Our courses and consultations weave theory and cases. Theories alone may seem highly abstract and remote from everyday problems. Teaching from cases without theory, however, gives too little direction when considering new or different problems. Cases illuminate theories and also help us “test” the theories. Cases in ethics, like experiments in science, may lead us to reject or modify a popular theory.

For example, one often hears defenses of the theory that all value judgments are based entirely on what is approved or disapproved in one’s culture and no rational basis exists for establishing that one set of cultural values is right and the other wrong. Good, bad, right and wrong, on this view, are culturally determined. This is the extreme version of ethical cultural relativism and, while popular, has problems that cases can bring out.

First, diagnosis and treatment decisions are evaluative and so, on this view, lack genuine intercultural authority and merely reflect the particular cultural views of individual members. Yet consider the following case where Soviet doctors use this theory to defend their practices: (Kopelman, 1997; Block 1981; and Reich 1981):

In the 1970s and 1980s, international psychiatric organizations criticized psychiatrists in the Soviet Union for misdiagnosing people who exhibit no signs of serious illness, and detaining and treating people as mentally ill for political reasons. Psychiatric diagnosis was employed, critics charged, to silence dissidents advocating human rights or nationalism for republics within the Soviet Union as well as to repress persons seeking to emigrate, having religious convictions, or embarrassing to the Soviet government. The Soviet psychiatrists defending these practices argued that these people were sick because they were maladjusted, nonconformist, and abnormal in their society and that this was demonstrated by their deviant and inappropriate social behavior. Diagnoses and practices, they argued, are framed by society’s own norms and values. These patients are sick people and should be detained and treated in Soviet society, even if they might not be in other societies.

The Soviet defenders use of extreme ethical relativism is also used by those defending other culturally-based “health” practices such as ritual burning or female genital cutting.

Second, since extreme ethical relativism depends upon identification of cultures to determine what is right, wrong, good or bad, defenders must show how to differentiate cultures so we can find out what is good or bad, or right or wrong. Or to put the point another way, how do we count cultures? Insofar as we cannot distinguish people’s cultures, then, on this view, we cannot decide what is good or bad, or right or wrong.

This theory presupposes cultures can be distinguished clearly enough to determine what is approved or disapproved within each. Most people if asked to consider the cultures to which they belong, produce long lists, including many social, ethnic, racial, professional and religious groups. It seems difficult to draw lines between cultures because each of us belongs to many. Cultures have differences within“ one” culture and overlap and have similarities to others. For example, criticisms of the Soviets’ practices first came from psychiatrists within the Soviet Union, who openly challenged what they viewed as a political misuse of psychiatry. Social deviance is not mental illness and to hold it is, they said, violates international psychiatric values. These groups condemned the national control of professions for political purposes. Members of international psychiatric organizations who believed psychiatric organizations should control psychiatric diagnoses and practices, not psychiatrists in the service of a political agenda, took up their criticisms. To respond that international psychiatric organizations are a unique culture raises the earlier problem of how to distinguish cultures.

Third, people from different cultures sometimes do act differently, have different beliefs, and have distinct norms. But it does not follow from this that it is impossible to have justifiable cross-cultural discussions and judgments about what we should do or value. We cannot criticize other cultures and coherently say that something in our culture, while widely approved, is wrong and needs to be changed. Extreme ethical relativism makes it impossible for us to say meaningfully that established cultural practices are wrong, such as slavery, apartheid, oppression, or the Soviet’s use of psychiatry. Agreement about such cases leads many people to abandon the extreme forms of ethical relativism.

On the other hand, theories can lead us to change how we assess situations and make decisions. For example, when theories about civil liberties were applied to medical situations, the doctrine of informed consent was generated, supporting the view that competent people had rights to be informed of all the salient information a reasonable person would want, and to make free and voluntary decisions based upon their own values. The practice of telling people “what was good for them to know” became unacceptable and many deeply rooted paternalistic practices in medicine began to erode.

The interplay between theory and practices or cases is an important part of all our programs.

REFERENCES

Block, S., “The Political Misuse of Psychiatry in the Soviet Union.” In S. Block and P. Chodoff Eds., Psychiatric Ethics. Oxford: Oxford University Press 1981: 321-341.

Kopelman, L.M., “Moral Problems in Psychiatry: The Role of Value Judgments in Psychiatric Practice” in Medical Ethics, Second Edition, ed. Robert Veatch, Boston, Massachusetts: Jones and Bartlett Publishing Company (1997), pp. 275-320; portions of this essay were adapted from this paper.

Reich, W. T. “Psychiatric Diagnosis as an Ethical Problem.” In S. Block and P. Chodoff, Eds., Psychiatric Ethics. Oxford: Oxford University Press, 1981: 61-88.