Is consensus building ethical?
Gonzalo Herranz, departmentof Bioethics, University of Navarra.
lectureDelivered in Buenos Aires, November 1999.
Definition and characterisation
The attractiveness of consensus
The negotiable, a field of consensus
Consensus, an opportunity for charity
Consensus, confession of faith
Ethical consensus is decisive for the life of the hospital
I am grateful for the invitation to discuss this topic.
You go around committees and commissions, where it is said: as a rule, we will reach agreements by consensus. It is kinder and less traumatic to reach agreements by consensus than by voting.
And indeed, things usually go well: speakerhas sent us its minutes with time to study them, some points are analysed and discussed, some paragraphs are changed in place and content, others are deleted or added, the style is polished. And, in the end, all from agreement. One is very happy, because consensus creates partnershipand harmony, which is a value in itself. And it creates valuable documents, which is an important instrumental value.
Occasionally, however, things do not turn out so well. There are debates which, because of subject, become more heated. The points of disagreement are many and strong. Some withdraw from discussionpro bono pacis. In the end, the subjectin which a agreementis reached is so scarce that any decision has to be postponed. It is like the story of the grey-haired Moor who had two wives, who left him bald and hairless.
But the organisers do not like this, as a kind of idolatry of consensus is taking place, which is preferred to the traditional procedureof voting. Consensus creates a false sense of unanimity. Voting, with all its limitations, is more honest in its numerical language.
One goes around in commissions, cooperating with consensus, but the opportunity to discuss subject is appreciated.
Having said that, I don't know where to start. Consensus is a complex operation. In order to deal with it, it is necessary to set conditions and budgets. To ask, moreover, whether it is ethical to reach a consensus is to add fuel to the fire.
It seems that, to begin with, "Is reaching a consensus ethical?" is a somewhat trick question, which necessarily provokes an ambiguous answer. Such a question should not be put to a Galician, because, invariably, he or she will answer that consensus, like so many other things, is sometimes ethical, and sometimes it is not: it depends.
In my opinion, sometimes reaching consensus is etiquísimo (this is the first time that word - etiquísimo - has occurred to me in my life), because reaching consensus, reaching agreements, is a rational and very human action, which can often be a wonderful manifestation of intellectual humility and respect for people and things. It creates the hope of having, as in other times, cor unum et anima una.
But at other times, despite its attractive appearance, it can be a violent act or a death trap, a disloyalty to oneself as a moral agent, a self-deception, an ethical surrender.
For if it is profoundly human, intelligent and desirable to stand with others in concord and rationality at agreement, it is dehumanising to deliberately betray the tabernacle of one's own conscience, to become an accomplice, for the sake of not giving oneself a hard time or not giving it, of what is false against what is true.
Definition and characterisation 
Genuine consensus refers to agreement, which is reached after a rational speechamong those who make up a groupor corporation, to hold something to be certain or valuable. Sometimes, consensus does not reach the Degreeof certainty, but that of dominant opinion. But it usually involves three elements:
a. epistemological: it is agreed to search for the truth/value of something.
b. procedural: agreementis reached through a rational discussion.
c. social: agreementis made among the members of a group.
Consensus means agreement, concord, unanimity.
True consensus is moral, rational, dialogued, reached after weighing the reasons, considering the pros and cons of each reason, one's own or another's, exchanging arguments, bringing positions closer, sincerely desiring rapprochement and true agreement.
But all that glitters as consensus is not gold. Alongside these active and responsible forms of consensus, there are other passive ones, born of alienation, of a lack of moral imagination, of induction through rewards or punishments, of blind and uncritical submission to the authority of experts, of tiredness to continue debating, of coincidentally convergent evolution, of renouncing to live in dissidence. These are examples of non-moral consensus. They are consensus in the physical, factual, non-ethical sense.
Kurt Bayertz, in the introductory articleto The Concept of Moral Consensus (Dordrecht, Kluwer, 1994) graduateMoral Consensus as a Social and Philosophical Problem, summarises his position in three postulates, which I interpret somewhat loosely:
1. Modern societies are neither homogeneous communities nor aggregates of independent individuals. And while there is much moral heterogeneity and a great deal of willingness to disagree, there are also social groups that have a common sense of moral family. Society is a collage of local dissensions and consensuses.
2. Social fragmentation is not simply an expression of a disparate ethical pluralism, a babelic confusion of moral languages. Apart from the fact that some of this confusion is more empirical than moral, disagreement cannot always be taken as something negative in itself, as a failure. There is a legitimate pluralism. It can also be said here that variety is the salt and pepper of life. Fragmentation provides many opportunities to enliven life, to show respect, to live together in peace. Acceptance of moral differences makes public discussionpossible.
3. Consensus is psychologically very comfortable and politically more useful. But it is not valid by itself: there are morally deficient consensuses, lacking moral authority. What is ethically valid in consensus is not the fact of having reached an intersubjective agreement, but the rational basis that sustains it. Consensus certainly has the right to claim moral authority, as a consensus, if, and only if, it is resultof a clean process of shared search, of mutual understanding, of a fair balance of interests. But this procedural cleanliness, though much, is no guarantee of success: social consensus does not provide an unshakeable basis for moral action: every consensus, by its very nature, must be open to moral revision.
So where does the prestige of consensus come from?
It comes to him from at least two sides:
First of all, as a human activity, consensus-building is a very attractive thing.
Secondly, it is an ideal instrument for resolving negotiable issues.
Sitting at a negotiating table and, after hours or days, arriving at agreementis a pleasure. Jean Monet, in his Mémoires, recounts the pleasure of negotiating in international affairs: the gradual rapprochement of positions as the interventions take place, the smoothing out of differences, the effect of the reasons of some on the reciprocal rapprochement.
The attractiveness of consensus
The many different ways of seeing things are a potentially positive value: four eyes see more than two, and four thousand see much more, especially when they observe the same reality from different angles and perspectives. The initial apparent disagreement is enriching: not only in terms of knowledge, but also in terms of human relations. It creates a sense of cooperation, makes coexistence productive, reveals how much we need each other, creates areas of respect, and a healthy perception that not everything has absolute value.
In ethics, consensus is at the service of moral truth: it is a moral consensus, not a political one. People like to jump on the winner's bandwagon, to be in the majority, because majorities win and govern. A lot of election propaganda is based on polls that claim that the majority is in favour of one side. There is an appeal of majorities. But that is a political, not an ethical, idea of consensus. Political history teaches us how often majorities are deceived or deceive themselves.
But, in general, history contains moments of splendour of social consensus: the consensus gentium of pagan rationality, the consensus fidelium from Nicea onwards, the democratic affirmation of vox populi, vox dei, the Universal Declaration of Human Rights.
The negotiable, a field of consensus
Most moral problems admit of several solutions. They deal with contingent, conventional issues, and are by their very nature susceptible of being solved in different ways.
In medical ethics, there are many questions that competent and honest doctors resolve in different ways. The circumstances of the school, the economic situation, and technological opportunities all play a role. Prudence allows for a wide latitude of action: it is not possible to say in advance whether a conservative or an aggressive approach is more justified, whether to innovate or to maintain, whether to sacrifice tradition for the sake of a significant increase in efficacy. We can go faster or slower, further to the right, further to the left or to the centre. If ethics committees exist, it is precisely to capture this constructive diversity, to bring together diverse opinions, to determine hic et nunc where they should converge. All this is negotiable when they are situated in the field of the ethically optional.
I can negotiate how much confidentiality I can give up to acquire maximum epidemiological efficiency, as happened with AIDS when its questionable exceptionality was extinguished. I can negotiate how much clinical freedom I sacrifice to generic prescribing to alleviate pharmacy costs. I can negotiate the limits of ethical cooperation with a pharmaceutical industry when it comes to setting criteria for a clinical essay. I can even negotiate the ethical rules for the practice of some varieties of alternative medicines. I can negotiate all this by sitting around the table with all stakeholders and carefully calculating the epidemiological, economic, pharmacological-clinical, academic and professional costs and benefits, weighing them against the ethical benefits and costs.
In addition to focusing on prudential issues, consensus bargaining can be directed towards elucidating questions of ethical intensity: it can be debated, within an institution and in the face of each specific issue, which of the different Degreesmoral requirements is chosen, between the minimum required and the maximum desirable, between mere compliance with the minimum legal or contractual duty and generous supererogation, or heroic sanctity.
Consensus, a reason for hope
In the bioethical discussion, everyone is faced with the dilemma of choosing between self-assertion, going it alone, playing the role of a moral eccentric, versus a sense of teamwork, where diversity is practised through cooperation as a value that enriches, not contradicts.
Be willing, all of us, to listen, to rehearse. Not to be a priori. In the very broad field of politics, of second-level regulations, it is advisable, in principle, to be flexible, open, daring, with the courage to backtrack. Blessed Josemaría spoke of his joy in rectifying, of saying I was wrong and starting again.
In medicine, we disagree on many things agreement. This happens in all areas: in the notion and classification of diseases, in diagnostic criteria, in therapeutic guidelines.
Is there a difference between hard, evidence-based, scientific medicine and soft, undefined, open to dissent, medical ethics?
It must be acknowledged that the disciplineof modern medical ethics is characterised by a greater variability than that of clinical medicine. There is a great variety of metaethical theories, of different ways of approaching problems and cases, of different decision-making procedures. One need only read the journals of medical ethics to realise that the norm is contradiction, diversity: a tower of babel, a dissonant chaos.
Most of what is published is to express disagreement: the study of any given problem is followed by a series of short articles containing dissenting opinions. On the student Education, a contradictory system is often used: student B is tasked to refute the thesis held by student A, or student C is given the task of contradicting his or her own convictions as vigorously as possible. One gets the impression that medical ethics has become sophisticated, that is, sophistic: there seems to be a certain pleasure, collective and academic, in taking the opposite view, in keeping bioethics alive by provoking a permanent moral crisis, in seeking the brilliant, even if it is fallacious.
There is a tendency not to recognise any moral authority. Sometimes, reading Bioethics journals, I have the impression that the rational search for moral truth is replaced, in a similar way to what happens in art (in music, painting, narrative), by an exasperated search for originality, by the determination to say things that nobody has said so far, to overthrow points of reference letterhitherto considered as guiding the moral speech, to set up fantastic scenarios, to erect unreal constructs. The promotion of Peter Singer to the Chairof Ethics at Princeton sampleis a course of action that can lead to success.
We do that very well by expanding and diversifying dissent, disagreement. But is that a good preparation? If everything can be debated and questioned, if we have all the freedoms to go our own way, we reach an unlimited capacity for dissent. It is easy, in the context of a discussion, not to agree agreementon the facts themselves or their ethical significance, on the criteria and principles in the light of which to evaluate them, or on the way out of the moral conflict.
Vanrell's anecdote. Disagreement is the rule. You think one way, I think another. What can we do? Let's say goodbye in peace, you with your truth, me with mine.
Yes, let's say goodbye with a fraternal embrace. But not before I have told our young students that we have not managed to reach an agreement agreement, but that, most certainly, one of us is wrong and the other is not. That we will have to continue to look for reasons, peacefully, because disagreement is not the irrevocable destiny.
Consensus, an opportunity for charity
This anecdote can serve as a bridge to consider the role of charity in the discussionfor consensus. There is, in the negotiation of consensus, a reason to live with others, to resist becoming strangers, to understand dissonant points of view, to build friendships, to discover what the Christian soul is.
In reality, true understanding and genuine compassion must mean love for the person, for his true good, for his authentic freedom. And this is certainly not given by hiding or weakening moral truth, but by proposing it with its profound meaning of radiating the Wisdom of God, received through Christ, and of service to man, to the growth of his freedom and the pursuit of happiness.
At the same time, the limpid and vigorous presentationof moral truth can never do without a deep and sincere respect - animated by patient and trusting love - which man always needs in his moral journey, often difficult because of difficulties, weaknesses and painful situations. The Church, which can never renounce the "principle of truth and coherence, according to which it is unacceptable to call evil good and good evil", must always be careful not to break the bruised reed or extinguish the wavering wick.
Pope Paul VI wrote: "To diminish in nothing the saving doctrine of Christ is an eminent form of charity towards souls. But this must always be accompanied by the patience and goodness of which the Lord himself gave an example in his attentionwith men. In coming not to judge but to save, He was certainly uncompromising towards evil, but merciful towards people".
The ethics of consensus, the whole programme for active participation in the discussion: the three elements (epistemological, procedural and social). An intense and difficult lesson, to live in the search for consensus. In what is essential, unity; in what is doubtful, freedom; in everything, charity. Saint Augustine.
There is a Spanish saying that there is no worse contempt than not appreciating. I must confess that in the bioethical discussionnothing is more hurtful or more disheartening than to respond with silence to a proposalfull of rationality. And that is a terrible weapon. I had never understood the wisdom of the above-mentioned saying until I saw how some critical points, of great dialectical interest, were ignored by an entire Commission. Such silence in response makes you think you are out of your depth. Not answering an engaging and compromising question is the supreme manifestation of a lack of intellectual charity.
Consensus, confession of faith
The discussionin medical ethics cannot do without the testimony of faith. It would be a betrayal of the consensus mentality if, alongside the powerful voice of utilitarians and secularists, the voice of believers were not heard at the meetings. The aim is to silence this voice. I have often been asked to acknowledge that my remarks came from my "confessionalism" and to withdraw them in the name of pluralism and tolerance. I usually reply that, indeed, my convictions are not difficult to classify as being in agreement with the Catholic faith, but that, in my opinion, they are a very characteristic element of the pluralism of which so much is said, because, although they come from faith, they are strongly imbued with reason.
To participate, as a Christian, in the plural dialogue is part of that mission statementto which John Paul II constantly calls us, to transform contemporary culture, because a faith that does not leaven the mass is a dead faith.
It is an affront to the rational and educated consensus mentality to argue that people of strong faith and moral convictions should dispense with them in debate when those ideas seem too strong or objectionable to others. It is frequently asserted that, in public service, doctors (and judges, and pharmacists) should separate religious convictions from professional practice. Some radical secularists believe that men of strong religion, practising their faith, whether orthodox Jews or Christians, should abide by the law or social custom, and either agree to provide services that are morally repugnant to them, or withdraw from professional practice or restrict it to their co-religionists. The standard of morality is that set by law and social custom. The space for exercising rights of conscience is shrinking.
An essential element of the ethical spectrum is Christian ethics. And, with much love and without offending anyone, we must humbly say, even if many do not understand it, that, among the possible rationalities, the one that links with faith is excellent. The Church, an expert in humanity, repeats this every day.
In Veritatis splendor, John Paul II tells us that the Church's steadfastness in defending the universal and permanent validity of moral truths is often judged as a sign of intolerant intransigence, especially in some of the complex and conflicting issues of life today. Some of these conflicts are bioethical.
And the Church is accused of not showing the understanding and compassion proper to a mother. But, John Paul II goes on to tell us, it is not possible to separate, in the Church, her condition as mother from her condition as teacher, it is not possible to separate her love of people from her love of truth. "As a teacher, she never tires of proclaiming rulemorality. Of such a ruleshe is certainly neither the author nor the arbiter. In obedience to the truth which is Christ, whose image is reflected in the nature and dignity of every human person, the Church interprets the moral ruleand proposes it to all people of good will, without hiding the demands of radicalism and perfection". (Familiaris consortio, 1981:33).
At summary: with courage and a lot of respect we have to say that truth can be reached with effort, a lot of effort, humility and friendly charity. It must be said that disagreement must be the starting point of a way to build a more complete and less unilateral truth, to help each other in the search for consensus. We cannot turn disagreement into a kind of constitutive feature of the contemporary personality, into the expression of an autonomy that tends to be dominant, almost absolute, wanted in itself, a kind of flight to free oneself from all heteronomous morality.
Consensus can play the role of a focus of hope: it is possible to agree on agreement.
Ethical consensus is decisive for the life of the hospital
Certainly, to be at agreementor to be at agreementin a hospital is decisive. I seem to have advocated the idea this morning: the hospital is an ethical groupthat needs to work in harmony, because the saying that the house divided against itself will be ruined applies excellently to the hospital.
There has to be a consensus, a willing acceptance, on the basic features: mission statement, ends, means, governance procedures, respect for individuals. A nuclear statement of core valuesthat energises and gives meaning to the individual. That expresses the identity of the house, that defines the permanent task, the spiritual attitude, the human style.
If we agree with agreementthat a hospital is an ethical agent, with a moral life of its own, it must be thought of as a smaller community in which consensus on fundamental issues is possible. Disagreement on significant issues is a wake-up call on the desirability of moral consensus.
Deliberative bodies, hospital commissions: a formidable field for consensus. Enemies, self-fanaticism, the sense of one's own excellence, the tyranny of imposing imported models, the antipathy staffthat leads to a systemic civil service examinationto the ideas of others. Even in the human sphere, a committeeis a lottery, or a providential confluence of Schoolsand prejudices, of defects and virtues that react in a combination.
The blessing of collegial government, a guarantee against the tyrannical and the frivolous: collegiality demands per se study, listening, pondering, debating. Consensus is reached through a process of purification and enrichment, of balance and combined moral energy.
Consensus institutionalises the wisdom of asking for committeeand opinion.
The limits of consensus
Consensus is therefore excellent. But it has its limits: in space, in time.
Consensus must be used wisely. It is necessary to leave ethical leeway, not to burden consciences with cumbersome precepts that trivialise the managerial function.
In a hospital, fury must be avoided rules and regulations. Marañón, who was very sceptical about codes subject, said that the distinctive traits of the good doctor - I would add, of the good nurse - are the inclination to do good, the reluctance to do evil and the unlimited capacity to create supererogatory, non-codifiable duties.
The ethical style of the hospital creates areas of freedom, because it respects the personality of its actors.
Regulations should be minimal and clear. Like the rules for the internshipof a sport: it points out the essentials, but leaves plenty of room for creativity, freedom, supererogation.
Diversity often creates critical situations. When stumbling upon intractable disagreement, it is necessary to recognise that one has reached the limit of what is consensual. It is time to go to agreementto disagree agreement, and to leave open a window of hope that the truth will one day reveal itself. Disagreement must not only be correct and polite, it must be, at least from the side of the follower of Christ, full of understanding and charity. Intransigence is to be had with the wrong, never with the wrong person.
The physician, and for that matter the hospital, is as much an ethical agent as the patient. Neither can impose their own religious values on the other. It is essential to know each other in order to respect each other. And it is precisely this respect that imposes on the doctor the serious obligation not to impede, but to assist in making authentically moral decisions, especially, as is so often the case, when patient and doctor share the same religious faith. With infinite respect for freedom, with delicate tact, it is possible to suggest a financial aidof chaplains to alleviate patients' concerns and doubts. Edmund Pellegrino points out that praying with the patient, participating, together with the family, in the sacrament of the anointing of the sick, and cooperating with priests are acts of healing, manifestations of authentic charity, meaningful to the patient and appreciated by the patient and the family.
It is important to insist on respect for freedom, not to abuse the doctor's moral authority. Evangelisation also requires the free and informed consent of the patient. It is one thing to help the patient to find meaning and meaning in illness and suffering, helping him or her to recover forgotten articles of faith and the comfort and hope of the Gospel, and quite another to possessively impose one's own beliefs on others. A violent conversion in such circumstances would be a moral and spiritual fraud. God has preferred to be served by free children.
I will now end with these very unravelled ideas. Progress in consensus is often not achieved by prolonging discussionto the point of exhaustion.
Dialogue has to be replaced in time by study and reflection. One has to go back to the sources, to fresh, crystalline ideas. Both in strictly professional matters and in doctrine. The discussioncannot be allowed to lose rationality, to lose vigour and rigour.
It is always necessary to act and debate with charitable affection. The most effective way to spoil everything and to discredit oneself as a person and as a Christian is to act with impatience, with verbal violence, with contempt from superiority, with condemnation of people. Such behaviour undermines the claim that the Christian faith makes us better. To be charitable and attentive to those who think very differently and oppositely does not imply that one is an ethical relativist. Intransigence goes with ideas, never with people. We must never break our friendship with them, for charity obliges us to do so.
A person's conduct may be immoral, but we are not called to judge his or her guilt. If by faith we know that God alone is the judge, our conduct would be inconsistent if we usurp God's prerogative to judge and unsympathetically condemn others.
To pursue consensus we need patience and a little joy. It seems to me that the worst enemy of living in peace with the wrong is resentment for their mistakes. We need an asceticism of good humour: many good ideas are defeated in the battles of consensus because they have been proposed with acrimony, with a sense of moral superiority, with indiscreet zeal. A hard lesson to learn is to recognise that proclaiming abstract ideas is worth far less than winning a soul.
If I knew Evangelium vitae and Veritatis splendor from report, if I made them the most brilliant and convincing exhibition, but I lack charity, I am like a clanging cymbal.