Culture of Death: The Assault on Medical Ethics in America. (Review essay: beating up bioethics).
Article Type: Book Review
Subject: Books (Book reviews)
Author: Jonsen, Albert R.
Pub Date: 09/01/2001
Publication: Name: The Hastings Center Report Publisher: Hastings Center Audience: Academic; Professional Format: Magazine/Journal Subject: Biological sciences; Health Copyright: COPYRIGHT 2001 Hastings Center ISSN: 0093-0334
Issue: Date: Sept-Oct, 2001 Source Volume: 31 Source Issue: 5
Topic: NamedWork: Culture of Death: The Assault on Medical Ethics in America (Book)
Persons: Reviewee: Smith, Wesley J.
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 80710660
Full Text: Culture of Death. The Assault on Medical Ethics in America. By Wesley J. Smith. San Francisco, Encounter Books, 2000. 285 pp. $23.95.

Bioethics in America. Origins and Cultural Politics. By M.L. Tina Stevens. Baltimore: The Johns Hopkins Press, 2000. 204 pp. $39.95;

Bioethics, although some thirty years old, is the new kid on the block where the moral disciplines have lived for centuries. It may seem a bit uppity, claiming to resolve old questions with fresh insights. And like any uppity kid, it can be a tempting target for a trouncing. Snide comments like "... bioethicists, the professionals who promise to guide us through these troubled waters," and "self-proclaimed bioethicists ... designated advice givers" are warnings of the trouble to come. Now two toughies have appeared, intent on beating up the bioethicists. Tina Stevens's Bioethics in America and Wesley Smith's Culture of Death are book-length batterings. There is a lot of pushing and shoving but, in my view, neither bully gets in a serious body blow. Strangely enough, although they both are out to teach bioethics a lesson, the lessons they want to teach are diametrically opposed.

A sage counselor once advised a college president, "if Professors A, B, and C (vocal members of the conservative faculty) criticize and Professors X, Y, and Z (the liberal voices) also complain, you are doing the right thing." Smith stands with A, B, and C and Stevens with X, Y, and Z among the critics of bioethics. Stevens tells a story of bioethics in which the bioethicists have become pusillanimous opportunists, subservient apologists for the powerful medical establishment. Smith's bioethicists, on the other hand, are insidious infiltrators of the ancient ethics of medicine, sapping its moral strength and injecting the poison of utilitarianism. Bioethics, then, is both vanquished and victor, willing slave to its master, the medical establishment, and powerful destroyer of that same establishment. This paradox may reflect reality: I seem to recall something in Nietschze about the power of the slave. However, I prefer not to see a paradox at all but two analyses that begin with different premises and carefully select the evidence that favor those premises. If bioethics can be criticized from two such different sides, it must be doing something right. At the same time, the virulence of the criticism strongly suggests it is doing something that, if not entirely wrong, is not quite right.

Tina Stevens teaches history at San Francisco State University. Her short book is done in the historian's style, referencing documents and constructing interpretations of the written and oral record. Three chapters review the origins of the Hastings Center, the revision of the definition of death and the story of Karen Ann Quinlan and the debate over foregoing life support. She prefaces these three documentary chapters with a thesis about the origins of bioethics in America. Recalling the moral turmoil over the use of atomic power in the early 1950s, and the moral qualms of some biological scientists about the new genetics in the early 1960s, Stevens situates the origins of bioethics in the "responsible science" movement of that era. She cites as well the major critics of technological culture, Mumford, Marcuse and Ellul (strangely ignoring the one critic who directly challenged technological medicine, Ivan Illich). Then, in Stevens's view, the early bioethicists and the responsible scientists take different paths.

While responsible scientists expressed ambivalence over the social implications of developments in physics and biology, the bioethicists "brought to bear specific modes of reasoning and philosophical principles on a wide range of specific medical and technological issues" (p. 28). The early bioethicists, in the spirit of the responsible scientists and the social critics, may have raised profound questions about the directions of medicine and biology, but they quickly merged into the general stream of this sort of concern: "the dominant bioethicai posture has become not one of antagonism toward medicine and science as players in a larger field of cultural domination; rather it is one of modest ethical discussion about the results of medical and scientific research" (p. 45). The attention of bioethics is attracted toward individual dilemmas and particular moral quandaries. By dwelling on these, bioethics gives a patina of morality to the dominant establishments of health care and scientific research. Stevens supports her contention by her interpretation of the three "case histories."

The Hastings Center, founded with the intent to address in an interdisciplinary fashion the issues raised by the new sciences, was absorbed into existing medical and scientific world views and frameworks. It was lured away from a piercing social and political critique of these institutions. Although figures such as Daniel Callahan, Paul Ramsey, and Robert Veatch at first challenged the establishments, the need to survive within the world that they had entered dampened their moral indignation. Stevens cites internal documents showing Hastings's tremulous response to the complaints that its approaches to issues were too critical. Money and prestige flowed into Hastings to ensure its survival in proportion to its modulation of criticism of the establishment. Despite founder Dan Callahan's qualms, Hastings became in short time, "a pro-technology agency, fostering quiescence over technology-induced social issues that might otherwise 'be greeted with hysteria'" (p. 71).

Stevens tells the stories of the redefinition of death and of the debate over foregoing life support in the same vein. The Harvard Committee for the Definition of Death, although ostensibly formed to resolve the problem of sustaining organic life with technological means, was in fact motivated by the concupiscence of surgeons to pursue their experiments with organ transplantation, a pursuit that required the harvesting of organs free from legal liability and ethical taint. The ethical concerns about life support became a surrogate for the needs of the new field of organ transplantation. This itself masked the true ethical problem, namely, the experimental nature of the field itself, in which patients were promised treatment but were, in effect, subjects of the highly investigational procedures that constituted transplant surgery at that time. In addition, transplanters worried about their own legal liability, unprotected by a legal definition of death that would authorize their removal of vital organs. The Harvard criteria and the Hastings Center's endorsement of those criteria quieted public concern and erected legal defenses. Thus "even in the midst of a raging public controversy over human experimentation generally, the public never prohibited organ transplantation on this score; in fact, transplantation was facilitated by the popular and legal support of new criteria for establishing when someone has died ... Heart transplantation research weathered its morally questionable experimental stage; the public allowed it to continue without turning its practitioners into `surgical criminals'." The story of the growth of bioethics "represents the (medical) professions endeavor to limit potential threats to its ultimate control" (pp. 107., 108).

The Quinlan story, in Stevens's version, makes the same point. The daily news coverage of "America's sleeping beauty," tethered to life by machines, was a boon for the emerging bioethics. Confusion over the newly defined brain death, the use of the respirator, customary medical practice and legal constraints opened a wide field for the wise comments and clarifications of bioethicists. However, under all this debate, the medical establishment won another victory for its own authority: the New Jersey Supreme Court decision, despite its fine language about autonomy, left the final decision to physicians and to a consulting ethics committee and made it clear that, should they choose to terminate life support, they would be protected from civil and criminal liability. The bioethicists had again played into the hands of the medical establishment. Bioethical discourse had failed because, by concentrating on the medical particulars of the case, it had "limited analysis by overlooking the long-term political genesis and reception of medical technology" (p. 147).

This is exactly Stevens's thesis about the fundamental failure of bioethics. She concludes her book by stating that, "as long as bioethics remains committed to the limited role of establishing guidelines for the use of procedures and technologies that it largely accepts as inevitable, it precludes itself from seeking answers to and informing the public about how and why specific biomedical technologies were created: by whom, or by what groups; on what criteria; for the benefit of which group (race, class or gender), and to whose detriment? ... [B]ioethics may ultimately be successful in helping to alleviate national anxieties (about bioethical problems) but will it ever be able to free itself from the sources that help generate the dilemmas it seeks to resolve?" (p. 159). Stevens is deeply disappointed that bioethics has not lived up to its promise as a radical critique of medical and scientific power.

Wesley Smith is a lawyer and a consumer advocate who has coauthored four books with Ralph Nader. His Culture of Death is redolent of the zeal of an activist lawyer. As one reviewer wrote in a Wall Street Journal article titled, "Are You a Person or a Nonperson? The New Bioethicists Will Decide," "Mr. Smith is not principally concerned with the philosophical underpinnings (of bioethics). He is a polemicist with a sharp eye for stories most likely to outrage the reader and to make his point about the troubling direction we are headed in." (2) The direction in which we are headed, as Smith sees it, is a slippery slope declining from the summit, where the Western moral tradition and the Hippocratic medical tradition long presided, into a dark valley in which we will "come face to face with the monster ... lurking in the shadows" (p. ix). The monster is bioethics, populated with individual monsters, "a cadre of `experts': moral philosophers, academics, lawyers, physicians and other members of an emerging medical intelligentsia, known generically as `bioethicists,' ... who presume a "moral expertise of breathtaking ambition and hubris" (p. 5). Their agenda is clear to Smith: they are set on "dismantling traditional western values and mores and forging a new ethical consensus based on values most people do not share" (p. 7). Their ideology is a stark utilitarianism that rejects the sanctity of individual life and the equality of all humans. Smith tracks these monsters through five dark chapters: "Life Unworthy of Life," "The Price of Autonomy," "Creating a Duty to Die," "Organ Donors or Organ Farms?" And "Protecting Animals at the Expense of People." He concludes with his own version of a "human rights bioethics."

Smith is indeed a polemicist. He collects horror stories and attributes them, willy-nilly, to bioethics. He tells stories of outrageous behavior to great effect. He finds cogent quotations from the practitioners and the critics of bioethics. He asks telling rhetorical questions. With these techniques he is able to demonstrate, to his satisfaction, that the mainstream of bioethics has devised a lethal weapon against traditional western morality and Hippocratic medical ethics. That weapon is the insidious substitution of "quality of life" for "sanctity of life." Almost unnoticed, the value of each unique person is depreciated into categories of lives more or less worth living. Those less worthy of life can be sacrificed to produce the greater good for society. Guidelines about futility or about rationing care are the sign-posts of this depreciation. Bioethicists have cleverly infiltrated medical ethics and health policy, gradually turning them away from dedication and respect for individual persons toward the destruction of the most vulnerable and undesirable among us.

Fatal Flaws

Stevens and Smith look at bioethics and see two quite different scenes. Stevens finds subservient apologists for the medical and scientific establishment who have long lost their radical energy; Smith discovers insidious infiltrators into the medical and scientific establishment who have radically changed its traditional values. A point by point critique of the books is beyond the scope of this review. Indeed, I have to agree with some portions of them, and I cannot deny the accuracy of most of their quotations and stories, although I could cavil and quibble with something on almost every page.

However, each of these books has, in my opinion, its own fatal flaw. Professor Stevens insinuates; Mr. Smith exaggerates. Steven's book is a historian's work and, as such, is a work of textual interpretation. Textual interpretation is a delicate art: some texts must be chosen without obscuring the entire context; meaning must be inferred from converging evidences. I suspect that Stevens failed at both these artistic tasks. Her choice of texts, in her reading of the Hastings record, the Quinlan story, and the definition of death episode, seem less to guide her interpretation of those events than to sustain her a priori thesis. She insinuates rather than infers meaning in words and events; that is, she draws conclusions, not from converging evidence, but from that evidences that suggests the soundness of her thesis. She builds her firm conclusions about the failure of bioethics on ambiguous grounds.

Stevens is certain that heart transplantation rather than the clinical problem of life support generated the brain death criteria. Henry Beecher, author of those criteria, explicitly denied that this was so, but Stevens simply does not believe him. Stevens affirms that the record of the Hastings debate on the criteria demonstrates her claim, although Dan Callahan, who sat through those debates, denies that this was so: "The main concern ... was really the question of taking people off of respirators." (3) Stevens is certain that the Quinlan decision did nothing more than reaffirm medical paternalism. Her evidence for this certainty is the final few sentences of the New Jersey Supreme Court decision, which states, "Upon the concurrence of the guardian and family of Karen, should the responsible attending physicians conclude that there is no reasonable possibility of Karen's ever emerging from her present comatose condition ... they shall consult with the hospital `Ethics Committee' ..." Life support systems, they said, may be withdrawn once all these parties concur that Karen will never return to a "cognitive, sapient state." This may be done "without any criminal or civil liability" (p. 141). Stevens infers that those words consecrate the autonomy and authority of physicians (though they begin with "Upon the concurrence of guardian and family). Those few words come at the end of an opinion that lays out a powerful case for patient and surrogate autonomy, for medical futility, and for quality of life, but Stevens discounts the import of all that. This is insinuation rather than inference. Other authors give alternative interpretations of the events in her chapters (as I have in my own Birth of Bioethics and as David Rothman did in his Strangers at the Bedside), (4) but Stevens discounts (not disproves) these alternative interpretations. Her interpretations are driven less by the context and evidence than by her fundamental ideology as a historian, namely, that all historical analysis is nothing more than the record of power seeking to perpetuate itself. I choose to believe that this view, though pervasive and popular in the historical and sociological disciplines, is not the whole story.

Smith's polemic takes a different tack. It constantly employs the rhetorical devise Pars pro Toto, the Part for the Whole. Again and again, he cites a bioethical author who holds an opinion that is, in his eyes, outrageous. He admits that "many bioethicists" would not agree with the offending author, but asserts that "most" would. Yet where are those many and those most? Here is a wonderful example of Pars pro Toto: "Although few modern bioethicists agree with the manner in which Binding and Hoche's euthanasia proposals were implemented in Germany, and most would certainly object to the authors' bigoted language, it is dear that the values expressed in [their book] Permission to Destroy Life Unworthy of Life fit snugly within the mainstream of the modern bioethics movement" (p. 39). When one discounts manner and language, it becomes difficult to discern "the mainstream." Where do George Annas, Dan Callahan, Arthur Caplan, Alex Capron, Al Jonsen, Mark Seigler, and others, all of whom have opposed euthanasia, fit in that "mainstream?" Again, "many (although certainly not all) modern bioethicists are agnostic or atheistic, a factor that colors their entire approach to issues of life and death" (p. 22). The some (Baruch Brody, Tristram Engelhardt, Stanley Hauerwas, Gilbert Meilander, Edmund Pellegrino, and so on) who are not agnostic or atheistic disappear from Smith's narrative. The overall impression is that bioethics as such is agnostic or atheistic.

Throughout the book, Smith displays his one big Part for the Whole, Princeton philosopher Peter Singer. Singer apparently once called religion "mumbo jumbo" (whether he did or not I cannot verify because instead of citing Singer, a footnote cites an article in a conservative and not easily accessible Catholic newspaper). But then Singer's alleged words are put into the mouths of "some bioethicists" (p. 22). Throughout the book, Singer is almost the single source of most outrageous views. It is easy for readers to believe that Singer is the leading representative of bioethics. The Wall Street Journal reviewer of Smith's book certainly got that impression, saying what Smith does not say but dearly implies, "The (bioethics) movement's highest High Priest is Peter Singer, who has argued in favor of killing disabled infants." (5) Peter Singer, despite his Princeton professorship, is not by any means the High Priest of bioethics; indeed, he hardly belongs to the same religion. He is a marginal and, to a great extent, a repudiated figure in the field. Yet his constant appearance in Smith's pages makes him the spokesman for the Whole of bioethics. Smith's entire thesis, in my view, suffers from terminal exaggeration.

It is clear by now that I did not like either book. Several reasons for my dislike are admittedly quite personal. The books impugn my livelihood and my colleagues. I also feel personally slighted: although both authors seem to know my book on the history of bioethics, in which many differing interpretations of the same events are offered, they do not even bother to refute me. Stevens `dismisses my work as a failure because it does not analyze bioethics as she does (pp. 33-34).

My third and fourth reasons for dislike are more objective, however. First, both authors (but particularly Smith) aim their criticism not so much at bioethics, but at broader social and cultural trends to which bioethics as a discipline is only peripheral. Smith, for example, excoriates the animal rights movement for putting animals before people and hindering medical research. He links this broad social movement and its spokespersons to bioethics. For example, he begins the chapter, "Protecting Animals at the Expense of People," with the bold assertion, "Indeed, comparing the way we treat animals and the way we treat people ... is something of an obsession within the contemporary bioethics movement" (p. 189). Peter Singer is indeed the High Priest of the animal rights movement, but his radical thesis about the rights of animals is not an obsession with bioethicists. Bioethicists certainly write about ethics and animals, but a review of the 350 articles indexed under "Animal Rights" or "Ethics and Animals" on the bioethics database Bioethicsline from 1990 to 2000 (containing some 10,000 entries) reveals that most of those articles focus on two topics central to bioethics--research with animals and xenotransplantation. Only about fifty of these address the animal rights issue directly, most of them challenging rather than supporting Singer's philosophy. This is hardly evidence for an obsession.

My final and principal reason for disliking these two books is that I am impatient both with insinuation and with exaggeration. Stevens's stealth bomb of insinuation makes it difficult for a defender to know where to mobilize the defense. Should I fault her basic historiographical thesis about the primacy of power in all human relationships? Should I counter her fundamental claim about bioethics, its pusillanimity before power? Should I disagree with the selectivity of her texts? Should I reparse the same texts, seeking alternative interpretations? Smith's exaggerations hit like a blockbuster, obliterating all evidence of different stories, beliefs, comments, and arguments. The smoke of his barrage obscures the view (but not the reality) of anything good and beautiful in bioethics.

Identifying "Bioethics"

These dislikes being aired, I must say closed each book with a sigh of relief. Neither bully had punched me out. Stevens did not convince me that I was a failure for having worked in a failed enterprise. Smith did not convince me that I was a monster devouring the fine ethos of medicine and western morals. Still, even if their assaults didn't damage my self-esteem as a bioethicist, they bothered by equilibrium.

One question raised by the books is why bioethics looks like this (or that) to some outsiders. We bioethicists believe we do good work and that our work is useful and widely appreciated. We believe that we are respecters of persons, beneficent, nonmaleficent, and just. Ah, but Wesley Smith anticipates my complaint. He says bioethicists will angrily repudiate his description of their work. "Their self-image is that of the ultimate rational analyzers of moral problems and facilitators of ethical dialogue who, were pipe smoking still fashionable, would sit back with pipe firmly in mouth and act as dispassionate mediators between advancing medical technology and the perceived need to impose reasonable limits on access to treatment as required by finite resources.... That may be their self-image, but it is also a dodge and self-deception" (pp. 5-6).

Although Paul Ramsey, one of Smith's only heroes among bioethicists, was the only pipe-smoking bioethicist I knew, I do affirm our identity as "rational analyzers of moral problems and facilitators of ethical dialogue." The failure of these critics is due to the fact that neither of them has actually been there. Like the American planners who bombed the Chinese embassy in Belgrade, these critics need to go to where bioethics is done and participate in its doing. Bioethics is an academic discipline and it can be found in textbooks, books and articles. But if one comes to know bioethics only from its books, one has but a superficial acquaintance. As I propose in Birth of Bioethics, bioethics is not only an academic discipline: it is a discourse in which many people discuss, argue, and attempt to resolve perplexities into decisions and policies. Academic bioethics, in the classroom and in the literature, generates an endless flow of ideas and arguments. Some of these are "far out," but that is the nature of an academic discourse that has descended from philosophical and theological ancestors. Disputation is the essence of these disciplines.

When academic bioethics encounters the world of clinical decisions or public policy, however, it tempers its tone. It meets there people who are not by nature or education "rational analyzers of moral problems." It meets concrete conditions of institutional possibilities, legal constraints, economic resources, cultural perceptions, and religious beliefs. It meets, above all, the imperative to come to a conclusion. A philosophical argument can roll on eternally; a bioethical problem is a problem that must be resolved at a certain time and place. Thus the bioethicists of literature become the bioethicists of commissions, committees, and consultation, where their words must be translated from theory into a practical discourse that all participants can understand, and where they must react to the arguments, concerns, and beliefs of others. The bioethicist may then realize that the carefully honed "rational analysis" confounds or confuses the others and that, worst of all, is not even seen by them as "rational."

The showpieces of bioethics are the products of the public bodies that have, from time to time, been convened by state and federal government and by various professional groups: The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, the President's Commission for the Study of Ethical Problems in Medicine, the DHEW Ethical Advisory Board, the National Bioethics Advisory Commission, and the bioethics commissions of New York and of New Jersey and others. These bodies, made up of a few bioethicists as members or consultants and of many other citizens as well, do study the available literature, but they also go far beyond that: they take into account general public attitudes and particular religious beliefs. They work within a context of actual legal, scientific, and political realities. They deliberate at great length, listen to many opinions, draft and redraft their reports. Their work, for all its imperfections, is American bioethics at its fullest and (in my view) at its best.

I was puzzled and disappointed that neither Stevens nor Smith even allude to the work of the commissions. Stevens's discussion of the criteria for determining death would have been significantly improved had she discussed Defining Death from the President's Commission. Her treatment of foregoing life support would have benefited from the careful, extensive analysis in the President's Commission document of the same name. Smith's remarks about organ donation should have reflected the work of the DHEW Panel on Organ Transplantation. In these and many documents like them, academic bioethics is refracted through the air of public discourse. Outrageous theories disappear; the moral values of Americans appear. Arguments pro and con are devised and displayed in as clear and logical a form as possible. Practical possibilities for action and policy are worked out. In all of this, academic bioethicists play a part, as "rational analyzers" and "facilitators of ethical discourse," but their part is only one role in the discourse. The resulting bioethics is the work of a broader spectrum of people than Smith or Stevens include in their cast of bioethicists.

An examination of bioethical discourse at this level will also contradict Smith's contention that bioethics is thoroughly utilitarian. Bioethical policy about research with human subjects, death and dying, and organ transplantation has been consistently nonutilitarian. Joseph Fletcher's rather naive utilitarianism and Peter Singer's more sophisticated utilitarianism have been pushed out of bioethical policy wherever it appeared. The deontological perspective of Ramsey and Hans Jonas and Richard McCormick has consistently prevailed when public bioethics discourse has issued in policy. To be more precise (a precision that escapes Smith), the "rule utilitarianism" that combines respect for rule and principle with the goals of human and social thriving is the dominant ethos of bioethics at the level of public policy. Despite its surname, it is an ethical theory far from the rough utilitarianism that Smith describes. Explained in careful fashion, as in Tom Beauchamp and James Childress's Principles of Biomedical Ethics, it provides a reasonable way of making ethical arguments in a public policy setting and can inhibit movement toward an undiluted and ill-defined "greater good." Even at that, the ethical theories at work within academic and public bioethics remain diverse, and few bioethicists are ideologically committed to any one theory in particular.

Public bioethics also casts doubt on Stevens's thesis. She seeks for a radical criticism of the structures of power. In her eyes, I suppose, the commissions and committees are nothing more than attractive, deceptive veils disguising the harsh reality of the power establishment. Yet I believe that the National Commission's work did radically change the practice of scientific research in America. I also believe that the pursuit of genetic screening was modulated by the President's Commission report on that topic. But more to the heart of her thesis, I cannot imagine how the radical critics whom she idolizes could ever have participated in this sort of public discourse. They could verbally demolish the social institutions that they accused of domination, but they had no means of actually revising or rebuilding them. They stood outside and shouted. Illich's slashing dissection of modern medicine and health care offered no alternative except the exhortation that people should take care of themselves. The work of public bioethics, while it was resigned to work within institutions, has effected change. Sometimes marginal, perhaps, but still within the real world where sick people, their families, their caregivers, scientists, judges, economists, and others actually live.

Another indication that neither Smith nor Stevens has dwelt within bioethics is their uncertainty about who the bioethicists are. Bioethicists are "self-appointed moral experts." They are sometimes philosophers, sometimes lawyers, sometimes physicians, and so on. There is a "relatively small `insider' clique of elite and powerful philosophers, academics, attorney and physician practitioners" (Smith, p. x). They wander in and out of these books, in a somewhat spectral way, occasionally uttering some portentous sentence (of death, if Smith is to be believed). Some people are identified as bioethicists because they have written or said something about a bioethical topic. Thus Smith identifies jurisprudent Ronald Dworkin as a bioethicist on the basis of one of his books, Life's Dominion. Stevens deems anesthesiology professor Henry Beecher a bioethicist. In fact, both contributed to bioethics, but I, at least, would not give the title "bioethicist" to either of them. In both books, long strands of narrative refer to people engaged in bioethical discourse, inferring that what they say and do is bioethics. People do not know who we are; indeed, we may not know who we are ourselves.

This is dearly the result of the initial desire to create an "interdisciplinary field of study." In the beginning, we knew that the kinds of problems we wished to study were not abstractly ethical, but were crammed with medical, scientific, psychological, cultural, and economic details. Our initial job was not to pick out the ethical piece, but to discern how the whole problem might be thought of as ethical. That is one of the intriguing problems of ethics: practices and institutions, not simply some segment or department of them, are moral or immoral. Thus, lacking many polymaths, we had to invite into the discourse many monomaths, experts in particular fields, hoping that by arguing together some focal concept of the ethical would emerge.

Certainly, adepts in two disciplines with a strong interest in morality--moral philosophy and moral theology--were central participants. But even these folks were, in a sense, multiclisciplinary. They did not sing a single song: the philosophers came with differing training from different schools; the theologians, even from within a particular faith, brought differing opinions about their doctrines. Although in recent years a course of training specifically for bioethics has appeared in many institutions, there is no central curriculum or doctrine against which one can test a bioethicist's identity or skills. There are a few people with "bioethics" in their job title, but there are many others, doing medicine or law or social work, who engage in bioethical discourse. So bioethics, diffuse as it is, is easy to criticize. Almost any quotation or article or policy or regulation emerging from this mix can be held up as representative of bioethics. Given the evolution of the field and its current makeup of personnel and programs, it is difficult to remedy this problem. Unquestionably few, if any of us, would advocate a bioethical orthodoxy. Still, we should be meditating on the consequences of our diffuse identity.

The Smith and Stevens books suggest another thing we may not be doing quite right. Bioethicists (whoever they may be) sometimes propose provocative opinions, "the duty to die" among the more striking of them These opinions find their way into the extensive literature of the field. Occasionally, the provocative opinion is noticed, inciting a response from other scholars and a whirlpool of controversy, minor or major. Often, however, the provocative opinion does not provoke and becomes part of the canon. This is a fault, I believe, in a field that pretends to reach beyond its own practitioners to the public. Peter Singer's undiluted utilitarianism, for example, is provocative. I and many of my colleagues dispute and repudiate his underlying theory and its applications, either in whole or in part, and Singer does not play a central role in American bioethics. Still, his opinions become part of the canon, by default. They should provoke serious intradisciplinary debate and dose criticism, in root and in branch. Only by such an examination can it be made clear that a provocative opinion is just that, not representative of the field itself but a legitimate challenge to critical evaluation. More vigorous intra-disciplinary criticism would make it more difficult for authors like Smith to blacken the whole field with one brush. I believe that we are generally too tolerant, too willing to let the provocative opinion slide into currency without scrutiny. Many of us who knew the great Paul Ramsey disliked his pugnacious assaults on our ideas (I was among the beleaguered), but perhaps some of that pugnaciousness (maybe kinder, gentler) should prevail among us.

I hate to say this: perhaps bioethicists should read the Smith and Stevens books. The salvos from the right and the left might make us more attentive to what we are, to what we do and to how we may be perceived. I continue to believe that the discipline and discourse that was born some forty years ago is a valid and vital contribution to our intellectual and social life, but it will continue to be such only by firm commitment to "the examined life."

References

(1.) M. Talbot, "The Desire to Duplicate," New York Times Magazine, 4 February 2001; S. Satel and C. Stolba, "Who Needs Medical Ethics," Commentary, February 2001.

(2.) A. Wolfson, "Are You a Person or a Nonperson? The New Bioethicists Will Decide," Review of Wesley Smith, Culture of Death, Wall Street Journal, 24 January 2001.

(3.) D. Callahan, personal communication, 28 January 2001.

(4.) A.R. Jonsen, The Birth of Bioethics (New York: Oxford University Press, 1998); D. Rothman, Strangers at the Bedside: A History of How Law and Bioethics Transformed Medical Decision Making (New York: Basic Books, 1991).

(5.) See ref. 2. Wolfson, "Are You a Person or a Non-person?"

Albert R. Jonsen is emeritus professor of ethics and medicine at the University of Washington. He is author of A Short History of Medical Ethics (Oxford University Press, 2000).
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