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A dispute exists about whether bioethics should become a new discipline with its own methods, competency standards, duties, honored texts, and core curriculum. Unique expertise is a necessary condition for disciplines. Using the current literature, different views about the sort of expertise that might be unique to bioethicists are critically examined to determine if there is an expertise that might meet this requirement. Candidates include analyses of expertise based in "philosophical ethics," "casuistry," "atheoretical or situation ethics," "conventionalist relativism," "institutional guidance," "regulatory guidance and compliance," "political advocacy," "functionalism," and "principlism." None succeed in identifying a unique area of expertise for successful bioethicists that could serve as a basis for making it a new discipline. Rather expertise in bioethics is rooted in many professions, disciplines and fields and best understood as a second-order discipline.

Approaches to clinical ethics dilemmas that rely on basic principles or rules are difficult to apply because of vagueness and conflict among basic values. In response, casuistry rejects the use of basic values, and specification produces a large set of specified rules that are presumably easily applicable. Balancing is a method employed to weigh the relative importance of different and conflicting values in application. We argue against casuistry and specification, claiming that balancing is superior partly because it most clearly exhibits the reasoning behind moral decision-making. Hence, balancing may be most effective in teaching bioethics to medical professionals.

After presenting the current version of principlism, in the process repudiating a widespread deductivist misinterpretation, a fundamental metaethical disagreement is developed by outlining the deductivistic critique of principlism. Once the grounds for this critique have been understood, the dispute between casuistry, deductivism and principlism can be restructured, and the model of "application" proven to be the central difference. In the concluding section it is argued that principlism is the most attractive position, if the perceptual model of weak intuitionism is made more explicit.

Most ethicists have paid little attention to the rhetorical features of case presentations. In order to examine the constructed nature of bioethics cases, this paper examines the literary characteristics of four presentations of Donald "Dax" Cowart's story. By comparing tellings of the same case, a pattern of redaction is revealed by which the tellers conceal the very features that would challenge the perspectives taken in their arguments. In conclusion, the issue of the applied nature of bioethics is examined.

Within the field of medical ethics there is a startling amount of diversity regarding which issues and relationships are deemed relevant for ethical inquiry and analysis, what strategies are appropriate for examining and resolving ethical conflict, what should be the goals for medical ethics, even who should participate in that project. What I will try to make clear in this paper is that how we go about this process of doing medical ethics, of examining, reflecting, decisionmaking, and behaving, makes a practical difference, and not just a philosophical one, in terms of the understandings we will reach about ethical matters. Without attempting to resolve any of the conflicts within or between different conceptions of doing ethics, I will try to articulate the differences in orientation, and particularly the tone and educational emphasis, that attend four major contemporary approaches to ethical inquiry and analysis: deductivism, principlism, modern casuistry, and feminist/relationist ethics.

The Dutch health care system is developing a two, or multiple, tier system. How can moral principles be of help in assessing whether this is the right track? Instead of dismissing as unhelpful the principles that have been suggested so far and exchanging them for other, usually more complex, principles, it is suggested that the methods of moral inquiry be reconsidered.

Different definitions of bioethics in American and Italian literature are reported. It is argued that they refer to three different conceptions of the epistemological status of bioethics: the first conceives of it as an application of moral principles to biomedical problems, the second as a methodology for the working out of clinical judgement, the third as a broader and interdisciplinary public inquiry. It is suggested that each approach grasps a part of the truth, for each singles out one level of the bioethical work. Bioethics is in fact a complex, three-level form of knowledge. The misunderstanding of this complexity has led to some confusion and to conflicts of attribution among those who are concerned with it.

James Tallmon has argued that my criticisms of Jonsen and Toulmin are ill founded. Tallmon argues that Jonsen and Toulmin argue for a method of rhetorical reasoning and not for a particular content. He argues that if one distinguishes the content and method of casuistry the Jonsen-Toulmin model can work. But Tallmon, like Jonsen and Toulmin, cannot escape the need for casuistry to have a content. Tallmon's response evidences that need since he assumes that there is a 'Medical Community' which has a moral vision.

Kevin Wildes has recently argued in the Journal that Albert Jonsen's model of casuistry is ill-suited to a secular world context, because this model is rooted in a particular history and because of the moral pluralism of contemporary society in which a content-specific method of moral reasoning cannot readily be deployed. Contra Wildes, two arguments are offered. First, casuistry is not tied exclusively to Roman Catholic theology; casuistry also has deep roots in Classical thought, roots that Jonsen and Toulmin underscore. Second, the context of Roman Catholic theology can be distinguished from the method of casuistry, permitting that method to be deployed successfully in morally pluralistic contexts.

Most theoretical approaches in bioethics begin with a theory that articulates and defends basic principles or rules that are more or less systematically related and that seek to yield more or less precise conclusions with regard to specific acts, cases, or policies. Concerns about the agent and descriptions of the context of action stand on the margins of the theory. This is ironic, given the overwhelming importance and impact the training of health care professionals has upon them and upon the practice of health care as a whole, and given the fact that many advocates of the theories themselves concede that one's beliefs and how one describes a situation and weighs "facts" and values relevant to the case strongly determine one's conclusions. While morality may not lead ineluctably to religion, as Kant believed, bioethics does appear inevitably to involve particularity. I examine the work of James M. Gustafson and Stanley Hauerwas to analyze two views of the role of particularity in bioethics. I then show the relevance of their work for addressing some problems with the practicality and concreteness of current models in bioethics.

In response to my earlier critique of recent attempts to rebut principlism as an ethical approach, Green, Gert, and Clouser (GG&C) have in turn offered their own critique of my appraisal. This essay identifies eight major criticisms GG&C raise in their response and offers a rejoinder to each. Among them, three are especially important: (1) that the label of 'deductivism' fails to capture GG&C's ethical method and should be replaced by 'descriptivism'; (2) that pluralistic accounts, including principlism, fail to offer any systematic way to resolve moral conflicts; and (3) that appeals to broader 'moral' principles beyond the moral rules are deceiving, since apparent differences in 'moral' judgment invariably involve disagreement about empirical facts rather than further moral considerations. In response to (1), I defend my earlier label by emphasizing the stipulated and invariant status of the moral rules GG&C invoke, even as I question the adequacy of their putative 'descriptivism'. In response to (2), I suggest the plausibility of pluralist approaches and reiterate the modified just-war criteria that Beauchamp and Childress invoke in situations when principles conflict. In response to (3), I suggest that a 'descriptivism' worthy of the name must systematically accommodate the appeal to moral principles that remains central to metaethical and normative discussions.

Four prominent views of the nature and methods of clinical ethics (especially in consultation forums) are reviewed; each is then submitted to a criticism intended to show both weaknesses and strengths. It is argued that clinical ethics needs to be responsive to the specific complexities of clinical situations. For this, the need for an expanded notion of practical reason within unique situations is emphasized, one whose aim is to facilitate decision-making on the part of those directly responsible for them and consonant with their own respective moral frameworks and conceptions of what is most worthwhile.

Several recent attempts to develop models of moral reasoning have attempted to use some form of casuistry as a way to resolve the moral controversies of clinical ethics. One of the best known models of casuistry is that of Jonsen and Toulmin who attempt to transpose a particular model of casuistry, that of Roman Catholic confessional practice, to contemporary moral disputes. This attempt is flawed in that it fails to understand both the history of the model it seeks to transpose and the morally pluralistic context of secular, postmodern society. The practice of casuistry which Jonsen and Toulmin wish to revive is a practice set in the context of a community with a shared set of moral values and structures of moral authority. Without a set of common moral values and rankings, and a moral authority to interpret cases the casuistry of the postmodern age will be pluralistic, that is, there will be many casuistries not just one.

Several scholars have recently criticized the dominant emphasis upon mid-level principles in bioethics best exemplified by Beauchamp and Childress's Principles of Biomedical Ethics. In Part I of this essay, I assess the fairness and cogency of three broad criticisms raised against 'principlism' as an approach: (1) that principlism, as an exercise in applied ethics, is insufficiently attentive to the dialectical relations between ethical theory and mortal practice; (2) that principlism fails to offer a systematic account of the principles of non-maleficence, beneficence, respect for autonomy, and justice; and (3) that principlism, as a version of moral pluralism, is fatally flawed by its theoretical agnosticism. While acknowledging that Beauchamp and Childress's reliance upon Ross's version of intuitionism is problematic, I conclude that the critics of principlism have failed to make a compelling case against its theoretical or practical adequacy as an ethical approach. In Part II, I assess the moral theory developed by Bernard Gert in Mortality: A New Justification of the Moral Rules, because Gert has recommended his approach as a systematic alternative to principlism. I judge Gert's theory to be seriously incomplete and, in contrast to principlism, unable to generate coherent conclusions about cases of active euthanasia and paternalism.

The field of bioethics has deployed different models of justification for particular moral judgments. The best known models are those of deductivism, casuistry, and principlism (under one, rather limited interpretation). Each of these models, however, has significant difficulties that are explored in this essay. An alternative model, suggested by the work of Henry Richardson, is presented. It is argued that specified principlism is the most promising model of justification in bioethics.

The doctrine of double effect continues to be an important tool in bioethical casuistry. Its role within the Catholic moral tradition continues, and there is considerable interest in it by contemporary moral philosophers. But problems of justification and correct application remain. I argue that if the traditional Catholic conviction that there are exceptionless norms prohibiting inflicting some kinds of harms on people is correct, then double effect is justified and necessary. The objection that double effect is superfluous is a rejection of that normative conviction, not a refutation of double effect itself. This justification suggests the correct way of applying double effect to controversial cases. But versions of double effect which dispense with the absolutism of the Catholic tradition lack justification and fall to the objection that double effect is an unnecessary complication.

This paper examines the 'justice' and 'care' orientations in ethical theory as characterized in Carol Gilligan's research on moral development and the philosophical work it has inspired. Focus is placed on challenges to the justice orientation--in particular, to the construal of impartiality as the mark of the moral point of view, to the conception of moral judgment as essentially principle-driven and dispassionate, and to models of moral responsibility emphasizing norms of formal equality and reciprocity. Suggestions are made about the implications of these challenges, and of the care orientation in ethics, for the ethical theory taught, the issues addressed, and the skills and sensitivities encouraged through bioethical education.

The theology of John Calvin has deeply affected the American mentality through two streams of thought, Puritanism and Jansenism. These traditions formulate moral problems in terms of absolute, clear principles and avoid casuistic analysis of moral problems. This approach is designated American moralism. This article suggests that the bioethics movement in the United States was stimulated by the moralistic mentality but that the work of the bioethics has departed from this viewpoint.

This article examines the emergence of casuistical case analysis as a methodological alternative to more theory-driven approaches in bioethics research and education. Focusing on The Abuse of Casuistry by A. Jonsen and S. Toulmin, the article articulates the most characteristic features of this modern-day casuistry (e.g., the priority allotted to case interpretation and analogical reasoning over abstract theory, the resemblance of casuistry to common law traditions, the 'open texture' of its principles, etc.) and discusses some problems with casuistry as an 'anti-theoretical' method. It is argued that casuistry so defined is 'theory modest' rather than 'theory free' and that ethical theory can still play a significant role in casuistical analysis; that casuistical analyses will encounter conflicting 'deep' interpretations of our social practices and institutions, and are therefore unlikely sources of increased social consensus on controversial bioethical questions; that its conventionalism raises questions about casuistry's ability to criticize norms embedded in the societal consensus; and that casuistry's emphasis upon analogical reasoning may tend to reinforce the individualistic nature of much bioethical writing. It is concluded that, not-withstanding these problems, casuistry represents a promising alternative to the regnant model of 'applied ethics' (i.e., to the ritualistic invocation of the so-called 'principles of bioethics'). The pedagogical implications of casuistry are addressed throughout the paper and include the following recommendations: (1) use real cases, (2) make them long, richly detailed and comprehensive, (3) present complex sequences of cases, (4) stress the problem of 'moral diagnosis', and (5) be ever mindful of the limits of casuistical analysis.

The literature on bioethics is diverse and confusing in its treatment of appropriate components for decision making. As a result, the literature on teaching bioethics is also confusing, even contradictory, in presenting an 'appropriate' framework within which learners may come to understand the nature and process of bioethics. The article sets out five decision components which are seen as common to all decision making. These components are then shown to have a significant influence both on bioethics decision making and on bioethics teaching. They are also shown to play a role in breaking down the separatism evidenced in contemporary bioethics literature aimed at individual professions.

"Applied" is a technical term describing a variety of new philosophical enterprises. The author examines and rejects the view that these fields are derivative. Whatever principles, judgments, or background theories that are employed to solve problems in these areas are either changed by how they are used, or at least the possibility exists of their being changed. Hence we ought to stop calling these endeavors "applied", or agree that the meaning of "apply" will have to include the possibility that what is applied may be changed. The so-called applied fields of philosophy, therefore, are not derivative. The strongest cases to the contrary are the foundationalist views that what we apply is epistemically privileged. Different foundationalist views take different principles, judgments, or background theories to be epistemically privileged. Strong and weak versions of each of these foundationalist views are considered but none establish these fields as derivative.