In search of a wide-angle lens.
Medical personnel (Practice)
Medical personnel (Management)
|Publication:||Name: The Hastings Center Report Publisher: Hastings Center Audience: Academic; Professional Format: Magazine/Journal Subject: Biological sciences; Health Copyright: COPYRIGHT 2011 Hastings Center ISSN: 0093-0334|
|Issue:||Date: May-June, 2011 Source Volume: 41 Source Issue: 3|
|Topic:||Event Code: 200 Management dynamics Computer Subject: Company business management|
|Product:||Product Code: 8010000 Medical Personnel NAICS Code: 62 Health Care and Social Assistance|
|Geographic:||Geographic Scope: United States Geographic Code: 1USA United States|
What issues should bioethics be looking at in the next forty years?
Rather than take on new issues, I believe bioethicists should rethink
our approach to bioethical topics more generally. Doing so will require
refashioning the field itself, but such a reinvention is the only way we
can help bioethics live up to its initial ideals and be relevant to our
Is Bioethics Necessary?
Thinking about the future of bioethics should begin with a fundamental question: Is bioethics even necessary? Most bioethicists would certainly think so, and they might find confirmation in histories of the field like David Rothman's Strangers at the Bedside, in which bioethics was a response to the collapse of doctor-patient relations in the mid-twentieth century United States. (1) Here, the field emerged to protect vulnerable populations from exploitative doctors and scientists. As such, it was allied with the civil rights and feminist movements. What could be more necessary than that?
But this rosy view of the field's development has been highly questioned. Roger Cooter has argued that bioethics appeared to allow doctors to maintain control over the provision of health care; rather than a progressive movement aligned with civil rights and feminism, it was a reaction to the anxiety these movements generated in physicians. (2) His reading would seem to be substantiated by Susan Lederer's account of the generation of the Helsinki Declaration, in which the opposition of U.S. doctors to the declaration's prohibitions on experimentation on children and prisoners was connected to the pharmaceutical industry's desire to maximize profit. (3) More recently, various authors have illustrated how foundational bioethical concepts like "autonomy" and "informed consent" are used in ways that exploit vulnerable populations, such as the poor and disabled. (4)
These sources show that we bioethicists, rather than looking for new issues, would do better to look at ourselves. The problem is the way we have framed our approaches to the field's key topics. We have been obsessed with questions of abortion, euthanasia, stem cell research, and the like. But the very framing of these issues in bioethical discourse can obscure the underlying forces that create the problems to begin with, whether these forces be the economic organization of society, internalized discrimination against the disabled, the epistemology of medicine, or (and most likely) some combination of all three. We need to find ways to understand the larger problems that create the "old" issues--problems in which we can productively intervene.
A New Model for Bioethics Education
Here we encounter a significant institutional problem: U.S. bioethics education remains tethered to a narrowly defined training regimen that is inadequate to explore the underlying causes of the field's problems. As such, it frequently does not prepare students to understand the issues they are supposed to resolve. Consequently, our primary concern should be reformulating bioethics education in a way that gives students the tools to understand and investigate the field's concerns.
Bioethics institutes, rather than being oriented around the transmission of rule-based knowledge, should provide a robust, interdisciplinary curriculum that produces thinkers capable of exploring the complex context of bioethical issues and proposing mechanisms to resolve present conflicts. The goal of this curriculum would not be to prepare thinkers to "take sides" on current bioethical debates, but instead to explore how the framing of these debates can mystify the real issues at play. Exploring the dynamics of problem constitution would be the first step toward problem solving. (5) This would make it possible to productively intervene in debates whose terms have become stagnant.
Students emerging from such programs would be prepared to comment on how the dichotomy between the secular "pro-choice" and the religious "pro-life" perspectives that frames our discussions of abortion and euthanasia obscures how the economic ideologies of both sides in the debate might encourage people to abort and engage in euthanasia, even as they negate whatever "freedom" might exist in that choice. The issue would be discussed in more than just economic terms: One could talk about how cultural discrimination against the disabled can be reflected both in the legal conception of liberty as negative freedom as well as in the biological reactions of individuals to particular diseases. The point would not be to privilege one area of exploration over another, but to understand that in bioethical issues, as in any issue in our society, our division of knowledge into neat, seemingly ahistorical disciplines imperils our ability to intervene in the problems we confront.
Is "Subcontracting" a Bioethical Issue?
I want to recount an anecdote that illustrates how an interdisciplinary approach can redefine our conception of "bioethical" issues. For one of the final classes of the course I teach at Emory University, "Bioethics in an Interdisciplinary Perspective," I organized the discussion around a recent controversy there: Over the preceding months, food service workers had complained about their treatment by Sodexo, the university's food service provider. They claimed that Sodexo had engaged in abusive labor practices and union busting. While such conduct was clearly against Emory's own labor policy, the university administration refused to intervene because Sodexo employees were subcontracted, and thus not under Emory's jurisdiction. The result was a two-tiered system of accountability between contracted and subcontracted employees that allowed for abuses to happen.
The issue, because of its proximity and pertinence, seemed to me a good case study for examining one of the key arguments of the course: that framing some issues as "bioethical" and others as unrelated hinders our ability to understand bioethical issues themselves. I assembled a packet that included: (1) relevant articles from the Emory newspaper, including statements by workers, students, Sodexo managers, and the university administration; (2) perspectives on the benefits and drawbacks of unionization for workers, employers, and society more generally; and (3) general literature on the legal and ethical dilemmas raised by subcontracting in Iraq. At the top of the packet, I included a list of questions, the first of which was: "What, if any, 'bioethical' issues does the Sodexo controversy raise?"
For many bioethicists, the answer to this question would be "none." My students and I came to a different conclusion. In class, we discussed the case of one of the workers, who, though pregnant, was denied break time and who, along with the other workers demanding unionization, was presumably struggling to pay her living expenses, including health care. "What if she decided to get an abortion?" I asked. "Would her labor situation be relevant to her decision to abort?" The answer to this question was clear, but the students went even further, pointing out that labor status was relevant not only to abortion but also to practically all of the bioethical topics we had discussed, including euthanasia, organ donation, and eugenics. At the same time, our examination of subcontracting in Iraq showed that, while Emory's decision to abandon the employees was certainly a moral failure, it was also part of a systemic shift toward subcontracting practices that had created ethical and legal conundrums throughout the world. That bioethicists had written hundreds of thousands of pages on "autonomy" without writing one article about its relation to subcontracting seemed, by the end of class, an indication that the field had misunderstood its own premises.
The goal of bioethics in the next forty years should be to guarantee that such fundamental misunderstandings do not occur. This will happen by stopping the search for new topics and instead becoming more reflective about our methods and more proactive in building institutions that can produce thinkers with the sensitivity and analytical skills to realize the field's founding ideals. Doing so will require redefining the contours of not only the field, but also our own identity as professionals. It will not be easy, but if we want to live up to our role as moral arbiters of some of our society's thorniest problems, it is work that we will be glad to undertake.
(1.) D. Rothman, Strangers at the Bedside: A History of How Law and Bioethics Transformed Medical Decision Making (New Brunswick, N.J.: Aldine Transaction, 2008).
(2.) R. Cooter, "The Resistible Rise of Medical Ethics," Social History of Medicine 8, no. 2 (1995): 257-70.
(3.) S.E. Lederer, "Children as Guinea Pigs: Historical Perspectives," Accountability in Research 10, no. 1 (2003): 1-16.
(4.) See, for example, O. Corrigan, "Empty Ethics: The Problem with Informed Consent," Sociology of Health and Illness 25, no. 7 (2003): 768-92; P. Farmer and N.G. Campos, "Rethinking Medical Ethics: A View from Below," Developing World Bioethics 4, no. 1 (2004): 17-41; and C. Gill, "The False Autonomy of Forced Choice: Rationalizing Suicide for Persons with Disabilities," in Contemporary Perspectives on Rational Suicide, ed. J.L. Werth (Philadelpia, Penn.: Routledge, 1998), 171-80.
(5.) For more on the investigation of "problem constitution" in philosophically oriented social science research, see S.K. White, "The Very Idea of a Critical Social Science: A Pragmatist Turn," in The Cambridge Companion to Critical Theory, ed. F. Rush (Cambridge, U.K.: Cambridge University Press, 2008), 310-35.
Harold Braswell, "In Search of a Wide-Angle Lens," Hastings Center Report 41, no. 3 (2011): 19-21.
Harold Braswell is a student in the interdisciplinary Ph.D. program at Emory University's Graduate Institute of the Liberal Arts. His research and teaching combine methods from cultural studies, law, philosophy, and the social sciences to analyze pressing bioethical dilemmas. He applies this interdisciplinary methodology in his dissertation, which examines the relationship of hospice care to end-of-life autonomy.
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