Abstract
When I teach undergraduate students theological bioethics, I do not rely upon the four principles of biomedical ethics made popular by Tom Beauchamp and James Childress, but as soon as we begin to name competing values in bioethics case studies, the four principles inevitably come up. At some point in their pre-health education, my students have absorbed the principles as the way to do bioethics. Many of the medical professionals I work with are similarly beholden to principlism. ‘Is this a case of autonomy conflicting with non-maleficence?’ our ethics committee members ask. In bioethics we play the ‘language game’ identified by Ludwig Wittgenstein. Grounded in ‘common morality’, it may be hard for many to notice that our concepts are not self-evident or may be too thin to address the fundamental questions within bioethics. In Ethics Lost in Modernity: Reflections on Wittgenstein and Bioethics, Matthew Vest offers not only an analysis of the problems in contemporary bioethics, but a necessary intervention, particularly for those interested in theological bioethics.
Vest begins with asking why bioethics has become so boring. The question is not his alone, various bioethicists who helped to form the field have puzzled over how bioethics went from a ground-breaking venture in the 1960s to a narrow discipline concerned with rules and procedures. Whereas once it took bravery to question scientific progress or to accuse doctors of evil paternalism, quasi-professional bioethicists now sit comfortably in seats of power, using common principles to render ethical judgements for complex ethical dilemmas. According to Vest, contemporary bioethicists do not offer earth-shattering revelations but procedural advice and sanction to medical science. In short, bioethics has become normalised. At this moment, bioethics needs to be shaken up and Vest's leading contender for rethinking bioethics is an unlikely interlocutor: Ludwig Wittgenstein. Vest is not the first to draw upon Wittgenstein within bioethics, but he does offer the first full-length monograph plumbing Wittgenstein's ethics as a resource for metaethical questions in bioethics.
Chapter 1 begins with the state of the field. Whereas ‘bioethics’ was first imagined by some as a wide-ranging heuristic for investigating our ecological crises, human communities, suffering, and finitude, it quickly became constricted to medical ethics. Vest synthesises the leading critics of contemporary bioethics including Stanley Hauerwas, H. Tristram Engelhardt Jr, Jeffrey P. Bishop, Tom Koch, Therese Lysaught, and John Evans each of whom levels a similar critique. Bioethics has been captured by modern, scientific thinking and functions as a biopolitics. Principlism is attractive in bioethics, because it is easily accessed, easy to deploy, dependent upon liberal secularism, and moves bioethics toward professionalisation, all while obscuring the foundational authority of the bioethicist.
Chapter 2 takes a sharp turn by introducing the book's main conversation partner, Wittgenstein. Vest provides a bird's-eye view of the wide-ranging disputes over how to interpret Wittgenstein: Is there one Wittgenstein or two? (Vest thinks one.) Is Wittgenstein a neo-Kantian? (Vests thinks yes and no.) This overview will help readers unfamiliar with Wittgenstein to get a lay of the land within Wittgensteinian scholarship and prepare them for chapters to come, though Vest himself would likely acknowledge that those already familiar with Wittgenstein will have a leg up in understanding how Wittgenstein's assessment of language offers an important methodological intervention for bioethics.
Chapter 3 delves further into Wittgenstein, while gesturing a bit more toward Wittgenstein's potential value for bioethics. Here, Vest explains Wittgenstein's understanding of language as therapy. Wittgenstein believes theoretical philosophy has a kind of sickness of misplaced expectations. Whereas many philosophers use language to float above reality, Wittgenstein draws upon actual language to ground us in reality. Against many leading philosophical voices, Wittgenstein argued that language is full of contradictions and underdeterminacy and so there can never be a logical purity in our language. Philosophy goes wrong when it aims at pure logic to make sense of the world, as if metaphysics were a kind of science. Metaphysics should produce wonder and humility rather than certainty. Language gestures toward, but cannot fully capture, the miracle of the world as it exists, which lies beyond language. Vest concludes by gesturing toward the significance of language therapy for bioethics: bioethics fails if it is enslaved to ‘the metaphysical gaze of principlism and scientific theories’ (p. 99). Vest posits that this insight is subversive. Bioethics must rid itself of disembodied language and abstraction.
Chapter 4 again critiques the field of bioethics (mainly principlism), but this time using the insights of Wittgenstein related to language. Principlism, according to Vest, is a shallow language game that does not consider its own philosophical or bioethical commitments. In this critique, Vest finds an unlikely ally in Julian Savulescu. Savulescu is a bioenhancement proponent (Vest mostly glosses over the differences between therapeutic bioethical considerations and considerations involving bioenhancement) who critiques bioethics for failing to make good philosophical analysis and arguments. Instead, bioethicists tend to ‘scientify’ ethics (p. 115) without upholding the fact/value distinction and they deploy mid-level principles without establishing a shared moral vision (p. 115). Of course, Savulescu does the same thing by failing to justify why his utilitarianist philosophy constitutes ‘good’ philosophy (p. 115). Vest concludes the chapter with a critique of Savulsecu's transhumanist commitments, which are merely Enlightenment ideals on steroids or a Nietzschean, self-referential language game.
Chapter 5 offers Engelhardt, rather than Savalescu, as a proper inheritor of Wittgenstein's philosophy. Engelhardt argues that bioethics in the public square must function as a thin, procedural bioethics or a modus vivendi, which acknowledges the deep differences that exist in moral communities, rather than a content-full morality that deploys a universal rationality. Anything else, according to Engelhardt, is the will to power. While Engelhardt did not draw much upon Wittgenstein in his work, Vest sees common affinities between the two philosophers, particularly between their modes of critique and Engelhardt's modus vivendi and Wittgenstein's Lebensformen. At the same time, Vest hints that whereas Wittgenstein did not detail how particular religious practices or commitments could fulfill his desire for ethics as activity, Engelhardt's Orthodox Christianity provided practical substance for the ethical life.
Vest ends the book with a constructive chapter that offers ‘cosmology’ as a productive turn for bioethics (p. 213). Like Wittgenstein, Vest draws upon the transcendental to move beyond scientific logic, such that the lines between philosophy and theology are blurred. Expanding upon themes from chapter 3, Vest looks to Wittgenstein's move toward wonder (which Vest calls a ‘religious’ way of thinking) as an alternative to modern, reductionist thinking (p. 177). Whereas there can be no miracles in scientific thinking, religious thinking reorients the philosopher toward the irreducible excess of the world. When one first sees a thing (or all of existence) as a gift, then that thing can never fully be explained using words. Science (playing a scientific language game) is not wrong for trying to explain the material world, but rather for reducing all things to their material components, just as philosophers are wrong to reduce all modes of apprehension to logic. Philosophy should not dispense with logic, but it should acknowledge the feeling of wonder that comes from contemplating the world. Rather than trying to explain the world with metaphysics, the philosopher describes things seen and unseen within human action. Within this stance, philosophers acknowledge they cannot explain things exhaustively and that they are part of the cosmos, they do not stand above it. Concretely for bioethics (what every bioethicist has been waiting for but won't get until the final pages of Vest's final chapter) this means that bioethicists must not view human nature, including human finitude, as something to be overcome (as the transhumanists do), but as part of what it means to be human within the cosmos. (Working as a disability theologian myself, this move resonates.) Cosmological thinking asserts that there is no abstract bioethics, because humans are also concrete persons acting in the world. Vest wants to move us ‘beyond bioethics’ (p. 213) with Wittgenstein; beyond scientific thinking and principlism and academic theorising toward concrete realities within the bios. A focus on the body, he believes, will draw Christians (and possibly non-Christians) towards other bodies—Edenic bodies, the body of Christ, and the resurrected body.
Ultimately, Vest provides much more analysis and critique of standard (principlist) bioethics than he does constructive intervention. The critique of mainstream bioethics, as evidenced by the many authors cited in chapter 1, is hardly new, but Wittgenstein does offer a unique lens into the ways bioethics has gone astray from its earliest iterations and novel interventions. Vest also goes further than others (Jeffrey P. Bishop, for example, ends The Anticipatory Corpse [University of Notre Dame Press, 2011] with a single sentence pointing toward the need for theology in medicine) in suggesting a theological reordering within bioethics. If bioethics aims at nothing less than theosis (a bold claim), then the bulk of scholarship in bioethics is misdirected. Theological bioethicists, particularly those with a background in twentieth-century philosophy, will welcome Vest's analysis and constructive moves, while those doing clinical ethics in healthcare settings may be left to wonder how to concretely enact Vest's vision. Perhaps it is those of us doing clinical work, however, that are Vest's rightful audience, as we are the ones dealing in concrete realities. If true, then we should be rightly shaken by Vest's critiques and prompted to consider how our bioethical work moves us toward, rather than away from, wonder.