The Transformation of Bioethics

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An upstart young discipline born some 30 years ago, idealistically determined to grapple with the moral dilemmas posed by modern medicine and to give patients more say, bioethics seems to be flourishing today.

It's a required subject in medical schools, a mandatory feature in hospitals, a frequent attraction in the media; degrees and certificates are awarded in it; centers, departments, and government commissions, as well as professional organizations and journals, are devoted to it. Attending physicians in hospitals can now ask bioethics "consultants" to help critically ill patients or their families decide whether life-sustaining medical treatments should he withheld or withdrawn.

Yet for all this activity and apparent success, some observers wonder if bioethics hasn't lost the promise of its youth and perhaps even its way. They disagree, however, on just what that promise was and what the proper path should be.

In an issue of Daedalus (Fall 1999) on "Bioethics and Beyond," philosopher Daniel Callahan, a pioneering bioethicist who cofounded the Hastings Center, in Garrison, New York, in 1969, confesses that he is unhappy with "the general direction" the field has taken. From the start, he explains in Daedalus and in another essay in the Kennedy Institute of Ethics Journal (Mar. 1999), two powerful currents were at work in bioethics. Reacting to abuses of human research subjects and doctors' characteristic paternalism toward patients, an "autonomy" movement sought to promote "individual rights and choice." A "cultural" movement, drawing on theology, nonanalytic philosophy, and social science, sought "the social and cultural meaning of the biomedical developments." To Callahan's disappointment, the "autonomy" current--favored by lawyers and analytic philosophers, and very much in tune with American liberal individualism--has proven much the stronger.

But bioethics has not become all that early enthusiasts for "autonomy" dreamed, either. It developed "as a critical enterprise, a response to felt inhumanities in our system of health care and biomedical research." But bioethics not only "questioned authority"--it has shored it up, observes Charles E. Rosenberg, a historian of science and medicine at the University of Pennsylvania, also writing in Daedalus. "As a condition of its acceptance, bioethics has taken up residence in the belly of the medical whale," there "serv[ing] ironically to moderate, and thus manage and perpetuate, a system often in conflict with [medicine's] idealized identity."

Many bioethicists today have been "rediscovering the virtues of paternalism," contends Ronald Bailey, science correspondent for Reason (Aug.-Sept. 1999). Instead of "doctor-knows-best," there is "bioethicist-knows-best." They "want to determine what patients need to know and what treatments they should get," he says. He cites a 1996 case in which doctors, following bioethicists' advice, initially refused to tell a patient what the results of her genetic test for breast cancer were. …