• philosophy of medicine
• ethics

I am grateful to the esteemed commentators for their critiques of my paper, ‘Why Not Common Morality’.1 As I read through their remarks, however, they seemed to be talking past my arguments. Their criticisms nevertheless make it clear that I need to explain myself better. I am therefore grateful to the editor for allowing me this opportunity to clarify my position.

My paper presented two arguments for concluding that common morality is untenable as an account of medical ethics. First, I provided a negative argument to show that common morality does not provide an adequate account of medical ethics. Second, I offered a positive argument that demonstrated why the medical professions require a distinct morality.

My negative argument relies on counterexamples to show that the duties of medicine are different from the duties of everyday life. It is intended as a refutation of the claim by Tom Beauchamp and James Childress that ‘The common morality is applicable to all persons in all places, and we rightly judge all human conduct by its standards’.2

Logically, if any of the duties of medical ethics are inconsistent with common morality, they are not compatible with common morality standards. My counterexamples demonstrate that standards of conduct judged acceptable by common morality are irreconcilable with duties of medical ethics. Hence, they could not follow from the same principles. If the standards of common morality lead to particular judgments about the morality of a certain conduct, those same standards cannot also be the basis for reaching the opposite judgments about that sort of conduct.

Charles Foster,3 Alex John London,4 Ruth Macklin5 and Bryanna Moore6 all suggest that exceptions to my examples refute my negative argument. As far as they go, their retorts merely suggest that, in some circumstances, medical professions should do just what others would be obliged to do. I do not deny any of that, and I certainly accept that conflicts of duty arise in any moral theory with more than a single principle. In fact, my forthcoming book, The Trusted Doctor,7 which explicates the implication of this paper, includes a chapter on ‘Resolving Ethical Dilemmas’.

‘The Distinctiveness of Medical Ethics’8 table illustrates some differences between the everyday life standard for ethical conduct and the standard for conduct of medical professionals. Unusual circumstances in ordinary life and professional life can justify exceptions. For instance, freely sharing information is standardly allowed in common morality, but a promise to keep a disclosure secret creates an exception that prohibits sharing. In contrast, upholding confidentiality is the ethical standard for medical professionals. Yet, a duty to protect someone could justify an exception and allow sharing information outside of professional boundaries. In my comparisons of medical ethics and common morality, standardly accepted behaviour for medical professions and others, and exceptions that require justification, go in opposite directions. In her commentary, Macklin notes that the differences lie in where ‘the presumption’ is. Macklin dismisses the point, but I consider it a telling distinction because it shows that the presumed standard for professional conduct is starkly different from the standard in everyday life.

My positive argument turns on my distinction between roles and professions. Laurence B McCullough9 and Søren Holm10 observe that I do not look to historical or legal examples of how the term ‘professional’ has been used. That plumbers are called ‘professionals’ is irrelevant to my argument. Instead, I am offering a novel way to distinguish professions from social roles and what Holm calls ‘skilled trades’.11 A good deal of time, effort and study are involved in the development of any skill or area of expertise. Obtaining licences and adhering with local regulations are also often elements of social activities and roles. But those are not the conceptually defining features of professions.

As I see it, societies allow professionals to employ powers and privileges that are not allowed to anyone else. The extraordinary liberties granted to professionals are potentially dangerous, so, aside from remarkably unusual circumstances, ordinary citizens are prohibited from performing acts that professionals are allowed to do under normal circumstances. Because common morality prohibits non-professionals’ employment of professional powers and privileges (eg, administering poisons, excising flesh from another’s the body), there are no common morality principles or rules to govern their legitimate use. Professional duties and the limitations on how the profession’s distinctive authority may be employed therefore must be delineated and explained from a perspective outside of common morality. This distinction makes sense of the need for distinctive professional obligations and provides a coherent framework that explains why the ethical standard for the medical professions is different from common morality.

Critics note that societies may invoke principles of beneficence and non-maleficence to justify investing professions with exclusive powers and privileges, but those reasons are different from the reasons that justify professional duties. Because the commissions granted to professionals are not standardly allowed to anyone outside of the professions, and because of the inherent dangers associated with employing their unique powers and privileges, professions require unique moral constraints to govern their uncommon commissions. The reasons that justify those ethical standards are, therefore, based on upholding the trust invested in the profession and maintaining the franchise to wield their exclusive society-invested powers and privileges. Consequently, all professions’ first and fundamental professional duty is to seek trust and be deserving of it, and their second duty is to use the profession’s distinctive powers and privileges for the benefit of society and its members . Additional profession-specific duties define the moral requirements for the trustworthy employment of the profession’s exceptional authorised commissions. As Tom Beauchamp remarks, contextual specification is a critical element in the articulation of any moral theory,12 and although professions define their own ethics, as Holm recognises,10 that is not done in a vacuum, but with awareness of the impact on and continued support from the public.

The rationale that supports common morality is different from the underpinning for medical ethics. Supporters of common morality see its judgments justified by what an overlapping consensus of rational and reasonable people would endorse in reflective equilibrium. That means common morality binds everyone, or at least all of those who are rational and reasonable. The moral force that creates medical ethics is,¹ however, the commitment of medical professionals to promote the interests of patients and society and to employ the necessary society-granted powers in a trustworthy way. It is precisely because not everyone but only medical professionals make that commitment that only medical professionals are committed to upholding their distinctive duties.

This turns out to be the most significant issue between me and Beauchamp. He writes that ‘The Belmont Report puts forward a system of ethical principles showing that physicians and other health professionals must conduct research in the service of the public interest and the well-being of patient subjects’.13 I agree completely. But whereas Beauchamp regards his statement as an expression of common morality, I regard it as a cornerstone commitment of professional ethics. In common morality, people are free to concern themselves with their own interests, but fiduciary responsibility is the hallmark of professional duty. I do, however, concur with Beauchamp’s critical point that we could not ‘even get started on a professional ethics’14 without overarching concepts like ‘keep your promises’ and ‘do your duty’ that define all morality. I also grant that my eight-page paper does not complete the tasks of articulating, explaining and justifying the specific duties and virtues that constitute medical ethics.15 The aim of my forthcoming book was to achieve those goals.16

After considering the comments offered in response to my paper, I remain unpersuaded by the objections offered thus far, and I am still committed to regarding medical ethics as an uncommon morality. Bioethics is a challenging and evolving field. Even though London laments that ‘[i]t would … be a sad commentary on the profession’4 if the distinction between medical ethics and common morality had gone unrecognised for decades, I see my colleagues as open-minded critical thinkers. While I sympathise with London’s embarrassment and pique, I am confident that other scholars are prepared to consider my arguments, welcome whatever insights my paper might afford, and rejoice in the clarification that significant conceptual distinctions can provide.