This is interesting, because I reject the set up, and I bet many other ethicists will too. In the medical scenario, I think that either the substituted judgment standard or the best interest standard is right, everywhere, not that one can be right in one place and the other right in another place. That is, I think if you spell out the features of the case sufficiently, it will turn out that the right thing to do won’t depend on whether you drop the case in the US or in China.
Thus, for example, if the patient had clearly expressed wishes for X after she goes into a coma, and this has been consistent her whole life, and doing X is trivial, and doing ~X is very violent and traumatic, and all this is common knowledge, and etc. etc. etc. (add as many favorable details as you like), then the right thing to do is X, and it won’t matter if you add at the end “and by the way, this is all happening in… CHINA.”
Conversely, if the patient’s wishes are hard to know, and doing ~X is trivial, and the consequences of X are really really bad, and all this is common knowledge, and etc. etc. etc. (add as many unfavorable details as you like), then the right thing to do is ~X, and it won’t matter if you add at the end “and by the way, this is all happening in… AMERICA.”
More generally I follow James Rachels’s classic introductory textbook in thinking that, to the extent that one might think morality is relative, we’re really just thinking about etiquette or convention, like what conventional behavior counts as being polite or rude in one culture or another. But morality is more like “don’t be rude”, which doesn’t vary across cultures. And the medical debate between substituted judgment and best interests in cases of incompetence are, I think, clearly about competing ethical values, rather than about different conventional ways one might express the same ethical value (maybe the overarching ethical value of “being nice”?).
If course the cases are much easier if you deny the initial judgment about China versus US. But I’d just say that it’s not just being in one geographical location versus another, and it’s not just about etiquette and conventions of coordination, like walking on the left versus right side of the road. The Chinese convention of “family interest” taking priority over individual autonomy is about the strength of reasons that override the strength of other reasons. I don’t think in the US there is no moral weight on family interest, and no moral weight on individual autonomy in China. I think the conventions have converged on the society by and large weighing the reasons ever so slightly in favor of family interest. One view is that one society is right and the other wrong about the strength of such reasons. That’s a coherent position. Another is that both are permissible. I don’t think that’s moral relativism and I think it can be a coherent position.
Thanks for the clarification, Barry. If I understand right, your position is that these surrogate decision making cases are difficult, because of different competing values, so reasonable people can disagree, and if one culture tends to weight one value more heavily than the other does, then the different outcomes they arrive at are fine.
That’s clearly right, and yeah it’s not moral relativism. But I think it’s a claim about difficult cases, and how it’s okay to disagree on those. Could there be easy, slam dunk cases of surrogate decision making? Like a case where the added beneficence of choosing the “best interest” option is the equivalent of $0.01 of value, but the patient’s wishes were clear as day to everyone? Or, conversely, a case where the patient was wishy-washy, and the added beneficence of choosing the “best interest” option are enough to save the world from extinction?
In other words, I don’t think surrogate decision making as a class has this feature where we should always respect cultural variation. That would follow on a relativist view, but not this one. What looks like cultural variation, on this view, is downstream from contingent (cultural) tendencies to weight different values differently, coupled with a focus on difficult cases. (Jehovah’s Witness cases are difficult!)
It might be that it’s all a matter of difficult cases, which cultures have made easier by developing conventions that signal a certain value had by most. If that’s the explanation, then the difficulty of the moral cases comes first, and the convention serves as a tie-breaker. That’s probably consistent with my initial thought that we’re in the realm of moral indeterminacy.
Is it totally unlike conventions of coordination? Obviously it's not like walking on the left vs the right, in that there's no obvious symmetry. But maybe there are a whole bunch of institutions built around conventional assumptions about what reasons get what weight, such that in a context where everybody around you is going to be relying on some reasons getting more weight, you ought to give those reasons more weight.
Here's a not totally analogous example, but which maybe gives the flavor of what I have in mind. What sort of support should children provide to parents in their old age? It seems to me very plausible that there's a conventional element to this. In a society where it's presupposed that children provide a lot of support, then parents maybe save less, and then it's worse for children to not provide that support, because parents were understandably relying on it. In a society where it's common for children to provide less support, parents are more likely to make long-term plans that don't presuppose they'll have support from their kids, so when it's not given, then they're in a better position to do without it.
This is interesting, because I reject the set up, and I bet many other ethicists will too. In the medical scenario, I think that either the substituted judgment standard or the best interest standard is right, everywhere, not that one can be right in one place and the other right in another place. That is, I think if you spell out the features of the case sufficiently, it will turn out that the right thing to do won’t depend on whether you drop the case in the US or in China.
Thus, for example, if the patient had clearly expressed wishes for X after she goes into a coma, and this has been consistent her whole life, and doing X is trivial, and doing ~X is very violent and traumatic, and all this is common knowledge, and etc. etc. etc. (add as many favorable details as you like), then the right thing to do is X, and it won’t matter if you add at the end “and by the way, this is all happening in… CHINA.”
Conversely, if the patient’s wishes are hard to know, and doing ~X is trivial, and the consequences of X are really really bad, and all this is common knowledge, and etc. etc. etc. (add as many unfavorable details as you like), then the right thing to do is ~X, and it won’t matter if you add at the end “and by the way, this is all happening in… AMERICA.”
More generally I follow James Rachels’s classic introductory textbook in thinking that, to the extent that one might think morality is relative, we’re really just thinking about etiquette or convention, like what conventional behavior counts as being polite or rude in one culture or another. But morality is more like “don’t be rude”, which doesn’t vary across cultures. And the medical debate between substituted judgment and best interests in cases of incompetence are, I think, clearly about competing ethical values, rather than about different conventional ways one might express the same ethical value (maybe the overarching ethical value of “being nice”?).
If course the cases are much easier if you deny the initial judgment about China versus US. But I’d just say that it’s not just being in one geographical location versus another, and it’s not just about etiquette and conventions of coordination, like walking on the left versus right side of the road. The Chinese convention of “family interest” taking priority over individual autonomy is about the strength of reasons that override the strength of other reasons. I don’t think in the US there is no moral weight on family interest, and no moral weight on individual autonomy in China. I think the conventions have converged on the society by and large weighing the reasons ever so slightly in favor of family interest. One view is that one society is right and the other wrong about the strength of such reasons. That’s a coherent position. Another is that both are permissible. I don’t think that’s moral relativism and I think it can be a coherent position.
Thanks for the clarification, Barry. If I understand right, your position is that these surrogate decision making cases are difficult, because of different competing values, so reasonable people can disagree, and if one culture tends to weight one value more heavily than the other does, then the different outcomes they arrive at are fine.
That’s clearly right, and yeah it’s not moral relativism. But I think it’s a claim about difficult cases, and how it’s okay to disagree on those. Could there be easy, slam dunk cases of surrogate decision making? Like a case where the added beneficence of choosing the “best interest” option is the equivalent of $0.01 of value, but the patient’s wishes were clear as day to everyone? Or, conversely, a case where the patient was wishy-washy, and the added beneficence of choosing the “best interest” option are enough to save the world from extinction?
In other words, I don’t think surrogate decision making as a class has this feature where we should always respect cultural variation. That would follow on a relativist view, but not this one. What looks like cultural variation, on this view, is downstream from contingent (cultural) tendencies to weight different values differently, coupled with a focus on difficult cases. (Jehovah’s Witness cases are difficult!)
It might be that it’s all a matter of difficult cases, which cultures have made easier by developing conventions that signal a certain value had by most. If that’s the explanation, then the difficulty of the moral cases comes first, and the convention serves as a tie-breaker. That’s probably consistent with my initial thought that we’re in the realm of moral indeterminacy.
Is it totally unlike conventions of coordination? Obviously it's not like walking on the left vs the right, in that there's no obvious symmetry. But maybe there are a whole bunch of institutions built around conventional assumptions about what reasons get what weight, such that in a context where everybody around you is going to be relying on some reasons getting more weight, you ought to give those reasons more weight.
Here's a not totally analogous example, but which maybe gives the flavor of what I have in mind. What sort of support should children provide to parents in their old age? It seems to me very plausible that there's a conventional element to this. In a society where it's presupposed that children provide a lot of support, then parents maybe save less, and then it's worse for children to not provide that support, because parents were understandably relying on it. In a society where it's common for children to provide less support, parents are more likely to make long-term plans that don't presuppose they'll have support from their kids, so when it's not given, then they're in a better position to do without it.
Could this case be a bit like your main case?