered the optionof ill-treating members of the public, with dueexpressions of regret, in order to extract importantconfessions.) If one wanted to corrupt people onemight try getting them to agree to do certain beastlythings in hypothetical cases. I have no empirical dataon the effectiveness of this technique, but it wouldseem suitable to the job in hand. A gradual approachwould clearly be desirable. One would begin byinducing them to accept such things as a live option,as a choice they could respect, even if it would not betheir own.

In saying that doctors (and the police) should not betaught in a way which presupposes that certain kindsof wickedness - assisting with torture, let us say - areto be regarded as open to choice, it might be thoughtthat I was wishing to make an exception for philoso-phers. Philosophers are not often called on to assistwith torture - that is a medical, or a military, hazard.But I do not think that we philosophers can safelyexempt ourselves. We have our own vulnerability.Those who want to torture might well look to thewritings of philosophers, particularly those inapplied ethics, for comfort and reassurance. In anycase, no one, philosopher or not, can know when hemight be tempted into grave wickedness, eventorture. So there are kinds of action that humanbeings quite generally, including philosophers, arenot to contemplate.What I have been saying here is not, I believe,

particularly new. It is very much in the spirit ofElizabeth Anscombe's celebrated article 'Modernmoral philosophy' (9). And Richard Hare hasemphasised that there are certain things that a goodman will simply not think of doing (10). Such agree-ment between philosophers who might be thought tohave rather little in common is quite impressive. Thepoint, however, is something that seems rarely to be

taken account of: I have never heard it raised inpractice when case studies are being thought up orpresented (1 1).

I said just now that I was not at all confident thatdisgusting case-study material would never be circu-lated to medical students. I am here moved by fourconsiderations: firstly, that case-study material isthought to be safe: after all, no real decisions arebeing taken (though efforts are made to make thecase studies as realistic as possible, and they arepresented to those who are shortly going to facethese problems and temptations in real life);secondly, that we are sometime encouraged, inmedical ethics circles, to think adventurously, andthis sounds just fine until one thinks what it mightmean; thirdly, that there seems to be an assumptioncurrent that if what one is being asked to contem-plate can be described as in some way humane, asrelieving distress, or as respecting something calledautonomy, it cannot be disgusting; and fourthly, Irely on actual experience. I have actually seen a smallsample of what is passed around. In general, I thinkwe need to be vigilant, to be more prepared toquestion the idea that certain matters can beregarded as open for our consideration. We shouldcertainly not take for granted that proposed discus-sions are all right simply because they are offered tous by decent-seeming people (who are kind toanimals), in a safe British university, with coffee andbiscuits provided (12).

Questions will still arise about what is plainly dis-gusting: for, as we saw at the beginning, we are oftenbetter able to grasp that a certain action or kind ofaction is bad than to explain why this is so. If this stilldoes not seem obvious it might help to reflect howchildren can readily understand that stealing, let ussay, is bad without being able to offer much insight inthe matter (13). We should not allow ourselves toconclude that the manifest uncertainty we philoso-phers have about the deeper theory renders ourelementary moral understanding about murder, lying,torturing, etc, entirely questionable, so that 'civilised'toleration is here the order of the day. The case-studymethod, in my experience, seems to work on theassumption that nothing is excluded ab initio, and thatwe cannot be soiled by our open-mindedness. It is thisassumption that we must be prepared to question.

Christopher Miles Coope, BA, BPhil, is Lecturer inPhilosophy in the Department of Philosophy at LeedsUniversity.

References and notes(1) I have since found that in these days of economic

stringency even this preliminary preparation is some-times left out. I do not know whether the students loseby this: there are plainly some swings and round-abouts to consider, and the net result might bepositive.



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(2) But perhaps to make things difficult. Jesus, 'in somerather uncomfortable remarks, says that he teacheswith the aid of stories so that those who do not haveaccess to his more direct teachings will fail to under-stand what he is on about. See: Mark, 4.11-12.

(3) Thus we know, without having to subject our view tocritical scrutiny, that rape is wrong. But do we knowin the same way that rape is wrong just because it ishomfying to the one who is raped? After all, we are sooften permitted under justice to act in ways to whichothers take strong exception. Or is it wrong because itfails to respect something we call autonomy? That mightsound satisfactory, seeing that it traces the matterback to someone's favourite list of 'principles'. But isit? And why the fuss about these 'principles' anyhow?An enquiry of this kind can be quite fruitful if we arepersistent with it.

(4) Hare R M. Essays in ethical theory. Oxford: OxfordUniversity Press, 1989.

(5) I can see that this remark might be thought undulyfrivolous. What about John Stuart Mill and his manyfollowers? But Mill was not a utilitarian in the senseexplained: his account of moral obligation, inUtilitarianism, chapter five, nowhere suggests that wehave a duty to maximise anything or to produce'enough' good things. He insists, indeed, and it is notone of his better thoughts, that it is reprehensible togive people more happiness than they can be said todeserve. In fact it is hard to see how his account canbe called utilitarian at all. It doubtless sets out to beutilitarian, but ends up, driven by good sense, assomething else. One is not sensibly thought of as apractising utilitarian simply because one sometimesoffers or accepts what are misleadingly called 'utilitar-ian reasons', that is to say reasons which appeal toconsequences, such as 'it would cheer her up' or 'itwould bum the house down'. Nor is one to be held tobe a utilitarian merely because one merely thinks thatwithin the bounds of tact, good sense and the morallaw, one ought somehow to 'do good'; or if onesupposes as is natural that moral injunctions musthave a point, and that this point has to do with what isnecessary with respect to some good that needs to besecured. (I note that the author of the introductoryarticle on utilitarianism in the Toronto edition ofMill, vol X, by D P Dryer, published by theUniversity of Toronto Press in 1969, begins: 'Themajority of serious students of ethics today are utili-tarians ...'. I clearly do not meet many seriousstudents.)

(6) Wall, A. Ethics and the health service manager. London:King Edward's Hospital Fund for London, 1989.

(7) For an example of these rising expectations in themedical context one could hardly do better than turnto Ian Kennedy's 1980 Reith Lectures. 'The majorityof decisions taken by doctors', said ProfessorKennedy, 'are not technical. They are, instead, moraland ethical'. (The unmasking of medicine [revised ed].London: Paladin, 1983: 83. On page 84 this sort ofthing is said to be 'a commonplace'). This, thedoctrine of pan-moralism as we might call it, is ofcourse excellent news for us in the medical moralsand ethics industry. Or it would be, if it were credible.

However, Professor Kennedy immediately goes on toundermine what he has just said. For he adds, mostrevealingly: 'They are decisions about what ought tobe done in the light of certain values'. At that rate, alldecisions what to do, even the medically technicalones, to say nothing of those investment, culinary,chiropody, and ballroom dancing decisions alluded toabove, are moral decisions. For one decides to act inthe light of ends in view, and anything wanted iswanted under the aspect of some good.

(8) Burleigh M. Death and deliverance, 'euthanasia' inGermany, 1900-1945. Cambridge: Cambridge Uni-versity Press, 1994.

(9) Anscombe G E M. Modem moral philosophy.Philosophy 1958; 33: 1-19.

(10) See reference (4): 64.(1 1) We can roughly distinguish between two kinds of dif-

ficult case. One is difficult because it is hard to knowwhat morality requires (supposing it to require some-thing). This kind of case will often involve border-lines. We may not be sure whether the killing of anembryo is the killing of a human being, and if it is not,whether there would then be no problem. Or we maynot be sure whether something intended to deceive isa lie. But there is another kind of case where the diffi-culty is one of performance. Sometimes we have tolive by a rule, perhaps an inflexible rule, and here wecan know in advance that there will occasionally be acost, and this might be a cost that something goodabout us, sympathy perhaps, makes it hard to bear. Adiet of hard cases of the latter kind could well becorrupting. One will call them 'moral dilemmas' andagonise whether one somehow ought to do the mostdespicable things.

(12) This brief, somewhat truistic, remark has been found'extremely irritating' by one of my readers. But it issurely superficial to think - and I hate to labour thepoint - that the friendly and tolerant atmosphere of amodem university, at least in matters not involvingthe political correctness of the day, insulates us fromcorruption.

(13) While there is so much that is good in Anne Maclean'sstriking book, The elimination of morality, (London:Routledge, 1993), she unfortunately retreats into themysteries of the unsayable over this search for the'why'. Mrs Maclean is surely right to argue that anaccount of 'the value of life' that is at all plausible issimply going to be a reflection, a somewhat misleadingreflection, of our beliefs about murder and the duty torescue, and as such is hardly going to be explanatory.But she then appears to rule out the possibility offurther insight. Thus after remarking, perhaps ratheroptimistically: 'We do not contemplate acting in certainways; it does not occur to us to do certain things topeople' she adds with a flourish, 'And the question ofwhether or not we are justified in this does not arise'(page 135, italics in text). A distinction is requiredhere between epistemic and explanatory justification.Epistemically, justification might be unnecessary, orindeed impossible. But that does not mean that thereis no more to understand. At this point we should sidewith Richard Hare (4). (I refer to his aim, not ofcourse to his execution of it.)



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