Thursday, January 27, 2011

On flogging concepts that refuse to die

Cultural reproduction is a strange thing. It is normal and often desirable to transfer cultural artifacts to future generations. We want to instill certain values in own children. We want to ensure that our mother tongue survives and retains its integrity. We want to keep scientific progress going, and we want to perpetuate valuable institutions like the law and modern medicine. There is much good in this. However, it is easy to get the mistaken impression that cultural reproduction is under our control. Culture also has a life and momentum of its own, and some aspects are reproduced even if we think they have worn out their welcome. Racism, homophobia and sexism live on, and a whole host of other dubious inheritances besides. And efforts to discredit these inheritances from a rational point of view seem to have less effect than we sometimes suppose. An artifact can exist, even thrive, despite being pretty much debunked.

These were my reflections while reading a recent article in the journal Bioethics by Heather Widdows, entitled "Localized Past, Globalized Future: Towards an Effective Bioethical Framework Using Examples from Population Genetics and Medical Tourism." Widdows takes dead aim at the concept of individual autonomy, claiming that (a) the individual autonomy is conceived as a crucial or foundational value in bioethics and (b) the concept is inadequate to make sense of (or help resolve) bioethics issues. It is like turning up to a gunfight with a plastic spoon. She uses the issues of population genetics and medical tourism to make her point, but the point has far wider applicability. The thing is, though, this has all been said before, in a variety of ways: it would not be hard to draw up a long list of bioethics articles devoted to debunking the oversold status of individual autonomy.

I am not criticizing Widdows for flogging a dead horse. Yes, debunking autonomy is practically a cottage industry, but I am guilty of contributing to it as well. What I am saying is that the horse has been flogged for ages, it is still not dead, and the current zombie-like state of the concept requires an explanation. Why is it, say, that people still find it attractive to say that organ trade between the rich and the poor could be reasonably conceived as a fair and unproblematic trade if conducted between consenting adults? Or that exploitation in international health research is morally acceptable if the 'exploited' party in the transaction adequately consented and might be worse off if he or she did not join a certain study? When a notion seems to be debunked but somehow survives, it is tempting to look past its content and look at the social function it may continue to serve. What does the use of the concept of autonomy 'do' for (some) people when deployed in bioethics arguments? Who gains and who loses when these issues are viewed and defended within frameworks that see individual choice as paramount?

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Blogger Kelly Hills said...

Dr. Goldberg of the Medical Humanities blog mentioned this post, and while I did make some of this comment there, I figured I would make the key part of it here as well (even though I suspect much of the questioning at the end of this musing is of the pedagogical, rhetorical variety).

I think that the "answer" is that in an environment where bioethics is as measured and scrutinized under scientific guidelines as those in the humanities, there are some people - who have been vocal and in a position to publish and otherwise be heard - who like autonomy because it's easy to measure. We have guidelines that people have agreed upon for what it means to be an autonomous individual, and the notion of autonomy is the same in sciences and humanities. This last bit, in particular, I think is really important - because it's one of the few times where you're going to find sciences-as-a-whole and humanities-as-a-whole speaking the same language.

Add to that that bioethics is a uniquely American field - in that while medical ethics has been a vague sort of medicine for, oh, ever, bioethics and the primacy of autonomy largely comes out of the Seattle God Squad case and crew - and Americans view "freedom" and "autonomy" as synonymous, you get something that's easy to measure, with a lexicon and concept/premise that "all Americans" understand (and has been exported to places where similar American values have ended up - see, for example, the difficulty in pushing autonomy in Asian countries).

Extending those thoughts out a bit from there to specifically address the issues you mention regarding exploitation and inequity, there's been an almost willful ignorance of power balance issues in bioethics and human subjects research, especially in developing areas of the world. I don't think that the ideal of autonomy was ever set up to address issues of justice - in fact, I'd say that's why principlism wants autonomy to work as a part of a larger picture that also includes (social) justice - because autonomy doesn't address power balance issues.

But that's drifting off topic a bit. What's the social value/function of autonomy? Shared language would be my inclination, at least.

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