Remembering Stephen Toulmin: How Medicine Saved the Life of Ethics

Dr. Daniel Sulmasy

This is a very special

Dr. Daniel Sulmasy

session for us on remembering Stephen Toulmin. My name is Dan Solmacy. I'm one of the associate directors in the McLean Center here. I had the privilege of meeting Stephen Toulmin only once in my life, but fortunately we have with us lots of people who are going to, who know him better and are going to talk to us more about him today. He's really well known, as you know, in bioethics for his famous paper on saving the life of ethics, the revival of casuistry. But he really, as a philosopher, had a remarkable career with depth and breadth in his scholarship logic and the nature of argument, philosophy of science. So for instance, just the other day I was, as the editor of Theoretical Medicine and Bioethics, looking up a paper a reference to try to get a better handle on a paper that came in on the philosophy of Ludwig Fleck, a Polish mid-20th century physician who wrote on philosophy of science and of medicine, and who do I find is the editor of the paper, collected papers on this, but Stephen Toulmin. So his work has really had a remarkable effect on lots of areas, but we want to particularly about his effects on the McLean Center and on bioethics in general. To discuss his work, we've got a cast of stars here who really need no introductions, but I'll tell you some things briefly. I'm not going to introduce each one, and these are going to be very short. We're going to start actually with a videotape from Al Johnson. Al Johnson, unfortunately, could not be with us here. But Al is currently the co-director of the program in medicine and human values at the California Pacific Medical Center in San Francisco. So we're going to start with a videotape from him. Then we will have Stephen Miles, again, well known to many here, former fellow here, currently professor of medicine and bioethics at the University of Minnesota Medical School in Minneapolis. Then we'll once again bring to the podium John Lantos, again well known to all here, Professor of Pediatrics at the University of Missouri, Kansas City School of Medicine and Director of the Pediatric Bioethics Program at the Children's Mercy Hospital in Kansas City. Then our host, Dr. Mark Ziegler, is the man who makes this whole thing happen. And then as a special treat, we're going to end the session with a video about Professor Toulmin that's going to be shared with us by, that's been kindly shared with us by his widow, Donna Toulmin, who's in the audience. Would you maybe stand up or at least wave so we can,

Dr. Daniel Sulmasy

we're very grateful that she was able to join us on

Steven Miles

this special occasion. Stephen Toolman was the finest teacher that I've ever had and the finest co-instructor that I've ever talked with. I arrived in Chicago in 1986 to be the education director of the newly established Clinical Ethics Fellowship. The program was in some disarray. James Gustafson was leaving, or had left. Leon Kass was disengaging.

Steven Miles

John Paris was a Jesuit moral philosopher of endless delight who was my office mate. And we had fine fellows during the Toulmin era and several brilliant medical students. But there was no curriculum. And there was no model for what a clinical ethics fellowship should be. And to complicate matters, clinical ethics at that time, which was a spinoff of bioethics, had not cohered as a field. At times, it even seemed something like a rehab program or a New Age religion. It was the Tao of four principles. There were four-step programs for ethics consultation. Some people proposed five professional virtues, others named seven. Ed Pellegrino, of course, argued that virtues, although real, were too sublime to either enumerate or name.

Steven Miles

There were mantras like double effect and substituted judgments that experts could use to cleave dilemmas, but each expert came with a different conclusion. And then people were split into more categories than a Briggs-Meyer pinwheel, There were the dead-dead. There was the brain-dead, which the cognoscenti insisted were the same thing, except when there was a conscientious objection, in which case they might be different. Others were comatose, persistent vegetative states, coma vigils, locked-in syndromes, demented, never competence, or people who had competence. And then there were the status incompetence as well. But notwithstanding all of these categories, Patients and clinical patient relationships were eerily insubstantial. Race, class, or gender was intangible. And this lack of social grounding affected clinical ethics in profound ways. The interest in or capability of writing an advanced directive, for example, was taken as some kind of normative life work. rather than as an activity that would only be undertaken by a highly peculiar subculture.

Steven Miles

Dying with full technology was an ethics problem. Dying because you did not have health insurance or access to clinics was a policy problem. These people were outside of hospitals and outside of the field of clinical ethics. And so I didn't know as a new ethics fellowship person whether my job was to teach this embryonic material or whether it was to inoculate the fellows against it before they headed out into life where the textures and tragedies of life would mock those kinds of pretensions. Fortunately there was Stephen. Stephen respected the issues. He pondered the dilemmas and he was somewhat bemused by the new discipline. And so without a plan or time to plan, we took the two received texts, neither of which had been in print long enough to lose their new ink smell, we tried them briefly, and then we set them aside.

Steven Miles

Steven got me to agree that clinical ethics required a face-to-face wrestling with ideas, and more importantly, those ideas in the history for a culture. And so we taught books rather than articles, digest, or algorithms. We began with Aristotle's Nicomachean Ethics, and we never looked back. We read Camus' The Plague with Katherine Hunter, teasing out the idea of human solidarity as a foundation for morality in an Age of Alienation, where we read McIntyre's After Virtue that examined the reason for the incoherence of virtues in our age. We saw no reason to read the Digests of Court Opinions when we could read the opinions ourselves. And so we read Quinlan and Saquowitz and Fox as cultural documents that had a cultural grounding, rather than as legal precedents and explored them that way. And along the way, we also read Bella and Sullivan's Habits of the Heart, Individualism and Commitment in American Life to illuminate the way our culture, its courts, talks about individualism and community. Later, of course, we got a lawyer, Ann Dudley Goldblatt, who would add legal coherence to these readings. But by then, the fellows knew that they could read court cases by themselves.

Steven Miles

In clinical cases, we tried the four steps and the four principles, but we soon devolved to case casuistry. How is this new case like this one which is settled? What detail's different? Do they matter? Why? We read Johnson and Tooleman's magnificent The Abuse of Casuistry, a book that I still use today. This is the practical reasoning that Al Johnson spoke of. Influential papers came out of the Toulmin years. They explored the basis of the concept of futility before anybody else was touching it. The meaning of equipoise is a condition for doing human research. That paper won an award. The duty of physicians to take care of AIDS, persons with AIDS, that paper changed AMA policy. Another paper analyzed how gender affected right to die decisions in that men had rational preferences, whereas women needed to be cared for. That paper is still being anthologized. And one paper was the first, only, and last paper to ever use the word phrenesis in the title and get into the annals of internal medicine. That, of course, is the term for practical wisdom from Aristotle.

Steven Miles

These papers matured the field and gave it depth. They mirrored the texture, the depth, the boldness, and the humor of Steve Toulma. Now my time with Stephen closed on a somewhat whimsical note, but an important one. His book Cosmopolis the hidden agenda of modernity. It is so interesting to give this talk with you sitting in the room, because I keep wondering whether I'm going to trash what he was saying. It's OK, though. Well, as Stephen tells it, in 1600, Europe desperately wanted peace from endless fundamentalist wars. Two solutions emerged. The first one was epitomized by Descartes. And that emphasized rationalism. And the other one, which Stephen puckishly personified in the French King Henry of Navarre, emphasized a cosmopolitan appreciation for the diversity of cultures by which all humans flourish. Henry of Navarre was a charismatic, passionate, and engaged leader. He was known for his love of life, food, and women, although the order of these affections varied by the hour. He forged a successful treaty with the jihadists of the Ottoman Empire, and he mollified Europe's Protestant fundamentalists. And then he was assassinated by a Catholic fanatic.

Steven Miles

Stephen argued that the struggle between fundamentalism, rationalism, and an open appreciation For the creative diversity of moral expressions by which human flourish continues to this day. The fundamentalists browbeat more than they can persuade. Rationalism and its step-style utilitarianism persuade, but they cannot console. Steve was a Cartesian turned Navarist, And again, only partly tongue in cheek, he proposed as an immigrant from the UK that the Beatles were the Renaissance or perhaps resurrection of Henry of Navarre. Clinical ethics works at bedsides over which magisteriums make blistering proclamations and to which rationalists bring cold comfort.

Steven Miles

in clinical ethics have no better alternative than the one that Stephen lifted up for us. A compassionate, non-dogmatic bending to the humanity before us.

Steven Miles

We're all better for his time with us. Thank you.

Dr. John Lantos

Well, Steve Miles was one of the greatest teachers I've ever had and still is. That was amazing. As I was preparing my remarks for this session, I reread parts of the Abuse of Casuistry and oddly was reminded of a scene in the great movie Il Postino in which Pablo Neruda is explaining metaphor to an illiterate Italian postman. The postman wants to become a poet, he tells Neruda, because as he says, you get to walk around a lot and you don't get fat.

Dr. John Lantos

He wants to know how to do it because he also wants to write a poem for a beautiful barmaid who he's trying to seduce and has heard that chicks love poetry. Neruda is trying to explain to him what a metaphor is, and in the scene, the postman gradually catches on to what exactly a metaphor is. and then takes Neruda by surprise with his realization that metaphors may be even more complex than Neruda himself thought. The mailman says to him as he starts to get it, you mean then that, for example, I don't know if I follow you, that the whole world, the whole world, the sea, the sky, the rain, the clouds, now you can say et cetera, et cetera, Neruda says. The whole world is a metaphor for something else. Ah, I'm talking crap. Neruda says, no, not at all, not at all. And the mailman says, you just pulled a strange face. And Neruda says, Mario, let's make a pact. I'll have a nice swim. I'll ponder your question, and then I'll give you an answer tomorrow. So I thought of this as I was remembering the seminars we had with Toulmin back in 1986.

Dr. John Lantos

I didn't realize at that time, I didn't realize, I thought the curriculum was very well organized. We came in, we read books, but I didn't realize that Tormund at that time was at the end of a remarkably productive decade of work that transformed the field of bioethics and would continue for the next few years. We knew and we had studied his two papers, seminal papers that he'd already published, The Tyranny of Principles and How Medicine Saved the Life of Ethics, but didn't realize how these had grown out of his attention to and engagement with some very specific problems in bioethics and public policy that he faced on the National Commission, or how they would be further developed in his big book with Al Johnson on casuistry. And the reason it reminded me of the scene in Il Postino, was that Toulmin was trying to weave together and make analogies or metaphors between two very different sorts of moral reflection. One had to do with questions about what it might mean to be a good physician, a moral question certainly, but a timeless one, and not one that was particularly central to the new modern bioethics. The other, to which I'll return later in the talk, had to do with what it might mean to be a good moral philosopher. In his

Dr. John Lantos

preliminary discussion of what it means to be a good physician, he tries to figure out the relationship between scientific theory and clinical practice in clinical medicine rather than in medical ethics. And he asks, quote, is all clinical medicine the reflective use of medical judgment in dealing with the specific conditions of particular patients simply applied biomedical science? To answer that question, he goes on, either with a plain yes or with a

Steven Miles

flat

Dr. John Lantos

no is equally misleading. Certainly major theoretical elements from the biomedical sciences lie behind modern clinical practice, but biology does not bear on clinical medicine in any simple or direct, let alone formal way. Their interrelations are substantive and subtle, unquote. He's laying the groundwork here for his elaborate metaphor that is the central argument in the abuse of casuistry. Medicine is like morals. Everything is a metaphor. Morality is like medicine. He goes on to explain how in medicine, theoretical science alone can somehow lead to inarguable conclusions about diagnosis and treatment, but not usually. He cautions that it often doesn't work. And he notes that in many cases, science suggests a number of possible diagnoses or treatment plans. and science itself cannot adjudicate among them. There, the skill of the clinician must take over because, as Tuoman notes, clinical knowledge does not automatically give out at the point where biology runs out of steam. What then, he asks, is this clinical knowledge? If it is not scientific, does that mean it's not rational or rigorous? He answers with an emphatic no. Clinical knowledge in such circumstances, he argues, does not become merely the personal hunches or expressions of taste with which individual doctors respond. Instead, he argues, doctors think casuistically, meaning that a medical condition is defined by a classic description of a case. He writes, as new cases present themselves for examination, the physician collects details from each patient's history, his own immediate observations, the results of lab tests, and he uses these facts to place a particular patient's condition in one or more recognized types. In marginal or ambiguous cases, clinicians who are equally skilled and conscientious may share their information fully and have the best wills in the world, yet through reading the same history and symptoms differently, they may come up with different diagnoses and different treatment proposals for one and the same case. The key element in diagnosis is the syndrome recognition that relies upon arguing from analogy. And this, he claims, is the methodology of practical reasoning rather than of theoretical proof. The conclusion is related to the evidence by substantive rather than formal connections. The conclusion is always a rebuttable presumption rather than a necessary entailment. The conclusion from evidence is circumstantial rather than timeless and independent of context. Reading this

Dr. Mark Siegler

today, one

Dr. John Lantos

realizes that in the intro to that book, Johnson and Toolman could have been, among other things, designing the template for the script writers of the television show House.

Dr. John Lantos

A show that, better than any ever written better, I'd say even than the Sherlock Holmes stories that serves its template, shows just how the process of differential diagnosis works, how it is fraught with error three times out of four on every show, even in the hands of the very best practitioners, how it involves careful judgment, trial and error testing, and ongoing willingness to reconsider the original hypothesis in light of new data, and eventually, sometimes, the arrival at a correct diagnosis. And as Toulmin and most physicians would no doubt agree, in each case there is, in fact, a correct diagnosis, even though experts may disagree and it may be hard to find. Or as House himself notes during an episode in which he's teaching a medical student class in a not particularly humanistic fashion, quote, This is house to a medical student. I'm sure this goes against everything you've been taught, but right and wrong do exist. Just because you don't know the right answer, maybe there's even no way you could know what the right answer is, that

Dr. Mark Siegler

doesn't make

Dr. John Lantos

your answer right

Dr. Mark Siegler

or even okay. It's much simpler

Dr. John Lantos

than that. It's just wrong.

Dr. John Lantos

At this point, Johnson and Tooleman make their brilliant and creative turn, the one that leads to their reflections on a different set of moral problems. They write, all these features of medical theory and clinical practice suggest parallel questions about ethical theory and moral practice. Here, too, they claim there is a middle ground between theoretical rigor and relativism, or the unpalatable choice between a strict moral geometry and the appeal to personal preferences. They don't claim this to be an original insight. They say it's St. Augustine and the Fourth Lateran Council. They cite William James at length, who wrote, there is no such thing possible as an ethical philosophy dogmatically made up in advance. And they conclude that there are two seemingly incompatible but potentially complementary views of ethics. One looks for underlying axioms or super principles to provide theoretical unity between the diversity of moral practice and experience. The other accepts the complexity and concreteness of moral experience at its face value.

Dr. John Lantos

How can these be complementary? A good physician and a good practical ethicist will use whatever tools are at hand to try to diagnose and treat the problems that they are called upon to solve. Sometimes consequentialist arguments work, so use them. Other times, patient autonomy is the solution to the problem, or professional scruples or some other deontological principles. Appeals to these tools from the philosopher's toolkit carry conviction within informed hearers only when the circumstances of the particular case create an appropriate occasion for an argument of that specific kind. The idea that deontology or consequentialism would be preferable at all times and all places is idiotic, as stupid metaphorically speaking as would an approach to medicine in which one would say, antibiotics and only antibiotics must be the solution to every problem. Or, and here is where the argument becomes the most profound, if one saw biological science as the only relevant grounding of a sound approach to medicine. Instead, the clinician must sometimes draw on economics, psychology, literature, magic, law, music, laughter, art, dance, food, to get where he or she needs to go. The tension was highlighted in Sinclair Lewis's great novel, Aerosmith, in which he creates the great German microbiologist Gottlieb, who, according to the author, would rather have the patient die with the right diagnosis than be cured with the wrong one. And I recently heard Charles Boss give a talk illustrating how this sometimes plays out in a different area of modern health care delivery. quality improvement movement. Bosk is now studying that, as he's been studying medical error and quality improvement for a long time. And he's trying to figure out how hospitals have responded or should have responded to the Institute of Medicine report on medical error and hospital deaths. And he cited a case in which a trauma patient he was observing as an ethnographer, a trauma patient came into the emergency department was treated and died. And then he went to the M&M conference, morbidity and mortality conference, and it was clear that they'd missed the diagnosis and could have saved the patient if they'd made the right diagnosis. And the resident on the case said in his defense, but I followed the protocol exactly. And to Bosk's surprise and chagrin, the attending physician said, well, yes, that's exactly what you should have done. We didn't do anything wrong in this case.

Dr. John Lantos

So Tormund's claim that medicine saved the life of ethics was a little perhaps too simple, perhaps premature, because his analysis of the types of problems that arose at the interface of the two fields, medicine and ethics, sheds lights on ways of thinking that are common to both. And neither field has been particularly hospitable to these insights. Medicine continues to try to establish itself as a rigorously scientific enterprise, one that is evidence-based and scientifically grounded. Bioethics continues to try to ground itself as principle-based. But the task of the clinician, the expert clinician, and the task of the bioethicist, the expert bioethicist, are a little bit different. The best practitioners are no more scientists than the best coaches or exercise physiologists or the best pilots, aeronautical engineers. The best practical bioethicists are not moral philosophers or theologians or even poets. We should not, do not train them to be theoreticians. But the task of training people in practical wisdom and in the skills of discernment and judgment that Toulmin tried to highlight remains as non-standardizable and difficult today as it was in Aristotle's day and as relevant and important.

Dr. Mark Siegler

Thanks. I was taken by all three of the presentations so far,

Dr. Mark Siegler

Al Johnson raised a question that I had actually not thought about for a while. And that is, when and how did I first come to meet Stephen? And my recollection is that as James Gustafson, James Gustafson was the person who introduced us. As Jim Gustafson was backing away from bioethics to write his two-volume systematics on theology,

Dr. Mark Siegler

he, that is Jim, who had been my teacher and mentor for the better part of six or seven years, felt that I needed a lot more seasoning and training. I wasn't quite finished. And so he took me by the hand to Stephen's office, which was up on the fifth floor of the Social Sciences building. It was a kind of area up there, quite difficult to get to. You had to traverse several staircases to actually make your way to that top floor of Social Science. And he introduced me to Stephen, who from that point forward did become a treasured mentor and teacher. It was at the time that I had begun to work with Al Johnson on the clinical ethics book. That work had started around 1979, culminated in the first edition of 1982. And because of Stephen's connections that you've heard with Al on the National Commission and through Jim Gustafson, there was this wonderful connection. that was achieved. It was a connection that meant so much to me in my own learning and stayed with me through the 80s and into the 90s. Even after Stephen went to Northwestern, he would often come back to our Wednesday case conferences because they were so meaningful to him and to us.

Dr. Mark Siegler

Donna and Stephen's son and granddaughter, I'm so glad you're here. Stephen, in his classic and often reprinted essay, How Medicine Saved the Life of Ethics, argues that Anglo-American philosophy of the 19th and 20th century had lost its way.

Dr. Mark Siegler

By following a scientific systematic approach that Stephen traced back to Henry Sidgwick at Cambridge in the 19th century and to Sidgwick's book, The Methods of Ethics. Stephen, this may be too strong a word, accused Sidgwick of introducing into philosophy, quote, a rigor, order, and certainty, end quote, associated with, for example, mathematical reasoning. As Stephen put it, now I quote again, Sidgwick ignoring all of Aristotle's cautions about the differences between the practical modes of reasoning appropriate to ethics and the formal modes appropriate to mathematics, set out to expound the theoretical principles of ethics in a systematic form." Stephen then described how Sidgwick's approach increasingly led to a focus on analytic philosophy and meta-ethics, and to a reluctance on the part of philosophers to engage substantive ethical questions about the big problems, the kind that John Lantos tells us that house engages, questions about whether right and wrong do exist. Further, Stephen pointed in his essay to an increased reliance on codes or rules or principles based on philosophical or religious authority that were frequently invoked to resolve these ethical disagreements. As he said, from the mid-19th century on, British and American moral philosophy treated ethics as a field for general theoretical inquiries and paid little attention to issues of application to particular types of cases. Stephen concludes this famous essay by saying that philosophical engagement with medicine, and now I quote from Stephen again, has had a spectacular and irreversible effect on the methods and content of philosophical ethics. By reintroducing into ethical debate the vexed topics raised by particular cases, they have obliged philosophers to address once again the Aristotelian problems of practical reasoning, which have been on the sidelines for too long. In this sense, we may indeed say that medicine--" and I'm still quoting Stephen--" has saved the life of ethics, in that it has given back to ethics a seriousness and relevance which it seemed to have lost for good." End quote. So this is what Stephen meant by medicine saving the life of ethics. that medicine gave back to ethics a seriousness, a relevance, a human dimension, which had apparently been lost for a hundred years or so.

Dr. Mark Siegler

I harassed poor Donna because I had in the back of my head a recollection that Stephen had written another essay, not the Tyranny of Principles essay, but another essay on whether ethics saved the life of medicine as a companion piece to that original one, How Medicine Saved the Life of Ethics. I don't know why I was persuaded or convinced that such an essay had been written. And Donna searched the bibliography, searched her records of published and unpublished papers to come back and assure me that such a paper had never been written. That was the question of whether ethics really saved the life of medicine.

Dr. Mark Siegler

perhaps it came out of conversation that Stephen and I had had rather than an actual publication, because I was so convinced of it.

Dr. Mark Siegler

And if my memory was correct, I suppose what Stephen and I were chatting about was that ethics saving medicine, it was in the sense of preserving or recapturing this human dimension, this personal caring, detail-based, case-based side of patient-centered medicine, saving it from the narrow, technical, scientific model of medicine that had emerged after World War II. You know, the model of scientific medicine driven by the expansion of the NIH had resulted in huge increases in science of medicine, in more specialists and generalists a rise in impersonal hospital care instead of care in the doctor's offices or the patient's home, all in all, a kind of falling away from the golden age of the doctor-patient relationship when everything was peaches and cream and Norman Rockwell imagery to the harsh realities of late 20th century medical practice with a loss of personal relationships, a greater enemy science substituting for human engagements, less care and less touch, and more machines, less humanity and more science. So the question in my mind, the one that Stephen and I played with, was how the emergence of medical ethics in the latter third of the 20th century helped revive medicine, saved it in this way from its narrow focus on science and technology to restore to it its former human dimensions of caring, compassion, and case focus. And I think it's quite clear that it's done so in many ways. It's done so by changing the fundamental paradigm of medicine or contributing to that change from the old paternalistic model to more modern models of patient involvement and patient centeredness. It's helped us enormously. in the period of exploding technology that started in that post-war era to integrate this new Promethean power of medicine that allows one to preserve lives, to delay death, to give us some way of dealing with this awesome capability. And that's another way in which ethics has helped save medicine. And I think it's done so in that third way that I've already referred to by infusing medicine, again, with fundamental questions of good and bad, right and wrong, these human dimension questions that come up in the cases.

Dr. Mark Siegler

That, it turns out, at least based on my reading, is a set of questions that seem to occur and reoccur in medicine roughly at intervals of a generation. Every 30 to 40 years, questions are raised about whether medicine has gotten too scientific and has lost its personal bedside focus. It was the theme of the Tumulty paper of 1970 on what is a clinician. It was the theme of Peabody's essay in 1927 on the care of the patient. Can you train people? in personal medicine in the impersonal setting of the hospital. I've actually tracked that question back to Philippe Pinel, physician and chief at the Salpêtrière in 1793, when he wrote this extraordinary essay on the clinical training of doctors, in which Pinel, here in the midst of the revolution, is arguing that medicine has become too scientific and must again recover its focus on the patient and on clinical activity. Pinel said at that point that the best teachers of medicine were patients and that physicians should pay more attention to care and to the psychological aspects of disease than to cure and the physical aspects of disease. I mean, that's 1793. My point in referring to Tumulty and Peabody and Pinel as well as to modern doctors, is to reinforce this notion that the struggle between the science and the human element of medicine is an ongoing struggle.

Dr. Mark Siegler

For now, I think I will conclude, as Stephen did 25 years ago, that medicine's impact on ethics was profound and thus far appears to have been a sustained impact. in driving us back to examination of important and deep questions that have troubled philosophers from before Aristotle to the present. And whether we'll be able to say the same about the impact of ethics on medicine, I think, may take one more generation to decide. But standing here remembering Stephen, remembering the wonderful people who worked with Stephen during those great days of the 80s is fabulous. And Donna, I'm so glad you're here. And I'm going to turn it over to Dan, because Donna has brought with her a short vignette. Thank you.

Dr. Daniel Sulmasy

I'd like to thank our presenters for the wonderful remembrances of a colleague, a teacher, a scholar, and a wonderful human being. And many lives have been touched by Stephen Toulmin. We're grateful for his effect on our thinking and our lives. And probably a question and answer period will not do justice to that. So I think we'll just end it at this moment. So thank you very much. Thank you.