The Second Stage of Bioethics and Institutionalist Economics
Lawson, Catherine L., Journal of Economic Issues
Changes in financing practices, health care delivery methods, and medical technologies have led to a process of intense self-examination and fundamental reorientation in the health care system. Medical ethics is one component under examination. Be it the formal codes of ethics internalized by professionals working in the field, the musings of academicians in the bioethics community, or the deliberations of hospital ethics committees and institutional review boards, the field of medical ethics increasingly finds itself called upon to address questions not formerly viewed as within its purview. Questions about what role health care institutions, corporate interests, and the larger society play in promoting or transgressing ethical behavior in the practice of medicine are beginning to supplant the bioethicist's historical preoccupation with individual patient-physician relationships, rights, duties, etc. Indeed, leading bioethicists are now talking with some urgency of the need to move on to the "second stage" of bioethics to address these new concerns [Potter 1996]. This paper outlines some of the details of these changes and indicates the role that institutionalist economics might play in this emerging bioethics debate.
Three main observations are offered in what follows. First, it is argued that the dominant position of ethical inquiry within institutionalist economics, as well as the institutionalist understanding of ethics as both social process and individual behavior, renders it of greater value than conventional economic theory to bioethicists searching for useful insights into the world of business and economics. Second, the abiding commitment of institutionalists to a "technological basis of value" [Klein and Miller 1996] suggests that many of the most critical questions emerging in bioethics at the present time should be of special interest and challenge to institutionalists. Finally, the institutionalist emphasis on custom and tradition and, particularly, on the potential for conflict between instrumental and ceremonial behavior offers some insights into the transition in health care financing from fee-for-service to managed care and, especially, of the acrimony accompanying this transition. (Indeed, one wonders whether it is not this acrimony, as much as the transition itself, that has propelled bioethicists into much of the heretofore unexplored terrain of the "second stage. ") In the following discussion, it will be useful to first review the history of the bioethics movement with an emphasis on its chief institutional manifestation, i.e., hospital ethics committees. Then, select characteristics of the current environment are examined in order to substantiate the foregoing observations and to illustrate the potential contributions of institutionalist thought in this area.
History of Bioethics
One of the most interesting aspects of the field of bioethics is the fact that as a formal, organized field of inquiry, it is a relatively recent intellectual undertaking. While philosophers working in the field of ethics have long provided occasional comment regarding particular issues in medical ethics, the larger "bioethics movement" dates only from about 1970, originating in events at a Seattle hospital concerning the allocation of kidney dialysis [see Wicks 1995, 617; Pelligrino 1993; Macklin 1987, 159]. In the period intervening between the 1970s and the 1990s, the activities of bioethicists have been sufficiently wide-ranging and hard-hitting to have made bioethics both a "part of the dialogue" in the practical sphere of medicine, with bioethicists occupying a variety of institutional roles, and a respected academic field of inquiry, attracting scholars from a wide range of disciplines [Wicks 1995, 604]. Evidence of its status as an academic field abounds, as bioethics conferences, journals, and faculty positions continue to be established at major universities across the country. Evidence of the practical impact of bioethics is also abundant, beginning with the 1976 Quinlan case prescribing a pivotal role for hospital ethics committees in decisions regarding withdrawl of life support [see Wolf 1991]. …