The Right (and Wrong) Answers

Sally Satel*

American bioethics was born out of a desire to be relevant. The philosopher Daniel Callahan has said that he and his colleagues founded the Hastings Center-the premier bioethics think tank-in 1969 because they wanted to give philosophy "some social bite, some relevance." Whether bioethics has achieved its goal is the urgent question at the core of this useful book, co-authored by Renée C. Fox, a highly distinguished sociologist, and Judith P. Swazey, a respected historian of medicine. Between them, Fox and Swazey have spent many decades as participant observers in the house of medicine. Their intensive involvement with physicians, theologians, and philosophers has given them ringside seats to the development of modern bioethics. Through enjoyable interviews with major figures in the field and a rich trove of personal observations, the book perceptively, if densely, chronicles the growth of bioethics as a profession.

If success is measured by breadth of institutional footprint, then bioethics has indeed succeeded. Major universities house bioethics centers that offer a plethora of both graduate and undergraduate programs. Bioethicists serve on hospital ethics committees and on research review boards. In many hospitals, bioethicists are "on call" to offer guidance on whether certain life-prolonging treatments should be initiated or withdrawn. In the public policy arena, bioethicists are appointed to presidential commissions and state and federal task forces that formulate guidelines and advise politicians.

By other measures of relevance, however, bioethics certainly falls short. Though clearly fond of the bioethicist-physicians, bioethicist-philosophers, and bioethicist-legal scholars they interviewed, Fox and Swazey describe themselves as "critical of what we regard as the field's deficiencies and blind spots." They identify these as the use of dumbed-down teaching formulae, an insensitivity to cultural differences, and the tendency of American bioethicists to emphasize "individual rights, and rationality" instead of "community, and common good," which are the values that Fox and Swazey favor.

The matter of ethical expertise-what it looks like, who can claim it-is a profound one. Bioethics' place in the academy, in the clinical realm, and in society turns on it. For most of us, the very idea of "right" answers to complex moral and philosophical dilemmas such as euthanasia, embryonic stem cell cloning, or organ remuneration is absurd on its face. After all, deriving an "answer" depends upon which type of moral theory one favors.

Fox and Swazey have faith that expertise in ethics does exist, but they believe that such expertise will not be fully realized until bioethicists take on matters of social justice. Disconcertingly, they are not concerned that a social justice agenda risks blurring the lines between disinterested ethical analysis (the authentic expertise of bioethicists) and outright political activism. This oversight is made even more peculiar because the authors seem quite appropriately exasperated by some of the day-to-day perversions of ethics "expertise." Ask almost any hospital physician about bioethicists and you will get, in reliable sequence, an eye roll, a sigh, and then an earful of anecdotes about swaggering cowboys posing as arbiters of right and wrong ("Wizards of Oughts," as one critic put it). In the media, the coverage of almost any biomedical controversy is sure to contain a quotation from a bioethicist with oracular pretensions. The unmistakable message of ethics punditry is clear: anyone who disagrees with us is thoughtless or unethical.

Such arrogance discomfits some bioethicists as well, as Fox and Swazey note. Erik Parens regrets the popular view of the ethicist as "priggish or foolish enough to lay claim to how other people should lead their lives." Fed up with Homo bioethicus, Carl Elliott, a physician and bioethicist, has remarked that "Many people working in and around bioethics wince if someone called them a 'bioethicist.'… Some resist the aura of professionalism and moral expertise that the term bioethics seems to imply. Others are just embarrassed by the incivility and glibness of our public spokespeople. Others just don't want to be viewed as the ethics police."

This raises a larger question. Is it politically desirable for society to credit bioethicists with expertise in resolving the most difficult moral questions? Fox and Swazey say yes, but only if bioethicists revise their mission. Instead of concentrating on issues surrounding biomedical technology, such as cloning, sex selection, nanotechnology, and so on, bioethics should address "inequalities in health and in access to health care in American society." The field should become "more centrally and deeply involved with [global] suffering and … issues of social justice.

Ruth Macklin, a self-described "liberal, humanitarian bioethicist," told the authors, "I acknowledge that my chief concern is in striving for greater social justice within and among societies, and reducing disparities in health, wealth, and other resources among populations in the world." These are noble sentiments, yes. But what particular authority or particular skill do bioethicists possess that allow them to add much in the way of unique scholarship, practical wisdom, or ethical reflection that is not already being applied today, for better or worse, by experts in international development, global health economics, and political theory? Fox and Swazey do not answer this question. They simply assume that bioethicists bring a needed perspective.

This is not to deny a productive role for applied ethics in modern life. 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 delineating conflicts, laying out the assumptions behind different positions, evaluating the soundness of arguments, and reflecting upon potential consequences.

Granted, many bioethicists endorse this as the proper role for bioethics. But they must compete to be heard in a field with widely divergent understandings of itself. Are we a field of scholarly inquiry, bioethicists ask themselves, or a learned profession, a consultancy, a form of policymaking or activism, an oversight apparatus that monitors researchers and physicians, a discourse, a project, or a collection of questions or issues? What training should a bioethicist receive? Should our field take stands on mainstream political issues, such as the war in Iraq or the crisis in Darfur? Are we excessively beholden to the institutions we serve?

Fox and Swazey portray bioethics as a field in turmoil. It suffers, the authors observe, from being "overly impressed with its importance" and steeped in a culture of "self-congratulation." But at the heart of such self-conscious ceremony, they astutely speculate, lies professional insecurity. Fox's and Swazey's own prescription-to expand the bioethics' franchise into global justice and activism-will not help. Bioethics would become politicized, thereby undermining the already shaky credibility of the field.