In this issue of the Report, Arthur Frank recommends a "Socratic approach" to the ethical evaluation of contested surgeries. Consumer protectionist bioethics--his term for the mainstream bioethical offshoot of modern liberalism--focuses on risks and benefits, adequate disclosure, and the "consumer's" sovereign choice. Socratic bioethics, by contrast, asks questions about the good life and its relation to health; it takes seriously the effects of someone's choice on the choices open to others. Without judging some types of surgery morally acceptable and others beyond the pale, Socratic bioethics can prove liberating, he argues, by expanding our awareness of options. Moreover, it can "show how decision-making can proceed in ways that command respect." Accordingly, Frank's aim is "not to offer guidelines for practice" but "to open up the discourses in which people both professionals and potential patients--are able to think about how their actions affect themselves and their communities."
Frank discusses four types of surgery: surgically shaping women's feet to fit into designer shoes, limb-lengthening surgery on children with congenital dwarfism, intersex surgery on children with anomalous genitalia, and craniofacial surgery on children with major facial deformities. His commentary on these surgeries is very valuable--open-minded yet critical, and insightful about cultural dimensions. While he emphasizes process--improving the way we think, talk, and decide about contested surgeries he hardly abstains from moral judgments about the surgeries, even though he avoids the language of right and wrong. But while I generally agree with his judgments, I respectfully disagree with several aspects of his approach.
Frank dichotomizes modern liberal bioethics and the Socratic approach. But the latter is a methodology, or style of questioning, whereas the former is a moral-political worldview. I reject the dichotomy. Indeed, I think vigorous use of the Socratic approach will vindicate some version of the modern liberal worldview. Moreover, I suspect that a robust liberalism better supports Frank's moral judgments than does the postmodernism that he apparently embraces.
Craniofacial surgery on children is often justified because, as Frank's observations suggest, it frequently serves the children's best interests; whether repeated follow-up surgeries are warranted depends largely on whether they help the children. But evidence abounds that many intersex surgeries on children have not only followed an anemic or even deceitful proxy consent process, but have violated the best interests standard: many who have undergone the procedure deeply regret the choice made for them. …