Sunday, February 14, 2010

Depoliticizing bioethics?

Book reviewers always work between two extremes. One says more about the book and its author, the other says more about the worldview of the reviewer. Some reviews more or less describe what the book is about and add a bit of commentary. Others make use the book's content as a point of departure for reviewer's own opinions. Most reviews lie somewhere in-between. But one thing is clear: whichever direction they take, book reviews in general don't generate a lot of excitement.

The same cannot be said, however, about Sally Satel's review of Observing Bioethics (by Renee C. Fox and Judith P. Swazey), at least in the small world of bioethics. Observing Bioethics is a sociology of bioethics as practiced in North America, and like any decent sociology of any social practice, it is a 'warts and all' view documenting strengths, pitfalls, successes and failures. The activity called 'bioethics' has become an important force in some (mainly North American and European) societies, on the one hand, while there have always been lingering doubts about the expertise and legitimacy of its practitioners. Fox and Swazey's research describes these doubts, while depicting bioethics as narrowly focused on individuals (more than groups and communities) and rationality (more than traditions and shared values), and being somewhat allergic to cultural diversity.

This is where Satel, the reviewer, takes the ball and starts to run with it. She takes the doubts about the expertise of those working in bioethics to answer ethical issues in medicine and research, and offers her own conception of the bioethicist's mission and social role:

Bioethicists can be great educators of students and physicians and policy-makers. When an expert in bioethics approaches a problem, such as an end-of-life decision, he brings a deep knowledge of the cultural history of that controversy and the relevant legal decisions. This allows him to draw analogies to current situations. He is skilled at deliniating conflicts, laying out assumptions behind different positions, evaluating the soundness of arguments, and reflecting on potential consequences.

According to Satel, what people working in bioethics should not do is something that Fox and Swazey in fact recommend: getting involved more centrally in issues of global suffering and social justice. Moving bioethics in that direction, according to Satel, would be a mistake. Bioethics should not be moving outward to engage with global issues, but stay closer to home: bioethics workers as educators, not advocates. And when they educate, they apparently should not be taking or promoting any firm position on the issues they are discussing. They should simply lay out the issues for those who will make the decisions in the 'real world'.

Those antithetical to bioethics have delighted in Satel's review. For them, she has taken bioethicists down a peg. Bioethicists claim in a sense to tell us how we ought to live, and Satel has reduced them from 'Wizards of Oughts' to masters-of-nought. It is easy to see the appeal Satel's view could have for those who wish bioethicists would not only disappear into the relative obscurity of academia, but vanish from the face of the earth. The only problem is that Satel does not argue for her position, but merely states it. And the view is not without its shortcomings.

The first problem concerns neutrality. Above all else, people working in bioethics formulate normative arguments in favor (or against) certain ethical positions, and not just offer a panorama of possibilities. They will, on the basis of those arguments, judge (by presenting reasons and evidence for) ethical positions as being better or worse than others. When they have reason to judge some positions as being better or worse than others, it would be irresponsible of them not to mention this, not only to those they educate, but also to the larger community, since the issues that bioethics deal with are social issues of common concern. Bioethicists do not have to possess some magical expertise, capable of producing definitive answers to complex ethical questions, to have something worth contributing to these debates. The activity of conducting normative analysis and argument about (bio)ethical topics is already political.

Second, the idea of a 'de-politicized' bioethics looks like a developed world fantasy, or luxury. Bioethics in other contexts has sometimes been a way of speaking truth to power in the domain of medicine, public health and health research, particularly against the background of corrupt Ministries of Health, dodgy pharmaceutical studies, and skyrocketing numbers of deaths from preventable and treatable diseases. When things get this ugly, a purely educative role for bioethics does not look like a mission worth having. It starts to look like a parlor game. As long as activism and advocacy is rooted in open, honest analysis and argument -- and not simple ideology from the right or the left -- there is nothing wrong with bioethics workers trying to help make the world a better place, or at least control the damage.

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