Critical bioethics: beyond the social science critique of applied ethics

This article attempts to show a way in which social science research can contribute in a meaningful and equitable way to philosophical bioethics. It builds on the social science critique of bioethics present in the work of authors such as Renee Fox, Barry Hoffmaster and Charles Bosk, proposing the characteristics of a critical bioethics that would take social science seriously. The social science critique claims that traditional philosophical bioethics gives a dominant role to idealised, rational thought, and tends to exclude social and cultural factors, relegating them to the status of irrelevancies. Another problem is they way in which bioethics assumes social reality divides down the same lines/categories as philosophical theories. Critical bioethics requires bioethicists to root their enquiries in empirical research, to challenge theories using evidence, to be reflexive and to be sceptical about the claims of other bioethicists, scientists and clinicians. The aim is to produce a rigorous normative analysis of lived moral experience.     

WHO'S ARGUING? A CALL FOR REFLEXIVITY IN BIOETHICS

In this paper we set forth what we believe to be a relatively controversial argument, claiming that ‘bioethics’ needs to undergo a fundamental change in the way it is practised. This change, we argue, requires philosophical bioethicists to adopt reflexive practices when applying their analyses in public forums, acknowledging openly that bioethics is an embedded socio‐cultural practice, shaped by the ever‐changing intuitions of individual philosophers, which cannot be viewed as a detached intellectual endeavour. This said, we argue that in order to manage the personal, social and cultural embeddedness of bioethics, philosophical bioethicists should openly acknowledge how their practices are constructed and should, in their writing, explicitly deal with issues of bias and conflict of interest, just as empirical scientists are required to do.     

Lessons from Queer Bioethics: A Response to Timothy F. Murphy

‘Bioethics still has important work to do in helping to secure status equality for LGBT people’ writes Timothy F. Murphy in a recent Bioethics editorial. The focus of his piece, however, is much narrower than human rights, medical care for LGBT people, or ending the HIV/AIDS pandemic. Rather, he is primarily concerned with sexuality and gender identity, and the medical intersections thereof (i.e. DSM diagnosis; access to SrS or ARTs). It is the objective of this response to provide an alternate account of bioethics from a Queer perspective. I will situate Queer bioethics within Queer studies, and offer three ‘lessons’ that bioethics can derive from this perspective. These are not definitive rules for Queer bioethics, since it is a field which fundamentally opposes categorizations, favoring pastiche over principles. These lessons are exploratory examples, which both complement and contradict LGBT bioethics. My latter two lessons – on environmental bioethics and disability – overlap with some of Murphy's concerns, as well as other conceptions of LGBT bioethics. However, the first lesson takes an antithetical stance to Murphy's primary focus by resisting all forms of heteroconformity and disavowing reproduction as consonant with Queer objectives and theory. The first lesson, which doubles as a primer in Queer theory, does heavy philosophical lifting for the remainder of the essay. This response to Timothy F. Murphy, whose work is certainly a legacy in bioethics, reveals the multiplicity of discourses in LGBT/Queer studies, many of which are advantageous – even essential – to other disciplines like bioethics.     

WHICH NATURALISM FOR BIOETHICS? A DEFENSE OF MODERATE (PRAGMATIC) NATURALISM

There is a growing interest in various forms of naturalism in bioethics, but there is a clear need for further clarification. In an effort to address this situation, I present three epistemological stances: anti-naturalism, strong naturalism, and moderate pragmatic naturalism. I argue that the dominant paradigm within philosophical ethics has been a form of anti-naturalism mainly supported by a strong 'is' and 'ought' distinction. This fundamental epistemological commitment has contributed to the estrangement of academic philosophical ethics from major social problems and explains partially why, in the early 1980s, 'medicine saved the life of ethics'. Rejection of anti-naturalism, however, is often associated with strong forms of naturalism that commit the naturalistic fallacy and threaten to reduce the normative dimensions of ethics to biological imperatives. This move is rightly dismissed as a pitfall since ethics is, in part, a struggle against the course of nature. Rejection of naturalism has drawbacks, however, such as deterring bioethicists from acknowledging the implicit naturalistic epistemological commitments of bioethics. I argue that a moderate pragmatic form of naturalism represents an epistemological position that best embraces the tension of anti-naturalism and strong naturalism: bioethics is neither disconnected from empirical knowledge nor subjugated to it. The discussion is based upon historical writings in philosophy and bioethics.     

How rational should bioethics be? The value of empirical approaches

Rational justification of claims with empirical content calls for empirical and not only normative philosophical investigation. Empirical approaches to bioethics are epistemically valuable, i.e., such methods may be necessary in providing and verifying basic knowledge about cultural values and norms. Our assumptions in moral reasoning can be verified or corrected using these methods. Moral arguments can be initiated or adjudicated by data drawn from empirical investigation. One may argue that individualistic informed consent, for example, is not compatible with the Asian communitarian orientation. But this normative claim uses an empirical assumption that may be contrary to the fact that some Asians do value and argue for informed consent. Is it necessary and factual to neatly characterize some cultures as individualistic and some as communitarian? Empirical investigation can provide a reasonable way to inform such generalizations. In a multi-cultural context, such as in the Philippines, there is a need to investigate the nature of the local ethos before making any appeal to authenticity. Otherwise we may succumb to the same ethical imperialism we are trying hard to resist. Normative claims that involve empirical premises cannot be reasonable verified or evaluated without utilizing empirical methods along with philosophical reflection. The integration of empirical methods to the standard normative approach to moral reasoning should be reasonably guided by the epistemic demands of claims arising from cross-cultural discourse in bioethics.     

Informed Consent and Genetic Information

In the last 25 years writing in bioethics, particularly in medical ethics, has generally claimed that action is ethically acceptable only if it receives informed consent from those affected. However, informed consent provides only limited justification, and may provide even less as new information technologies are used to store and handle personal data, including personal genetic data. The central philosophical weakness of relying on informed consent procedures for ethical justification is that consent is a propositional attitude, so referentially opaque: consent is given to specific propositions describing limited aspects of a situation, and does not transfer even to closely related propositions. Assembling genetic data in databases creates additional difficulties for ethical justification. This is not because genetic information is intrinsically exceptional, but because the merger of genetic and information technologies make it possible to assemble massive quantities of complex information that defeat individuals' best efforts to grasp what is at stake, or to give or withhold informed consent. The future agenda for bioethics will need to take account of both these limitations of appeals to informed consent.     

Anthropological and Sociological Critiques of Bioethics

Anthropologists and sociologists offer numerous critiques of bioethics. Social scientists criticize bioethicists for their arm-chair philosophizing and socially ungrounded pontificating, offering philosophical abstractions in response to particular instances of suffering, making all-encompassing universalistic claims that fail to acknowledge cultural differences, fostering individualism and neglecting the importance of families and communities, and insinuating themselves within the “belly” of biomedicine. Although numerous aspects of bioethics warrant critique and reform, all too frequently social scientists offer ungrounded, exaggerated criticisms of bioethics. Anthropological and sociological critiques of bioethics are hampered by the tendency to equate bioethics with clinical ethics and moral theory in bioethics with principlist bioethics. Also, social scientists neglect the role of bioethicists in addressing organizational ethics and other “macro-social” concerns. If anthropologists and sociologists want to provide informed critiques of bioethics they need to draw upon research methods from their own fields and develop richer, more informed analyses of what bioethicists say and do in particular social settings.     

Segmentation and moral status in vivo and in vitro: a scientific perspective

A basic consideration in research on human embryos is the controversy about when the embryo acquires moral status. The author refutes the contention that segmentation is the determinant of moral status. She notes that segmentation, as a stage in embryonic development, does not coincide with the development of "irreversible individuality" upon which the segmentation argument depends. Dawson also finds a lack of clarity in the meaning of "individuality." These problems, she maintains, prevent segmentation from being morally important and render the proposed 14-day limit on embryo research unnecessary. Dawson concludes that to introduce a time restriction on embryo research is premature because it is based on an inadequate philosophical argument.     

Gender context of personalism in bioethics

Personalism is one of the philosophical perspectives which hold that the reality in person and the human person has the highest intrinsic value. This paper makes reference to Louis Janssens' eight criteria in adequate consideration of the human person but further argues that there is need to consider people as situated agents especially within gender relational perspectives. The paper identifies gender as an important social construction that shapes the consideration of the human persons within socio-spatial spheres. The main crux of the paper is that there is a gender context of personalism and this has profound implications for bioethical agendas. Gender is part of the human condition, especially when we philosophically or sociologically engage the notion of equity and equality within the social system, because social realities in the relational perspective are not impartial, impersonal and equal. Gender does not determine morality but it plays a role in morality and expectations from moral agents. Women have been categorised as a sociological group because their integrity, freedom/autonomy and dignity (which are basic concerns of bioethics) are capable of being threatened. A gender perspective provides important incentives for moral theory which searches for possible conceptual imbalances or blind spots in ethical reflections. The paper refers to Sen's faces of gender inequality and expands on the notion that natality inequality is one of the fundamental levels of gender inequality, which in turn is the primary starting agenda in bioethics. The paper avers that the recognition of the fundamental importance of gender to the organization of social reality and the development of personal identities have important practical implications for bioethics.     

The intellectual basis of bioethics in Southern European countries

Today the Western world harbors, at least, three very different ethical traditions, each with its own characteristics: the Anglo-Saxon, the Northern (or Central) European, and the Mediterranean. Because modern bioethics made its appearance in the Anglo-American culture, Europeans in general, and Mediterraneans in particular, have attempted not simply to "import" or "translate" bioethics, but rather to "recreate" or "remake" the discipline according to their own cultural and ethical traditions. In my presentation, I would like to explain the peculiarities of Mediterranean bioethics, analyzing the following seven points: First, how they think bioethics should be philosophically founded; Second, the Mediterranean ethics of virtue and the doctor-patient relationship; Third, the relationship between Ethics and Law; Fourth, Health Care Systems and Ethics, Fifth, the problems concerning patient rights; Sixth, ethics by Committees; and finally, some general conclusions.     

Ecoethics: Now Central to All Ethics

A few years ago, I wrote on the need for expansion of the environmental areas of bioethics, and covered some of the topics touched on here. Sadly, although it is possible to find some notable exceptions, bioethics does not provide much of an ethical base for considering human-nature relationships. Here I’m not going to deal with these philosophical issues or others about the nature of ethical decision-making. The rapid worsening of the human predicament means that applied ethical issues with a significant environmental connection (what I call “ecoethics”), must be dealt with without waiting for the more interesting theoretical issues to be resolved. I define ecoethics very broadly to deal with dilemmas over a vast range of scales, and believe they now should penetrate virtually all areas of human activities. Ecoethics must struggle with issues of intra-generational (and interperson/group/nation) equity and the dilemmas of discounting by distance (valuing distant persons/events/costs/benefits less than those closer to the observer in physical or mental distance). Ecoethics also deals with the difficult dilemma of inter-generational equity—of discounting the future. That is especially troublesome when actions today can have significant environmental consequences 50 or more generations from now. Here I would like to highlight the ubiquity of those questions and the importance of seeking answers.     

Pain, paradox, and value

The author argues that "as soon as one begins to study the understanding and management of pain in science, human medicine, and veterinary medicine, one begins to encounter a variety of apparent paradoxes." He contends that these paradoxes, ten of which he identifies and discusses in this essay, are based on flawed philosophical and valuational assumptions underlying science and medicine. Rollins concludes that, as social morality increasingly has an impact on science, a new ideology will evolve that is more receptive to the moral universe and more capable of a "coherent vision of pain, one which acknowledges that the medical notion of adequacy of anaesthesia is as much a moral as a scientific one."     

From human wrongs to universal rights: communication and feminist challenges for the promotion of women's health in the Third World

This article argues that in the quest for global bioethics in its relation to the promotion of women's health and women's rights, the main challenge is to, first, rise above the relativist trap and second, to solve the false dilemma between individualism and collectivism. Particularly in order to improve women's position and advance their well-being in many developing countries with patriarchal cultural practices, there is an urgent need to introduce modern medicine and to share more evenly and efficiently the health care resources of the industrialized societies. This presumes that we can find a normative bioethical approach that promotes the rights of individuals without striving for cultural assimilation and disrespect.
From the philosophical point of view this means that we have to overcome the debate between the rival views of justice, and rather find the shared features of the various approaches, thus diminishing the exaggerated polarizations between them. The author claims that despite its importance in women's rights protection, feminist bioethics cannot remain as a normative alternative that can replace either liberal or communitarian approaches. Instead feminism needs to be part of both liberal and communitarian ethical thinking. Communitarianism, for its part, cannot offer an alternative to either liberalism or feminism, but it can function as an essential critical balancing force within these approaches. Individualist liberalism, on the other hand, has to find its way into collective social structures and accept their maintenance, instead of exhausting itself in its attempts to lift individuals above or beyond their social contexts.     

In the shadow of "death with dignity": medicine and cultural quandaries of the vegetative state

In this paper I address one site of technological development and cultural production, the permanent or persistent comatose condition and the institutions and practices that enable this life form to exist. As with other medical sites of ambiguity and change under recent scrutiny by anthropologists, the locations in which comatose bodies thrive are those in which the routinization of technology use in the clinic and a legitimating social and economic context come together to permit and create a further remapping of the notions of "life" and "person." I explore the new forms of knowledge, practice, and the body that are created at this site and how they are negotiated, and I discuss how the shifting understanding of "'culture" and "nature" both have an impact on and are informed by American quandaries about approaching death. I argue that beings who are neither fully alive, biologically dead, nor "naturally" self-regulating, yet who are sustained by modern medical practices, destabilize the existing social order in ways that are different from other hybrid forms, [medical anthropology, anthropology of the body, bioethics, personhood, culture/nature dichotomy]     

A method of Reflexive Balancing in a Pragmatic,Interdisciplinary and Reflexive Bioethics

In recent years there has been a wealth of literature arguing the need for empirical and interdisciplinary approaches to bioethics, based on the premise that an empirically informed ethical analysis is more grounded, contextually sensitive and therefore more relevant to clinical practice than an ‘abstract’ philosophical analysis. Bioethics has (arguably) always been an interdisciplinary field, and the rise of ‘empirical’ (bio)ethics need not be seen as an attempt to give a new name to the longstanding practice of interdisciplinary collaboration, but can perhaps best be understood as a substantive attempt to engage with the nature of that interdisciplinarity and to articulate the relationship between the many different disciplines (some of them empirical) that contribute to the field. It can also be described as an endeavour to explain how different disciplinary approaches can be integrated to effectively answer normative questions in bioethics, and fundamental to that endeavour is the need to think about how a robust methodology can be articulated that successfully marries apparently divergent epistemological and metaethical perspectives with method. This paper proposes ‘Reflexive Bioethics’ (RB) as a methodology for interdisciplinary and empirical bioethics, which utilizes a method of ‘Reflexive Balancing’ (RBL). RBL has been developed in response to criticisms of various forms of reflective equilibrium, and is built upon a pragmatic characterization of Bioethics and a ‘quasi‐moral foundationalism’, which allows RBL to avoid some of the difficulties associated with RE and yet retain the flexible egalitarianism that makes it intuitively appealing to many.     

The presence and influence of religion in American bioethics

From the inception of the relatively short history of American bioethics in the mid-to-late 1960s, the place of religion in this field has been complex and controversial. It has also been a subject of more than casual interest and concern to bioethicists, and to an array of medical and non-medical groups in U.S. society for whom the activities and issues in which bioethics is engaged have ongoing import. The questions and the tensions linked to the status and influence of religion in the sphere of bioethics have ramifications that extend beyond bioethics and biomedicine into matters involving the relationship of religion to the institutional structure of American society--most particularly its political, legal foundations, and realm of public affairs--and to its cultural attributes and tradition. It is within this larger perspective that we will consider the association between American bioethics and religion. Our analysis includes two case studies: (1) how, in the early years of bioethics, a pioneering organization in the field dealt with the "redefinition of death" in its discussions and in a major medical journal publication; and (2) the way in which the most recently appointed federal bioethics commission, the National Bioethics Advisory Commission, involved religion in its work on cloning and stem cell research.     

Moving beyond bioethics: history and the search for medical humanism

From both within and without bioethics, growing criticism of the predominant methods and practices of the field can be heard. These critiques tend to lament an emphasis on logically derived rules and philosophical theories that inadequately capture how and why people have the moral attitudes they do, and they urge the use of more empirically grounded social sciences--history, sociology, and anthropology--to draw attention to the complex factors behind such attitudes. However, these critiques do not go far enough, as they do not question why debate over ethical categories should have such a central role in voicing concerns about medicine. The importance of using other forms of inquiry, especially that of history, to examine aspects of medical practice and the emergence of bioethics itself is not simply to refine bioethical moral analysis. Instead, history can be employed to counter the preoccupation with translating concerns about medicine into moral terms and to move towards what is more sorely needed: a true medical humanism.     

An African theory of bioethics: reply to MacPherson and Macklin

In a prior issue of Developing World Bioethics, Cheryl Macpherson and Ruth Macklin critically engaged with an article of mine, where I articulated a moral theory grounded on indigenous values salient in the sub-Saharan region, and then applied it to four major issues in bioethics, comparing and contrasting its implications with those of the dominant Western moral theories, utilitarianism and Kantianism. In response to my essay, Macpherson and Macklin have posed questions about: whether philosophical justifications are something with which bioethicists ought to be concerned; why something counts as 'African'; how medicine is a moral enterprise; whether an individual right to informed consent is consistent with sub-Saharan values; and when thought experiments help to establish firm conclusions about moral status. These are important issues for the field, and I use this reply to take discussion of them a step or two farther, defending my initial article from Macpherson's and Macklin's critical questions and objections.     

Biohumanities: rethinking the relationship between biosciences, philosophy and history of science, and society

We argue that philosophical and historical research can constitute a "Biohumanities" that deepens our understanding of biology itself engages in constructive "science criticism," helps formulate new "visions of biology," and facilitates "critical science communication." We illustrate these ideas with two recent "experimental philosophy" studies of the concept of the gene and of the concept of innateness conducted by ourselves and collaborators. We conclude that the complex and often troubled relations between science and society are critical to both parties, and argue that the philosophy and history of science can help to make this relationship work.