Moral reasoning--the unrealized place of casuistry in medical ethics.

If the practice of ethics consists of the justifiable application of moral principles, then the challenge will always be to ensure, first, that the principles are well chosen and, second, that their application to the case in point is overtly justifiable. In this editorial, having briefly mentioned “principlism”, which itself involves the application of ethical principles in practice, we shall make the case for casuistry (case-based) reasoning. Most of us like to think that our decisions are the result of logical deductions – that we consider ethical principles germane to a given clinical problem and we deduce the correct course of action. In reality this is seldom the case, because strict deductive reasoning is extremely taxing. It requires an unbroken chain of syllogistic reasoning – carefully crafted and open to scrutiny, internally consistent and advancing in minute steps – just like the proof of a mathematical theorem. This demanding process is not feasible in clinical practice: most ethical discussions rely heavily on inductive reasoning, interspersed perhaps with elements of “nested deductivism”, i.e. short strands of tight, logical argument. Murray (1994) has cogently criticized deductivism. He argues, amongst other things, that: (a) since moral theories are generally too abstract to be directly applicable to specific moral judgement, there is a temptation in deductivism to be inattentive to the particularities of cases – hence, rules may be applied insensitively; (b) most situations are complex enough to invoke more than one fundamental principle and unless some definitive scheme for ordering principles is provided, no conclusive answer seems possible; (c) deductivism typically pays little or no attention to the social or historical context in which moral problems appear.